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Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, Refuting Gluteal Tendinopathy Myths with Alison Grimaldi. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who just like you have been through vicious injury cycles and when searching for answers, struggled to decipher between common myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. Alison is a physiotherapist here in Australia, an absolute guru around hip conditions. She is a practising physiotherapist, but also a researcher and has just recently released a paper titled, Gluteal Tendonopathy Masterclass, Refuting the Myths and Engaging with the Evidence. So we're going to dive into what is gluteal tendinopathy? What causes it? What are a lot of the myths surrounding a diagnosis, best treatments? And once we have busted these myths, go into what is actually effective. Even if you don't have gluteal tendinopathy, good to have in your back pocket for preventing this type of injury. And if you get it in the future, you'll know the exact advice to ignore and the exact treatment path to follow. I'm a physiotherapist in Brisbane, Australia. So I did my original degree, my bachelor of physiotherapy degree, graduated in 1990. And then I returned to UQ in Queensland to do my masters in sports physiotherapy. in 1997 and then had a particular interest in the hip. So ended up going back to uni again to do my PhD, my doctorate in the area of the hip. So that was completed in 2008. And since then I've been continuing to be involved in research, but actually my primary job is as a physiotherapist. And so I've worked in clinical practice for over 30 years now, and I've had my own physiotherapy clinic here in Brisbane for over, yeah, about 20 years now. So yeah, I'm a bit of a combo between a clinician and an ongoing researcher, and I educate other physios and health professionals, not only around Australia, but around the world. So I do lot of international travel with education as well. Any particular story behind developing the interest for hip issues? Well, it's a common thing, isn't it? You you have a bit of your own problem. So in my 20s, I had a little bit of hip pain and went to try to get some answers for my own self and went to the literature and went to courses. And it became pretty clear that at that time that there was very little understanding of conditions around the hip and really little research available. But it's been a really exciting time to be involved in the hip space because we've had such an increase in interest in the area and research in the area over the last 10, 15, even 20 years. But in the last 10 or 15 years, we've had an explosion of research through the area, which has been fantastic because we've got such a higher level of understanding of the anatomy and function and conditions that occur around the hip now. Excellent. This most recent paper I've got in front of me, Gluteal Tendonopathy Masterclass, Refuting the Myths and Engaging with the Evidence. What's the idea or interest behind writing this paper? Well, this was an invitational paper from the journal from Musculoskeletal Science and Practice. So they reached out and asking for a paper and it was sort of a bit of, you know, open whatever you want to write about in the field of gluteal tendonopathy. And so I grabbed a couple of co-authors, Anthony Nassar and Charlotte Ganderton. And we decided that we wanted to have something that was really clinically useful for health professionals. And so we went along the route of the myths because we wanted some clear, easily digestible sort of messages for gluteal tendinopathy that can hopefully help us shift away from some of the the misconceptions or myths that there are around this condition. Excellent. And like I say, the audience, might not be too, might not have too much of a medical understanding. So if you had a runner that had a gluteal tendinopathy, how would you describe that particular pathology or diagnosis? Sure. So gluteal tendinopathy is really just referring to painful gluteal tendons. And so the gluteal tendons that we're referring to here are specifically the gluteus medius and minimus tendons. So the gluteus medius and minimus are the glute muscles that sit towards the side of your pelvis. So those muscles help you stand on one leg and lift your leg out to the side. So they are your hip abductor muscles. And then the tendons are the fibrous things that join the muscle down onto the bone, the greater trochanter, which is the bony bit that sticks out to the side of your hip. And so people presenting with gluteal tendinopathy will have pain over that bone and tenderness over that bone. So it's often painful to lie on that side at night. But even when lying on the other side, when the hip is in a position where the knee crosses across the body, that can wrap up the iliotibial band or the IT band around the greater trochanter and that can cause symptoms and pain as well. And so, yeah, so this is a condition of painful tendons that often comes on in association, particularly with the running population, associated with some sort of change in loading or some change in general health. Based on that description, it seems like it's not necessarily people might hear the gluteals involved and they you know think of their buttocks but I guess pain that's around the muscle itself sort of like around the behind wouldn't really be common with this particular condition it seems more localized to the outer portions where it attaches onto the bone. Yeah exactly it's much more localized to the side of the hip so the greater can of that bony area but it can You can get some discomfort up into the muscle, but the diagnosis of this condition is really around that pain around the greater trochanter. And then you may get pain also that extends down the lateral thigh, so the outer part of the thigh, and very occasionally into the upper part of the outer leg as well, so the outer shin, if you like. So very occasionally through that area. But it's the... the pain around the greater trochanter that makes us really think gluteal tendinopathy, because there's lots of other conditions that might give you buttock pain. So particularly, referral from the back or even from the sacroiliac joint or even muscular overload type pains that we might get through the muscle belly or the major area of the buttock there. So it's particularly that pain pain and tenderness over the greater trochanter that makes us think potentially gluteal tendinopathy and that sort of pain and tenderness online but also people with this condition will have pain during tasks that particularly load the hip abductors, make those hip abductors, those lateral glutes work hard and that might be standing on one