Find solutions for gluteus medius tendinopathy with chiropractic care that enhances your comfort and mobility.
Abstract
Welcome to our educational series. I am Dr. Alex Jimenez, and I am honored to guide you through a comprehensive exploration of a very common yet often misunderstood condition: gluteus medius tendinopathy. This condition is a frequent cause of lateral hip pain, often misdiagnosed as trochanteric bursitis. In this post, we’ll take a detailed look at a real-world clinical scenario involving a 57-year-old gentleman who presented to our clinic with persistent left hip pain. We will use his case to deconstruct the diagnostic process, from precise anatomical palpation to confirming the pain source. Following this, we will delve deep into the anatomy and biomechanics of the gluteus medius muscle and its tendon, understanding its pivotal role in pelvic stability and gait. We will explore the pathophysiology of tendinopathy, moving beyond the outdated concept of “tendinitis” to embrace the modern understanding of tendinosis—a degenerative process characterized by cellular and matrix disorganization.
This discussion will be grounded in the latest scientific evidence, drawing on findings from leading researchers using modern, evidence-based methods to understand and treat musculoskeletal conditions. We will dissect the intricate cascade of cellular events that lead to tendon breakdown and explain why traditional anti-inflammatory treatments often fall short. A significant portion of this post outlines a sophisticated, multifaceted treatment strategy. We will detail the rationale and application of diagnostic and therapeutic injections, such as the one performed in our case study, explaining how they serve to both confirm a diagnosis and provide immediate, albeit temporary, relief. More importantly, we will transition to the core of our integrative treatment philosophy. I will explain how our unique practice model at Injury Medical Clinic PA in El Paso, Texas, combines expertise from multiple disciplines to foster true healing.
I am privileged to work alongside Dr. Maria Guadalupe Cardenas, MD, a board-certified internist with over four decades of experience, who serves as our Medical Director and Collaborative Physician. Our multidisciplinary setup allows seamless integration of the chiropractic care I provide under Dr. Cardenas’s medical oversight. We will explore how integrative chiropractic care plays a crucial role in addressing the biomechanical dysfunctions that underpin conditions like gluteus medius tendinopathy. We will cover specific chiropractic adjustments, soft tissue mobilization techniques, and functional rehabilitation protocols designed to restore proper joint mechanics, alleviate muscular imbalances, and retrain movement patterns. We will also explore functional medicine principles, nutritional interventions that support tendon health, and advanced rehabilitation strategies that progressively load the tendon to stimulate regeneration and restore its load-bearing capacity. Our goal is to provide a definitive, easy-to-understand resource that explains the “what” and “why” of gluteus medius pain and illuminates a clear path to lasting recovery through an integrated, patient-centered approach.
A Clinical Encounter: Identifying the True Source of Hip Pain
On the morning of September 15, 2026, a 57-year-old gentleman walked into our clinic, discomfort etched on his face. He had been grappling with a persistent pain in his left hip for two months, a nagging ache that was beginning to impact his quality of life significantly. As a clinician, my first and most critical task is to listen—to understand the story the patient’s body is telling. His pain description was specific. He pointed not to the front of his hip, nor the groin, but to an area just behind and slightly above the prominent bone on the side of his hip. This bony landmark is the greater trochanter of the femur, a large, bony knob that serves as a crucial attachment site for several powerful hip muscles.
His location immediately steered my diagnostic thoughts away from common intra-articular hip problems like osteoarthritis and toward the soft tissues surrounding the joint—the muscles, tendons, and bursae. This region is often referred to collectively as the “lateral hip,” and pain here is frequently given the blanket diagnosis of “trochanteric bursitis.” However, decades of clinical experience and a wealth of modern research have taught us that this label is often inaccurate. In many cases, the true culprit isn’t an inflamed bursa but a distressed tendon.
The Power of Precise Palpation
To confirm my suspicions, I began the physical examination. The goal was to replicate his exact pain with precise, targeted pressure. This is a fundamental diagnostic technique. If I can reproduce the patient’s specific “concordant sign”—the very pain that brought them to the clinic—with a specific maneuver or palpation, I can be much more confident in my diagnosis.
I had him lie on his side and began palpating the area around the greater trochanter. I started by gently pressing on the trochanter itself. He reported no significant pain there. Then I moved my fingers slightly posterior and superior, as he described.
“Any pain right there?” I asked, applying firm, focused pressure.
“Some,” he replied hesitantly; it wasn’t quite it.
I adjusted my position slightly, moving a little further down, probing the tissue. “How about here?”
“Right there,” he said, his body tensing. “Right in there.”
The critical question followed: “Does that exactly replicate the pain that you’re having today?”
“Slowly, yes,” he confirmed. “Yes.”
This was our eureka moment. We had found it—the epicenter of his discomfort. The area I was pressing corresponded perfectly with the gluteus medius tendon’s insertion point. This is not the large, fleshy part of the buttock muscle (that’s primarily the gluteus maximus), but a smaller, fan-shaped muscle located on the outer surface of the pelvis, whose tendon wraps around to attach to the greater trochanter. This muscle is a powerhouse of hip stability, and when its tendon becomes pathological, it can be a significant source of pain.
Having located the precise spot, I took out a surgical marker and drew a small “X” on his skin. This mark would serve as our target. We had a strong clinical diagnosis: gluteus medius tendinopathy. The next step was to confirm this diagnosis while also providing immediate relief. The plan was to perform a diagnostic and therapeutic injection into the gluteus medius tendon insertion.
