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Current Concepts of Hip Tendinopathies:An Exercise & Manual Therapy Approach
• Allied Health Education and the presenter of this webinar do not have any financial or other associations with the
manufacturers of any products or suppliers of
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in this presentation. • There was no commercial support for this presentation.
• The views expressed in this presentation are the views
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information contained in this presentation.
Outline30 min: Updates in hip tendinopathy research
15 min: Differential diagnosis
10 min: Clinical assessment of tendinopathy
5 min: Questions
15 min: Explanation of postural strategies and patient education
15 min: Intervention Strategies – Manual Therapy
15 min: Intervention Strategies – Therapeutic Exercise
5 min: Conclusion
10 min: Questions
2
Learning Objectives
By the end of this presentation, audience members will be able to:
1. Understand the most current research related to common hip tendinopathies
2. Describe examination components in the evaluation of tendinopathy
3. Utilize exercise and manual therapy strategies for pain management and treatment of the entire kinetic chain
4. Develop a rehabilitation program that incorporates guidelines for tissue loading progression and return to activity
Hip tendinopathies warrant postural modification, patient education, and loading progression
Understanding of Tendinopathy Continues to Change
1.Exercise and manual therapy are effective management approaches
1.Psychosocial factors may play a role in the severity of hip tendinopathies
Hip tendinopathies warrant postural modification, patient education, and loading progression
Understanding of Tendinopathy Continues to Change
1.Exercise and manual therapy are effective management approaches
1.Psychosocial factors may play a role in the severity of hip tendinopathies
3
Hip tendinopathies warrant postural modification, patient education, and loading progression
Understanding of Tendinopathy Continues to Change
1.Exercise and manual therapy are effective management approaches
1.Psychosocial factors may play a role in the severity of hip tendinopathies
Hip tendinopathies warrant postural modification, patient education, and loading progression
Understanding of Tendinopathy Continues to Change
1.Exercise and manual therapy are effective management approaches
1.Psychosocial factors may play a role in the severity of hip tendinopathies
What is Tendinopathy?
“…nonrupture injury in the tendon or paratendon that
is exacerbated by mechanical loading”
Scott et al. 2015
4
Extrinsic
Sport –Training Errors
Work –Improper
equipment or repetitive
tasks
Overload or Underload
Intrinsic
Metabolic
Age
Genetics
Relevant Factors
Hallmark Signs of
Tendinopathy
Tendon pathology
Pain system changes
Motor system impairments
Hallmark Signs of
Tendinopathy
Tendon pathology
Pain system changes
Motor system impairments
5
Hallmark Signs of
Tendinopathy
Tendon pathology
Pain system changes
Motor system impairments
Hallmark Signs of
Tendinopathy
Tendon pathology
Pain system changes
Motor system impairments
The Problem
Tendinopathy: 30% of all general practice musculoskeletal consultations
Gluteal tendinopathy is most common of all lower limb tendinopathies
Prevalence:
Gluteal tendinopathy: 10 – 25%
Psoas/hamstrings tendinopathy: unclear
Low Diagnostic accuracy of orthopaedic tests Grimaldi et al. 2015
Anderson 2015
Mellor 2016
6
Gluteal Tendinopathy
Commonly present over age 40
Affects more women than men (2.4 – 4:1) - up to 23.5 % women & 8.5 % men between ages 50 and 79
Low incidence of bursal change
Prevalence in people with low back pain: 35%
