Gold Standard Scaffold for Gluteal Tendinopathy Part 2 ...
Transcript of Gold Standard Scaffold for Gluteal Tendinopathy Part 2 ...
Gold Standard Scaffold for Gluteal Tendinopathy
Part 2: ManagementMarisol Reyes Fuentes
B.Phty, M.Musc Phty, APAMAPA Musculoskeletal Physiotherapist
Certified APPI Pilates InstructorMember Hip Pain Professionals
Most common misbeliefs• It will get better with rest
• Stretching the glutes is good for it
• It doesn’t hurt when I am running, therefore, running is not a problem
Medbridgehttps://www.medbridgeeducation.com/patient-education-library/condition/91-Gluteus-
Medius-Tendinopathy
Hip Pain Helphttps://hippainhelp.com/gluteal-tendinopathy-trochanteric-bursitis-greater-trochanteric-pain-syndrome-gtps/
Tension within the ITB may result in frictional trauma to GMed/min tendons and their bursae, similar to the effect of the acromion process on the rotator cuff
Aiming to reduce compressive loads over a 24h period – key in early pain management
Grimaldi, A. Lateral hip pain: mechanism and management. Sourced from https://dralisongrimaldi.com/lateral-hip-pain-mechanisms-and-management/
Tendon Decompression
• Posture, gate modification• Reduce stairs climbing• Use wedge cushion• Avoid sitting in low chairs• Change sleeping position (back, ¾ prone, side lying with pillows*)• Check car seat• Check previous rehab/gym/pilates program (clams, side leg lifts, glute/hamstring stretch?)
https://www.medbridgeeducation.com/patient-education-library/condition/14367-Gluteus-Medius-Tendinopathy-Dos-and-Donts
Do not stretch• Stretching glutes is NOT indicated in the acute/sub-acute phase• Use massage, self-trigger point releases, dry needling and/or heat instead.
Isometrics• WHY? Pain relief, early stages of tendon load
• GRADUAL RAMP OF ACTIVATION - VISUALISE
• Supine or high sitting
• Use belt around mid-thigh
• 5x10sec 2 sets at 50%MVC (Alison Grimaldi’s protocol)
• 10x10sec at comfortable contraction, feeling PGM contracting, low or no pain (Henry Wajswelner’s protocol)
• 3-4 times a day, use as PANADOL
• Small study: 6 volleyball players with PT
• Compared immediate and 45min effect after isotonic and isometric quadriceps contraction
• HEAVY isometric contractions (5x45sec, 2 min rest 70%1RM) reduced tendon pain immediately and • for at least 45min post-intervention
• The effect of exercise on the motor cortex may be modulated in the presence of pain. Exercises that are painful to complete may change motor control and cause cortical reorganisation, as pain itself is known to alter cortical representation. This may contribute to persistence of tendon pain
Key aspects of managementEmphasize
relevance of postural
alignment in EVERYDAY activities
Be SPECIFIC in muscle
assessment & rehab
Address muscle dysfunction in a FUNCTIONALLY specific manner
Let patients PROVE you that they are ready
for a progression (i.e.: DL to SL)
Week 1 Familiarisation
Low load activities: static abd supine/std
Pelvic control -functional
loading: Bridges
Functional strength: DL squat
Abductor loading in frontal plane:
Side step
Week 2Early Loading and
Movement Optimisation
Low load activities = W1
Pelvic control -functional
movements: DL and offset bridge
Functional strength: DL and
offset squat
Abd loading in frontal plane =
W1
Week 3-8Graduated Loading
Low load activities = W1
Pelvic control -functional
movement = W2 but harder
Functional strength = W2 but
harder
Abd loading in frontal plane: side
step, band slide (hard)
Wee 3-8 in clinic
Warm up: sliding platform abd in
upright and squat position
High level loading: as warm up but heavy. Scooter
Early strengthening
Key Exercises
Bridges
Mini-squats Standing Abduction
Step up/down (avoid add moment)
OPEN CHAIN OR CLOSE CHAIN?