leg and more dynamic conditions like, you know, walking, so landing on that leg or of course running. and particularly running longer distance, higher speeds uphill, know, upstairs and for our running population may be doing bounding sort of drills, you know, particularly upstairs, things that really make those muscles work hard and have sort of those high impact forces on one leg can create those provocative loads in those tendons at the side of the hip there. Yeah. And as we know with tendons, it's usually a abrupt increase in load that increases that risk and you know, running, running hills, running stairs is fine to do provided that it's a safe gradual progression near listening to your body along the way. And you did mention uphill, but as you're discussing that, was also thinking maybe downhill might be a particular variable that might increase loads. Like if you're going against gravity, if you're thumping your way down a hill, your glutes would need to work pretty hard to keep your pelvis quite stable. Have you seen that at all? Yeah, so it can be downhill and downstairs. So some patients with gluteal tendinopathy will have pain on the down as well. But yeah, it can be either. Uphill, we tend to get a lot more force generated, I suppose, through the gluteal structures. Downhill, like your quads and your knee take a lot of that load, you still use your glutes of course and particularly as you say if you are you know that uncontrolled downhill like if you just you know bang bang bang landing on one leg, yes that can certainly have an effect. And then there's other things like and particularly with that you know the lateral glutes here things like running on the camber of a road or running on a beach. where we sort of have a downward slope that we're running across. Now that can be something that might bring on or provoke gluteal tendinopathy and that's because we end up with the one hip slightly adducted. where the foot is, the pelvis is to the side and the foot is more towards the middle. Or there might be particular technique. running techniques that also influence the development of this condition. So for example, runners who midline strike or cross midline strike. So if you're landing with your foot very much in the middle of your pelvis or across towards the other side, that puts the hip in a very adducted position. So that winds up the iliotibial band. And we think that one of the reasons for the development of this condition is excessive compression of the tendons underneath the iliotibial band as it wraps around the side of the hip. So the ITB and most runners are pretty familiar with the ITB. It starts from the outside of your pelvis, runs over that greater trochanter, the bone at the side of your hip, and then runs down the side of the thigh to join in just below the knee there. And so any sort of movement patterns that use an excessive amount of adduction where that band is wound up. So running on the camera of the road, running the same way around a track all the time, running with that midline striking sort of technique can wind that up. Or movement patterns where we're using excessive pelvic tilt or excessive sideways shift of the pelvis or even excessive sideways shift of the trunk. So all of those things can also change load in the gluteal tendons. I'll get to that, surely, because we might look at treatments and sort of helping those unhelpful movements. But I want to get to diagnosis, because there might be a lot of runners who might be having similar symptoms, and they're wondering if it is or not. And like you say, we've talked about the location of symptoms, but also there can be a lot of other. diagnoses around the hip that might not be gluteal tendinopathy. So what's your advice on diagnostic tools or methods? Sure. So the diagnosis of gluteal tendinopathy should be primarily a clinical diagnosis in terms of you don't need to run off and get imaging or scans. We can diagnose this condition through listening to your history, understanding where you're getting the pain, what's hurting, and then doing a range of clinical tests. And there's a couple of those tests that really people with this problem can do themselves. For example, just rubbing over that bone, so pressing on that bone, is it tender to touch? So pain or tenderness over that bone is one of the the factors that we use in the diagnosis. But that alone is not good enough for a diagnosis because there's a lot of people who are tender on that bone who don't have the condition. So we need to also make sure that we're pairing that with other clinical tests. And so one of the tests that we would use that runners can do themselves is even just standing on one leg. And so we get people to stand on one leg side onto a wall. And so the sore side is furtherest away from the wall. We get them to put a finger of their close side on the wall just for balance. And then they lift off their unaffected side, so the non-painful side, lift the foot off the ground so that they're just standing on that painful side. And then we get them to stand there for up to 30 seconds. And so if standing on one leg reproduces that pain over the greater trichina, over that bone at the side of the hip, then that increases the chances that they have this condition. And so that's one useful test and an easy thing for people to do themselves at home. Other things that we would do as physiotherapists is some bed sort of tests. And so we might do some resisted hip abduction. And so that is getting the patient to force the leg against our resistance out to the side. And there's various different positions that we would do that in, but generally with the patient lying on the side. And then we would resist them pushing up towards the ceiling. in the trial that we did, we did this test with their hip in an adducted position. So with the foot sort of dropped down relative to the hip. And so that winds up that iliotibial band causes a bit of compression. And then we asked the patient to push up and resist against us. So that's one test. And again, we're looking for reproduction of their pain over the greater trichina. And then another test we do is called the fader test, which is just a patient lying on their back. We flex the hip to 90 degrees, take the knee across the body, wind the hip into external rotation. And then we ask them, the patient, just resist. as we try to push their foot into a little bit more external rotation, their hip into some external rotation. So again, it's just winding up the band and getting the patient to resist against that. So those are the tests that we would do as a health professional, as a physiotherapist. And these are things if we're getting a couple of test positives together with some tenderness on palpation that