Gluteal & Hamstring Tendinopathy

Question 1

what is the primary pathology of tendinopathy? secondary?

Answer 1

gradual change
inflammation

Question 2

what is the most prevalent LE tendinopathy?

Answer 2

gluteal tendinopathy

Question 3

who is more at risk for GTPS?

Answer 3

women
> 40
sedentary individuals (doing too little is same as doing too much)

Question 4

what are risk factors for GTPS?

Answer 4

female
high BMI
excessive hip ADD
weak hip abductors
coxa vara
plyometric overuse

Question 5

what structure is primarily involved in gluteal tendinopathy?

Answer 5

greater trochanteric bursa

Question 6

what muscles are involved in GTPS?
—primary
—secondary

Answer 6

primarily glut med/min
secondarily TFL/IT band

Question 7

in relation to greater trochanter what position does the following muscles sit:
GMed
piriformis
GOGOs
quadratus femoris

Answer 7

12 o’clock
11 o’clock
10 o’clock
9 o’clock

Question 8

what is the primary driver of gluteal tendinopathy?

Answer 8

abnormal mechanical loading

Question 9

what are the two ways excessive loads are applied longitudinally or perpendicularly?

Answer 9

tensile loads occur with concentric loads
tensile and compressive loads occur with eccentric loads, particularly in lengthened ranges

Question 10

could TFL/IT band over recruitment play a role in GTPS?

Answer 10

yes - L4-S1 regional interdependence can also play a role

Question 11

could excessive femoral adduction (one example of impaired LE control) cause GTPS also?

Answer 11

yes - excessive loads can occur with impaired LE control

Question 12

what are symptoms of GTPS?

Answer 12

gradual and unknown onset but possible overuse/lower supply
increasing lateral hip P! and maybe lateral thigh

Question 13

what could increase symptoms of GTPS?

Answer 13

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

Question 14

what would decrease symptoms of GTPS?

Answer 14

rest

Question 15

what would you possibly also find with GTPS?

Answer 15

lumbar hypermobility/instability symptoms if aggravated

Question 16

what would you find in your observation/functional tests for GTPS?

Answer 16

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

Question 17

what would you find for ROM for GTPS?

Answer 17

• 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

Question 18

where would you find weakness and P! with resisted testing for GTPS?

Answer 18

abduction, esp in adducted position
ER in neutral
IR and H ABD in 90 hip flex
abductors and ERs weak and atrophied

Question 19

what special tests would be (+) for GTPS?

Answer 19

(+) ER (g med and min lengthening) and H add (piriformis lengthening) in 90 deg flexion
possible (+) Obers

Question 20

where would appear to be TTP with palpation for GTPS?

Answer 20

over bursa (hallmark sign) > GMed

Question 21

what is PT Rx for GTPS?

Answer 21

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

Question 22

should you recommend stretching for a patient with GTPS?

Answer 22

no
that is causing max compression and lengthening and may keep it inflammed

Question 23

what are the primary purposes for MET for GTPS?

Answer 23

tendon proliferation and stabilization (hip and lumbar)
tendinosis parameters - 3 sets, 10-15 reps, heavy load

Question 24

how should you progress MET exercises for a pt with gluteal tendinopathy?

Answer 24

1. isometric loading without compression from lengthening
2. isotonic loading without compression from lengthening
3. isotonic loading with compression from lengthening
4. Closed chain hip abd, ER, ext
5. plyometric loading

Question 25

what are MD Rx for gluteal tendinopathy?

Answer 25

corticosteroid injections
platelet rich and other regenerative injections

Question 26

why is hamstring tendinopathy more common among athletes?

Answer 26

they are creating more abnormal hamstring movement patterns compared to the general population

Question 27

what are risk factors for hamstring tendinopathy?

Answer 27

prior injury
regional interdependence (L4-S1) lumbar hypermobility
weak glut max, glut med and/or adductors

Question 28

what are examples of other deficits that could cause hamstring tendinopathy?

Answer 28

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

Question 29

what structures are involved with hamstring tendinopathy?

Answer 29

hamstring proximal tendon
adductor magnus - shared origin and fascial connections with hamstrings
ischial bursa
rarely sciatic n.

Question 30

what could cause hamstring tendinopathy/

Answer 30

repetitive hamstring action with hip in flexion
–> running, jumping
–> training errors (overuse, sprints, hills, plyometrics)
excessive prolonged stretching
sedentary lifestyle
muscle imbalances
prior injury

Question 31

during the deceleration period, how are the hamstrings involved?

Answer 31

eccentrically control knee extension

Question 32

during heel strike and foot flat periods, how are the hamstrings involved?

Answer 32

after lengthening, hamstrings act in lengthened position with hip in flexion

Question 33

what are symptoms of hamstring tendinopathy?

Answer 33

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

Question 34

signs of hamstring tendinopathy in scan:
- observation?
- functional tests?
- ROM?
- Resisted
- neuro

Answer 34

• 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

Question 35

signs of hamstring tendinopathy in biomechanical exam:
- special tests
- palpation

Answer 35

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

Question 36

PT Rx for hamstring tendinopathy?

Answer 36

same as gluteal tendinopathy plus…
- education
–> stand > sit
–> avoid low seats and prolonged sitting
- dry needling
- neural mobilizations if sciatic n involved

Question 37

what position would you begin to load the tendon in?

Answer 37

shortened

Question 38

how would you progress MET for someone with hamstring tendinopathy?

Answer 38

1. isometric loading without compression
2. isotonic loading without compression
3. isotonic loading with compression from lengthening (consider both hip and knee)
4. Closed chain hip abd, ER, ext
5. plyometric loading

Question 39

what would you want to focus on with MET exercises for hamstring tendinopathy?

Answer 39

eccentric training (reduces P! and injury)
lumbopelvic stabilization to improve hamstring activity that supports regional interdependence

Question 40

what is the prognosis for hamstring tendinopathy?

Answer 40

good out to at least 6 months with 8-10 weeks of PT