The logic behind this procedure is twofold:
Diagnostic Confirmation: By injecting a local anesthetic (a numbing agent) directly into the suspected source of pain, we can test our hypothesis. If the pain is significantly reduced or eliminated after the injection, it strongly confirms that the injected structure was indeed the primary pain generator.
Therapeutic Benefit: The injection often includes a corticosteroid, a potent anti-inflammatory medication. While we now understand that tendinopathy is more degenerative than inflammatory, a targeted steroid can calm localized chemical irritation and reduce inflammatory cell activity that contributes to the pain cycle, providing a window of relief. This pain-free window is not the cure itself, but it is incredibly valuable. It breaks the pain cycle, lets the patient do rehabilitative exercises without severe discomfort, and provides the psychological boost of feeling better.
We would inject a combination of a local anesthetic and a small amount of corticosteroid. My goal was not to bathe the entire area in fluid, but to be precise. I explained to the patient, “I’ll fan that out a little bit when I get in there. Because the gluteus medius is a fairly broad tendon that comes down and inserts on the trochanter.” The idea is to deliver the medication across the breadth of the tendon insertion where the pathology lies. The needle would be aimed directly at the “X” I had marked.
The Injection Procedure: A Step-by-Step Explanation
With the location identified and the plan in place, we proceeded with the injection. Patient safety and comfort are paramount. The first step is meticulous skin preparation to minimize infection risk.
Aseptic Technique: I began by cleansing the area thoroughly with alcohol swabs. Next, I used several passes of povidone-iodine, a powerful antiseptic that effectively kills bacteria, viruses, and fungi on the skin. We allowed it to air-dry to ensure maximum efficacy.
Topical Anesthesia: To make the initial needle entry as comfortable as possible, I used a vapocoolant spray. I told the patient, “I’m going to give you a free spray of this area.” This spray, often ethyl chloride, evaporates rapidly on the skin, creating an intense cold sensation that temporarily numbs superficial nerve endings. “Right, is that cold?” I asked. “Yeah, I bet,” I said. This simple step can significantly reduce the anxiety and discomfort associated with the needle prick.
The Injection: With the area prepped and numbed, the procedure began. I took the syringe with a fine-gauge needle and aimed for our target. The key to a successful tendon injection is feeling the different tissue layers as the needle advances. It passes through the skin and subcutaneous fat, then enters the muscle or tendon. A skilled practitioner can feel the change in resistance.
“Okay. Now I feel it enter the muscle, the tendon, right there,” I noted as the needle advanced. I explained a technique I often teach: “If you just slide down with your fingers along the sides of the syringe, right when it starts to slip, that’s where you know you’ve got increased resistance.” The dense, fibrous tissue of a tendon offers more resistance than the softer muscle or fat around it. This tactile feedback is crucial for accurate placement.
“So I believe I’m there,” I stated, confident in my position. Next, I confirmed with the patient. I administered a very small amount of the anesthetic. “Let me give you a little injection there. Okay. Does that actually feel like the pain that you have?”
“Yes,” he confirmed.
This is another critical diagnostic clue. Injecting a small amount of fluid into a pathological, sensitive structure often momentarily reproduces the patient’s familiar pain before the anesthetic takes effect. It’s a sign that the needle is in the right neighborhood.
With our position confirmed, I administered the medication using a fanning technique to distribute it across the tendon insertion. “Okay. I’m going to fan it just a little bit. Okay. Give you a little bit right here.” I repositioned the needle slightly without withdrawing it from the skin, allowing me to treat a wider area of the tendon. “Let me do it one more time, and advance right there. Injection is in.”
The entire process took only a few seconds. “Right, I’m out. The needle is out,” I announced, promptly and safely disposing of the needle.
Immediate Post-Procedure Assessment
The procedure itself was complete, but the assessment was not. I immediately began gently massaging the area. “Now, let me massage the area here. So, want to massage that in?” This helps disperse the medication within the tissues and can also alleviate some of the immediate post-injection soreness.
I acknowledged his experience during the procedure. “You had quite a bit of discomfort during that procedure,” I said, validating his experience. It’s important to be honest; even with careful technique, injecting into an already painful area can be uncomfortable.
Now came the most important part of the assessment—the re-test. I returned to the same spot I had palpated before the injection. “Okay. Does this hurt? What I’m doing right now.”
“Just a little,” he replied.
This was promising. I then pressed over the bony part of the hip, the greater trochanter itself, which hadn’t been painful before. “Let me press over the outside part of the hip bone.” “That’s okay,” he confirmed. “Yep.”
I returned to the primary spot, the gluteus medius insertion. “How about here?”
“Just a little tender,” he said.
This was the key question: “Is it less than it was earlier?”
“Yes, it was,” he confirmed without hesitation.
“Okay. All right. So that’s a good sign,” I explained. “That means that the numbing medicine is in the right spot for that, so I’m encouraged by that.” The significant reduction in his palpation tenderness within minutes of the injection strongly confirmed our diagnosis. We had correctly identified the gluteus medius tendon as the source of his two-month-long ordeal.
I finished by cleaning the area one last time and applying a simple adhesive bandage. “Let me just go ahead and put a Band-Aid on it, and then we’re done.”
This clinical encounter is a perfect entry point for a deeper discussion. We have identified the “what” and the “where.” Now, we must explore the “why.” Why did his gluteus medius tendon become painful? What is happening at a cellular level within that tendon?
