Gluteus Medius Syndrome and Hip Pain

Pain in the hip and gluteal region can arise from many causes, and dysfunction in one muscle can trigger a cascade of problems in neighboring structures. Gluteus medius dysfunction and/or tendinopathy – sometimes called greater trochanteric hip pain – are frequently the culprits behind hip, pelvic and low back pain.

Gluteus medius syndrome often occurs in sedentary people who sit for most of the day, without adequate exercise to engage and challenge the gluteal hip extensors. Gluteus medius ruptures and tendinopathies often occur in athletes who play high-impact sports.

Gluteus medius physical therapy helps to reactivate sleepy glutes and restore balanced muscle tension in structures surrounding the hip. However, in moderate to severe cases of gluteus medius tendinopathy, physical therapy may not be enough. Many high-evidence studies suggest that focal shockwave therapy is an effective treatment for resolving tendinopathy and restoring gluteus medius function.

The gluteus medius is a large fan-shaped muscle at the back of the hip. The architecture of its muscle fibers runs perpendicular to the ilium of the pelvis, giving the muscle its capacity to generate high forces. The gluteus medius spans along the crest of the ilium and narrows as it approaches its insertion at the side of the greater trochanter of the femur.

The gluteus medius works together with the gluteus maximus, the largest muscle in the human body, to extend the hip. It also serves to abduct the leg and rotate the hip inward. The gluteus medius muscle plays an important role in pelvic stability.

Gluteus medius pain and dysfunction occurs in both physically active and sedentary individuals, although the underlying causes are polar opposites.

Causes of gluteus medius dysfunction include:

• Tears and ruptures
• Tendinopathy
• Gluteal muscle clenching due to stress
• Poor hip flexibility
• Sitting and sedentary lifestyle
• Bursitis of the trochanter
• Compression of the iillio-tibial (IT) band
• Lateral ankle instability
• Habitually shifting weight to one hip while standing
• Sacroiliac (SI) joint instability
• Fascial adhesions (densifications)

Gluteus medius muscle tears and ruptures are often seen in high-impact athletes and runners. Athletes in sports such as basketball, rugby, soccer and tennis are at high risk, as are professional ballet dancers. Sudden bursts of activity combined with tight gluteal muscles are often the core cause of gluteal ruptures. Tears of the gluteus medius can lead to trochanteric bursitis, an inflammation of the bursa sac that cushions the bone over the greater trochanter, causing side hip pain.

Sedentary people who spend long hours sitting are at risk of a condition called gluteal amnesia, aka “dead butt syndrome.” Sitting causes the gluteal muscles and tendons to elongate and weaken. At the same time. excessive sitting also causes the hip flexors at the front of the pelvis to shorten and become tight. Tight hip flexors can cause the pelvis to tilt forward, compressing the vertebrae of the lower back and causing back pain.

Gluteal amnesia is a type of tendinopathy where signals from the motor neurons that activate the gluteal muscle complex are insufficient to innervate the muscle fibers of the gluteus medius, forcing the hamstrings and low back muscles to compensate. In essence, the gluteus medius muscle “forgets” how to forcefully contract.

Symptoms of gluteal amnesia include:

• Tightness in the hamstrings after exercise
• Forward pelvic tilt
• Valgus (inward caving) of the knees when doing squats or lunges
• Stiffness, pain and weakness in the hip

Compensation by the lower back and hamstring muscles to offset gluteal amnesia can cause injuries to the lumbar spine, hips, knees and ankles. Physical therapists often include glute exercises when rehabilitating lower back pain and lower extremity injuries.

A 2020 study used ultrasound imaging to compare gluteus medius muscle activation in 27 subjects with patellofemoral pain syndrome (PFPS), aka runner’s knee, to activation patterns of a control group with no knee pain. Results showed that the patellofemoral pain syndrome group had a significantly larger gluteus medius activation imbalance between the right and left sides compared to the control group. The imbalance in the PFPS group was strongly correlated with knee pain scores.

Another study done in 2020 looked at the hips of 2452 patients undergoing hip arthroscopy for femoroacetabular impingement, where the tranchanter of the femur does not glide smoothly in the socket of the acetabulum. They found that 10.7% of the patients had gluteus medius tendinopathy.

Because the structures of the body are highly interdependent, it is not enough to simply treat the locus of pain. It is critical to look for compensation patterns in other areas of the body and treat them as well, to restore total body synergy.