Grimaldi & Fearon 2015Grimaldi et al 2015
Psoas & Proximal Hamstrings Tendinopathy
• Psoas disorders account for 12 – 36% of chronic groin pain in athletes
• Hamstrings: considerable variation in location of tendon pathologyocommon hamstring tendon 23%
obiceps femoris 41%
osemimembranosus 29%
osemitendinosus 6%Anderson 2015
Goom et al. 2016
Grimaldi et al. 2015Anderson 2016Goom et al. 2016
Muscle Function
GlutealHip abduction torque
Functional pelvic stability
Psoas Powerful hip flexor
Pelvic/spine stability
HamstringsEccentric knee extension
Pelvic stability
7
Grimaldi et al. 2015Anderson 2016Goom et al. 2016
Muscle Function
GlutealHip abduction torque
Functional pelvic stability
Psoas Powerful hip flexor
Pelvic/spine stability
HamstringsEccentric knee extension
Pelvic stability
Grimaldi et al. 2015Anderson 2016Goom et al. 2016
Muscle Function
GlutealHip abduction torque
Functional pelvic stability
Psoas Powerful hip flexor
Pelvic/spine stability
HamstringsEccentric knee extension
Pelvic stability
Grimaldi et al. 2015Anderson 2016Goom et al. 2016
Muscle Function
GlutealHip abduction torque
Functional pelvic stability
Psoas Powerful hip flexor
Pelvic/spine stability
HamstringsEccentric knee extension
Pelvic stability
8
Grimaldi et al. 2015Anderson 2016Goom et al. 2016
Muscle Function
GlutealHip abduction torque
Functional pelvic stability
Psoas Powerful hip flexor
Pelvic/spine stability
HamstringsEccentric knee extension
Pelvic stability
Gluteal Tendinopathy & Motor Control
• Differences in walking gait:
• Greater hip adduction moment
• Modified activation levels of hip abductor muscles
oMore sustained burst activity of posterior gluteus minimus& middle gluteus maximus
oMuscle activation patterns were less variable within & between GT participants
Allison et al. 2018
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Tendon Cell Response
Neovascularizaion
CentralSensitization
9
Tendon Pain
Explained
Inflammation “Tendinitis”
Cook et al. 2016
Inflammation
Classic inflammatory response
Rupture or laceration
Response in pathological tendons
Inflammatory markers
Cellular degradation and synthesis
Serves as basis for R.I.C.E. treatments
Cook et al. 2016
Inflammation
Classic inflammatory response
Rupture or laceration
Response in pathological tendons
Inflammatory markers
Cellular degradation and synthesis
Serves as basis for R.I.C.E. treatments
10
Cook et al. 2016
Inflammation
Classic inflammatory response
Rupture or laceration
Response in pathological tendons
Inflammatory markers
Cellular degradation and synthesis
Serves as basis for R.I.C.E. treatments
Cook et al. 2016
Inflammation
Classic inflammatory response
Rupture or laceration
Response in pathological tendons
Inflammatory markers
Cellular degradation and synthesis
Serves as basis for R.I.C.E. treatments
Cook et al. 2016
Inflammation
Classic inflammatory response
Rupture or laceration
Response in pathological tendons
Inflammatory markers
Cellular degradation and synthesis
Serves as basis for R.I.C.E. treatments
11
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Cook et al. 2016
Collagen Dysrepair
Initially thought of as “kinking” of collagen fibers
Currently thought of as under-stimulation of tendon
Used as rationale for use of cross friction mobilization
Cook et al. 2016
Collagen Dysrepair
Initially thought of as “kinking” of collagen fibers
Currently thought of as under-stimulation of tendon
Used as rationale for use of cross friction mobilization
12
Cook et al. 2016
Collagen Dysrepair
Initially thought of as “kinking” of collagen fibers
Currently thought of as under-stimulation of tendon
Used as rationale for use of cross friction mobilization
Cook et al. 2016
Collagen Dysrepair
Initially thought of as “kinking” of collagen fibers
