Grimaldi 2014 - Manual - Understanding Tendinopathies of The Hip & Pelvis

Tendon loading paradigm
Maintenance
Catabolism > Catabolism = Anabolism >

Anabolism Anabolism Catabolism
(Tendon Weakens) (Homeostasis) (Tendon Strengthens)
• Compression esp • Regular optimal • Graduated
under tensile load loading increases in tensile
• Stress Shielding loading, allowing
• Excessive tensile time for positive
load - SSC adaptation
Rehabilitation
Tendinopathies of the Hip & Pelvis
Gluteal Proximal Iliopsoas Adductor

Hams & IRGP & ARGP
Copyright Alison Grimaldi 2014 1

Diagnostic
Tests
Management
Gluteal tendinopathy

Clinical Assessment
Pain provocation tests
SLS 30 secs
FABER
Hip FADER
SMT in FADER
Obers
SMT in Neutral & Obers
Palpation
Standing:
Sustained SLS
SLS for 30 seconds
Does pain develop over
the greater trochanter?

Supine:
FABER
Tensile loading of anterior tendons
- Hip flexion, abduction, ER
Not specific to gluteal tendinopathy

Also loads:
- ant hip capsule & assoc labrum
- SIJ
Supine:
FADER
i) Passive compression test in hip F

- Hip flexion 90°
- Hip add to EOR or P1
- ER to EOR or P1
ii) Static muscle test under compressive load in hip F

- Static IR (all Gmed & Min IR at 90°F)
- ‘Don’t let me move you’ from above position
- not necessary if positive at Step i)

Sidely:
Ober’s
Obers
i) Passive compression test in hip neutral
- Hip extension to 0°
- Hip add to EOR or P1
Also provides an indication of soft tissue
length – long or short through lateral structures?
ii) Static muscle test

a. Neutral abd/add
b. Under compressive load in hip add
- Static Abduction
- ‘Push up against me’
- Can use HHD to measure force
exerted to P1
Thorborg
Sidely:
Palpation
Gluteus Medius –Proximal &

Central (Lateral facet)
Gluteus Minimus
Piriformis
(Anterior facet)
12
OI &
9 3
Gamelli Vastus Lateralis
6
QF
Falvey et al 2009

GT: Management
Load Management Exercise Therapy

Decompression Loading the tendons
- as per online content Addressing the underlying
Avoid high tensile loading deficits
- energy storage & release
Load monitoring – 24 hour

response
Exercise therapy
Static Abduction
Supine;Sidelying; Standing
Bridging
Double leg bridge; Offset; Single leg progressions
Functional Retraining
Double leg squats; Offset; Single leg progressions
Dynamic Abductor Loading

Sidestepping
Reformer work – bilateral abduction, and scooter

Static Abduction
Static abduction – GMin & deep Med with no TFL/UGM/VL

Slow & gentle – ramp of activation. Hold 5-10s; 5-10 x; 1-2sets; bd+
Visualise abduction, Preparation for lift
Can preset TA/corset
No physical movement, No pain*
Purpose - motor control – training recruitment phase
- early ‘mechanotherapy’ – stimulate signalling
- assists with pain relief (Bement et al 2008)
Static Abduction
GMIN
ILIUM
HOF

Bridging
Double leg Offset Single foot Single leg Single leg

hover extensions dips
No posterior pelvic tilt – neutral Lx

Preset lower glute max
Progressive increase in GMed activation
Purpose - Lower limb patterning
- Graduated increase in abductor loading
Functional retraining
Double leg Offset Squat Single Leg Single leg Step Up

squat Stance squat
Functional WB progressions
Priority – minimise functional adduction
Progressive increase in GMed activation

Dynamic abductor loading
Skating in Skating in
upright minisquat
Optimal solution for high load training

