Gluteal Tendinopathy - How Physio Can Help

How do I know if I have gluteal tendinopathy?

The pain associated with gluteal tendinopathy is usually centred over the greater trochanter, the large bone that you can feel at the side of the hip, but may extend down the outer thigh towards the knee.

Pain may be felt when walking, particularly at speed, uphill or upstairs and when standing on one leg to dress.

It is common to experience pain and a feeling of stiffness when rising from a chair after prolonged sitting. Night time is often worse, particularly when lying on your side.

Your physiotherapist will take note of your history and symptoms and perform a number of physical tests in order to diagnose gluteal tendinopathy and rule out other potential sources of pain.

Radiological investigations such as an ultrasound scan or MRI may be used to confirm the diagnosis.

Many people without pain have tendon changes on scans, therefore clinical testing is required to determine whether scan findings are relevant to your current condition. It is not necessary to have scans before presenting to your physiotherapist for assistance. Most people can be diagnosed with clinical tests.

 

What causes gluteal tendinopathy?

Researchers are still working on clearly determining the causes of tendinopathy.

It is currently thought that the pain of gluteal tendinopathy often appears when the tendons become overloaded. This may be due to rapid increases in training or exercise load, a large force associated with a slip or fall or an increase in bodyweight.

Sometimes there has been no particular incident but there may have been a gradual weakening of the tendons over time associated with lack of stimulus of the gluteals due to low activity levels, or certain postural and movement habits.

Those with gluteal tendinopathy have been shown to have weakness in the gluteal muscles that attach to the problem tendons. If the muscles and their tendons become weak enough, they will fail to cope with everyday loads and your nervous system may warn you about this in the form of pain.

How can physiotherapy help with gluteal tendinopathy?

Physiotherapy can help in multiple ways. Your physiotherapist can advise you about controlling aggravating tendon loads—everyday postures, movement habits and activities that might be provoking your pain. Your physiotherapist can help to address poor postural and movement habits, including gait retraining.

Research has found that exercise provides the best long-term outcomes for tendon pain.

A specific exercise program that aims to improve your movement patterns, gradually strengthen the muscles involved and improve the health of your hip tendons is essential. Massage, self trigger point releases, acupuncture, dry needling and heat may assist with short term symptomatic pain relief.

However, a specific exercise program and being taught how to control loads across your tendons are key strategies in managing this condition for the longer term.

Stretching of the gluteals or Iliotibial band (ITB), while a common strategy, will usually only aggravate the tendons. Corticosteroid injections have previously been recommended, but these have been found to have only short term benefits. Surgery is reserved for cases that have not responded to any conservative treatments.

How effective is physiotherapy for gluteal tendinopathy?

There is currently a lack of evidence available from clinical trials for any interventions specifically designed for people with gluteal tendinopathy. Given this limited information, physiotherapists use information from other tendinopathy research, which shows that addressing the underlying causes of the tendinopathy and known strength deficits is the best way to manage tendinopathy.

What can I do at home?

Avoid stretching and rubbing firmly over the bone and avoid activities that worsen your pain. It is important to remember that complete rest does not heal tendon problems and the more inactive you become, the weaker you become.

Visiting your physiotherapist as soon as possible will help you to get on track with a tailored education and exercise program.

It’s best to avoid crossing your legs and when standing keep your weight over both legs evenly.  Hanging off one hip in standing tends to compress the gluteal tendons and make the pain worse.

How long until I feel better?

With specific advice and a tailored exercise program, most people will notice some reduction in pain within 2-4 weeks. However, it will usually take a commitment to an exercise program over a number of months to regain adequate improvements in strength and movement patterns to consistently control symptoms and regain normal activity levels.

The time frame can vary significantly depending on the severity of the tendon problem, duration of the problem, previous interventions, level of muscle weakness or physical conditioning, other coexisting health problems and adherence with advice and exercise prescription.

Book A Free 20 Minute Discovery Session:

Includes:

• full injury history and movement assessment
• accurate diagnosis
• detailed treatment plan

*Valid for new patients only.  Only 3 available per week.