Currently thought of as under-stimulation of tendon
Used as rationale for use of cross friction mobilization
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Tendon Cell Response
13
Cook et al. 2016
Tendon Cell
Response
Tenocytes maintain cellular
environment
Cell activation
Proteoglycan expression
Changes in collagen types
Used to explain
development of fibrocartilage
Cook et al. 2016
Tendon Cell
Response
Tenocytes maintain cellular
environment
Cell activation
Proteoglycan expression
Changes in collagen types
Used to explain
development of fibrocartilage
Cook et al. 2016
Tendon Cell
Response
Tenocytes maintain cellular
environment
Cell activation
Proteoglycan expression
Changes in collagen types
Used to explain
development of fibrocartilage
14
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Tendon Cell Response
Neovascularizaion
Neovascularization
Healthy tendons are relatively avascular
Neurovascular ingrowth
Conflicting evidence on neovessels
Used for diagnosis purposes and use of medical procedures
Cook et al. 2016
Neovascularization
Healthy tendons are relatively avascular
Neurovascular ingrowth
Conflicting evidence on neovessels
Used for diagnosis purposes and use of medical procedures
Cook et al. 2016
15
Neovascularization
Healthy tendons are relatively avascular
Neurovascular ingrowth
Conflicting evidence on neovessels
Used for diagnosis purposes and use of medical procedures
Cook et al. 2016
Neovascularization
Healthy tendons are relatively avascular
Neurovascular ingrowth
Conflicting evidence on neovessels
Used for diagnosis purposes and use of medical procedures
Cook et al. 2016
Neovascularization
Healthy tendons are relatively avascular
Neurovascular ingrowth
Conflicting evidence on neovessels
Used for diagnosis purposes and use of medical procedures
Cook et al. 2016
16
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Tendon Cell Response
Neovascularizaion
Central Sensitization
Plinsinga et al. 2015
Tompra et al. 2016
Central Sensitization
“Altered somatosensory
perceptions”Peripherally and
centrally
Helpful in short-term, maladaptive in long-
term
Characterized by mechanical or
thermal sensory gain
Reduced pressure pain threshhold
Plinsinga et al. 2015
Tompra et al. 2016
Central Sensitization
“Altered somatosensory
perceptions”Peripherally and
centrally
Helpful in short-term, maladaptive in long-
term
Characterized by mechanical or
thermal sensory gain
Reduced pressure pain threshhold
17
Plinsinga et al. 2015
Tompra et al. 2016
Central Sensitization
“Altered somatosensory
perceptions”Peripherally and
centrally
Helpful in short-term, maladaptive in long-
term
Characterized by mechanical or
thermal sensory gain
Reduced pressure pain threshhold
Plinsinga et al. 2015
Tompra et al. 2016
Central Sensitization
“Altered somatosensory
perceptions”Peripherally and
centrally
Helpful in short-term, maladaptive in long-
term
Characterized by mechanical or
thermal sensory gain
Reduced pressure pain threshhold
Plinsinga et al. 2015
Tompra et al. 2016
Central Sensitization
“Altered somatosensory
perceptions”Peripherally and
centrally
Helpful in short-term, maladaptive in long-
term
Characterized by mechanical or
thermal sensory gain
Reduced pressure pain threshhold
18
Clinical Relevance of Central Sensitization
Higher severity = lower quality of life (Coombes 2015)
Predictor of poor outcomes in those with chronic musculoskeletal pain (Coombes 2015, Kim 2015)
Mediates treatment outcomes (Kim 2015)
Can be present with gluteal tendinopathy (French et al. 2019)
Current Concept: Psychological Considerations in Gluteal Tendinopathy
• Patients with more severe pain & disability demonstrated:ogreater psychological distress
opoorer quality of life
ogreater waist girth and BMI