And most importantly, what does the journey to long-term recovery look like? The injection was just the first step. The real work, healing and rehabilitation, was about to begin.
The Architect of Stability: Understanding the Gluteus Medius
To truly grasp why a patient like our 57-year-old gentleman develops debilitating hip pain, we must first appreciate the elegant design and crucial function of the muscle in question: the gluteus medius. This muscle is one of the body’s unsung heroes. While its larger and more famous sibling, the gluteus maximus, gets all the attention for its role in powerful hip extension (think climbing stairs or sprinting), the gluteus medius works tirelessly in the background, providing the stability that makes fluid, efficient movement possible.
Anatomy of the Gluteal Region
The gluteal region is comprised of three primary muscles:
Gluteus Maximus: The largest and most superficial of the three, forming the bulk of the buttocks. Its primary role is powerful hip extension and external rotation.
Gluteus Medius: A fan-shaped muscle that lies underneath the gluteus maximus on the outer surface of the hip.
Gluteus Minimus: The smallest of the three, lying deep to the gluteus medius.
Our focus is on the gluteus medius. It originates from the outer surface of the ilium (the large, wing-like bone of the pelvis) between bony landmarks called the posterior and anterior gluteal lines. From this broad origin, its fibers converge downward to form a thick, powerful tendon. This tendon travels to the side of the hip and inserts on the posterosuperior aspect of the greater trochanter of the femur—precisely where our patient experienced maximal tenderness.
The gluteus minimus has a similar function but is situated deeper. It also originates on the ilium and inserts on the anterior aspect of the greater trochanter. Because of their close anatomical and functional relationship, the gluteus medius and minimus are often referred to as the “rotator cuff of the hip,” drawing a parallel to the group of muscles that stabilize the shoulder joint.
The Biomechanical Powerhouse: Function of the Gluteus Medius
The primary function of the gluteus medius is hip abduction, lifting the leg out to the side. If you are standing and lift your right leg straight out to your right side, your right gluteus medius is the prime mover. However, this isn’t the muscle’s most important role in daily life.
Its most critical function is stabilizing the pelvis during single-leg stance, which happens with every step we take. Let’s break this down:
The Gait Cycle: When you walk, at some point your entire body weight is supported by one leg. This is known as the stance phase of gait.
Pelvic Stability: Imagine you are standing on your left leg. Gravity and your body weight pull the right side of your pelvis downward. If this happens, your pelvis drops on the unsupported side, leading to a lurching, inefficient gait known as a Trendelenburg gait.
The Role of the Gluteus Medius: To prevent this pelvic drop, the gluteus medius on the stance leg (the left leg in this example) must contract powerfully. This isometric contraction acts like a strong cable, pulling the stance-side pelvis downward and holding the opposite side level.
This action is crucial for smooth, efficient, pain-free walking and running. The gluteus medius works in concert with other core and hip muscles, like the quadratus lumborum on the opposite side, to maintain a stable “core cylinder” during movement.
What Happens When the Gluteus Medius is Weak or Injured?
When the gluteus medius is weak, inhibited by pain, or has a compromised tendon (as in tendinopathy), this critical stabilizing function breaks down. This can lead to a cascade of biomechanical problems, not just at the hip but throughout the kinetic chain.
Trendelenburg Sign: Clinically, we can test for gluteus medius weakness with the Trendelenburg test. The patient stands on one leg. A positive sign occurs if the pelvis on the non-stance side drops, indicating weakness in the stance-leg gluteus medius. Often, to compensate, the person will lurch their upper body over the stance leg to maintain balance. This is the compensated Trendelenburg gait.
Increased Joint Stress: This altered gait pattern is not just inefficient; it’s damaging. The failure to control pelvic motion leads to increased stress on multiple joints:
The Hip Joint: The femoral head may not sit optimally within the acetabulum (the hip socket), leading to abnormal wear and tear. More relevant to our case, the altered mechanics can place excessive compressive and tensile loads on the gluteus medius and minimus tendons as they wrap around the greater trochanter.
The Lumbar Spine: Compensatory side-bending or “hip-hiking” can compress the facet joints in the lower back, contributing to or exacerbating low back pain. It’s incredibly common for patients with gluteus medius tendinopathy to also complain of concurrent low back pain.
The Knee: Poor pelvic control often results in the femur adducting and internally rotating excessively (the knee collapsing inward). This condition, known as dynamic knee valgus, places significant stress on the ligaments of the knee (like the ACL) and can lead to patellofemoral pain syndrome (runner’s knee) and iliotibial (IT) band syndrome.
The Foot and Ankle: The collapse of the kinetic chain can continue down to the foot, leading to overpronation and conditions like plantar fasciitis or Achilles tendinopathy.
Understanding these biomechanical connections is central to our integrative approach. Our patient’s hip pain wasn’t just a localized tendon problem. It was a symptom of a broader pattern of movement dysfunction. A simple tendon injection provides temporary relief, but it doesn’t address the underlying cause. True, lasting recovery requires identifying and correcting the biomechanical faults that overloaded the tendon in the first place. This is where comprehensive rehabilitation, including chiropractic care to restore joint mechanics, becomes essential.
Beyond Inflammation: The Modern Understanding of Tendinopathy
For many years, people almost universally labeled painful tendon conditions with the suffix “-itis.” We had “tendinitis,” “bursitis,” and “fasciitis.” The “-itis” suffix implies that inflammation is the primary pathological process. Consequently, the primary treatment approach focused on anti-inflammatory strategies: ice, rest, and anti-inflammatory medications like NSAIDs (ibuprofen, naproxen) or corticosteroid injections.
