It started as mild tightness and has now progressed to debilitating butt pain. Rest, physical therapy, and medications did not help. Your trainer thinks you injured your gluteus medius. What is the gluteus medius? What are the different types of gluteus medius injuries? What causes gluteus medius pain? What are the symptoms of gluteus medius tendonitis and tendon tears? How is the diagnosis made? What are the traditional treatment options? What regenerative options exists? What are the consequences of not treating gluteus medius pain? Let’s dig in.
What Is the Gluteus Medius?(Butt Muscle)
The gluteus medius is one of the major muscles in your buttock and hip (1). There are three gluteal muscles you have probably heard about: They layer one upon the another much like a layer cake. The gluteus minimus is closest to the body followed by the gluteus medius and then the larger gluteus maximus
Gluteus Minimus
The gluteus minimus is the smallest of the three gluteal muscles. It is a small triangular muscle that lies underneath its bigger brother, the gluteus medius. It functions to stabilize the hip, rotate the thigh, and move the hip in an outward direction.
Gluteus Medius
A powerful muscle that starts at the backside of your waist bone ( Aka the iliac crest) and travels downward in the diagonal fashion towards the outside aspect of your hip. It then attaches onto the outer boney outcropping of the hip which is called the greater trochanter. A tendon attaches the gluteus medius to the boney surface. This is important as the tendon can become irritated or injured and become a source of pain. The gluteus medius muscle stabilizes the hip and pelvis, helps bend the hip upward (flexion), and rotates the leg inward and outward. Approximately one-third of the muscle is covered by the larger, gluteus maximus muscle.
Gluteus Maximus
The Gluteus maximus is the largest and outermost of the three gluteal muscles. It stabilizes the hip joint as well as extends and rotates outwardly the hip joint. This large muscle starts on the waist bone and attaches to the boney prominence on the outside of the hip in addition to the iliotibial band (ITB)
Are there Different Types of Gluteus Medius Tendon Injuries? (Inflammation and Tears)
Yes, there are different types of gluteus medius tendon injuries. Tendons are thick pieces of connective tissue that connect muscle to bone. They are susceptible to inflammation, injury, and tears. Inflammation of a tendon is called tendinitis. To learn more about this condition please click here. Tendon tears can be classified into three broad groups (2).
Partial Thickness Tear
This type of tear only involves only a portion of the tendon.
Full-Thickness Tear without Retractions
A full-thickness tear also known as a complete tear extends across the entire tendon. The fibers of the tendon however are held together by some of the remaining, non-torn tendon fibers.
Full-Thickness Tear with Retractions
Snapped Rubber Band: Ends are Physically Separated
A full-thickness tear with retractions is a serious injury where the tear involves all tendon fibers and they are pulled apart. Think of a rubber band that breaks under tension. The ends become physically separated. So too with a full-thickness tendon tear with retraction.
Causes of Gluteus Medius Pain & Injuries
Gluteus medius pain can arise from a number of different injuries. The two most common causes of gluteus medius pain are tendonitis and tendon tears.
Tendonitis AKA inflammation of the tendon can be caused by a number of different factors. Common examples include repetitive activity, overuse, poor posture, and poor technique (3).
Tears in the gluteus medius tendon are commonly seen in runners and other high-impact athletes in sports such as such as basketball and soccer. The exact cause of the tears is unclear however there is evidence to support that it is a degenerative and progressive process (4). This is similar to tears in the rotator cuff tendons in the shoulder. Other factors that are associated with gluteus medius pain and dysfunction include:
- Patients with poor gluteal and hip muscle strength as this places increased stress on the tendon
- Patients with low back nerve irritation as this leads to reduced strength and more muscle tightness and dysfunction (5)
- The incidence of gluteus medius tears peaks around the seventh decade of life (6)
- More common in women (6)
Gluteus Medius Tendonitis and Tendon Tear Symptoms (Pain!!)
Symptoms vary depending upon the type and the severity of the gluteus medius injury. Common symptoms include:
- Pain and tenderness on the outside of the hip or buttock. One study demonstrated that 46% of studied patients with chronic buttock pain had a gluteus medius tear on MRI.(7).
- Swelling or inflammation
- Difficulty sitting or walking
- Limp while walking
- Decreased hip range of motion
- Pain is often worse when lying on the affected side.
- Pain at night, sometimes preventing sleep
Diagnosis ( Physical Examination, X-ray and Ultrasound)
Diagnosis of a gluteus medius injury requires completion of a history and physical examination and selection of appropriate studies. Pain in the outer aspect of the hip and buttock is typically gradual in nature.
Physical Examination
Positive Trendelenburg Test
Pain over the outer aspect of the hip along with a reduced range of motion is common. The Trendelenburg test is the most sensitive and specific physical exam finding for this condition (9). The test requires the patient to stand on one leg for 30 seconds. A positive Trendelenburg test occurs when the patient is unable to maintain their pelvis level to the floor. The pelvis on the non-standing leg drops as illustrated in the picture to the right. This occurs due to gluteus medius and minimus weakness or injury. The gluteus medius muscle is colored red.