TOP 10 STRETCHES FOR RUNNERS

The Best Defence Is A Good Offence

If you've had a few niggles or been in pain recently, you might find yourself feeling a little overwhelmed. Sometimes the pain forces us into a defensive or protective mode.

Defensive strategies could include:

• ignoring the pain & hoping it will go away
• regularly taking pain killers / anti-inflammatory to numb the pain
• reducing or eliminating any sort of exercise for fear of causing a flare up

You may also find yourself bracing your body rigidly, every time you move or you may hold your breath (subconsciously) the majority of the time.

Defence IS an important short-term strategy for a new injury, don't get me wrong.

But, after a few months, you're tissues have generally healed the best they can.

Then you've got to take a leap of faith and breakout out of defence and start to re-build proactively...step by step.

When planning your offensive play...success comes from having multiple strategies.

Just like in sport, if you're repeating the same offensive strategy all the time, your body will quickly see it coming and the positive adaptations become limited (and the risk of overuse injuries increases).

The best offence to build resilience in your body would include a good variety of types of movement.

Forming the foundation would be doing a form of Cardio aerobic exercise (whatever you enjoy), Pilates, Yoga, strengthening with a PT, and weight bearing exercise to stimulate bone growth.

Challenge for 2018:

Try x 5 NEW types of exercise or movement approaches that you haven't tried before.

TIP: try something that is the opposite of what you currently do. If you tend towards high intensity exercise than try something easier. If you tend to do easy stuff try something more intense.

Some movement options you could try:
- hiking, stand up paddle boarding, rock climbing, triathlon, cross fit, F45, orange theory fitness, Feldenkrais, karate, surfing, dancing, Parkour, BOUNCE, acroyoga, foam rolling, restorative Yoga, sprinting, 7 min workout, mountain biking, tennis, Aussie rules (especially for women!)

Keep challenging yourself.

Your body and mind will thank-you :-)

Runner's Knee

Patelleo-Femoral Pain Syndrome / Runner's Knee Treatment in Adelaide

The Resilient Knee Project is an innovative solution for people with chronic knee pain that empowers individuals to self-manage their pain and most importantly, get them back to enjoy the physical and mental benefits of running.

Founded by Daniel O’Grady, dedicated professional with first hand experience of overcoming knee pain and running the NYC Marathon, the project aims to be a world leader in restoring people’s confidence in their knees and get back to doing what they love.

Is The Resilient Knee Program right for you?

Start a conversation with our new Chat Bot HERE

What is Runners Knee (Patellofemoral Pain PFP)?

Patellofemoral pain (PFP) is a common condition where pain is felt on the front of the knee, either around or behind the patella.

It occurs in up to 20% of the population (1).

The patellofemoral joint is made of the kneecap (patella) sitting on the front of the thigh bone.

The patellofemoral joint functions as a pulley system to help the quadriceps muscles straighten the knee most efficiently.

There are around 20 muscles that hold the patella centred and aligned.

Pain often results when there is excessive compression on the patella or a muscle imbalance around the patella causes misalignment of the patella.

Over time, this causes rubbing of the joint surfaces, creating inflammation and pain.

What are the most common symptoms of PFP?

• general ache/pain in the front of the knee

• pain aggravated activity involving a bent knee and body weight on the leg (e.g. walking up and down stairs, squatting, kneeling, jumping or hopping)

• pain aggravated by sitting for prolonged periods e.g. driving or sitting in a movie theatre.

• some people also hear and feel a grinding / clicking around the knee with mild swelling

An x-ray or MRI is not usually necessary to diagnose PFP.

Patello-femoral pain is often mis-diagnosed as knee osteo-arthritis in young people, due to the deep ache that is often felt. 

An assessment by a Physiotherapist will help to clarify your diagnosis.

Who is most likely to be affected by PFP?

The main risk factor for developing PFP is recent spike in training load. 

PFP is common in:

• runners

• cyclists

• triathletes

• cross fitters

• football, basketball, jumping sports

• hikers (especially going downhill)

Biomechanical issues that can predispose to PFP include:

• weakness in glutes, quads (VMO), core, calves

• tight ITB, TFL, quads (outer), hamstrings, calves

• stiffness in ankles (e.g. post ankle sprain)

• stiffness in the hip joints / hip flexors

• runners with who predominantly heel strike

 White et al (2009) showed that patients with patellofemoral pain had shorter hamstring muscles than asymptomatic controls.