ono significant difference in hip abductor strength
Plinsinga et al. 2018
Littlewood et al. 2013
De-conditioned
tendon
Episode of
relative overuse
CNS scrutinyNegative
perception
Fear avoidance
Positive
perception
Positive
outcome/output
Cycle of Chronicity
Pathway to
Recovery
19
Littlewood et al. 2013
CNS scrutiny
Tendon Pain
Explained
Inflammation “Tendinitis”
Collagen Dysrepair
“Tendinosis”
Tendon Cell Response
Neovascularizaion
Central Sensitization
Advantages of Pathophysiology Models
• Directs choice of medical interventions
• Patients often ask about the cause of their pain
• More commonly used among various medical providers
20
Variable
Does Not Account for Changes in Pain Over Time
Neglects Role of Central Pain Processing
No Direct Relationship Between Structure, Pain, & Dysfunction
Pitfalls of Pathophysiology Models
Current Concept: Continuum Model
Normal
TendonReactive
TendinopathyTendon
Dysrepair
Degenerative
Tendinopathy
Current Concept: Continuum Model
Reactive
Tendinopathy
Tendon
DysrepairDegenerative
Tendinopathy
21
Current Concept: Continuum Model
Tendon
Dysrepair
Degenerative
Tendinopathy
Current Concept: Continuum Model
Normal
TendonReactive
Tendinopathy
Tendon
Dysrepair
Degenerative
Tendinopathy
Underloaded
Overloaded
Gradual Loading
Load Modification/Re-loading
Current Concept: Continuum Model
Normal
TendonReactive
Tendinopathy
Tendon
Dysrepair
Degenerative
Tendinopathy
22
Current Concept: Continuum Model
Normal
TendonReactive
Tendinopathy
Tendon
Dysrepair
Degenerative
TendinopathyNormal
Function
Current Concept: Continuum Model
Cook 2015
Advantages of Continuum Model
Does Not Emphasize Pathophysiology
Based on Clinical Presentation
Guides Intervention Selection
Explains Changes Over Time
23
Pitfalls of Continuum Model
• Clinical presentation can change
• More complex for patients to understand
• Still not used by wide range of medical professionals
Current Concept: Tendon Compression
Grimaldi et al. 2015
Type of Tendon Load Biological
Response
Outcome
Tensile:1. Less than normal2. Normal
3. Slightly greater than normal
4. Much greater than normal
1. Catabolic2. Catabolic = Anabolic3. Net Anabolic
4. Net Catabolic
1. ↓ tensile strength2. Homeostasis3. ↑ tensile strength4. Failure to adapt
Compressive Catabolic ↓ tensile strength
Examination
24
Differential Diagnosis
Medical Conditions
Spine Conditions
Hip Conditions
Examination
Screening• Medical conditions
• Lumbar spine contributions
• Central nervous system sensitization
Orthopedic examination• AROM PROM Joint Assessment Palpation Special Tests
Assessing the effects of different lumbopelvic postures
Recognizing Central Sensitization
Ask about changes in senses
Have patient self rate their quality of
Stress, Sleep, Nutrition, Physical activity
Patient Reported Outcome Measures
TendonQ, FABQ, Central Sensitization Inventory
25
Special Tests
• Glute TendonoSingle leg stance
oLateral derotation test
oFlexion-Abduction-External Rotation (FABER)
oHip adduction + resisted abduction
• HamstringsoChair bridge
oArabesque
• PsoasoNo defined clinical test
Grimaldi et al. 2015
Goom et al. 2016
Clinical Assessment of Hip Pain
Video
Intervention
26
Current Concept: Continuum Model
Cook 2015
Current Concept:Reactivity: “24 hour rule”
Reactive pain: symptom aggravation following energy storage
activities
Irritable:provocation lasting greater than 24 hours
Stable: settles within 24 hours
Current Concept: Physical Therapy vs Surgery
Surgery: not superior to sham surgery in midterm & long term
Tendon loading exercises: as effective as surgery in midterm & long term for pain, function & quality of life.
Surgery should be reserved for selected cases & only after a sufficiently long course (12 months) of evidence-based loading exercise has failed.
