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
Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vincenzino B. Br J Sports Med. 2018 Nov;52(22):1464-1472. doi: 10.1136/bjsports-2018-k1662rep.
Take Home Message: Exercise with education or a corticosteroid injection led to superior patient-reported outcomes among people with gluteal tendinopathy compared to a wait-and-see approach. Exercise and education resulted in the greatest perceived improvements and is a viable choice for treating these patients.
Gluteal tendinopathies are often treated either conservatively with hip strengthening and stabilizing exercises or with corticosteroid injections. Though previous studies have compared injections with “wait and see” approaches, the authors were interested in looking at how an education with exercise would influence patient-reported outcome measures. Therefore, the authors conducted a randomized controlled trial to compare 204 patients’ global and pain outcomes up to 52 weeks following one of 3 treatment strategies: 1) education plus exercise, 2) a corticosteroid injection, and 3) “wait and see”. The education plus exercise group attended a 60-minute baseline session and received handouts and DVDs on appropriate tendon loading. They also attended 14 sessions of supervised rehabilitation along with 4-6 home-based hip strengthening and dynamic control home-exercises, which they performed daily for 8 weeks. The corticosteroid injection group was given a single dose at baseline, and the “wait and see” group received general information from a physiotherapist. A physiotherapist (blinded to group) collected the primary outcomes of global rating of change and pain intensity periodically up to 52 weeks after starting treatment. Overall, 93% of participants completed all evaluations. About 77% of participants completing the education with exercise intervention had a successful outcome (global rating of being at least moderately better) compared with 59% for participants receiving a corticosteroid injection and only 29% for the “wait-and see” group at 8 weeks. The numbers needed to treat for successful outcomes compared to the “wait and see” group was 2 patients for education plus exercise, and 3.4 patients for an injection. The intervention groups also reported less pain than the “wait and see” group. At the 52-week follow-up, 79% of participants who completed the education with exercise had success compared with 59% of the injection group and 52% in the “wait-and-see” group. Pain outcomes at this point were lower than the control group for both intervention groups.
In all, the authors performed a high-quality, longitudinal study to investigate the effects of common clinical approaches to treating gluteal tendinopathy. Although the authors found the two interventions improved patient outcomes compared to the control group, the education with exercise benefits held up well over the next 12 months while the injection and control group had similar success rates after 1 year. This complements otherstudies where researchers showed that corticosteroid injections may only provide short-term benefits. This study importantly showed that education plus exercise may be a more beneficial approach to treating patients with gluteal tendinopathy for long-term outcomes. This information is promising because the exercises targeted the source of the pathology by reducing excessive tendon loading. Thus, abductor strengthening, adductor dynamic control exercises and activity modification instructions to address loading should be clinically considered as a management option for gluteal tendinopathy treatment.
Questions for Discussion: What management approaches have you implemented for your gluteal tendinopathy patients? Do you include other muscle groups into your exercise protocol for managing hip pain? What activity modifications do you suggest for gluteal tendinopathy to address tendon loading?
Written By: Alexandra F. DeJong
Reviewed By: Jeffrey Driban