However, over the past two to three decades, our understanding of chronic tendon pain has shifted. This shift was driven by researchers who began examining pathological tendon tissue under a microscope. What they found was surprising and has revolutionized how we approach these conditions.
The Seminal Work of Khan and Cook
Pioneering researchers like Karim Khan, Jill Cook, and their colleagues drove this change. Through numerous studies involving biopsies of painful tendons (Achilles, patellar, rotator cuff, and lateral elbow), they consistently found a distinct lack of inflammatory cells (macrophages, lymphocytes, neutrophils), the hallmark of an “-itis” condition (Khan et al., 1999).
Instead of inflammation, they found failed healing and degeneration. They proposed the term tendinosis to describe the underlying pathology more accurately. This distinction is not merely academic; it has profound implications for treatment. The term tendinopathy is now widely used as a broader clinical descriptor for painful, dysfunctional tendons, encompassing the underlying degenerative process of tendinosis.
What Does Tendinosis Look Like? The Histopathological Findings
When a pathologist examines a healthy tendon under a microscope, they see a beautiful, highly organized structure. It consists of:
Type I Collagen Fibers: These are strong, thick protein fibers that are densely packed and aligned parallel to the direction of force. This parallel arrangement gives the tendon its incredible tensile strength.
Tenocytes: These are the specialized fibroblast cells of the tendon. They are elongated and lie between the collagen fibers, responsible for maintaining and repairing the tendon matrix.
Minimal Ground Substance: There is very little “filler” material between the collagen fibers.
Limited Vascularity: Healthy tendons have a relatively poor blood supply, which is why they heal slowly.
In contrast, a biopsy of a tendon with tendinosis reveals a picture of chaos and disorganization:
Collagen Disarray: The neat, parallel alignment of Type I collagen is lost. The fibers are thinner, fragmented, and disorganized. There is also an increase in the weaker Type III collagen, which is more characteristic of early wound healing and scar tissue, not strong, mature tendon tissue.
Cellular Changes: Tenocyte number increases (hypercellularity), but their shape changes. They become rounded and more “active,” but this activity is dysfunctional. Instead of producing healthy Type I collagen, they produce inferior matrix components.
Neovascularization and Neoinnervation: A hallmark of tendinosis is the ingrowth of new, disorganized blood vessels (neovascularization) and accompanying nerve fibers (neoinnervation) (Alfredson et al., 1999). This is a crucial finding. While more blood supply might seem good, these new vessels are leaky and poorly formed. Critically, the new nerve fibers that travel with them are often nociceptive (pain-sensing). Many researchers now believe this neurovascular ingrowth is a primary driver of tendinopathy pain. These nerves secrete chemicals like substance P and calcitonin gene-related peptide (CGRP) that can further contribute to a disorganized healing response.
Increased Ground Substance: The space between the collagen fibers fills with more water-loving molecules called glycosaminoglycans. This leads to tendon thickening, but it is dysfunctional, not a sign of strength.
In summary, tendinopathy is not an inflammatory condition; it is a degenerative, non-inflammatory tendinosis characterized by a failed healing response. The tendon is stuck in a cycle of producing poor-quality, disorganized tissue instead of regenerating its strong, organized structure.
The Load-Continuum Model of Tendinopathy
To explain how a tendon moves into this pathological state, Professor Jill Cook and her colleague Craig Purdam developed the influential Tendon Continuum Model (Cook & Purdam, 2009). This model proposes that tendinopathy exists on a spectrum and that the tendon’s response depends on the type and magnitude of the load it experiences.
The model describes three main stages:
Reactive Tendinopathy: This is the acute response to a rapid increase in load or a period of unaccustomed activity. For example, a runner who suddenly doubles their mileage or a person who spends a weekend doing heavy gardening. In this stage, cells proliferate briefly and the ground substance increases, causing the tendon to swell. This protective response increases the tendon’s cross-sectional area to diffuse the load. At this stage, the tendon structure is largely intact, and the condition is highly reversible if the load is appropriately managed (i.e., reduced). This may be the only stage in which a small, transient inflammatory component is present.
Tendon Dysrepair (Failed Healing): If the tendon is not unloaded and remains exposed to excessive load, it progresses to this stage. This corresponds to the early histopathological changes of tendinosis. The tendon’s matrix begins to break down. We see greater collagen disorganization, an increase in Type III collagen, and the beginnings of neovascularization. The tendon attempts to heal, but the process becomes disorganized and ineffective. The potential for reversibility begins to decrease, but with careful load management and targeted interventions, you can still stimulate a healthier healing response.
Degenerative Tendinopathy: This is the final stage, often seen in older individuals or those with a long history of chronic tendon pain (like our 57-year-old patient). Here, widespread cell death (apoptosis), extensive matrix disorganization, and significant neovascularization occur. The collagen structure is severely compromised. At this stage, the changes are largely irreversible. The tendon has lost much of its structural integrity and is at an increased risk of partial or full-thickness tearing. Even in a degenerative tendon, some areas may remain healthier and can be targeted with rehabilitation to improve overall function.
This continuum model is clinically useful. It helps us understand that the treatment for a young athlete with acute reactive tendinopathy should be very different from the treatment for an older individual with chronic, degenerative tendinopathy. The former may need relative rest and activity modification. At the same time, the latter requires a long-term, structured rehabilitation program designed to improve the load-bearing capacity of the remaining healthy tendon tissue.