substantially increases the chances that they have this condition. As a physio, we would also do other tests that just help to rule out other most common things that might cause pain around the side of the hip. And that would be hip joint conditions or problems with the lower back. So we would also screen those things as well to try to make sure that it's not something referred from the hip joint or referred from the lower back. What about hip bursitis? I hear that a lot. And I know there are several bursa around those attachment sites. I could imagine like those similar tests would produce pain or is it all similar conditions, similar treatments for each? Yeah, good question. So this condition has previously been referred to as trichanthric bursitis or hip bursitis. Now, as you say, there's a number of bursi. There's one large one called the trichanthric bursa that sits underneath the iliotibial band and on top of the gluteal tendons over that bone there. And then there's a couple of other bursi that sort of sit between the tendons and the bone, so underneath the tendons. So those bursi are like little fluid-filled sacs and in a normal situation they're quite flat and they don't really have much fluid in them, but they just sort of help the tendons and the bone and the ITB slide and glide across each other. So that's their normal function. Now in some people with pain at the side of the hip, they will also have some changes in the bursi, some thickening in the bursi. Now that has traditionally been referred to as bursitis, thinking that that condition was an inflammatory condition. But actually the research has shown that it's not really an acute inflammatory condition that we get with those bursi. and that when we see changes in the bursary, it's very rarely by itself. So we most commonly see that together with changes in the tendon. And so in those with changes in the tendon, maybe about 20 to 30 % of people with pain and changes in the tendon might also have changes in the bursary. So that's why we've gone to referring to it as gluteal tendinopathy, because we now understand that the primary problem there is a problem of the tendons. Plus or minus, they might have some additional changes in the bursi as well. But it all seems to be associated with the same sort of problem. So it's not like they're two different conditions. It's just like a spectrum of soft tissue pathology, so changes within the tissues at the side of the hip there that might occur when we expose the tendons to. too much compressive load or combinations of compression and tension. And so when we do diagnostic tests, yet we can't, with our clinical tests, tell you how much of the pain is coming from the tendon or how much of the pain is coming from the bursa. We use the same tests, but the treatment is the same because the underlying reason for the condition is the same. So it doesn't really matter. And even if you have imaging that shows, you know, that the tendons, know, changes in the tendons, changes in the bursi, just looking at that on imaging doesn't actually tell you whether it's painful and what is actually causing pain because we know from studies that, you know, up to almost 90 % of people who, particularly people above the age of 45, who are asymptomatic, who don't have pain, may have some changes in the tendon and the bursi on imaging. And so we can't just look at a scan and go, oh, yep, that's the problem. That's where the pain is. So that's why we really, even with imaging, we always need to be putting that together with our clinical assessment to make sense of what we're seeing on scans. One of the myths in your paper was talking about the... the diagnosis and management should be based on imaging. That was the myth that we're busting. And there was some useful findings in there showing that up to 50 % of people who have no pain actually have a diagnosis of tendinopathy upon scans. So you can have the healthy population get scanned and 50 % can have that particular diagnosis, which is why we need to be very, very careful of using images or interpreting findings. But another thing that I found interesting when you were quoting another paper within your study that tenderness on palpation plus the 32nd single leg test, if that was reproducing someone's symptoms, had a 99 % accuracy of interpreting that diagnosis. Like I said, I was referring to a previous study in the one that you were mentioning, but found that quite interesting. And I guess if someone had tenderness on palpation yet wasn't painful with the single leg test, doesn't mean we're ruling it out. It just means if it is painful, we can have some pretty good accuracy of ruling it in. Would that be fair to say? Yeah, absolutely. So that sustained single leg stance test, the 30 second test that we do there, it's got really useful, what we refer to as positive predictive value. So that just means when it's positive, it substantially increases the probability that someone has gluteal tendinopathy, particularly when paired together with a tenderness on palpation, but it's not nearly as good as a negative predictor in terms of if they are negative, it doesn't mean they definitely don't have the condition. They may still have the condition. And so that's why we have to have some other tools in our tool bags and other tests that we use. And those are the ones that we referred to the resisted abduction and the fader test as well. Yeah. Like I say, one of the myths that you mentioned was about imaging for diagnosis and management. Because this is a paper about myths, I thought I would rather than diving straight into effective treatment, talk about ineffective treatments or at least some misconceptions around treatment. The first myth that I found in the paper was about ITB stretches as a method of treatment. But we're busting that myth in this particular paper. Do you mind diving in a bit deeper? Absolutely. And this comes from a commonly held belief that the reason for the development of gluteal tendinopathy plus or minus bursal change is related to tightness in the iliotibial band. We actually don't have any scientific evidence that supports that. And from a long time now in clinical practice, That is rarely what we see. So there is a small subsection of the population with gluteal tendinopathy that may have some tightness in the structures at the side of the hip, so the muscles and the band. But more commonly, actually, people with gluteal tendinopathy tend to be longer in their ITB and their abductors. And that is because they're more likely to be people who might use sustained hip adduction in their posture. So for example, they might stand and hang on one hip, so let their pelvis drop down as they're standing on one leg. So that's putting that ITB