Few studies have investigated the physical impairments in individuals with GT. This study investigated hip abductor muscle strength because of the involvement of the hip abductor muscle tendons in GT. The results of this study demonstrated significant weaker hip abductor muscles, bilaterally, in individuals with unilateral GT than those of healthy asymptomatic controls. Strength differences were also apparent between the symptomatic and asymptomatic hip in individuals with unilateral GT, although the difference between limbs was smaller than the difference between groups.
Several case studies of GT have reported reduced cross-sectional area (atrophy) of the gluteus medius (17,43,52) and minimus (43) muscles on the basis of visual report of a radiologist in the presence of MRI-confirmed symptomatic gluteal tendon pathology. Atrophy of these muscles would contribute to hip abductor weakness in GT. Similarly, in studies of hip osteoarthritis, unilateral gluteus medius muscle atrophy is consistently reported as the mechanism underpinning hip abductor weakness when contrasted to the asymptomatic side (36). Limited evidence for gluteal muscle atrophy in GT precludes conclusions regarding whether muscle atrophy is unilateral, whether it is a consistent feature of GT, or whether atrophy precedes or results from GT. However, it is plausible that gluteal muscle atrophy and hip abductor weakness could result from unilateral symptomatic GT as a result of disuse or inhibition of these muscles in the presence of lateral hip pain, particularly given the typically chronic nature of the condition and aggravation of symptoms with day-to-day activities such as walking and stair climbing (9,53). Certainly, reduced physical activity has been reported in individuals with GT (21), and this could underpin more widespread muscle wasting including the presentation of bilateral hip abductor weakness.
This study has some limitations. As the present study had a cross-sectional design, it cannot be ascertained whether hip abductor weakness is a consequence of GT and/or a precipitating factor for its development. Further research is required to establish this relationship and how it might affect management of GT. Although participants in the present study were recruited from the general public and met a minimum severity of lateral hip pain, we did not ascertain whether participants were seeking treatment and so we would suggest that caution must be used in this regard when inferring to patients attending a health care clinic. We did not have available data to compare physical activity levels between groups, so although the groups were matched for age and gender, varying physical activity levels might have influenced the results. However, given that hip pain in GT is typically reproduced with weight-bearing activities (21,48), individuals with GT are likely to have negative or altered responses to physical activity that might differ from those of healthy controls. Regardless of physical activity level, our results suggest that strengthening exercises may be indicated for individuals with GT.
The study was supported by a National Health Research and Medical Research Council Program Grant held by Prof. Kim Bennell, Prof. Paul Hodges, and Prof. Bill Vicenzino. No other financial support or benefits from commercial sources were associated with any part of this study or article.
The authors declare no conflicts of interest.
The results of the present study do not constitute endorsement by the American College of Sports Medicine.
1. Al-Hayani A. The functional anatomy of hip
abductors. Folia Morphol (Warsz)
. 2009; 68(2): 98–103.
2. Albers S, Zwerver J, van Den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in the general population. Br J Sports Med
. 2014; 48(S2): A5.
3. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med
. 2003; 22: 703–10.
4. Anderson TP. Trochanteric bursitis: diagnostic criteria and clinical significance. Arch Phys Med Rehabil
. 1958; 39(10): 617–22.
5. Andersson G, Danielson P, Alfredson H, Forsgren S. Presence of substance P and the neurokinin-1 receptor in tenocytes of the human Achilles tendon. Regul Pept
. 2008; 150(1–3): 81–7.
6. Barnthouse NC, Wente TM, Voos JE. Greater trochanteric pain
syndrome: endoscopic treatment options. Oper Techn Sports Med
. 2012; 20(4): 320–4.
7. Benjamin M, Ralphs JR. Fibrocartilage in tendons and ligaments—an adaptation to compressive load. J Anat
. 1998; 193(Pt 4): 481–94.