Challoumas et al. 2019
27
Current Concept: Gluteal TendinopathyEvidence for Exercise & Education
Education & Exercise (Mellor et al. 2018)
Comprehensive Education (Ganderton et al. 2018)
Current Concept: Psoas & Hamstrings
Not Well Studied
Interventions: Hip Exercise
Video
28
Interventions: Hip Manual Therapy
Video
Interventions: Education
Educational InterventionsMinimize compressive positions until irritability reduces
Gluteal Psoas Hamstrings
Raising seat height when sitting
Avoiding crossing legs
Sleeping on back (knees
supported)
Avoid lying on painful side
Sleep with pillow between knees
Walk with wider gait mechanics
Avoid excessive stretching into
hip extension
Avoid deep ranges of hip flexion
Alter gait speed to comfortable pace
Avoid sitting too upright
Use cushion to sit
Avoid deep ranges of hip flexion
Avoid excessive hamstrings
stretching
Avoid excessive forward bending
Alter gait speed to comfortable pace
29
Educational Interventions
Recommendations for exercise
Gluteal Psoas Hamstrings
Midrange hip adduction
isometrics
Reduced energy storage
loading
Gradual hip abduction loading
Modify squat range (0-45 degrees) until irritability has
reduced
Midrange hip flexion isometrics
Reduced energy storage loading
Gradual hip flexion loading
Midrange knee flexion
isometrics
Reduced energy storage
loading
Gradual hamstrings loading
Modify squat range (0-45 degrees) until irritability has
reduced
Hip tendinopathies warrant postural modification, patient education, and loading progression
Understanding of Tendinopathy Continues to Change
1.Exercise and manual therapy are effective management approaches
1.Psychosocial factors may play a role in the severity of hip tendinopathies
References1. Scott A, Backman LJ. Speed C. Tendinopathy: Update on Pathophysiology. JOSPT. 2015;45:833-
841.2. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in
its management. JOSPT. 2015;45(11):910-922.3. Anderson C. Iliopsoas pathology, diagnosis, and treatment. Clin Sports Med. 2016;35:419-433.4. Mellor, R., Grimaldi, A., Wajswelner, H., Hodges, P., Abbott, J. H., Bennell, K., & Vicenzino, B.
Exercise and load modification versus corticosteroid injection versus ‘wait and see’for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomised clinical trial. 2016. BMC musculoskeletal disorders. 17(1).196.
5. Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med. 2015;45:1107–1119.
6. Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. JOSPT. 2016;46:483-493.
7. Allison K, Salomoni SE, Bennell KL, et al. Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scand J Med Sci Sports. 2018;28:686–695.
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References8. Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its
merit in clinical practice and research? Br J Sports Med Published Online First: April 28, 2016. Doi:10.1136/bjsports-2015-095422.
9. Plinsinga ML, Brink MS, Vicenzino B, Van Wilgen CP. Evidence of nervous system sensitization in commonly presenting and persistent painful tendinopathies: a systematic review. JOSPT. 2015;45:864-875.
10.Tompra N, van Dieen J, Coppieters M. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med. 2016;50: 1004-1007.
11.Coombes BK, Bisset L, Vicenzino B. Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors. Clin J Pain. 2015; 31: 30– 35.
12.Kim SH, Yoon KB, Yoon DM, Yoo JH, Ahn KR. Influence of centrally mediated symptoms on postoperative pain in osteoarthritis patients undergoing total knee arthroplasty: a prospective observational evaluation. Pain Pract. 2015; 15: 46– 53.
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14.Littlewood C, Malliaris P, Bateman M, Stace R, May S, Walters S. The central nervous system: An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. Manual Therapy. 18 2013;18:468-472.
References15. Challoumas D, Clifford C, Kirwan P, et al. How does surgery compare to sham surgery or
physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ OpenSport & Exercise Medicine. 2019;5:e000528. doi:10.1136/bmjsem-2019-000528
16.Ganderton C, Semciw A, Cook J, Moreira E, Pizzari T. Gluteal loading versus sham exercises to improve pain and dysfunction in postmenopausal women with greater trochanteric pain syndrome: a randomized controlled trial. J Women’s Health. 2018;27:815-829.
17.Mellor R, Bennell K, Grimalid A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomized clinical trial. J Sports Med. 2018;52:1464-1472.
18.Plinsinga ML, Coombes BK, Mellor R, Grimaldi A, Hodges P, Bennell K, Vicenzino B. Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross-sectional study. Eur J Pain. 2018;22:1124-1133.
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