Spring resisted WB abduction
Allows high tensile load with no compression
Disadvantages ‘ITB tensioners’, so helps shift bias to trochanteric abductors –
GMed & Min
WB – aids stimulus of deeper synergists
Purpose - Supply concentric-eccentric loading
- Hypertrophy GMed & Min
- Graduated tensile load for tendons
- Improve tendon structure, reduce pain
Dynamic abductor loading
Sidestepping Doorway
sideslides
Home alternatives
Sidestepping
- watch trunk posn
- don’t bring feet together, just hip width apart
- focus on a controlled push from the WB side
Sideslides
- pelvis and non-moving leg stay in start position, only move other leg
- avoid overuse of quads

Higher level progressions
Step & land Side shuffles Sidestepping

drills
Graduated increase in speed & power – as appropriate to pts needs
Ensure lower limb control maintained
Introduce slowly – monitor 24 hr response
Purpose – rehabilitate sport specific skills
- graduated exposure of tendon to high energy storage &
release tasks.
AVOID
Tend to aggravate gluteal tendinopathy

May compress/friction tendons
Seem to upregulate superficial synergists; NWB – no proprioceptive stim
High compression risk

AVOID
High compression risk
Avoid aggressive ‘ITB release’
GT: Summary
Primary aetiological mechanism
Compression - GMed/Min tendons & bursae beneath ITB
- Occurs in hip adduction; F/Add
Assessment Management
Complains of pain over GT Settle pain - load Mx key
+/- radiation down lat thigh
- Avoid compression & SSC
Postural & movement habits
exhibiting excessive adduction - Isometrics at 25%MVC
Poor abductor function Optimise kinetic control
Pain on compression +/- SMT Heavy Slow Loading Abductors
TOP over GT Slowly return to power/speed
Sport/needs specific training
Maintain regular tensile loading
Continue to minimise compression

Proximal hamstring
tendinopathy
Clinical Assessment
Standing fwd lean tests

Standing heel drag, shoe off
Puranen-Oravo Test
Bent knee stretch/ MBKS
BKS with active loading
Supine bridge tests
Palpation

Standing:
Standing forward lean
Standing forward lean
Active test moving into compression
+ve – reproduction of pain over ischium +/- thigh pain
Neck F/E to help differentiate SN
Bilateral Unilateral Waiters Bow
HIGH LOAD esp if add Loads SIJ, but pain

step & speed, or load should not be ischial
Standing:
Heel Drag & Shoe Off
Standing Heel Drag
Symptoms of pain/discomfort at
ischium
Bowman et al 2013
Taking Off The Shoe Test

90°ER/20-25°KnF – Biceps Fem
Reiman et al 2013
Modified Taking Off The Shoe Test

Pull heel back against toe of back
foot, hip IR/add & in forward lean
position
* Semimem with tendon compression

Standing:
Puranen-Oravo Test
Stretch forward
Symptoms of pain/discomfort at
ischium
Puranen & Oravo 1988

Cacchio et al 2012
Reiman et al 2013
Supine:
Bent Knee Stretch
Bent Knee Stretch
Passive test
Maximal hip flexion
Then slow knee extension
to EOR or P1
Fredericson et al 2005
Modified Bent Knee Stretch

As above except the examiner
rapidly extends the knee
Take care. Perhaps more
appropriate as an
apprehension test for RTS Cacchio et al 2012
Cacchio et al 2012
Reiman et al 2013

Supine:
BKS + Active Loading
Active load superimposed
on passive compression
i) + SMT knee flexion

- cup hand around heel
ii) + SMT hip extension

- cup hands around arch of foot
ii) + Single leg bridge

Pushing down on examiners shoulder
Supine:
Supine Bridge Tests
Single leg bent knee bridge
Single leg straight leg bridge (plank)
MODERATE LOAD
LOW LOAD
Fredericson et al 2005
Bowman et al 2013
Evaluation of hams pain/weakness

May be too much load for shoulders
Try on hands, or shoulders on step

Semitendinosis
Biceps Femoris
Semimembranosis
Sidely:
Palpation
SM
CO
Copyright
Primal Pictures

PHT: Management


response
Exercise therapy
Static Hams & Glutes

Low load, in hip neutral, slow contract/relax
Graduated Strengthening
Glutes & Hams
Other associated muscle groups