This modern understanding of tendinopathy as a load-induced, degenerative condition, rather than an inflammatory one, underpins our entire integrative treatment approach. It explains why simply resting or taking anti-inflammatory pills often fails in the long run. The solution isn’t to eliminate inflammation that isn’t there, but to address two key factors: dysfunctional tendon tissue and the excessive load that caused the problem in the first place.
The Role of Compressive Load in Gluteus Medius Tendinopathy
While we’ve established that excessive load causes tendinopathy, not all loads are created equal. Leading researchers, particularly Dr. Jill Cook’s group, have highlighted the particularly damaging role of compressive load on tendons, especially at their insertion points on bone (Cook & Purdam, 2012).
A tendon is brilliantly designed to handle tensile (pulling) forces. That’s its primary job. However, when a tendon also experiences compression, especially where it wraps around a bony prominence, it can trigger pathological changes.
Think of the gluteus medius and minimus tendons. They wrap over the bony prominence of the greater trochanter. In certain positions, these tendons can get squashed between the greater trochanter and the thick, fibrous iliotibial (IT) band that runs over them.
Positions and Activities that Increase Compression
Certain postures and movements dramatically increase this compressive load on the gluteus medius and minimus tendons:
Hip Adduction: Any position where the thigh moves across the midline of the body (adduction) will increase the tension in the IT band and press it firmly down onto the gluteal tendons and the greater trochanter.
Sleeping on your side: Lying on the unaffected side with the painful hip on top often causes the top leg to fall into an adducted position, compressing the tendons for hours. Lying directly on the painful hip also creates direct compression. This is why night pain is a classic symptom of gluteus medius tendinopathy.
Crossing your legs: Sitting with legs crossed pulls the hip into adduction and flexion, a prime position for compression.
“Hanging“ on one hip: Shifting all your weight to one side and letting the other side of the pelvis drop forces the stance hip into adduction and compresses the tendons.
Deep Hip Flexion: Positions like deep squats or sitting in low chairs can also increase the compressive forces around the hip.
Running on a cambered surface: Running on the side of a road that slopes down forces the uphill leg’s hip into greater adduction to keep the foot level, increasing compressive load.
Stretching the IT Band: Ironically, a common prescription for lateral hip pain has been to stretch the IT band by pulling the leg across the body. We now understand that this stretch is one of the most provocative things you can do for gluteus medius tendinopathy, as it directly compresses the painful tendons over the bone. We now actively tell patients to avoid this stretch.
The Cellular Response to Compression
Research has shown that tenocytes (tendon cells) respond differently to compressive load than to tensile load. When subjected to compression, they can undergo a process called chondroid metaplasia. They begin to behave more like cartilage cells (chondrocytes), producing molecules like aggrecan that resist compression in cartilage but harm tendon health. This changes the tendon matrix, making it less able to handle tensile loads and more prone to the degenerative changes of tendinosis (Verdonk et al., 2005).
The combination of excessive tensile load (from weak or fatigued muscles) and provocative compressive load (from poor movement patterns or postures) creates a perfect storm for the development of gluteus medius tendinopathy.
This understanding has direct and practical implications for treatment:
Patient Education is Key: The first step in management is to teach the patient to avoid these compressive positions. We provide specific advice on modifying sleeping posture (e.g., placing a pillow between the knees to keep the hips in neutral alignment), sitting posture (e.g., sitting with feet flat on the floor and knees slightly apart), and standing posture.
Rehabilitation Must Focus on Avoiding Compression: Early-stage rehabilitation exercises must be performed in positions that minimize hip adduction. For example, instead of side-lying leg lifts (which can involve some adduction at the bottom of the movement), we might start with isometric abduction exercises in a standing or bridging position.
Re-evaluate Common “Stretches“: We must eliminate any stretching protocols that create compression. The focus shifts from “stretching” the painful area to progressively loading it in a way that stimulates healthy adaptation.
By identifying and mitigating compressive loads, we remove one of the primary drivers of the pathology. This “unloads” the tendon, giving it a chance to move out of the reactive or dysrepair stage and creating an environment where targeted strengthening can be effective. This nuanced understanding of load is a cornerstone of modern, evidence-based tendon rehabilitation.
The Integrated Treatment Blueprint at Injury Medical Clinic
Our encounter with the 57-year-old gentleman with hip pain perfectly illustrates the philosophy that guides our practice at Injury Medical Clinic. The injection he received was a crucial first step, but it was far from the entire treatment. It was an entry point into a comprehensive, multifaceted program designed to produce lasting results. Our approach is built on integrative care, a collaborative model that brings together the strengths of different disciplines to address every aspect of a patient’s condition.
At the heart of our practice is the dynamic collaboration between me, Dr. Alex Jimenez, a Doctor of Chiropractic with advanced credentials in nursing and functional medicine, and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a Board-Certified Internist with over 40 years of clinical experience. Her extensive medical knowledge and diagnostic acumen provide the essential medical oversight for our practice. This multidisciplinary setup, where an MD provides medical direction alongside a chiropractor and other allied health professionals, is common in cutting-edge integrative and injury care clinics. It lets us offer a spectrum of care that a single-discipline clinic can’t match.
Our treatment blueprint for a condition like gluteus medius tendinopathy is not a one-size-fits-all protocol. It’s a personalized journey that unfolds in phases, addressing the “why” behind the pain, not just the “what.”
Phase 1: Pain and Load Management – “Calm Things Down”
The immediate goal after diagnosis is to reduce the patient’s pain and, critically, modify the loads perpetuating the problem. This is where the injection comes in.