in a lengthened position. And when sitting, they might sit with their knees crossed or sit with their knees held together. Again, that puts the ITB in a more lengthened position. And often when they're functioning, they might be functioning with excessive hip adduction, so actually functioning with that band at a longer length. And so when we do a length test in people with this condition, so we put them on their side and we have a look at how far we can get their foot down relative to their hip, and we often find they're actually more commonly long than short in that ITB mechanism. And so that's one good reason to not bother spending lots of time on ITB stretching because it's in most cases it's not the cause. But the other thing is that ITB stretching, even if you are a part of that subpopulation that is short in the ITB, stretching is usually more likely to be provocative than helpful. And that's because when we do ITB stretches, and so that's anything where, you know, For example, you're standing and you're sticking your hip out to the side or crossing those ankles and leaning over to the side away from the painful hip or glute type stretches where we're sort of maybe lying on your back and pulling your knee across the body. So any of those things that wrap the iliotibial band firmly around the side of the hip. That can be provocative for the tendons and the bursi because particularly when they're painful, they don't really love that sustained compressive load. So that being squished, if you like, between the ITB and the underlying bone. So what I've found in clinical practice is that people who've been doing a lot of ITB stretching. generally are people who haven't progressed, who haven't been able to get over their condition because they're continually sort of irritating their condition. So often when we take away from some of those provocative things, then the pain finally starts to settle a little bit more. Thanks for clearing that up. And going back to the traits of a runner who might have, say, a crossover step width and can be accumulating high compressive loads, on that lateral hip. It's hard to imagine they would have a tight ITV anyway, because the fact that they're reaching across their body means that their ITV is long enough to actually make that movement achievable. And therefore, doesn't really seem wise as to why stretches might be a part of that treatment, because it's not necessarily tight. So appreciate clearing that up. And I really was glad to look at this next myth around the clamshell exercise. For those who aren't familiar, side lying, knees bent at around 90 degrees and then opening up just that top knee towards the ceiling, sort of opening up like a clamshell in order to activate the glutes and the external rotators of the hip. And I get, I see a lot of clients that get prescribed this a lot. I've had, you know, glute issues. I do my clamshells daily and those sorts of things, very commonly prescribed, but why is this a myth? Yes, so this is a myth in terms of that this is the exercise you should go to when you have gluteal tendinopathy because and there's a couple of reasons for that. The first reason is because it is also often provocative. So it will often make the pain worse or irritate the pain. And that's because when you're lying in that side lying position. I mean, if the painful side is on the underneath side, then you're lying directly on that painful tendon. So that can be provocative. But when the painful side is the top side, when you're starting from that position where the knees are together, your knee is actually lower than your hip when you're lying on your side. So that ITB is on tension. And so then when you're lifting and lowering and lifting and lowering your leg, you're actually sort of rubbing the iliotibial band across those sensitive structures. So that can be provocative for the condition. So that's the other thing that I find, you know, people who've been doing ITB stretching and clams, if we take them off both of those things, that really helps start to settle them down. But the other reasons why clams aren't really a great go-to is because they're not a very effective exercise for creating good force and stimulus across the muscle. And particularly for the more anterior or the parts of the gluteus medius and minimus that are more towards the front side of the hip, they are really poorly activated in this exercise. And yet this is where we often see tendon changes in that part of the muscle and the tendon. And so with exercise, what we're trying to do is gradually reload those areas of the tendon to make them more load tolerant and hopefully more. healthy and so this exercise is not really often going to get to the parts of the muscles and the tendons that are most affected. And then in terms of if we're trying to achieve strength change or change in muscle size, then this exercise is quite inefficient and ineffective at creating the sort of stimulus we need to get changes in strength and and size of the muscle. And so we would much prefer patients do weight bearing exercise where we have the foot in contact with the ground. That seems to be a much better stimulus for our gluteal muscles. Well said. And we will talk about some effective treatment approaches in a second. And you put it very nicely when talking about like the effectiveness of the treatment and what sort of stimulus we want for this tendon in order to recover. Because I see, I talk to people when they do their clamshells, I'm like, that's like a level one exercise. But when you're walking and going downstairs, that's like level 10. Like we're talking about the single leg stance. Your tendons are going through like your entire, essentially most of your body weight going through that tendon when you stand on one leg and you're doing that a lot when you walk and when you go downstairs. And even if you're running with this condition, that's a lot, a lot of load through that tendon. Multiple times of your body weight when you commit to running. And they're like, I don't know why I'm getting, I'm not getting better. I'm progressing. I'm progressing my clamshells. I have progressed to having a band, having a stronger band doing three sets of 10, three sets of 12, three sets of 15. It's just, it's just not cutting it. But when you look at the strain and the load that's actually required and what's needed to restore the capacity of that tendon, we're nowhere near reaching the mark. And so. Absolutely. Absolutely. And there was a, A really nice paper done by colleagues and colleagues a couple of years ago. And it was really nice because it looked at different types of exercises and the amount of force that was sort of created across the glutes, including the glute med and the glute