Trunk (abs/multifidus), Hip abd’s & flexors
Functional Retraining/Strengthening

Static Hams & Glutes
Static Kn F Static H Ext Static H Ext or Kn F
In hip neutral initially to minimise compression

Slow ramp of activation to 25% MVC. Hold 10x10s/5x30s, 2-4xday
Can preset TA/corset
No physical movement, No pain*
Purpose - motor control – training onset & offset
- early ‘mechanotherapy’ – stimulate signalling
- Assists with pain relief
Static hams – higher load

Supine

Hamstring curls
May need to start just with leg load for older or v painful pts
Start slow – 3 seconds up and 3 seconds down
Bridging

No posterior pelvic tilt – neutral Lx,

Gently preset lower glute max
- Strengthening glute max and hamstrings

Bridging with higher hamstring bias
Allows more advantageous length tension relationship

for hams
Bridging with higher ecc load

Mid-outer range
- better length-tension relationship
Slow & controlled
Can progress to single leg with care
Start low reps, gradually progress
With band resistance

Nordic Hamstrings – Ecc only
Modified for
lower level
For hamstring tendon pathology

May need to introduce more slowly
Week Sessions Sets & repetitions
Petersen et al 2011, AJSM 39(11) per week
Designed for prevention of 1st week 1 2x3
hamstring muscle tears/reinjury introduced
2 2 2x4
Week Sessions Sets & repetitions
per week 3 2 2x6
1 1 2x5 4 3 3 x 4-6
2 2 2x6 5 3 3 x 6-8
3 3 3 x 6-8
6 3 3 x 8-10
4 3 3 x 8-10
7-12 3 3 sets – 12, 10, 8reps
5-10 3 3 sets – 12, 10, 8reps
10+ 1 3 sets – 12, 10, 8 reps 12+ 1 3 sets – 12, 10, 8 reps
Double leg Offset Squat Single Leg Single leg Split lunge Step Up
squat Stance squat
Minimise functional adduction
Initially minimise depth & forward trunk inclination due to
compression
Purpose - Lower limb patterning – improve fem-pelvic control
- Graduated increase in hip extensor loading

Other associated muscle groups
As Required
Hip abductor strengthening & Hip flexor strengthening &
endurance endurance
Inadequate pelvic control may To improve knee lift, and

result in increased use of thigh enhance ability of hip flexors
musculature to stabilise from
below to provide an increase in
cadence, as required
Address other contributors
Ankle and knee ROM

Calf length
Hip flexor length

AVOID
Hamstring loading in hip flexion
AVOID
Hamstring stretching should be avoided
Cook & Purdam 2012, Lempainen et al 2009
Use massage, trigger point release, acupuncture/needling

PHT: Summary
Compression - Hams tendons *SM against ischium
- Occurs in flexion esp with hams active/on tension
Complains of pain over IschTub Settle pain - load Mx key
+/- radiation down post thigh
- Avoid compression (F) & SSC
Postural & movement habits
exhibiting hip F> triple F - Isometrics at 25%MVC
Increased low load tone Optimise kinetic control
Reduced force generating capacity Heavy Slow Loading Hams/LGM
Usually poor LGM function Slowly return to power/speed
Often poor abd & hip F function Sport/needs specific training
Pain on compression +/- SMT Maintain regular tensile loading
TOP over IT Continue to minimise compression
Iliopsoas tendinopathy
+/- associated bursal impingement

+/- associated labral impingement

Review of presentation
Aggravating activities:
Walking or running
esp long distance & fast pace
Stairclimbing
Lift leg to dress;get in/out car
Sitting in deep chairs
Cough/sneeze
+/- snapping with hip

flexion/extension movements
Clinical Assessment
Standing hip flexion

WB hip extension- Fast gait, long strides, bounding
½ Kneel hip flexor stretch+ SMT
High sitting hip F + SMT
Thomas test + SMT
Ant snapping hip test
Hip Joint Screen:
F/Rotn/Q/Imp/FABER
Palpation