CKC exercises provide proprioceptive imput similar to the demands of WB functions (walking/climbing stairs)
Studio Rehab
Reformer
Footwork on bar
Scooter
Standing Abduction (Splits)
Feet on straps (keep it wide and less than 90deg HF) – subacute
Trap Table
Supine legs in straps (DL, SL)
Bridges with arm pull on box (low level),
crook lying, sustained bridges, arm pulses
Assisted squats with glute rack +/- belt around knees or
ankles
Wunda Chair
Standing leg press front, side +/-
standing on unstable surface
Step up
Step down (lunges) -advanced
Gait Retraining
Cue neutral spine
Cue neutral/wide stance and gait
Avoid waddling
Avoid adduction moment
Prefer neutral or wide foot position, hip ER and avoid
deep hip flexion to reduce tendon compression
Kinetic Chain
Abdominals
TT: Standing arms DL, split stance or SL +/- heel
raises.Seated abdominal curls
RF/TT: Seated Abdominal curls
Quadriceps
RF: Footwork, seated quads
TT: Seated Quads with ankle weights
TT: high kneeling assisted eccentric quads
Hamstrings
RF/ TT LIS
TT: Prone Hs curl with ankle weights
Calves
RF: Footwork
Calf raises
High LevelPilates Based
Progressions on load (springs), repetitions (endurance)
Add small equipment (IronEdgeband, chi ball, weights)
Functional
Combined movement i.e.: hip abd + trunk rotation
SL standing from a chair
Sports Specific
Landing/jumping/kicking/surfing
Running
Golf/Tennis (trunk rotation)
PRACTICAL (10min)EARLY REHAB
Team up and teach each other 1 progression and 1 regression of the following exercises:Bridge
Mini-squatStanding Abduction
Step up/Down
(Include isometrics and use small equipment)
PRACTICAL 2 (30min)STUDIO WORKSHOP
Team up are rotate through the stations to teach and practice exercises(Include isometrics and small equipment)
• Allison, Bennell, Grimaldi, Vicenzino, Wrigley, & Hodges. (2016). Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait & Posture, 49, 108-113
• Connell, D., Bass, A., Sykes, C., Young, C., & Edwards, J. (2003). Sonographic evaluation of gluteus medius and minimus tendinopathy. European Radiology, 13(6), 1339-1347.
• Cowan, R.M., Semciw, A.I.,, T., Cook, J., Rixon, M.K., Gupta, G., Plass, L.M. and Ganderton, C.L. (2020), Muscle Size and Quality of the Gluteal Muscles aPizzarind Tensor Fasciae Latae in Women with Greater Trochanteric Pain Syndrome. Clin Anat. doi:10.1002/ca.23510
• Dr Alison Grimaldi with Practical Physiotherapy Tips on Treating Lateral Hip Pain https://soundcloud.com/bmjpodcasts/dr-alison-grimaldi-with-practical-physiotherapy-tips-on-treating-lateral-hip-pain?in=bmjpodcasts/sets/bjsm-1#t=0:00
• Falvey, E., Franklyn-Miller, A., & McCrory, P. (2009). The greater trochanter triangle; a pathoanatomic approach to the diagnosis of chronic, proximal, lateral, lower pain in athletes. British Journal of Sports Medicine, 43(2), 146.
• Fearon, Neeman, Smith, Scarvell, & Cook. (2017). Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study. Gait & Posture, 52, 237-243.
References
• Impellizzeri FM, Jones DM, Griffin D, et al. Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018. British Journal of Sports Medicine Published Online First: 17 February 2020. doi: 10.1136/bjsports-2019-101456
• Grimaldi, A. (2017). Conservative management of lateral hip pain: The future holds promise. British Journal of Sports Medicine, 51(2), 72-73.
• Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2017). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine, 51(6), 519.
• Hoeger Bement, M., Dicapo, J., Rasiarmos, R., & Hunter, S. (2008). Dose response of isometric contractions on pain perception in healthy adults. Medicine and Science in Sports and Exercise, 40(11), 1880-9.