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1 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 commercial services that may be discussed or displayed in this presentation. There was no commercial support for this presentation. The views expressed in this presentation are the views and opinions of the presenter. Participants must use discretion when using the information contained in this presentation. Outline 30 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

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Page 1: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

1

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

commercial services that may be discussed or displayed

in this presentation. • There was no commercial support for this presentation.

• The views expressed in this presentation are the views

and opinions of the presenter.• Participants must use discretion when using the

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

Page 2: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 3: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 4: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 5: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 6: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

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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

Page 8: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

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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

Page 10: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 11: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 12: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 13: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 14: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 15: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 16: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 17: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 18: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 19: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 20: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

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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

Page 22: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 23: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 24: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 25: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 26: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 27: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 28: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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

Page 29: Current Concepts in Shoulder Tendinopathies: …...Recognizing Central Sensitization Ask about changes in senses Have patient self rate their quality of Stress, Sleep, Nutrition, Physical

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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.

13.French HP, Jong CC, McCallan M. Do features of central sensitisation exist in Greater Trochanteric Pain Syndrome (GTPS)? A case control study. Musculoskeletal Science and Practice. 2019; 43:6-11.

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.

19.Frizziero A, Vittadini F, Pignataro A, Gasparre G, Biz C, Ruggieri P, Masiero S. Conservative management of tendinopathies around hip. Muscles, Ligaments and Tendons Journal. 2016;6 (3):281-292.