What is gluteal tendinopathy and how common is it?

Gluteal tendinopathy presents as lateral hip pain and tenderness over the greater trochanter and is associated with significant functional impairment and reduced quality of life.

It is most prevalent in middle-aged women (with reports of up to 24 per cent in women aged 50–79 years), in those who are overweight and in those leading sedentary lifestyles.

The primary pathology is now considered to be a non-inflammatory insertional tendinopathy, with possible coexistence of bursal distention.

What were the three regimens that you compared and why did you choose each one for the comparison?

Education plus exercise—an eight-week program of comprehensive education about tendon care, particularly focusing on appropriate amounts and gradual progression of tendon loading, plus twice-weekly supervised progressive exercises over 14 physiotherapy sessions, supported by daily home exercises.

This intervention was based on the principles of physiological healing processes and the load-bearing capacities of damaged tendons. It targeted the specific muscles affected and integrated progressive loading into functional activities and positions.

Corticosteroid injection guided by ultrasound—one injection of celestone chronodose with local anaesthetic (lignocaine) by a radiologist, supported by a basic advice handout on tendon care.

This is a common primary care treatment that generally provides a substantial short-term reduction in pain.

Wait and see—a single session with a physiotherapist to provide reassurance and general advice to keep active while respecting pain.

This was included to maintain participant involvement and engagement and to provide some basic health advice while minimising any likelihood of treatment effects that would contaminate the comparison.

What was the primary outcome and what did it show?

The primary outcome was a patient-reported global rating of change in their hip condition and pain intensity in the past week, measured at an eight-week follow-up.

Seventy-seven per cent of participants in the education plus exercise group reported success in the global rating of change, compared to 58 per cent in the corticosteroid injection group and 29 per cent in the wait and see group.

Pain intensity was also much lower for the education plus exercise group (1.5/10 points) than for the corticosteroid injection (2.7) and wait and see (3.8) groups.

What about the economic analyses that you conducted; what did they show?

We estimated the relative cost-effectiveness of each of the three regimens from both a health system perspective (which includes the cost of the treatment as well as any other healthcare participants received for their hip pain) and a societal perspective (which adds other costs, such as time off work or travel to attend appointments) over one year.

Cost-effectiveness was assessed using the incremental cost per quality-adjusted life year gained.

We found that the education and exercise program was highly cost-effective, from both a health system and a societal perspective, compared to either corticosteroid injection or wait and see.

There was little difference in cost-effectiveness between corticosteroid injection and wait and see.

Did you consider any sensitivity analyses in your assessment of the cost-effectiveness of the three management approaches?

Cost-effectiveness analyses in clinical trials are always subject to uncertainty, given the difficulty of measuring all healthcare costs as well as the natural variation in healthcare use within any group of patients.

Nevertheless, we found that the education plus exercise program had a probability of at least 85 per cent cost-effectiveness compared to the wait and see approach and 90 per cent compared to corticosteroid injection.

What do you think research in this field should address next?

Implementation research is crucial—how can we best integrate the cost-effective, non-invasive education plus exercise program into widespread primary care?

Further research into the development of more condensed and affordable programs, without losing intervention effectiveness, is also warranted.

>> Dr Ross Wilson is a health economist at the Centre for Musculoskeletal Outcomes Research at the University of Otago in Dunedin, New Zealand. He works with physiotherapists and other clinical researchers to find the most cost-effective approaches to treating musculoskeletal conditions.