Gluteal & Hamstring Tendinopathy Flashcards
what is the primary pathology of tendinopathy? secondary?
gradual change
inflammation
what is the most prevalent LE tendinopathy?
gluteal tendinopathy
who is more at risk for GTPS?
women
> 40
sedentary individuals (doing too little is same as doing too much)
what are risk factors for GTPS?
female
high BMI
excessive hip ADD
weak hip abductors
coxa vara
plyometric overuse
what structure is primarily involved in gluteal tendinopathy?
greater trochanteric bursa
what muscles are involved in GTPS?
—primary
—secondary
primarily glut med/min
secondarily TFL/IT band
in relation to greater trochanter what position does the following muscles sit:
GMed
piriformis
GOGOs
quadratus femoris
12 o’clock
11 o’clock
10 o’clock
9 o’clock
what is the primary driver of gluteal tendinopathy?
abnormal mechanical loading
what are the two ways excessive loads are applied longitudinally or perpendicularly?
tensile loads occur with concentric loads
tensile and compressive loads occur with eccentric loads, particularly in lengthened ranges
could TFL/IT band over recruitment play a role in GTPS?
yes - L4-S1 regional interdependence can also play a role
could excessive femoral adduction (one example of impaired LE control) cause GTPS also?
yes - excessive loads can occur with impaired LE control
what are symptoms of GTPS?
gradual and unknown onset but possible overuse/lower supply
increasing lateral hip P! and maybe lateral thigh
what could increase symptoms of GTPS?
walking, running, stairs, any single leg loading
prolonged sitting, esp crossing legs as IT band tension increased thru Gmax lengthening, particularly in lower seat and then first few steps
lying on involved side - interrupts sleep
–> could be painful to lay on other side due to hip ADD
what would decrease symptoms of GTPS?
rest
what would you possibly also find with GTPS?
lumbar hypermobility/instability symptoms if aggravated
what would you find in your observation/functional tests for GTPS?
possible antalgic and/or trendelenburg gait
impaired LE control
–> P! and/or weakness with 30 sec single limb stance
–> may need to assess higher level ADLs like jumping/running
what would you find for ROM for GTPS?
- possible lat hip P! and limitation with adduction and IR in neutral (glut med is compressing bursa and/or tendon)
- limitation w/ ER (GMed/Min lengthening) and H add (piriformis lengthening) in 90 deg flexion
where would you find weakness and P! with resisted testing for GTPS?
abduction, esp in adducted position
ER in neutral
IR and H ABD in 90 hip flex
abductors and ERs weak and atrophied
what special tests would be (+) for GTPS?
(+) ER (g med and min lengthening) and H add (piriformis lengthening) in 90 deg flexion
possible (+) Obers
where would appear to be TTP with palpation for GTPS?
over bursa (hallmark sign) > GMed
what is PT Rx for GTPS?
address the cause (victim or culprit?)
–> itis or osis
–> regional interdependence
patient education
– soreness rule
– load management
– avoid provoking positions (prolonged sitting, esp crossing legs and lying on involved side)
– pillow between knees when on uninvolved side to keep you from going into more adduction
POLICED
modalities - shockwave therapy proposed but not substantiated
should you recommend stretching for a patient with GTPS?
no
that is causing max compression and lengthening and may keep it inflammed
what are the primary purposes for MET for GTPS?
tendon proliferation and stabilization (hip and lumbar)
tendinosis parameters - 3 sets, 10-15 reps, heavy load
how should you progress MET exercises for a pt with gluteal tendinopathy?
- isometric loading without compression from lengthening
- isotonic loading without compression from lengthening
- isotonic loading with compression from lengthening
- Closed chain hip abd, ER, ext
- plyometric loading
what are MD Rx for gluteal tendinopathy?
corticosteroid injections
platelet rich and other regenerative injections
why is hamstring tendinopathy more common among athletes?
they are creating more abnormal hamstring movement patterns compared to the general population
what are risk factors for hamstring tendinopathy?
prior injury
regional interdependence (L4-S1) lumbar hypermobility
weak glut max, glut med and/or adductors
what are examples of other deficits that could cause hamstring tendinopathy?
excessive hip flexor recruitment leads to anterior pelvic tilt and adds to excessive tension/compression
inadequate ham: quad ratio
–> excessive quad recruitment
–> overuse/lower supply with hamstring inhibition
advanced age - less pliable tissue equals greater tension/compression
what structures are involved with hamstring tendinopathy?
hamstring proximal tendon
adductor magnus - shared origin and fascial connections with hamstrings
ischial bursa
rarely sciatic n.
what could cause hamstring tendinopathy/
repetitive hamstring action with hip in flexion
–> running, jumping
–> training errors (overuse, sprints, hills, plyometrics)
excessive prolonged stretching
sedentary lifestyle
muscle imbalances
prior injury
during the deceleration period, how are the hamstrings involved?
eccentrically control knee extension
during heel strike and foot flat periods, how are the hamstrings involved?
after lengthening, hamstrings act in lengthened position with hip in flexion
what are symptoms of hamstring tendinopathy?
post. hip/buttock P! (a deep ache)
less symptomatic with warm up
worsened with activities that lengthen hamstring with or without muscle action
stiffness after prolonged positions, particularly sitting
signs of hamstring tendinopathy in scan:
- observation?
- functional tests?
- ROM?
- Resisted
- neuro
- possible atrophy if long standing
- P! w activity involving lengthening with muscle action (squat, lunge, running)
- possible limitation and P! w hip flexion & knee extension
- possible weakness and P! with hip ext and knee flexion, esp in lengthened position
- possible dural mobility limitations if sciatic n. involved
signs of hamstring tendinopathy in biomechanical exam:
- special tests
- palpation
bent knee stretch test
–> hip and knee flexed, PT slowly straightens knee
shortened muscle length test
TTP over proximal tendon and bursa at ischial tuberosity
PT Rx for hamstring tendinopathy?
same as gluteal tendinopathy plus…
- education
–> stand > sit
–> avoid low seats and prolonged sitting
- dry needling
- neural mobilizations if sciatic n involved
what position would you begin to load the tendon in?
shortened
how would you progress MET for someone with hamstring tendinopathy?
- isometric loading without compression
- isotonic loading without compression
- isotonic loading with compression from lengthening (consider both hip and knee)
- Closed chain hip abd, ER, ext
- plyometric loading
what would you want to focus on with MET exercises for hamstring tendinopathy?
eccentric training (reduces P! and injury)
lumbopelvic stabilization to improve hamstring activity that supports regional interdependence
what is the prognosis for hamstring tendinopathy?
good out to at least 6 months with 8-10 weeks of PT
