Your Invited Topical Review recognises a diverse array of treatment options for gluteal tendinopathy. Your findings suggest that corticosteroid injections provide only short-term relief. Why do you think they remain a popular treatment option?

Corticosteroid injections have long been the treatment mainstay for gluteal tendinopathy.

In many cases, they provide almost instant pain relief in the short to medium term, likely giving the impression of an effective treatment when they are merely a ‘quick fix’.

Corticosteroid injections don’t address underlying biomechanical issues or impairments and there are harmful effects associated with multiple injections.

Frequently, the problem returns.

Exercise and education appear to offer the best long-term outcomes. What specific elements of these interventions make them so effective?

Currently, we don’t have a definite answer regarding which elements make education and exercise effective.

Based on the secondary analysis of the LEAP trial, education and exercise provide patients with higher levels of self-efficacy, enabling them to feel more in control of their situation.

Providing patients with education about reducing tendon compression and overload appears to reduce ongoing aggravating factors.

When this education is combined with exercises to improve lower limb strength, patients may experience better outcomes.

Were there any surprising insights from the research that challenged existing treatment paradigms?

I was surprised that in the long term it didn’t seem to matter what type of lower limb exercises were prescribed; patients improved.

I expected exercise programs that focused on strengthening the lateral hip structures to be superior to the less targeted lower limb exercises.

Patients’ improvement may stem from their deconditioned state, meaning that almost any exercise will help, or perhaps by providing the exercises we are giving patients some control of the situation.

How should physiotherapists modify their approach when managing patients with gluteal tendinopathy who have comorbidities like lower back pain or knee osteoarthritis?

I make sure the patient knows that the two or three concurrent conditions are linked and that we need to address all of them.

Using a patient-centred approach, I set goals with the patient and then prescribe an exercise program that addresses their comorbidities based on the patient’s exercise preferences.

I may also provide short-term hands-on therapy, eg, a few sessions of spinal or knee mobilisation to improve range of movement.

What future research directions do you think are most important for advancing our understanding and treatment of gluteal tendinopathy?

A key priority is the development of a core set of outcome measures for gluteal tendinopathy.

This work is currently underway.

Another significant task is identifying treatments that rapidly reduce pain as effectively as cortisone injections, without their iatrogenic issues, while empowering patients to take control of their situation.

We know from the LEAP trial that pain can be reduced in four weeks.

However, I think that both patients and GPs are looking for faster-acting treatments.

We need to address this to move away from cortisone injections.

Exercise and education may accomplish this but short-term outcomes haven’t been reported, so we don’t know.

In my clinical experience, and with some preliminary data, Dynamic Tape provides short-term benefit to some patients; however, more robust testing is needed.

Dry needling appears to achieve this too but includes a passive patient interaction with the therapy itself.

Another priority area is improving our understanding of the patients most affected by night pain (some patients only have night pain).

Addressing this would transform many patients’ lives.

We need more high-quality randomised controlled trials on relevant education and exercises, alongside better methods to translate the findings into practice.

Ideally, these trials will include patients with comorbidities.

This likely means conducting trials with large sample sizes and creative protocols that can incorporate the patients’ comorbidities while addressing the primary research question around management of gluteal tendinopathy.

>>Dr Angie Fearon APAM is an associate professor at the University of Canberra, where she teaches entry-level physiotherapists and undertakes clinical research. She is also a researcher and clinical physiotherapist with over 35 years of clinical and over 15 years of research experience. Angie’s research aims to provide clinicians with tools to address daily clinical challenges and her primary focus is the assessment and management of hip pain.

Course of interest:

• Advanced Mastering Lower Limb Tendinopathy course - Practical Frameworks & Tools to Elevate your Practice