Standing Hip Flexion
Movement Control
Pain? Where?
Standing:
WB hip extension
Walking fast, long strides
Bounding – may be required for athletes
Does the pain occur during WB extension (compression+ tension)

or swing phase flexion
(muscle, tensile load tendon, possible traction)

Standing:
Half kneeling stretch
Stretch into hip extension, then pull knee fwd –
static hip flexion
Reproduction of groin pain

Compression of iliopsoas tendon against *HOF/pelvic brim
Compression vs Traction
Hip Extension Hip Flexion

Tendon Contact with HOF < 15 °F No bony contact after 60 °F
Compression Traction
Iliopsoas Tendon
Iliopectineal bursa If adhesions present
Acetabular labrum Yoshio et al 2002

Sitting:
Sitting static muscle test
Hip flexor static muscle test

Pain? weakness?
Dynamometry
To P1 – evaluate P location
MVC
Thorborg et al 2013
Sitting:
Thomas Test + SMT
i) Passive compression test in hip E
Also provides an indication of soft tissue length – long or

short through anterior structures?
ii) Static muscle test under

compressive load in hip E
- Static flexion –adds tension
- ‘Push up against me’
- If pain increases – may indicate iliopsoas tendinopathy,
+/or labral impingement/jt pathology
- If pain reduces may indicate positive stabilisation of HOF

Supine:
Hip Joint Screen
Hip Flexion
- Active
- Passive
(SMT through range -Tendon/Jt)
Hip Rotation
Quadrant/Impingement
Sensitive but not specific to
joint/labral pathology
Austin et al 2008
Iliopsoas tendon also impinged
by flexion/adduction
FABER
Supine:
Anterior Snapping Hip Test
Passive hip flexion/abduction/ER Active eccentric lowering
Try passively
providing medial
force,
or stabilising
with AP pressure
Preset Tendon is
tendon thought to
lateral to snap
IPE & HOF medially
over IPE or
HOF

Supine:
Anterior Snapping Hip Test
OR….. Tendon rolls over muscle belly &
snaps back down onto pelvic brim
Video kindly supplied

Iliacus by Andrew Wilmot
GE Healthcare,
Australia
Tendon
Mechanism
described by:
Deslandes et al 2008
Winston et al 2007
Try increasing iliacus thickening

& stabilisation of tendon by adding manual resistance
Palpation
IP IP
TFL Fem A S
P
S P TFL
RF
RF
Rohan & Yokochi 1984 Falvey Groin Triangle 2009

IT: Management


response
Exercise therapy
Low load recruitment

IL, TA, PF,
Graduated strengthening
Considering recruitment, range & loads
Dynamic drills
Progressing to velocity specific training
Address other deficits &

Functional strengthening

Low load recruitment
Sartorius
Preparation for lift into flexion

Iliopsoas only, No TFL/Sart/RF TFL
Static holds max 25%MVC
Can also do in sitting Iliacus
HOF
Supine
Standing - avoid compression zones <15°F

- consider traction in higher flexion
High Sitting - WB side – avoid sway/hip ext

In Weightbearing
Start small range

Limit range initially
Gradually may progress into some hip extension
Avoid high load into hip extension
Iliopsoas endurance
Pendulum – 1 sec fwd, 1 sec back

Iliopsoas maintains hip in flexion while biarticular flexors
are involved in knee flexion/extension

Dynamic Drills
Walking A’s
A Skips
Running A’s
Youtube:Tritrainingca
Dynamic Drills
Wall Drills
High knee holds
Switch & hold
Abs & iliopsoas maintain
alignment.
Don’t sag into hip extension
Triple exchange
Sprint intervals – 15 secs, 5-6x,
2-3x/wk