min. And they didn't do the clam shell, but they did do like lying on your side, lifting your legs, so side lying hip abduction. And they did it. And then they did a variety of other standing weight bearing type of exercises. And they did all exercises with body weight only and then with 12 RM resistance, so the amount of resistance that you could do 12 repetitions. And they showed that side lying hip abduction with 12 RM resistance still didn't even create as much force as a simple single leg squat using body weight. alone. just getting up and working with your body weight and can be much more effective than doing, you know, lying down on your side type exercises. Great insights there. I have one more myth to cover in the treatment sphere, and that is around corticosteroids as a effective option for people with this condition. Why is that a myth? Yeah, so particularly a myth in terms of the first thing you should try, just go and get a quick fix from the doctor and get an injection to reduce that pain. Now, we've got evidence that corticosteroid injections do provide a lot of people with fairly rapid sort of reductions in their pain, but there is a downside in that corticosteroid injections are, you know, So the substance that they use is toxic for the tendon tissues and we don't really know how much is safe. And so, you know, better to avoid it if you can. And we've got good evidence from the trial that we did, the LEAP trial on gluteal tendinopathy, that actually an education and exercise approach is much more successful both in the short term and in the long term than a corticosteroid injection. And the other thing that I find with the corticosteroid injections is that if you're having an injection that quickly, like really quickly, reduces your pain, then you're really not aware of when that tendon is being provoked or when those tissues are being provoked. And so what we've found is that people who have a cortisone injection and then go and have rehab as well, they might they are less likely to actually learn how to control their pain effectively because they're not really getting those little reminders. For example, if we're giving patients information on changing their walking or running patterns or how they go up and down stairs, when the person with pain goes and does those tasks again and they get a bit of pain as a reminder, then they'll immediately go, oh. That's right. That's right. I'm supposed to do this and do that. And it's actually a really helpful pain is a good educator. So it's a really helpful way of, yeah, OK, I've got to change this. I've got to change this. And also in terms of their response to activity or running, if they're getting pain during or in the 24 hours after that, it's a good indication that actually they're not really exercising at an optimal load at the moment. They're doing too much. So they learn how to better manage tendon loads. When you're not getting that response, because you've had this sort of quick fix, if you like, you're more likely to just keep running, keep running. And then we find that people tend to fall in a heap at about four weeks afterwards. And because they haven't really learned anything about controlling their pain, they continue to overload the tendon, then the pain just comes back. And if they then go, right, well, I'm going to go and have another injection. And they go down that pathway of repeat injections. We tend to see poor and poorer outcomes with more and more injections. So we would much prefer people avoid the injection and just learn how to manage their condition from day one. And we find that we just see much better sort of outcomes, particularly in the longer term. Yeah. Previous papers have also mentioned with corticosteroids into other tendons like the Achilles, actually inhibits collagen synthesis, the turnover that we need for tendons to break down, build up and come back stronger. so, another reason why we don't really want it inhibiting any sort of adaptation responses for the longterm. so plenty of reasons there to be wary when it comes to corticosteroids. exactly. So it will often delay and reduce our outcomes from exercise and active interventions exactly. That can be one of the reasons because of the effect on the response of the tendon. And people would be familiar listening to previous episodes about listening to your body, listening, okay, we're not necessarily aiming for symptom-free responses to exercises or to running. We're wanting the low levels of exercise there. Low levels of pain are acceptable, but provided that it calms down relatively quickly. And, you know, week by week, we're starting to see improvements in function and improvements in pain as well. I would be very, I'd be worried if I had to get an injection and then all of a sudden I couldn't rely or have a trustworthy signal for my body to what is too much, what's not enough. so, yeah, hopefully another reason for people to be wary. But if we're on that topic as well, we're following on from that topic. What would you suggest as some good effective exercises for a runner who might have gluteal tendinopathy? So we would usually do a range of exercise, ranging from some gentle isometric exercises to some graduated strengthening type of exercises and progressing to some heavy slow loading as well. So in terms of isometric exercises, we'd usually start with some sort of exercise where we are pushing our legs apart, but not actually moving. And so there's a couple of different options that we used in the LEAP trial. So the first one was lying on the back with a pillow underneath the knees, belt around the lower thighs, and the knees positioned just a little bit apart. So we've got no sort of compressive load at the side of the hips there. And then the patient is just nice and slowly ramping up that pressure, sort of pushing their knees sideways, outwards into that belt. But slow and gentle is the key. So we don't want to do rapid fast things. It's sort of slow, gentle, then maintaining that tension for about 10 seconds, 10 times. We do that morning and evening. And then during the day, we would do a standing version of that. So in standing. Just standing with the feet slightly wider than the hips, again, to take away the irritating compression at the side of the hips. And then again, slowly, gently thinking about pushing the feet out to the side, but the floor is resisting you there. So you're not actually moving, but you're thinking about pushing out to the sides, sort of like you're doing a skating action, if you like. So again. holding there for 10 seconds or so. And so getting people to do that at least a couple of times during the day, five or 10 times in a row is great. So there are little isometrics. And then we would usually