The Diagnostic/Therapeutic Injection (Medical Oversight by Dr. Cardenas): As performed in our case, an injection of local anesthetic and corticosteroid helps confirm the diagnosis and provides a powerful, albeit temporary, pain reduction. We make the decision to use a corticosteroid carefully. While we know tendinopathy is not primarily inflammatory, a targeted steroid can quiet the chemical irritation and nociceptive activity within the tendon, breaking the pain cycle. This creates a valuable “window of opportunity” for us to begin the next phase of treatment. This procedure falls under the medical scope of practice and is performed with the oversight of Dr. Cardenas.
Pain Education: This is perhaps the most critical part of Phase 1. We spend time educating the patient about their condition. We explain the concept of tendinosis, the difference between helpful and harmful loads, and the specific role of compression.
Activity Modification: We provide a “do” and “don’t” list based on the principles of avoiding compressive load.
Don’t: Cross legs, stand “hanging” on one hip, sleep without a pillow between the knees, perform aggressive IT band stretches.
Do: Sit with knees apart, get up from a chair by pushing up evenly with both legs, consciously engage gluteal muscles during stair climbing, sleep with a pillow between the knees.
Isometric Loading: Even in this early phase, we introduce gentle, pain-free exercises. The best evidence now supports using heavy, long-duration isometric contractions for pain relief in tendinopathy (Rio et al., 2015). An isometric contraction is where the muscle produces force without changing length. For the gluteus medius, this could be:
Standing isometric hip abduction: The patient stands next to a wall with the affected hip away from it. They place a small ball or rolled-up towel between their hip and the wall and gently push their hip into the wall, holding the contraction for 30-45 seconds. This activates the gluteus medius without moving the hip joint through a range of motion.
Why it works: This type of loading is thought to provide a powerful analgesic effect (pain relief) by altering the way the brain processes pain signals from the tendon. It does this without placing compressive or excessive tensile stress on the tendon itself. We typically prescribe multiple repetitions of these long-hold isometrics throughout the day.
Phase 2: Restoring Movement and Building a Foundation (Integrative Chiropractic and Rehabilitation)
Once the initial pain is under control, we transition to the core of our rehabilitative strategy. This is where my role as a chiropractor becomes central. Tendon pain is a symptom of a broader biomechanical dysfunction. My job is to identify and correct the underlying movement faults.
Chiropractic Assessment and Adjustment: The body is a kinetic chain. A dysfunctional gluteus medius is often associated with restrictions and imbalances elsewhere. I perform a thorough biomechanical assessment of the entire chain:
Lumbar Spine and Sacroiliac (SI) Joints: Restriction in the SI joints or lumbar facet joints can alter pelvic mechanics and inhibit proper gluteal muscle firing through a process called arthrogenic muscle inhibition. A joint that isn’t moving properly sends inhibitory signals to the muscles that cross it. Using specific, gentle chiropractic adjustments, I work to restore normal motion to these joints. This is not just “cracking the back”; it’s a precise neurological input designed to improve joint mobility and “re-awaken” the surrounding musculature.
Hip Joint: I assess the hip joint’s mobility. For example, a lack of internal rotation can force compensatory movements that overload the gluteal tendons. Gentle hip mobilization techniques can help restore this lost motion.
Thoracic Spine: A stiff, flexed upper back can shift a person’s center of gravity, forcing the pelvis and hips to compensate and overload. Thoracic spine adjustments and mobility drills are often a key part of the program.
Soft Tissue Mobilization: Muscles around the hip often develop trigger points and fascial restrictions in response to injury. I use techniques like myofascial release or instrument-assisted soft tissue mobilization (IASTM) on surrounding tight muscles like the tensor fasciae latae (TFL), quadratus lumborum, and hip flexors. Crucially, we avoid aggressive, direct work on the painful tendon insertion itself in this phase, as this can be provocative. The goal is to release the tension in the “neighborhood” to improve overall movement quality.
Early Strengthening and Motor Control: This phase focuses on re-educating the gluteus medius to fire correctly and building a foundation of strength. The exercises are still carefully chosen to avoid compression.
Clamshells (with proper form): The classic “clam” exercise can be useful, but only if done correctly. The patient must be cued to roll their torso slightly forward to ensure the gluteus medius is targeted, not the TFL, and the movement should be small and controlled.
Bridging Variations: Glute bridges are excellent for activating the entire posterior chain. We can progress from a simple two-leg bridge to a bridge with a band around the knees (to cue abduction) and eventually to single-leg bridges.
Quadruped Hip Extension: On all fours, extend one leg back, focusing on squeezing the gluteal muscles without arching the lower back.
Phase 3: Progressive Loading for Tendon Adaptation – “Build It Back Up”
This is the most critical phase for long-term recovery. Based on the principle of mechanotransduction—the process by which cells convert mechanical stimuli into a chemical response—we know that to strengthen a tendon, we must load it. The key is to load it progressively and appropriately. The goal is to stimulate tenocytes to produce healthy, strong Type I collagen and remodel the disorganized matrix.
Isotonic Strengthening: We now move from isometrics (static holds) to isotonics (movement through a range of motion). The exercises become more challenging and functional.
Standing Banded Hip Abduction: Place a resistance band around the ankles, and have the patient perform slow, controlled leg lifts to the side.
Side-Stepping with Bands: “Monster walks” or “crab walks” with a band around the knees or ankles are fantastic for training the gluteus medius in its role as a stabilizer during dynamic movement.