What is the most effective treatment?

There is strong evidence to support a tailored physiotherapy (including exercise, education, taping), compared to placebo in the short (six weeks) and long-term (one year).

Evidence shows a personalised exercise program (combination of stretching and strengthening) gives the best long term outcomes. 

Ideally this exercise program is set up by a Physiotherapist after a comprehensive assessment. 

How long until I feel better?

As our understanding has grown, it has become clear that PFP is not necessarily something that will disappear on its own, and some people can have episodes on and off for many years.

As such, in order to have the best chance of recovering from your PFP and reducing the likelihood of it recurring, it is important to understand your condition, your individual contributing factors and what you can do.

For many people, a program of ongoing and progressive exercise (as prescribed by your physiotherapist) is necessary to build and maintain muscle strength, and good movement coordination.

Additionally, there is evidence suggesting that people with PFP may have an increased risk of going on to develop patellofemoral osteoarthritis (OA). Therefore, seeing an experienced physiotherapist for a management program will help you keep your patellofemoral joints functioning as well as possible, and keep you as active as you’d like to be now and into the future.

What can I do?

• avoid aggravating activities

• ice your knee to eliminate the inflammation (15 mins x 2 day for 2 weeks)

• home exercises - foam rolling (see below) and strengthening

For Runners:

• avoid hills

• cut back on your running mileage

• increase your cadence by 5-10%

• check your shoes - time for a new pair?

• focus on cross training - swimming, pilates, yoga e.t.c.

Some of the common foam roller exercises we prescribe:

Calf

Hamstring

ITB

Quads

How can a Physiotherapist assist with recovery?

1.  Assessment and Diagnosis

A Physio Assessment early on  in your journey pays big dividends in terms of identifying relevant contributing factors and helping you get on the fast track to healing. 

We spend a lot of time in the beginning educating you so you know what to expect in terms of recovery and what you need to do, to manage your recovery successfully.

2.  Dry Needling / Massage and Taping

Generally a short burst of targeted hands manual therapy over 3-4 sessions will help re-set your tissues, balance the muscles around the knee and get you into a position where you can confidently self-manage. 

Muscles that are commonly tight and affecting your knee include:

• ITB

• TFL

• hamstrings

• quads and calves

Foam rolling and spiky ball massage are effective at maintaining flexibility, but dry needling has the ability to get to the deeper part of the muscle and get a more effective release. 

Find out more about dry needling here.

We can also show you how to tape your knee to provide relief in the short-term.

3.  Guidance on load management

We will give you advice on how to gradually re-load your tissues to safely protect your knee from future flare-ups.  We work with your coach or trainer to manage your return to doing what you love. 

4.  Building a personalised home exercise program

You are the most important part of the healing process and what you do is the most important part getting you better. 

We use the convenient Physitrack App to build your personalised home program with videos delivered to your smart phone.

5.  Movement Re-Training

Once your pain is under control we then watch how you move and optimise your movement patterning to decrease the chances of the knee pain returning.

People with patello-femoral pain are often hip flexor and quadricep dominant and need to learn how to activate the glutes and hamstrings.

We have some specific exercises to show you to help you fast track this process.

Is Knee Pain or Injury keeping you from being as active and healthy as you want?

Don't delay your treatment...

The occasional ache or pain may be nothing to worry about, but failing to pay attention to strong pain may end up causing you a lot of problems in the future. If knee pain is reducing your ability to take part in the activities your normally do, then it is time to get it looked at. In general, chronic knee pain or clicking that is affecting your life is a sign that something is wrong.

A serious problem will not correct itself, and left untreated, can result in more pain and irreversible damage. 

Bookings:

If you think we are the right fit for you and you wish to get relief right away, use our simple online booking system to make an appointment.  If you would prefer to speak to us directly,  call us 1300 657 813

References:

1.  Boling M, Padua D, Marshall S, et al. Gender differ- ences in the incidence and prevalence of patellofe- moral pain syndrome. Scand J Med Sci Sports 2010;20(5):725–30.

