Gluteal Medius Tendinosis and Illiopsoas Bursitis

Hi,

I have been suffering from hip pain for the last 6 years. I finally got some MRI results last week that said "illiopsoas bursitis" and "gluteal medius tendinosis".

I used to run and suspect that nursing an Achilles injury for years has caused this.

How would you treat? My thoughts are:

1, illiopsoas bursitis - just light stretching?

2, gluteal medius tendinosis - eccentrics, stretching, cross friction massage and ice.
For eccentric I was thinking of doing monster walks, with a theraband, using the good leg to load, then slowly adducting the effected side?

Exercise, should I be doing anything or resting completely? At what stage could I cycle and hillwalk?

Thoughts? Anything else I could be doing?


Should I be doing concentric work as well? Or just eccentric?


Thanks,

Mick

You have come up with a reasonable plan the busa would probably benefit from passive release & icing.

Either way you are focusing on MRI results but not why you have this problem.

Really I would be looking at your pelvic tilt you will either have a posteriorly tilted pelvis (tight buttocks and flat tummy) and a reduced lordosis or a anterior tilted pelvics (weak buttocks and weak abs)

My bet is the former.

Either way it's a complicated condition that will require specific massage release, pelvic manipulation, rehab and relearning of a no doubt disturbed gait pattern. All this will need constant guidance and reviews as well as hands on therapy for long term recovery.

Hope that helps

Thanks, I agree with the anterior tilted pelvis and my gait is definitely disturbed. I suspect that an Achillies problem on the other leg, has cause me to overuse this side.

I am concentrating on getting rid of the gluteal medius tendinosis, since this is the biggest cause of my pain. I'm just not certain how to do this, at the moment I am trying to load it eccentrically, but not sure the best way to do this, or if this is the correct initial step.

I also suspect my glutes are weak/inactive, so will be working on strengthening/activating them once my tendinosis has improved.

Eccentric work is a good call for larger tendon bodies (Achilles and petella) however eccentric loading is normally how you tendon is caused. Rather than over use it tends to come from poor activation.
Foam rolling is probably better it will loosen muscles de stressing the tendon. If that does work the tendon can be stimulate with ESWT.

The psoas m is best treated with passive release therapy.

Both areas should be rested and iced.

Muscles bellies will respond to heat although psoas m is going to be hard to get focused heat into.

Hope that helps

Hi MickyBee, thanks for your post. I suppose we need to know a little about how recently you were doing sport/activities that would have lead to this situation. A diagnosis of a bursitis should have a route cause but if you have not been running for some time then this should have resolved by now. If not (e.g. a more persistent chronic bursitis) it could be perhaps nudged along in some way.

A problematic achilles would indeed lead to altered and assymetrical mechanics when running that could give rise to all sorts of issues (hip/knee/sacral/low back etc) and unlocking that chain of movement would be wanted to achieve the best possible outcome. This means that whilst your symptoms are in one area, the problem in the chain is elsewhere and we need to find that/those areas. A six year history means there could well be some incidental findings that also may be the result of reactive changes rather than mechanical insufficiencies driving your problem.

I would want to go to a local physio for a thorough assessment of range of motion, symmetry, mobility of your body as it is now. We can then look at a 'problem' list with particular interest in asymmetry (where right side does not equal left side). In the end your symptoms will be the subjective feedback to show if the treatment and rehabilitation approach is working. i.e. we don't want to temporarily mask the pain only to leave the culprit that was causing it alive and well.

Let us know more details as you find them. :-)

Thanks,

1. "how recently you were doing sport/activities"

I have tried to restart running several times over this period, but have always stopped because of peroneal/achillies pain (left side - opposite to hip problems), my opinion is that my pelvis was dropping on the left, causing my foot to crossover. I notice this when I walk occasionally, my left foot feels to far over, sometimes causing me to overbalance. I had a volume injection in my achillies last year, so was attempting to run again, before I got these results.
Videos of me running show I wobble from side to side, a bit like Trendelenburg gait.

Even when not running I am active, mountain biking and hillwalking. I guess walking up mountains with a rucksack will not help my tendonosis. I have never tried complete rest, mainly because I never had a proper diagnosis.

I also have herniated L4/L5 and previously had some sciatica like symptoms on my right side (the one with hip pain).

2, "a local physio"

I have seen several, they mainly find:
Everything is tighter on my right side
Hip flexors
Hamstring
Glutes
Quad

They suggest stretching hip flexors and glutes.