In addition to reviewing your health history and symptoms, and conducting a physical exam, we use advanced technologies to diagnose and treat gluteus medius pain and dysfunction:

• Surface Electromyography (SEMG): SEMG involves placing electronic sensors at strategic locations on the patient’s body and recording muscle activation patterns with the patient in motion. Results are then compared for the right and left sides of the body, to look for variations in muscle firing patterns.
• Diagnostic Ultrasonography. Diagnostic musculoskeletal ultrasonography is the easiest and most precise way to diagnose gluteus medius pain syndrome and/or tendinopathy. Due to the superficial location of the gluteal tendons, high resolution ultrasonography is far superior to MRI. It is able to visualize the body’s structures in motion, in real time, and provides much higher resolution at lesser depths. In addition, entrapment of the superior gluteal nerve can mimic greater trochanteric pain syndrome, and MRI is not able to visualize such small nerves. Ultrasound also enables us to measure bilateral gluteus medius muscle thickness, at rest and during contraction. Muscle activation is calculated as a percentage of change in thickness during contraction vs rest. Activation of injured vs non-injured sides can then be compared.

Gluteus medius physical therapy works to restore balanced muscle tension and optimal joint alignment in the hip and pelvic region, and throughout the lower kinetic chain. At NYDNRehab, your gluteus medius rehabilitation program may include:

• Balance and stability training to restore muscle function and promote pelvic stability.
• Exercises for hip extension, rotation and abduction, to recruit and strengthen the gluteus medius.
• AI enhanced feedback retraining to restore neuromotor pathways between the muscles and the brain.
• Training assisted by musculoskeletal ultrasonography, to visualize the muscles as they contract.

In addition to treating your gluteus medius, we will look for compensation patterns that impact your hamstrings, back, hips, knees and ankles, to ensure that balance is restored throughout your body.

To restore optimal activation of the gluteal muscle complex, try these 5 classic exercises. Prior to adding load, practice correct execution with just body weight or light resistance, to reduce your risk of injury.

1. Supine hip lift

• Lie on your back, palms on the floor at your sides
• Bend your knees and place your heels beneath them
• Press your heels and palms into the floor as you contract your glutes and thrust your hips toward the ceiling
• Hold for a count of 2
• Slowly return to your start position
• Repeat 10-15 times

2. Bench step-ups

• Stand erect in front of a bench or staircase, knees soft, feet hip-width
• Contract your core and maintain a straight back as you step up, planting your full foot on the bench
• Fully contract your glutes at the top and extend your hips
• Step down slowly, resisting gravity
• Alternate right and left for 10-15 repetitions
• Add dumbbells or a medicine ball once you master the execution

3. Elastic band side squats

• Loop an elastic resistance band around your thighs, just above your knees, with enough tension to keep it from slipping
• Stand erect, knees soft, feet shoulder-width
• Contract your core and maintain a straight back as you step to the side and perform a squat
• Return slowly to your start position
• Squat to the other side
• Alternate right and left for 10-15 repetitions

4. Classic loaded squats

• Stand erect, chest up, shoulders back, feet shoulder-width
• Shift your weight to your heels and do not lift them off the floor
• Contract your core and maintain a straight back as you sit back into a squat position
• Slowly return to your start position, fully contracting your glutes and extending your hips
• Repeat 10-15 times
• Add dumbbells or a body bar once you master the execution

5. Loaded deadlift

• Hold a light body bar or dowel in front of you, your grip shoulder-width
• Stand erect, chest up, shoulders back, feet shoulder-width
• Keeping the bar close to your body, gaze ahead and hinge forward from your hips with a flat back until your torso is parallel to the floor – do not allow your spine to round
• Slowly return to your upright position, fully contracting your glutes and extending your hips at the top
• Repeat 10-15 times
• Add dumbbells or a barbell once you master the execution

Your body was designed to move freely, without pain or dysfunction. The majority of pain syndromes, including gluteal tendinopathy and gluteal tears and ruptures, can be resolved with conservative care. Dr. Lev Kalika has devoted his life’s work to finding the most effective ways to diagnose, treat and resolve musculoskeletal pain and dysfunction. His expertise in diagnostic ultrasonography coupled with years of experience as a tendon specialist make NYDNRehab the clinic of choice for gluteus medius syndrome and hip pain.

If you are suffering from hip or glute pain, contact NYDNRehab today, and get back to fluid pain-free movement.

Resource

Carlisi, Ettore, et al. “Focused extracorporeal shock wave therapy for greater trochanteric pain syndrome with gluteal tendinopathy: a randomized controlled trial.” Clinical Rehabilitation 33.4 (2019): 670-680.

Gilpin, Morgan M., et al. “EMG Analysis of Neural Activation Patterns of the Gluteal Muscle Complex.” International Journal of Exercise Science: Conference Proceedings. Vol. 2. No. 12. 2020.

Payne, Karlie, Justin Payne, and Theresa A. Larkin. “Patellofemoral pain syndrome and pain severity is associated with asymmetry of gluteus medius muscle activation measured via ultrasound.” American journal of physical medicine & rehabilitation 99.7 (2020): 595-601.

Meghpara, Mitchell B., et al. “Prevalence of Gluteus Medius Pathology on Magnetic Resonance Imaging in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: Asymptomatic Tears Are Rare, Whereas Tendinosis Is Common.” The American Journal of Sports Medicine 48.12 (2020): 2933-2938.