2. 

Wood L, Muller S, Peat G. The epidemiology of patellofemoral disorders in adulthood: A review of routine general practice morbidity recording. Prim Health Care Res Dev 2011;12(2):157–64.

---

Dan O'Grady is a results driven qualified Physiotherapist and member of the Australian Physiotherapy Association.  Dan has a special interest in treating knee pain.  He has been working in private practice for 15 years with (over 20,000 patient consults). He is passionate about helping people to move better, feel better and get back to doing what they love.

Other blogs to help with your knee pain and get your performing at your best:

NYC Marathon In Review

Thursday 2nd November 2017

Up at 3:30am to get on a 6am Qantas flight from Adelaide to Sydney.  Thank-you Mum for dropping me at the airport!  Flew Adelaide - Sydney - LA - JFK.  Sat next to a guy from Sydney who was also running the NYC marathon.  It seemed like half the plane was traveling over for the marathon (technically there were 1006 Aussies running). 

On the plane, had the chance re-read the George Sheehan classic, 'Running and Being'.  Written by a cardiologist, runner and writer his approach to writing and running always inspires. 

Landed into JFK and collected my bags.  Waiting along side Hawthorn great (now Brisbane Lion) Luke Hodge who was also there to run the marathon.  (He did a very decent time of 3:21 by the way).

Friday 3rd November

Had dinner with friends Luke and Marie last night. It was a nice feeling being back in NYC and seeing some familiar faces.

Headed to the expo at the Javits Centre.  Was super impressed by the organisation and speed of number pick-up considering how many people were going through. 

Adelaide to New York...only a 20 hour plane ride away!

Met a lady who was running the marathon for the fifth time.  Her secret was to consume a beer at the 32km mark.  She thought that was the absolute key to finishing strong - with a good combo of carbohydrates, electrolytes and alcohol to numb the pain.  I will have to try that next time.

After the expo, I headed over to my old gym, the New York Health & Racquet club on 56th street.  Ran three kilometers on the treadmill. Ran a couple of kilometers on the treadmill and then went for a swim, stretch and massage on the foam roller.  Unwinding the residual tightness from the flight. 

A quick lunch at Starbucks and then headed over to Central Park to hear Dean Karinazes speak about his ultra-marathons.  His main advice for the marathon - take it easy in the first half and come home strong.

Saturday 4th November

Went to the NYRR in the morning to hear the world champion runners speak and about their careers and NYC marathon strategy. 

Running Royalty...from left Haile Gebrselassie, Paula Radcliffe, Bill Rodgers, German Silva and Ryan Hall

There were many pearls of wisdom, but Paula Radcliffe's advice particularly stood out:

“Run the first third of the marathon with your head, second third with your legs and the final with your heart”

After listening to the runners, I  dropped my bag off at Orthology, located a stone's throw from the finish line at Columbus Circle.   Had a quick run in Central Park to stretch the legs out one last time. 

Then spent the afternoon with the feet up and watching the running documentary, Breaking 2.

Inspirational watching these guys run and put everything on the line.  I won't wreck the ending if you haven't already seen it, but just to say, if you haven't yet seen it, please do. 

Cooked up some pasta for dinner and tried to have an early night.

Race Day - Sunday 5th November

Didn't sleep too well, as you'd expect.  Woke at 2am and didn't really get back to sleep.  Got up at 4:45am and had a quick breakfast of toast and cereal and then walked over to the 72nd St subway station to get the 1 train down to South Ferry. 

Got on board the 6:30am ferry to Staten Island and then a bus over to the start line. 

Passed the first test - getting over to Staten Island in one piece. Even had time for half a bagel and cup of tea

I was in wave 2 that started at 10:15am, so I had a few minutes to do some final preparation - ensuring my laces were down up properly, taping my knees, doing a few hip openers, applying some sunscreen and preparing my gels and snacks in my flip belt for easy access.

A few deep breaths and then we were called up to the start line.  