Address other deficits
May have other control issues eg in glutes
Specific retraining to functional strengthening
as required
AVOID
Hip flexor stretching
Completely initially
Modified when resolved
Avoid repetitive, sustained

or loaded hip extension
beyond neutral

IT: Summary
Compression - IT against bursa, labrum, HOF, pelvic brim
- Occurs in <15°F, into extension esp
Snapping/friction - Against pelvic brim/HOF
- ??Tightness or weakness iliopsoas, motor control
Traction - In hip flexion * >60°if adhesions present
Complains of mid-inguinal P Settle pain - load Mx key
+/- radiation ant thigh, abdo, Lx - Avoid compression (Ext), snapping,
Postural & movement habits repetitive flexion esp if traction poss.
exhibiting excessive hip extension - Isometrics at 25%MVC
Substitution strategies TFL,Sart,RF Optimise recruitment/motor control
Heavy Slow Loading Hip flexion
Reduced force generating capacity
Slowly return to power/speed
Often poor abd & hip E function
Sport/needs specific training
Pain on compression +/- SMT Maintain regular tensile loading
Usually TOP over ant hip Continue to minimise compression
Adductor tendinopathy
& adductor related groin pain

Clinical Assessment
WB loading
Thomas test
- PS Stress Tests/SMT’s
Squeeze test – 0, 45, 90°hip flexion
Bent Knee Fall Out
Curl up/ Oblique Curl Up
Palpation
Standing:
Weightbearing loading tasks
Squat, wide squat, split lunge
SLS, SLSquat, Hop

Standing hip flexion
Sideshuffle, Change of direction as appropriate
Assess form
Pain provocation? Where?

Sitting:
Thomas test: PSST’s & SMT’s
Pubic symphysis stress tests & tendon loading tests
i) Muscle length
ii) Passive extension/SMT into F
iii) Passive abd/SMT into add
Pain? Where?
Plus abdo preset
– change symptoms?
(Anthony Hogan)
Supine:
Hip Joint Screen
Hip Flexion
Hip Rotation
Quadrant/Impingement
FABER
Austin et al 2008

Supine:
Squeeze Tests Pain provocation tests
0, 45, 90° flexion – PBU/Sphygmo cuff/Load Cell

MVC or to P1
Good for screening & to monitor progress/provocation
Lovell et al 2012
Supine:
Bent Knee Fall Out Function/Mechanism
Bilateral BKFO
Muscle Tests - Hip Adductors
Or measure fib head distance to

broomstick under legs
Malliaris,Hogan et al 2009
Indication of adductor guarding

May also be limited by other structures eg hip capsule, ant
abductors/internal rotators – Where does pt feel the pull/pain?

Supine:
Abdominal loading tests Function/Pain
Curl up – straight
- oblique + resistance at shoulder
- plus with legs down straight – more compression
Supine:
Palpation Pain provocation test
Supine
1. In unilateral BKFO
Start point: Add longus tendon
- Add longus muscle –guarding?
- Add longus insertion
- Add brevis mm & insertion
- Gracilis
- Add Magnus
- Inferior PS/arcuate lig
- Pectineus (medial to fem pulse)
- Iliacus (lat to fem pulse)
2. Legs neutral, over pillow

Start Point: RA insertion
- PS – Sup, anterior
- Inguinal lig insertion – pub tubercle
- Inguinal lig

Supine:
Falvey 2009 – The Pubic Clock

Superficial
Inguinal Conjoint
Ring Tendon Superficial
Inguinal RA
RA Ring
Inguinal PS
Inguinal
Lig
Lig
AL
PS
AL Pubic
Tubercle
Supine:
IL
Pect
Pect AL
AB
AL
AM
Gracilis
Rohan & Yokochi 1984

Supine:
Grays
Anatomy
ARGP: Management


response

Exercise therapy
Adductor & trunk recruitment

Start Low load, slow CR – Add, TA, PF, MT
Gluteal retraining
Glute Min, Med & Max
Iliopsoas retraining/strengthening
Coronal plane load adductor training
Adductor & Trunk Recruitment
Gentle adductor contract/relax

Aims - gentle tensile input into tendon
- teach low load offset
- assist with pain relief
- 25% MVC
Deep trunk muscle retraining as required
- TA, PF, MT
- start low load postures – supine, prone
- move to upright postures