Hip impingement has also been suggested, but orthopaedic consultant has looked at x-rays and MRIs and ruled this out. I did try some Mulligan distraction, but this did not help.

I saw one earlier this week that suggested working on glute activation and strength. progressively loading (concentric and eccentric) my tendinosis.

I am seeing a different one this morning so may report back later. Is there anyone you would recommend, in the Staffs/Cheshire area?

Thanks,

Mick

What side is the bursa and the tendonitis?

As a disc bugle never goes way we know two things:

There is likely some compensatory limp and lean

Second the L5 nerve root may still have slow conduction. This indicates a impingement and reduced nerve flow to feed the glut med muscle.

Long story short you might have a unfixable nerve impingement that you might need to modify your activities around. Reduce running and jump activities ad opt for cyclic ones (avoid cycling shoes)

If you had it sometime ago and didn't go through go rehab for the lower back - it is possible that you have develop and antalgic scoliosis. With you current symptoms I would say this is very very likely.

The condition wont be solved until you look at whole function of spine and pelvic girdle.

Get a x-ray done of the lumbar pelvic region to determine state of scoliosis and corresponding hip tilt.

Ok, just seen someone else this morning.

He got me doing one leg tests:
Standing on one leg - I could do without problem

Jumping off a step and landing on one leg:
I did ok on my "good side" (left)
on my "bad side" (right) my left hip drops and I lean over to the right to balance.

This feels like what I do when I run.

He advised that I do:
hip hikes, focussing on endurance by holding at the top
jump forward onto one leg, trying to keep pelvis level
stretch psoas

He also did some dry needling in my glutes.


Back
When I had my back problems, I did Mckenzie exercises which seemed to help.
The MRI said (2010)
At L4/5, broad-based central protrusion is noted indenting the anterior theca. No compression to transiting or exiting nerve roots.
At L5/S1, minor central bulge is noted with annular tear, No canal/foramina narrowing.

Its good you considered getting a second opinion and do perform the exercises suggested by the the doc.

Progress update 1 week of doing prescribed exercises:

When doing hip hikes and mini lunges my left (uninjured side) is significantly weaker than my right
When I single leg stand on my right, everything looks and feels good.
When I try on my left, my body shifts out over my foot (to the left), if I squeeze my glute, this almost corrects it.

Right glute medius is still sore, especially when the waistband of my trousers presses on it.

Not done any other exercise all week.

Just been to see physio again, he wants me to continue the strengthening exercises for another couple of weeks, then see him again.

Thoughts:
I feel that sorting my glutes out will address the cause of my problems, but I am concerned that I am still not doing anything to fix the tendinosis.

Slight update here: Gluteal Tendinosis Rehab | Will I run after a tendinopathy?

Just wondering what I should be doing for my psoas bursitis? Just stretch and icing?

I recommend this article about gluteal tendinopathy: Gluteal Tendinopathy | RunningPhysio

Not made any progress with Physio so getting steriod injection in bursa and glute med.

Thanks for the further update. As you know this might address pain, and perhaps a chronic inflammation that need not be that way, but nothing in relation to the causes. Of course you have been doing a lot to address that. Long term though you need to have a video assessment of your running (shirt off and at the time of symptom provocation) to see what is really happening and how assessment and assistance of your foot mechanics might help. Often the non-painful side is the issue and some of your comments do suggest issues in that area. Deep tissue massage to the glutemedius is usually beneficial to reduce pain in that area however I can't help agreeing with nmarman that the issue might have a chronic lumbar spine connection as well.

Let us know how you get on 4-6 weeks post injections and best of luck.

I totally agree, treating symptoms not the cause.

"Long term though you need to have a video assessment of your running"

I agree again, can you recommend anyone? I live in Staffordshire but will travel.

Not created any improvement with Physiotherapist so getting steriod hypodermic injection in bursa and glute med.

Hi,

I have had injections into my psoas bursa and great trochancter bursa.

Is there anyone in the UK who could help me?

Mick

Hi,

I am still really struggling with this. Can anyone offer further advise or recommend anyone i can get an appointment with?

Mick

Hi,

I am still struggling with this. I still have chronic anterior hip pain as well as adductor pain.

I am not able to walk at all without aggravating my symptoms.

Is there anyone in the UK who can help, or suggest anyone?

Mick