8. Berthelot JM, Potaux F, Alliaume C, Prost A, Maugars Y. A case of hip
rotator cuff tear revealed by refractory gluteus medius tendinosis. Joint Bone Spine
. 2001; 68(4): 360–3.
9. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain
syndrome. Arthritis Rheum
. 2001; 44(9): 2138–45.
10. Birnbaum K, Siebert CH, Pandorf T, Schopphoff E, Prescher A, Niethard FU. Anatomical and biomechanical investigations of the iliotibial tract. Surg Radiol Anat
. 2004; 26(6): 433–46.
11. Birnbaum K, Pandorf T. Finite element model of the proximal femur under consideration of the hip
centralizing forces of the iliotibial tract. Clin Biomech (Bristol, Avon)
. 2011; 26(1): 58–64.
12. Bjur D, Danielson P, Alfredson H, Forsgren S. Immunohistochemical and in situ hybridization observations favor a local catecholamine production in the human Achilles tendon. Histol Histopathol
. 2008; 23(2): 197–208.
13. Bjur D, Danielson P, Alfredson H, Forsgren S. Presence of a non-neuronal cholinergic system and occurrence of up- and down-regulation in expression of M2 muscarinic acetylcholine receptors: new aspects of importance regarding Achilles tendon tendinosis (tendinopathy). Cell Tissue Res
. 2008; 331(2): 385–400.
14. Blankenbaker DG, Ullrick SR, Davis KW, De Smet AA, Haaland B, Fine JP. Correlation of MRI findings with clinical findings of trochanteric pain syndrome. Skeletal Radiol
. 2008; 37(10): 903–9.
15. Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain
syndrome: a randomized controlled trial in primary care. Ann Fam Med
. 2011; 9(3): 226–34.
16. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med
. 2012; 46(3): 163–8.
17. Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI diagnosis of tears of the hip
abductor tendons (gluteus medius and gluteus minimus). AJR Am J Roentgenol
. 2004; 182(1): 137–43.
18. Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain
syndrome: a systematic review. Br Med Bull
. 2012; 102: 115–31.
19. Dougherty C, Dougherty JJ. Managing and preventing hip
pathology in trochanteric pain syndrome: treatment often is directed toward conservative measures. J Musculoskeletal Med
. 2008; 25(11): 521.
20. Fearon A, Stephens S, Cook J, et al. The relationship of femoral neck shaft angle and adiposity to greater trochanteric pain
syndrome in women. A case control morphology and anthropometric study. Br J Sports Med
. 2012; 46(12): 888–92.
21. Fearon AM, Cook JL, Scarvell JM, Neeman T, Cormick W, Smith PN. Greater trochanteric pain
syndrome negatively affects work, physical activity and quality of life: a case control study. J Arthroplasty
. 2014; 29(2): 383–6.
22. Fearon AM, Scarvell JM, Neeman T, Cook JL, Cormick W, Smith PN. Greater trochanteric pain
syndrome: defining the clinical syndrome. Br J Sports Med
. 2013; 47(10): 649–53.
23. Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain
syndrome. Am J Sports Med
. 2009; 37(9): 1806–13.
24. Gaida JE, Ashe MC, Bass SL, Cook JL. Is adiposity an under-recognized risk factor for tendinopathy? A systematic review. Arthritis Rheum
. 2009; 61(6): 840–9.
25. Grimaldi A. Assessing lateral stability of the hip
and pelvis. Man Ther
. 2011; 16(1): 26–32.
26. Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med
. 2015; 45(8): 1107–19.
27. Grimaldi A, Mellor R, Vicenzino B, Bennell K, Hodges P. Gluteal tendinopathy: clinical diagnosis vs MRI diagnosis. Br J Sports Med
. 2014; 48(S2): A43.
28. Hardcastle P, Nade S. The significance of the Trendelenburg test. J Bone Joint Surg Br
. 1985; 67: 741–6.
29. Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med
. 2011; 21(6): 540–1.