Gluteal retraining
Early recruitment exercises as required
Static Abduction Bridge prep – bilat bridge

Glute Min/deep Med Glute Max
Belt may be required to rest
against to reduce adductor
gripping
Bridge progressions

No posterior pelvic tilt – neutral Lx

Preset lower glute max
Purpose – Pelvic control & lower limb patterning
- Graduated increase in pelvic & lower limb loading
May require belt around knees in earlier levels, depending on
adductor gripping

Double leg Offset Squat Single Leg Single leg Step Up

squat Stance squat
Purpose – Pelvic control & lower limb patterning

Hip flexor progressions
Static hip flexion – preparation for lift

Ensure ideal early recruitment – Iliacus initiates. Adductor longus
relaxed
May need belt around knees to completely let adductors go
Aim - restore normal muscle patterning
- restore more appropriate AL low load behaviour
Graduated higher load progressions – As for IT, beware of loading into hip
extension due to compression adductor longus tendon

Higher level abdominal loading
Curls Leg loading Folding Knife - Holmich

+ Ball Squeeze ?? Inappropriately high levels of activity for the task?
Bent Knee Fall Outs

Oblique loading &
Ecc/conc adductors
Higher level abdominal loading
As appropriate for patients needs

Beware with any co-existing shoulder pathologies/weakness
Dynamic control rather than rigid stability

Loading adductors in coronal plane
Test tolerance with low reps first

Start with small range, mid-inner
(outer range, greater compressive loading under tension)
On abduction phase focus on allowing the muscle to lengthen
‘visualise lengthening’
C/R; massage after to ensure adductors let go
Alternative – slide mat with band resistance
Star training
Star steps
Start low load
- Increase reps
- Increase depth
- Increase complexity
- Increase speed
Step & Land

Start low reps, ht, velocity
- Increase reps
- Increase height/power
- Increase speed

Return to running
Walk programme first
- avoid overstriding, soft impact
- build to 30-45 mins
Introduce run intervals when:

- walking is painfree
- painfree squeeze
- (If PS involvement, painfree PSST’s)
- nil/minimal adductor guarding
Start with RTJogging, progress to RTSprint as required

- monitor 24 hour pain response & squeeze test
- <3/10 pain during & quickly eases off, no morning pain or stiffness,
squeeze test remains painfree & recovers to pre-run level – ok to continue
- If not didn’t cope – response will determine delay in next trial
- Also check guarding – reduced BKFO, inability to turn off indicates didn’t
cope well, not ready
Return to Sprint
Anthony Hogan Programme – Run Through Drills
10-20m 10-20m
60-80metres @ 60-70% max speed
acceleration deceleration
10-12 reps
Walk recovery
Rest Repeat 3 x over a week

Didn’t cope Coped to establish consistent
& Reconsider
response
Increase reps
2-3/session to 20
60-70% max @ 80-90% 60-70% max

Reduce Mid 20-30m Reduce
distance to distance to
accelerate decelerate

Return to COD Sports
Tyler et al 2001: Strength Ratio’s Only when painfree
Should not RTS unless:
Left : Right Ratio
Should not be > 10%
difference add strength
between sides
Abductor : Adductor Ratio Thorborg et al 2010

Adductor strength should not
be < 80% of abductor
strength
Sidely or Supine:
Muscle Strength Tests
Only when painfree, or test
Side Lying or Supine only to P1
Thorborg
et al 2010
Krause et al 2007- Sidelying more reliable

Thorborg et al 2010 – Supine more reliable -held on with hands
Make (isometric) or Break (eccentric)(Sisto & Dyson-Hudson 2007)

Eccentric produces greater force, may be more sensitive to
deficits but greater risk of injury or pain aggravation
(Thorborg et al 2010)

Sports Specific Drills
Dancers - Bar class initially avoiding:
end range extension or abduction
deep plie’s esp in 2nd
fast closing movement
Football codes/field sports – once coping well with straight line run
- Side shuffles
- Side stepping drills
- Weave
- Figure of 8’s
- Zig Zag - predictable
- COD – unpredictable (whistle)
Kicking – Introduce last
- Start small range controlled direction
- Monitor & control volume
- not when pre-fatigued
AVOID
No stretching into hip extension or abduction