Single-Leg Stance and Balance Drills: Simply practicing standing on one leg challenges the gluteus medius in its primary stabilizing role. We can progress this by standing on an unstable surface or closing the eyes.
Heavy Slow Resistance (HSR) Training: A growing body of evidence supports using HSR for tendinopathy (Beyer et al., 2015). This involves using heavy weights and performing exercises very slowly (e.g., a 3-second concentric/lifting phase and a 3-second eccentric/lowering phase). Exercises might include:
Weighted Hip Abduction Machine
Leg Press (with emphasis on single-leg work)
Weighted Squats and Lunges (once form is perfected)
Why HSR works: The combination of heavy load and slow speed appears to strongly stimulate collagen synthesis and matrix remodeling, while the slow speed minimizes injury risk by keeping the tendon under constant, controlled tension.
Eccentric Loading: Eccentric exercise (the lengthening phase of a contraction) has also been a mainstay of tendon rehab. For the gluteus medius, you can incorporate this into exercises like the single-leg squat, focusing on a very slow, controlled descent.
Phase 4: Return to Function and Sport – “Test It”
The final phase gradually reintroduces the specific activities the patient wants to return to, whether that’s running, playing tennis, or simply walking without pain.
Plyometrics and Energy Storage Loading: For athletes, we need to retrain the tendon’s ability to store and release energy, which it uses during activities like running and jumping. This involves introducing exercises like hopping, skipping, and jumping, starting with low intensity and gradually increasing. For example, a runner might start with a walk/run program while carefully monitoring the tendon’s response.
Sport-Specific Drills: We work with the patient to break down the movements of their sport or desired activity and create drills that mimic those demands in a controlled way.
Throughout this entire process, we monitor the patient’s pain. A key rule in tendon rehab is the “24-hour pain rule.” Pain during the exercise is acceptable if it’s mild (e.g., < 3/10) and does not increase after the session or the next morning. If pain is worse the next day, the load was too much, and we need to scale back.
The Functional Medicine and Nutrition Component
As a Functional Medicine (IFMCP)- certified practitioner, I also look beyond biomechanics. Systemic factors influence tendon health.
Nutritional Support: We provide guidance on an anti-inflammatory diet rich in whole foods, antioxidants, and quality protein. Specific nutrients are crucial for collagen synthesis:
Vitamin C: An essential cofactor in the cross-linking of collagen fibers.
Collagen/Gelatin Peptides: Supplementing with hydrolyzed collagen may provide the body with the specific amino acid building blocks (glycine, proline, hydroxyproline) needed for tendon repair (Shaw et al., 2017). Taking this 30-60 minutes before a rehab session may improve delivery to the targeted tissue.
Other Minerals: Zinc and copper also support enzymes involved in matrix production.
Addressing Systemic Inflammation: We screen for and address other sources of systemic inflammation that could be impairing the body’s sling capacity, such as poor gut health, metabolic dysfunction (e.g., insulin resistance), or nutrient deficiencies. For example, high blood sugar can lead to the formation of advanced glycation end-products (AGEs), which can stiffen collagen and impair tendon health.
This truly integrative model—combining medical diagnostics and interventions under Dr. CardCardenas’section, with targeted chiropractic care, advanced rehabilitation, and a functional medicine approach—is what allows us to move beyond temporary fixes. We are not just treating a painful hip; we are restoring a person’s movement, function, and quality of life from the ground up.
The Unique Contribution of Chiropractic Care in Tendinopathy Management
It’sIt’sortant to specifically highlight why chiropractic care is not just an adjunct but a central component of this integrated model for treating conditions like gluteus medius tendinopathy. The traditional view of chiropractic may be limited to spinal adjustments for back pain, but a modern, evidence-based chiropractor specializes in neuromusculoskeletal function. Our expertise lies in the intricate relationship between joints, muscles, and the nervous system.
For a condition rooted in biomechanical overload, this expertise is invaluable:
Restoring the Foundation of Movement: As mentioned, I assess and treat joint restrictions in the lumbar spine, sacroiliac joints, and hips. Think of these joints as a house’s foundation. If the foundation is crooked, the walls (muscles) will be under abnormal stress, and the windows (tendons) will start to crack. A physical therapist might focus on strengthening the muscles (the walls), but if the underlying joint dysfunction (the foundation) isn’isn’trected, the problem will likely recur. Chiropractic adjustments provide a specific, powerful input to restore motion to these foundational joints, creating the mechanical environment muscles and tendons need to function properly.
Neurological Reset: A chiropractic adjustment is more than just a mechanical “pus”” on”apushnt. It is a potent neurological stimulus. By stimulating mechanoreceptors (nerve endings that sense movement and pressure) in the joint capsule and surrounding tissues, an adjustment sends a barrage of information to the central nervous system. This can help to:
Down-regulate pain: The input from mechanoreceptors can inhibit the transmission of pain signals from nociceptors, a concept known as the “gate control theory of pain.”
Rest and Muscle Tone: It can break the cycle of arthrogenic muscle inhibition, essentially “rebooting” the connection between the joint and the muscles that control it, allowing for better activation of inhibited muscles like the gluteus medius.
Improve Proprioception: By restoring normal joint motion, we improve the body’s awareness of its position in space (proprioception), leading to better coordination and motor control.