prescribe a series of bridging exercises. So that's lying on the back with the knees bent and then lifting the bottom off the bed. And then we progress that from a double leg to an offset where they're weight on one leg more than the other. and then single leg when they're up to that. And then also a series of squat type progressions. And these are great because it's a great opportunity that we can really learn to control our hips and our pelvis a little bit more. And so that might start as a double leg squat and just making sure that we're sitting back like we're going to sit on a chair, but the thighs are staying parallel, the knees are staying facing straight ahead. So we'd start with a double leg squat. Then we'd go to an offset squat where we basically start standing on one leg, but then we rest the ball of the back foot just on the ground, just behind us there. Starting up nice and tall with the hip in from the side. And then that same sort of squat pattern where we're folding at the hips, bringing the hips back like we're going to sit backwards on a chair. Or like you're getting into a run start position or riding a scooter type position. But the really important thing there is the hip doesn't push out to the side. So if you're looking in a mirror, you want to see nice straight lines down the outside of your body and your hip and your thighs. And so you're trying to keep the hip in from the side so you're not sticking out into a pointy sort of hip out to the side. So bring that hip in and slowly pushing up and controlling down. And you can have your hand on some, you know. back of a chair or a bench on the other side if you need some balance control, then we'd progress that to standing on one leg up nice and tall and then a single leg squat and then we might progress that to a step up and then maybe a faster sort of running step. And of course we can add resistance by adding hand weights or a bar into any of those exercises as well. But the progression is really around Can you do it without significant aggravation of the pain at the side of your hip? So anything more than a two out of 10, changing your pain. And we're listening for responses over 24 hours as well. So was it stirred up that night, next day? So can they do the exercise without significant aggravation of their pain? Can they do the exercise with good technique is really important. So that is. without their knee dropping in or their hips shifting out to their side or their body shifting over to the side. So we're looking for that good technique. And then we're also looking at the amount of effort. So once we get to the pain starting to settle, we're really wanting to load the muscles and the tendons a little bit more than we want them to start working a bit harder. So if you think about an effort score from 0 to 10 or an RPE, a rating of perceived exertion between 0 being no effort, and 10 being maximal, we want them to gradually build up to, you know, working at that seven, eight out of 10. So if the exercise is less than five out of 10, then we probably want them to be working a bit harder. But that's just, once we get to that level, those sort of exercises, we're just doing three times a week. So we're working at a hard to very hard level, three times a week. The other exercise that we used to create heavy, slow loading across the gluteal tendons, was a reformer exercise or an exercise on a spring-resisted sliding platform and that was just standing upright on two legs initially and then just slowly pushing the legs apart against spring resistance and we also did this in a semi-squat position pushing the legs apart. So if you've got access to a Pilates reformer it's a great exercise and we found that with this exercise people could gradually increase that load and they were unlikely to get an aggravation in their pain because there wasn't really any compressive load with that exercise. So as long as they gradually increase the load, that was really great for them. At home, if you don't have a spring-resistant platform, then we use what we call a banded side slide. So that is standing like in a semi-squat position with one foot on something a little bit slippery. And so that might be on a polished floor with a microfiber cloth or something like that underneath their foot and then a loop of band around their ankles. So from that semi squat position, they're just doing a single leg skating action if you like. So one leg at a time, just slowly skating out to the side and slowly controlling it back in. And just making sure on the non-boot moving side that they're not sort of dropping into that pelvic tilt or pelvic shift. So the hip has to stay in from the side on the non moving side as they slowly slide out to the side. So they are the primary exercises that we'd usually prescribe for someone with gluteal tendinopathy. Excellent. I can imagine with that skater sort of movement, you're working the leg that's moving pretty hard, but also that stance leg would be working considerably hard as well. Yeah, absolutely. And people will usually find that it's the non-moving side where they'll actually get that fatigue first. And so if they're looking to work their painful side less initially, so the lighter or the easier part of the exercise is for their painful side to be the moving side. And then they can try their painful side being the non-moving side, which is actually, as you say, a bit of harder work. I'd also imagine like if someone has mild symptoms, they could pretty much graduate through this system pretty quickly. I could imagine if like they're doing the isometric hip abduction, keeping their feet in place, but really trying to push outwards. If you can move from that to like to say, single leg stance, kind of like that single leg stance movement and holding that for 10 seconds. If that's tolerated, I could imagine you could graduate towards that skater pretty quickly. Would that be fair to say or is that jumping at too much head? No, absolutely. So it is not the program is not dictated by time, if you like. So it's not like you have to do the isometrics and then you have to do this and then you have to do that. So we prescribe the moving exercises at the same time as isometrics. So we'd usually say, do the isometrics because they can be useful for pain relief. but also for teaching better coordination of the muscle if you're doing that nice, smooth, slow contraction. But then, where we start in terms of the bridge progressions or the squat progressions really depends on the patient and their ability to control their body in space and what their symptoms are like during that task. And as you say, the standing on one leg test is quite a good indicator as a load tolerance test, if you like. So if they can stand upright for