Holmich et al 1999: Stretching not necessary to achieve
increases in ROM and may provoke the condition
Use massage, self massage, needling, Contract/Relax

ARGP: Summary
Compression - AL tendon against pubic ramus
- Occurs in hip abduction & extension
Tensile overload – Large forces across adductor-abdominal couple
Complains of medial groin P Settle pain - load Mx key
+/- radiation down med thigh - Avoid compression (Ext/Abd) & SSC
Postural & movement habits - Isometrics at 25%MVC only
exhibiting excessive extension Optimise kinetic control
High volume adductor loading Strengthen glutes & flexors 1st
through ext & abduction Heavy Slow Loading Adductors in
Increased low load tone coronal plane as pain settles
Reduced force generating capacity Slowly return to power/speed
Often co-existing inadequate Sport/needs specific training
function hip F, abd, extensors Straight line run before COD
May have reduced hip ROM esp Rot Continue to minimise compression
Pain on Squeeze test +/- TT & optimise mm function & ROM
around pelvis
TOP over Add tendon/origin
Thank You
For further information
e: info@physiotec.com
Online Learning/Courses:
www.dralisongrimaldi.com

Grimaldi 2014 - Manual - Understanding Tendinopathies of The Hip & Pelvis

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Tendon loading paradigm

Catabolism > Catabolism = Anabolism >

Tendinopathies of the Hip & Pelvis

Gluteal Proximal Iliopsoas Adductor

Copyright Alison Grimaldi 2014 1

Copyright Alison Grimaldi 2014 2

Copyright Alison Grimaldi 2014 3

Not specific to gluteal tendinopathy

i) Passive compression test in hip F

ii) Static muscle test under compressive load in hip F

Copyright Alison Grimaldi 2014 4

ii) Static muscle test

Gluteus Medius –Proximal &

Copyright Alison Grimaldi 2014 5

Load Management Exercise Therapy

Load monitoring – 24 hour

Dynamic Abductor Loading

Copyright Alison Grimaldi 2014 6

Static abduction – GMin & deep Med with no TFL/UGM/VL

Copyright Alison Grimaldi 2014 7

Double leg Offset Single foot Single leg Single leg

No posterior pelvic tilt – neutral Lx

Double leg Offset Squat Single Leg Single leg Step Up

Copyright Alison Grimaldi 2014 8

Optimal solution for high load training

Dynamic abductor loading

Copyright Alison Grimaldi 2014 9

Step & land Side shuffles Sidestepping

Tend to aggravate gluteal tendinopathy

High compression risk

Copyright Alison Grimaldi 2014 10

High compression risk

Avoid aggressive ‘ITB release’

Copyright Alison Grimaldi 2014 11

Standing fwd lean tests

Copyright Alison Grimaldi 2014 12

HIGH LOAD esp if add Loads SIJ, but pain

Taking Off The Shoe Test

Modified Taking Off The Shoe Test

Copyright Alison Grimaldi 2014 13

Puranen & Oravo 1988

Modified Bent Knee Stretch

Copyright Alison Grimaldi 2014 14

i) + SMT knee flexion

ii) + SMT hip extension

ii) + Single leg bridge

Evaluation of hams pain/weakness

Copyright Alison Grimaldi 2014 15

Copyright Alison Grimaldi 2014 16

Load Management Exercise Therapy

Load monitoring – 24 hour

Static Hams & Glutes

Other associated muscle groups

Copyright Alison Grimaldi 2014 17

Static Kn F Static H Ext Static H Ext or Kn F

In hip neutral initially to minimise compression

Static hams – higher load

Copyright Alison Grimaldi 2014 18

Double leg Offset Single foot Single leg Single leg

No posterior pelvic tilt – neutral Lx,

Copyright Alison Grimaldi 2014 19

Allows more advantageous length tension relationship

Bridging with higher ecc load