Studies
X-ray is helpful as it can exclude hip osteoarthritis and fracture. Radiographic signs of gluteus medius injury include bone irregularities on the greater trochanter. In-office ultrasound is very helpful in evaluating the integrity of the gluteal tendons (8). Ultrasound can identify inflammation of the tendon as well as different types of tendon tears. At the Centeno-Schultz Clinic patients with hip pain or restricted range of motion undergo ultrasound evaluation. When not available, MRI is the next appropriate study.
Treatment Options for Gluteus Medius Pain and Injuries (Conservative, Steroids & Surgery)
Treatment will depend upon the severity of the injury and underlying medical conditions. Treatment options include conservative care, steroids, and surgery.
Conservative
When appropriate, conservative care should always be the first-line treatment. The goal is to reduce pain, minimize intramuscular bleeding, control the inflammatory response and improve strength and flexibility. Treatment options include rest, physical therapy, chiropractic care, gentle stretching, dry needling, and ultrasound.
Injections
Steroid injections are often recommended for patients who do not respond to conservative treatment. Steroids have many different brands and names which include dexamethasone, methylprednisolone, betamethasone, and cortisone. Steroids are powerful anti-inflammatory agents that have a significant number of side effects. These include injury to cartilage, tendons, and ligaments. To learn more about the harmful effects of steroids please click here.
Surgery
Surgery is rarely indicated with the exception of when a patient has sustained a full-thickness tendon tear with retractions. In this condition, the tendon is completely torn with two physical ends that are separated.
Regenerative Treatment Options for Gluteus Medius Pain (PRP and Stem Cells)
Two principal regenerative options exist.
PRP (Platelet Rich Plasma)
PRP is rich in growth factors that can increase blood flow and promote healing. PRP has been demonstrated to be superior to steroids for the treatment of hamstring injuries (10).
Stem Cell Treatment
Stem cells are your body’s own powerhouses for healing. At the Centeno-Schultz Clinic, we are experts in the treatment of buttock and hip pain with both PRP and stem cells. In 2005 we were the first clinic in the world to inject stem cells into the low back disc for severe back pain. We have published extensively on the benefits and use of PRP and stem cells for common orthopedic conditions. To review our list of publications please click here.
Stem cell treatments are appropriate for patients with ongoing gluteal pain who have failed to receive significant healing from PRP injections or those who have severe gluteus medius tendonitis and partial thickness tearing of the tendon. At the Centeno Schultz Clinic, you can be assured of the following:
- Board Certified Fellowship trained physicians will perform all injections
- Stem cells and PRP will be injected under direct visualization with ultrasound. This will ensure that cells will get into the injured tissue. Blind injections are beneath our standard of care as there is no assurance that the injected cells get into the targeted tissue.
Consequences of Not Treating Gluteus Medius Pain (Progression of Tear, Knee, Hip and Ankle Injuries Including Arthritis)
Gluteus medius pain is a warning sign that you have a problem that warrants further investigation. Think of it as the warning light in your car that illuminates as you are heading out of town for a three day road trip. If ignored the potential consequences are significant. They include your car’s engine malfunctioning costing you thousands of dollars and quickly ending your weekend sojourn. So too with gluteus medius pain that is not treated. Potential consequences include:
- Progression of injury from tendonitis to partial thickness tear.
- Progression of partial thickness tear to complete tear with retractions. All nonsurgical treatment options are eliminated when this occurs.
- Knee instability. Dysfunction of the iliotibial band can cause lateral knee instability
- Knee osteoarthritis
- Changes in the way you walk (gait)
- Low back pain due to changes in the way you walk (gait)
- Develop hip osteoarthritis (11). The gluteus medius stabilizes the hip and pelvis. Without this stability the hip is at risk for cartilage, labrum and tendon injury.
- Ankle tendon, ligament and cartilage injuries including arthritis.
In Conclusion
- The gluteus medius is one of the major muscles in your buttock and hip.
- The buttock is compromised of three muscles that layer upon one another: the gluteus minimus, gluteus medius and gluteus maximus.
- The gluteus medius stabilizes the hip and pelvis, bends the hip upward and rotates the leg inward and outward.
- The gluteus medius muscle starts at the waist bone and travels downward until it’s tendon attaches to the outer boney prominence of the hip (greater trochanter). This tendon can be inflamed, injured or torn and a source of significant pain.
- There are three broad groups of tendon tears: partial thickness, full thickness without retractions and full thickness with retractions.
- Tendonitis and tendon tears are the most common cause of gluteus medius pain.
- Gluteus medius tendonitis and tendon tear symptoms vary depending upon the severity. Common symptoms include pain of the outside of the hip/buttock, difficulty walking, reduced range of motion and pain when lying on the affected side.
- Diagnosis of gluteus medius tendonitis and tendon tear starts with history and physical examination. X-ray can exclude fracture and in-office ultrasound can make the diagnosis.
- Treatment options include conservative care, steroid injections and surgery.
- Regenerative treatment options include PRP and stem cell injections. Not all clinics are the same. For best clinical results insist upon a fellowship trained physician who performs the injections under ultrasound guidance.
- Gluteus medius pain is a warning signal that you have a problem that warrants further evaluation. If ignored the consequences can be significant and include progression of injury, knee instability, knee osteoarthritis, low back pain, hip osteoarthritis and ankle injury and pain.
If you or a loved one suffers from gluteus medius pain or dysfunction please schedule a new patient consultation where you can learn what regenerative treatment options are best for you.
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