This is the moment of truth and before every race I always feel a lot of gratitude, just to make it to the starting line.  It's a nice chance to reflect on your journey, the many small battles won and the abundant learning experiences training for a marathon provides.  And most importantly, very grateful to all of the people that helped me along the way. 

The weather was close to perfect - about 14 degrees with heavy cloud cover and a few light showers in the forecast, although I would have liked it a little colder.

I decided to run with the 3:40 pacer and that allowed me to run on top of the Verrazano-Narrows bridge.  After the gun went off to signal the start, we hear Frank Sinatra's song New York, New York playing out across the bridge. 

My goal during the race was to stick with the 3:40 group as long as possible.  Runners, like cyclists, can benefit from a drafting effect.  The person running in front of you buffers you from the wind and you save precious energy.  There were probably about 20 people in the group.

As I did most of my long training runs on my own, running in a big group is so much easier psychologically.  It is almost like being carried through the streets in a big comfy lounge chair.  You just have to be careful of potholes and obstacles on the course that come up quickly due to your lack of peripheral vision.  

The best thing about running with a pacer is that they know the course inside out and know when to push and when to take it easy. 

Mentally that frees you up big time so you can then pay attention to what's going on in your body.  The main metric that I tracked on my GPS watch was cadence.  I was trying to maintain 175-180 as much as possible. 

When I started feeling a bit tired or sluggish, I noticed my cadence had dropped to 165-170 and by increasing by 5-10% it would immediately ease the pressure on my legs.

It's one of the ironic things about running that I'm still trying to get my head around. 

Intuitively, you'd think to run faster you need to step out with a bigger stride.  But the opposite is true - higher cadence, turning your legs over more quickly with a forwards lean actually makes you go faster, (with better efficiency). 

Running with the pacing group was also beneficial because you didn't have to constantly check times and pace so you could enjoy the spectacle that is the NYC marathon!

For me, the NYC race is all about the people. 

The way New Yorkers get behind the marathon is second to none.  They 100% have your back on race day.  If you are showing even the slightest bit of struggle they will go out of their way to yell your name and put a fire in your belly.  The day after the marathon, again many people go out of their way to congratulate you on finishing.

Anyway, back to the race.  

The first mile is up and down the Verrazano-Narrows bridge and after that, it's a pretty flat run through Brooklyn and up through Queens. 

Things went well early on and I was enjoying the feeling of running and seeing the miles tick by quite quickly and reasonably enjoyably. 

At the first 5km checkpoint, I ate a banana and then from there, every 5km a Winners gel (30g of carbohydrate) along with one Allens lolly snake and either a gulp full of water or Gatorade. 

At around 12km, I felt the early inklings of some leg cramps, so I downed the salty pickle juice that my nutritionist had recommended.  That seemed to help calm the legs over the next 10km. 

By the 25km mark I was holding pretty strong as we ran up the Queensborough bridge - the second steepest part of the race.  There were lots of people slowing down and feeling the burn...and I was one of them.  Managed to lose contact with Paul, the 3:40 pacer. 

At the top of the bridge, I was pushing close to my limit and was around 300m behind the pacer. 

On the downhill I picked up the pace and latched back onto him as we were greeted with a  massively cheering crowd on 1st avenue in Manhattan.  

From there, it was a long, straight stretch up to the Bronx.  This was a hard part of the race where the reality of running a marathon really kicks in.  The race really goes up a notch as the intensity from the crowd ramps up.  Trying to keep up with Paul the pacer was tough as I think he picked up the pace a bit too.  Thankfully he did the difficult job of weaving around people and making a path and I was close on his heels.

Over the Willis Ave bridge (that connects Manhattan to the Bronx), at about 31km, my legs had enough and I could feel a full blown cramp not too far off.  It was mainly in the back of legs in the hamstrings, but the quads weren't too far off either.   My legs were pretty cooked after chasing the pacer down the bridge and the glycogen stores were running low.  I slowed right down to a walk for about a minute and then once over the bridge and started shuffling again.  Thank-fully the walk freshened up the legs and I started feeling better.