that 30 seconds or without pain, but even if they can stand for a couple of seconds without pain, then we might work on improving the way they stand on one leg and starting with some weight shifts. So up nice and tall when you stand on, when you transfer that. weight onto the one leg, avoiding that excessive side shift. thinking of pushing through the heel, growing tall through the crown of the head, having some hand support, so holding onto something initially, trying to keep that pelvis nice and level and the hip in. If they can do that without any significant pain at the greater trochetta, then we gradually progress to getting that foot off the ground and increasing the amount of time that they can do that for, you know, up to that 30 seconds. So once they can stand for 30 seconds on that one leg without pain, that's great. So that's a good indicator that they should be able to do some more single leg tasks like a single leg squat or a step up or a single leg bridge. But really it's just... testing the level. you know, seeing a physio would usually go through and say, okay, at what level are they at? You know, and that's where we would sort of target or start the program. Excellent. Thanks for clarifying on that. I also want to just briefly mention other management strategies. One would be aggravating factors outside of your exercises. So if you're soreness, if you have sore, if you have pain lying on that side, avoid sleeping on that side, maybe put a pillow between your knees or pillow underneath your knees, lying on your back or on the other side to help with that management. But avoid low sitting, crossing legs. If you find that's particularly aggravating, just trying to come up with methods throughout the day of avoiding those particular irritants. And then when we're talking about running, if they are able to tolerate running, just finding their tolerance, finding their speeds, finding their terrains, like you mentioned, if there is a camber. sloped off to the side, we to be very careful about those, how much running volume we do in that camber, we want to try to avoid that as much as possible, if symptoms aren't tolerating that very well. And then maybe there might be a conversation of consciously trying to widen their step width, if someone does present with a crossover step width, and they have this reoccurring lateral hip issue, might be open to a conversation of changing their movement mechanics a little bit, anything to touch on? regarding that? Yeah, absolutely. So all of those things that you just mentioned, they're all really important parts of the overall management program. And so that's in that, that load management, understanding what things are most likely to irritate the tendon. And it's usually things that are loads that are sustained or repetitive, so things that you're doing a fair bit of the time. So, you know, as you mentioned, the sitting with the knees crossed. if we can spend less time doing that. Try to avoid it or at least minimize the amount of time you're spending with your knees crossed or standing, know, hanging on one hip. Nighttime positions are really important as well, as you mentioned. So trying not to lie directly on that side for prolonged periods of time. So you can lie on your back or if you're lying with the sore side up, big fat pillow between your knees and your ankles. But actually we find one of the most useful positions is lying halfway between side lying and lying on your tummy. And so that means that you can actually return to lying on the painful side. But what you do from that side lying position, you straighten the bottom leg and then you actually roll your body halfway towards your tummy. So you're actually rolling off the bone. And so the weight of your body is then resting on your thigh rather than on the bone. So that's a really useful position. And it's usually best if you then use a pillow and fold it or roll it lengthways or use a body pillow and wedge that underneath the top hip and in front of your body. So that means your body is sort of the weight of your body is resting on that pillow or on that body pillow. So that can be a really useful position because the bottom side isn't compressed. And once you look. once you roll halfway towards your tummy, the top hip is also more open. And so that's a great position as well. So getting all those little boxes checked is really important in terms of reducing the overall aggravation and then exactly the things that people are doing in their running. And yet we may need to cues around, you know, running with their feet a little bit wider or going and sort of running somewhere where there's a line marked like in a a field or something like that and just sort of making sure that your feet are not sort of know landing on that line or crossing that line but they're sort of just clipping each side of it and so there's different ways that we can sort of train that slightly wider gait. So those are important things that we might need to go through with our patient but if they're struggling with the condition and it's particularly aggravated by running it's a really good idea to go to a physio who does running assessments and get a video assessment because that really helps fine tune or understand what are the things that you might be doing in your running technique. But outside of that, as you mentioned, just being aware of running on canvass of the road, unstable environments are a little bit more challenging. like beach running or trail running are a little bit more challenging. So for a little while, sticking to more stable on the road or on the Footpath can be a little bit easier initially. Also watching stride length. So stride length can impact those gluteal tendons as well. A little bit like we were talking about with running downhill. That sort of uncontrolled long strides. That can be similar with just running on the flat. Even if you're sort of taking big, slow, long strides, you will tend to get more load. around the side of the hip. So sometimes just focusing on landing more softly will tend to reduce that stride width and often increasing that cadence a little bit, but reducing the stride length can help with reducing loads as well. Yeah. I think if someone has an issue with lateral glute pain and you do look at their running and they do have a low cadence, that might be something to manipulate to try to see if that helps because what I've found is if someone does have a crossover step pattern and they increase their step rate, they don't have time to crossover. They tend to land a little bit sooner underneath their hips anyway. But obviously with the stride as well, if they find themselves over striding and you increase their cadence, will correct that as well. So maybe some