Holistic Biomechanical Analysis: Chiropractors are trained to look at the body as an integrated whole. We don’t look at the painful hip. We analyze the patient’s posture, their gait, and the function of the entire kinetic chain, from the feet to the head. We might find that a patient’s foot pronation triggers a chain reaction of internal tibial and femoral rotation, leading to hip adduction that compresses the gluteal tendons. In such cases, the treatment plan might include not only hip-focused work but also foot adjustments and orthotic recommendations. This whole-body perspective is essential to identify and address the root cause of the overload.
Hands-On Soft Tissue Expertise: Beyond adjustments, chiropractors are proficient in a range of manual therapies. Techniques like myofascial release, trigger point therapy, and instrument-assisted soft tissue mobilization address the muscular imbalances and fascial restrictions that accompany tendinopathy. By releasing a tight tensor fasciae lata (TFL) or quadratus lumborum (QL), we can reduce the antagonistic forces pulling on the pelvis and allow the gluteus medius to work more effectively.
In our collaborative practice, we seamlessly weave this chiropractic expertise into the patient’s plan. Dr. Cardenas provides medical clearance and oversight, ensuring no underlying medical contraindications. I then apply my neuromusculoskeletal expertise to correct the biomechanical faults. I then implement a targeted rehabilitation program, often co-managed with physical therapists or athletic trainers on our team. The result is a synergistic approach in which each discipline contributes its unique strengths, leading to a more comprehensive and effective outcome than any single approach could achieve alone.
Conclusion: A New Paradigm for Hip Pain Recovery
Our journey began with a simple yet profound clinical moment: pinpointing the exact source of a 57-year-old gentleman’s sonic hip pain. That precise palpation and diagnostic injection opened the door to a deeper exploration of his condition. We moved from the “what”—a painful gluteus medius tendon—to the “why.” We unraveled the hip’s complex biomechanics, understanding the gluteus medius as a cornerstone of pelvic stability. We delved into the tendon’s cellular world, replacing the outdated notion of “- it’s” with the modern, evidence-based understanding of tendinosis as a degenerative condition of failed healing, often driven by a combination of tensile and, critically, compressive loads.
This new paradigm demands a new approach to treatment. It moves us away from passive, short-term fixes like prolonged rest and repeated anti-inflammatory interventions and toward an active, engaged, and integrated strategy. At Injury Medical Clinic, this strategy is our blueprint for success. It is a collaborative effort, spearheaded by the combined expertise of our Medical Director, Dr. Maria Guadalupe Cardenas, and our entire team of chiropractic, rehabilitation, and functional medicine practitioners.
Our approach is a phased journey tailored to the individual:
We begin by calming the system, using targeted interventions like a diagnostic injection to reduce pain and comprehensive education to empower the patient to remove the offending loads from their daily life.
We then rebuild the foundation. Through integrative chiropractic care, we address the underlying joint restrictions and biomechanical faults in the spine, pelvis, and hips that created the overload in the first place. We use manual therapies to restore muscle balance and introduce specific exercises to re-awaken and retrain the inhibited musculature.
Next, we stimulate adaptation. We apply the principles of mechanotransduction, using a carefully progressed program of heavy, slow resistance and functional strengthening to send a powerful healing signal to the tendon, encouraging it to remodel and rebuild stronger, more organized tissue.
Finally, we return to life. We guide the patient back to the activities they love safely and gradually, ensuring their body is resilient and prepared for the demands of sport and life.
A functional medicine perspective supports all of this by considering the whole person—their nutrition, systemic health, and unique physiology—to create an internal environment primed for healing.
The pain that brought our patient to the clinic was a signal. It signaled that a critical component of his movement system was failing under load. Our job wasn’t just to silence that signal, but to listen, understand its message, and respond with a comprehensive plan to restore the strength, integrity, and function of the entire system. This is the promise of modern, integrative care. It’s a journey from pain to performance, and we are honored to guide our patients every day.
References
Alfredson, H., Bjur, D., Thorsen, K., Lorentzon, R., & Sandstrom, P. (1999). High-power color Doppler sonography in the management of tendinosis. British Journal of Sports Medicine, 33(1), 41. https://bjsm.bmj.com/content/33/1/41.1
Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M., & Magnusson, S. P. (2015). Heavy slow resistance versus eccentric training for patellar tendinopathy: a randomized controlled trial. The American Journal of Sports Medicine, 43(7), 1704–1711. https://doi.org/10.1177/0363546515584111
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. https://doi.org/10.1136/bjsm.2008.051193
Cook, J. L., & Purdam, C. (2012). Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine, 46(3), 163–168. https://doi.org/10.1136/bjsm.2010.081419
Khan, K. M., Cook, J. L., Bonar, F., Harcourt, P., & Astrom, M. (1999). Histopathology of common tendinopathies. Update and implications for clinical management. Sports Medicine, 27(6), 393–408. https://doi.org/10.2165/00007256-199927060-00004
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386
Shaw, G., Lee-Barthel, A., Ross, M. L., Wang, B., & Baar, K. (2017). Vitamin C–enriched gelatin supplementation before intermittent activity augments collagen synthesis. The American Journal of Clinical Nutrition, 105(1), 136–143. https://doi.org/10.3945/ajcn.116.138594
Verdonk, P. C. M., Demol, J., Almqvist, K. F., Veys, E. M., Verbruggen, G., & Verdonk, R. (2005). Implantation of viable meniscal allograft. Survivorship analysis and clinical outcome of 59 cases. The Journal of Bone and Joint Surgery. American Volume, 87(4), 715–724. https://doi.org/10.2106/JBJS.D.02508
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