30. Heales LJ, Lim EC, Hodges PW, Vicenzino B. Sensory and motor deficits exist on the non-injured side of patients with unilateral tendon pain and disability—implications for central nervous system involvement: a systematic review with meta-analysis. Br J Sports Med
. 2014; 48(19): 1400–6.
31. Hollman JH, Ginos BE, Kozuchowski J, Vaughn AS, Krause DA, Youdas JW. Relationships between knee valgus, hip
, and hip
-muscle recruitment during a single-limb step-down. J Sport Rehabil
. 2009; 18(1): 104–17.
32. Jaric S, Mirkov D, Markovic G. Normalizing physical performance tests for body size: a proposal for standardization. J Strength Cond Res
. 2005; 19(2): 467–74.
33. Kendall F, McCreary E, Provance P. Muscles: Testing and Function
. Baltimore (MD): Williams & Wilkins; 1993.
34. Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy—a systematic review of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc
. 2012; 20(8): 1632–46.
35. Lequesne M, Mathieu P, Vuillemin-Bodaghi V, Bard H, Djian P. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Rheum
. 2008; 59(2): 241–6.
36. Loureiro A, Mills PM, Barrett RS. Muscle weakness in hip
osteoarthritis: a systematic review. Arthritis Care Res (Hoboken)
. 2013; 65(3): 340–52.
37. Martin RL, Sekiya Jk. The interrater reliability of 4 clinical tests used to assess individuals with musculoskeletal hip
pain. J Orthop Sports Phys Ther
. 2008; 38(2): 71–7.
38. Martin RL, Irrgang JJ, Sekiya JK. The diagnostic accuracy of a clinical examination in determining intra-articular hip
pain for potential hip
arthroscopy candidates. Arthroscopy
. 2008; 24(9): 1013–8.
39. McLeish RD, Charnley J. Abduction forces in the one-legged stance. J Biomech
. 1970; 3: 191–209.
40. McMahon SE, Smith TO, Hing CB. A systematic review of imaging modalities in the diagnosis of greater trochanteric pain
syndrome. Musculoskeletal Care
. 2012; 10(4): 232–9.
41. Mitchell B, McCrory P, Brukner P, O’Donnell J, Colson E, Howells R. Hip
joint pathology: clinical presentation and correlation between magnetic resonance arthrography, ultrasound, and arthroscopic findings in 25 consecutive cases. Clin J Sport Med
. 2003; 13(3): 152–6.
42. Oakley SP, Bird P, Kirkham BW. Gluteus medius (GM) tears presenting as the clinical syndrome of trochanteric bursitis. Arthritis Rheumatism
. 1999; 42(9): S340–S.
43. Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip
arthroplasty in asymptomatic and symptomatic patients. Radiology
. 2005; 235(3): 969–76.
44. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther
. 2003; 33(11): 639–46.
45. Pua YH, Wrigley TV, Cowan SM, Bennell KL. Intrarater test-retest reliability of hip
range of motion and hip
measurements in persons with hip
osteoarthritis. Arch Phys Med Rehabil
. 2008; 89(6): 1146–54.
46. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med
. 2009; 37(10): 1981–90.
47. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med
. 2013; 47(9): 536–44.
48. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain
syndrome: epidemiology and associated factors. Arch Phys Med Rehabil
. 2007; 88(8): 988–92.
49. Shbeeb MI, O’Duffy JD, Michet CJ Jr, O’Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol
. 1996; 23(12): 2104–6.
50. Spear IM, Lipscomb PR. Noninfectious trochanteric bursitis and peritendinitis. Surg Clin North Am
. 1952: 1217–24.
51. Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Søballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop
. 2009; 80(3): 314–8.
52. Walsh G. MRI in greater trochanter pain syndrome. Australas Radiol
. 2003; 47(1): 85–7.
53. Woodley SJ, Nicholson HD, Livingstone V, et al. Lateral hip
pain: findings from magnetic resonance smaging and clinical examination. J Orthop Sports Phys Ther
. 2008; 38(6): 313–28.