manipulation for someone who does have a cadence that we suspect is a bit lower than optimal. Yeah, absolutely. That often helps. Yeah. a lot of different sort of issues, including that pelvic tilt. So we find that if we reduce that over striding with that increase in cadence, we don't seem to see that rapid, you know, dramatic sort of drop in the pelvis as well. So, yep, it can help a lot of those little technique issues if we reduce the stride length, increase cadence, if they have a low cadence and an excessively long stride. One last thing I want to quickly touch on is the myth around tears. someone has a tendon tear can be quite alarming language for people if they do have scans that comes back as that. And it may seem like, if it's a tear, need surgery to help repair that. Where does the myth fall into this? Yeah, and it can be scary because patients are often given access to their imaging reports now. And it might say something like partial thickness tear or a full thickness tear. And that is a bit alarming and it might make you think, oh, I need to run off and get that surgically repaired. But what we're talking about there, when they say a partial thickness tear, they're really just talking about a very small area of the tendon where there might be some fibers on the deep surface of the tendon that may have let go. But we're talking about very small areas of the tendon. Even a full thickness tear doesn't mean a rupture of the tendon. A full thickness tear just means that there's some change in the tendon. Some area of the tendon has detached from the greater trichanda. And that might be like a little split tear, if you like, that goes through the full thickness of the tear. But that's just one area of the tendon. So in most situations, you have most of the tendon still fine and intact. Again, people without symptoms can have tears in their tendons as well. As we age, and the older we get, the more likely we are to have tears in different things. It's a little bit like having wrinkles on the inside. So it doesn't mean you need to rush off and get anything done surgically with that. And in the LEAP trial, actually, 40 % of the people that we had in that trial had a partial thickness or a full thickness tear. in the tendons and we had a success rate of just under 80 % success rate in both the short term and the long term. So you can still get really good success, you know, even having those partial full thickness tears in the tendon. Where it's something that might require a specialist opinion is where we're more having, you know, significant areas of the tendon detached. or ruptured if you like, but that's a different thing. And so when we're seeing those large sort of ruptures, then we might need some surgical opinion with that. But what we're generally seeing, and particularly in the younger running population, if we're seeing tears or that generally healthier sort of running population, we're generally only seeing partial and full thickness tears. So it's only a small area of the tendon that's affected. And that tear doesn't have to heal for you to be pain free and for you to be full function again, because you've got plenty of other tendon and we work towards improving the capacity and the health of the rest of the tendon. And so it's not something to get too stressed about. And I wish it were the case, it's not going to be practically. know, feasible, but for someone to have like a say an MRI of their hip and then have an MRI of their other hip on their other side and see if there's any tears there. Because, like you say, it could be perfectly normal in the healthy population. And what's to say if you develop a tendinopathy and then get it scanned, whether there was tears there to begin with, we want to be very careful with incidental findings. And like you say, functionally speaking, Tendon can function perfectly fine with some tears in there, we just need to build up its capacity and restore its function that could be easily done with a tendon that has some tears in it. I think there's a lot of people that might fear if I load it, then the tear might get worse. But as you might have alluded to, that's not necessarily the case. No, no, that's right. And as I mentioned, we're not expecting with rehab to heal that little area of the tendon that is torn. what we're aiming for is to improve the health of the rest of the tendons. So they're actually a little bit more resilient to tears. So we're actually aiming to improve the health of the tendon in our rehab. Alison, thank you for writing this paper. It's a very practical, like you say, the original aim was for it to be quite practical, but I think it's quite relevant for therapists and for, you know, just athletes in general to read. very easy read and it can get the point across quite nicely and help debunk a lot of myths that people might be going through. I know you are quite active on social media and you do have your website and put out a lot of hip content. Where can people go if they want to learn more? Sure, the best place is probably my website at drallisandgramalthy.com. And that is a site where I have resources for professionals, but also I've recently put some resources on there for the general public. So for people with pain. So there is a course in the self-help area now that is for gluteal tendinopathy. So if patients want to go and have a look at that and access a self-help course, it goes through educational videos going in detail about the sort of load management things that we talked about today and a series of exercises that can be self-progressed or that course can be used in conjunction with their local health professional as well. And so they might find that helpful. And then, yes, as you say, I'm on most of the social media platforms. So at Alison Grimaldi or at Dr. Alison Grimaldi. Great. I'll find those links. I'll add the link to your website, but also go and find that other link to the self-help gluteal tendinopathy course and put that as a separate link as well so people can go right there. Like I say, thanks again. This has been great. It's hopefully opened a lot of people's eyes to. gluteal tendinopathy, understanding the mechanics around and how to effectively treat it and ignore a lot of these common myths that are floating around. thank you very much for coming on. If you are looking for more resources to run smarter or you'd like to jump on a free 20 minute injury chat with me, then click on the resources link in the show notes. There you'll find a link to schedule a call plus free resources like my very popular injury prevention five day course. You'll also find Run Smarter book and ways you can access my ever-growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritising your running wisdom.