In 2015 I also suffered from cramps and so this time, I carried some salt packets, with me.  The sodium helps replace the loss from your sweat.  I went through the packets pretty quickly and thankfully, the first aid stations were also handing them out and I found these really gave me a few more kilometres of cramp-free running. 

Made it through the Bronx and then back over into Harlem and finally made it up 5th Avenue which is long slow uphill.  Getting over that and then a few nice downhills in Central Park, although I was slowing right down by then and doing a walk / run combo. 

Finally, over to Colombus Circle and up to 67th street Central Park, crossing the finish line in a time of 3:46:50. 

Really happy, relieved and actually quite shocked by the time...easily beating my goal of under four hours!

Just after crossing the finish line...

Slow walk up Central Park West

After party at Orthology with Sophia and Jun

Monday 6th November

Walked over to the morning at the Marathon Pavillion, getting my medal engraved and some more foam rolling and stretching out.  Then over back over to the NYRR to watch a replay of the marathon.  Didn't feel too bad, all things considered.  As the day progressed, the delayed onset muscles soreness crept in, in particular the quads...damn subway stairs!

Stretching out in a sea of foam rollers and therabands the day after the marathon. Thanks to the Physios at the Hospital For Special Surgery

My Biggest Struggle

I don't think anyone is every 100% fit before a marathon. 

There are always niggles and you try and manage the best way you can. 

For me, my left knee was the major concern. 

An old football injury nearly 20 years ago resulted in a torn medial meniscus and degeneration.  I had an MRI done a few months before the marathon and it didn't look great. 

I must admit that deflated me a bit. 

Obviously I was wary of any aggravating the pain and potentially causing more damage to the knee.  But I also found that the more running I did, the better the knee felt. 

What really helped was making a list with two categories - modifiable and non-modifiable contributing factors to knee pain:

Non-modifiable Risk Factors

• Structural pathology - damage already down to the mensicus

• Genetics

• Age

Modifiable Risk Factors

• Load management

• Running technique

• Recovery strategies

• Food / diet

• Strength / Flexibility

• Weight

• Movement habits

Accepting that my knee was not 100% and never will be allowed me to focus on ensuring the rest of the foundation was as optimal as possible.

Reflecting back over the past few months, I came up with a few other things that I think helped me achieve my marathon goal:

Philosophy

Capacity vs Demand

Build capacity in a developmental sequence, allowing plenty of time at each stage for adaptation to occur.  Running is a high load activity e.g. running 10km is 10,000 steps at 3 x body weight.  All that force has to go somewhere. 

Recovery

• Nutrition advice from Steph Gaskell at Nutrition Strategies in particular ensuring intake of 20g protein x 3-4 spread throughout the day, rather than all at dinner time.

• Daily foam roller + tennis ball release (great techniques learnt thanks to Yoga with Jem)

• Restorative Yoga with Evelyn at Yogita

• Pilates x 1 week

• Regular ice baths

Got A Running Coach

Thanks to Sam Hicks who really helped me with strength training and building a road map towards my goal.  He had me do some quality runs in the last few weeks before the marathon that really helped prime my body for race day. 

More Running, Less Hills

Previously I did too much Mt Lofty.   Running up there x 2 week was good for the cardio-vascular fitness at the expense of my hip flexors getting really tight.  This time I trained hills x 1 per week but they were short sharp repeats that allowed more time for the longer runs.

Flip belt

This was a life saver - carrying my gels, lollies etc in a comfortable position around my waist.  I would recommend you try this in all of your long runs as it took a little bit of getting used to.

Music During The Marathon

In 2015 I wanted to experience the full vibe of NYC and didn't wear head phones. 

This time I took my phone and at around the half way point (as soon as I was starting to struggle) put on the NYC playlist. 

I found this was a REALLY good way to re-focus. 

Even though the crowd is amazing, it's sometimes nice to get back in your own space for a few minutes. 

You can check and out my cheesy motivational Playlist here

In Summary

NYC marathon was an incredibly fun and inspiring experience - it's definitely a 'bucket list' thing to do.  I can say the process and learning journey building up to the marathon  was just as satisfying as the race itself.  

If you ever get the opportunity to run the NYC marathon, I'd highly recommend you take it!