Current and future advances in practice: tendinopathies of the hip

Key points

1. 01Palpation alone is insufficient for diagnosing gluteal tendinopathy; combining palpation with resisted hip abduction and a 30-second single-leg stance test improves diagnostic accuracy
2. 02The LEAP trial showed education and exercise had significantly higher success rates than corticosteroid injection or wait-and-see at both 8 weeks and 52 weeks
3. 03Corticosteroid injections provide short-term pain relief but reduce cell viability, collagen synthesis, and tendon mechanical properties, and long-term outcomes are no better than wait-and-see
4. 04Gluteal tendinopathy affects up to 23.5% of middle-aged women; disability and quality-of-life levels equate to end-stage hip osteoarthritis
5. 05Proximal hamstring tendinopathy is frequently misdiagnosed; diagnosis is clinical, with ischial pain worsened by sitting and hip-flexion loading being hallmark features

How it was conducted

Design

Narrative clinical review

Conditions covered

Gluteal tendinopathy and proximal hamstring tendinopathy

Key trial cited

LEAP randomized clinical trial (education and exercise vs. corticosteroid injection vs. wait-and-see for gluteal tendinopathy)

Follow-up

Short term (8 weeks) and long term (52 weeks) for the LEAP trial

Population focus

Primarily postmenopausal women for gluteal tendinopathy; both athletic and non-athletic populations for proximal hamstring tendinopathy

What they found

• LEAP trial: education and exercise group showed significantly higher Global Rating of Change success rates than corticosteroid injection and wait-and-see at both 8 weeks and 52 weeks
• Corticosteroid injection was superior to wait-and-see at 8 weeks but showed no difference in success rates at 52 weeks
• Pain intensity reduction was greatest in the short term with education and exercise; in the longer term, pain intensity was not significantly different between exercise and corticosteroid groups
• Improvements in pain constancy and quality of life were significantly better in the education and exercise group at 52 weeks
• One RCT comparing corticosteroid injection to placebo saline injection found no significant between-group differences at 4 weeks or 6 months
• Ultrasound showed sensitivity of 89.5% vs MRI 64.7% and specificity of 16.7% vs 66.7% for detecting gluteus medius tendon pathology
• A small RCT (n=15) comparing PRP to autologous whole blood for proximal hamstring tendinopathy found no significant difference at 6 weeks, 12 weeks, or 6 months
• A single small RCT (n=40) found shockwave therapy had a large positive effect on proximal hamstring tendinopathy symptoms and function compared with a 6-week multimodal programme in both short and long term
• Fluoroquinolone bilateral Achilles tendon involvement in 44% of affected cases
• In proximal hamstring tendinopathy PRP case series, the largest (n=29) showed a small but not clinically meaningful improvement in physical function at 8-week follow-up
• PRP adverse event rates following injection in proximal hamstring tendinopathy varied from 0-10%, including high pain post-injection and sciatic nerve irritation

Limitations

• Evidence base for proximal hamstring tendinopathy is largely low-quality case series without control groups; conclusions rely on extrapolation from gluteal tendinopathy and Achilles tendon research
• No high-quality evidence exists for PRP versus wait-and-see or education and exercise alone for either hip tendinopathy
• Surgical evidence for both conditions is limited to low-quality studies with high risk of bias and no control groups
• Outcome measures used in gluteal and proximal hamstring tendinopathy trials have been identified as needing urgent refinement, limiting pooling of results across studies

Why it matters

For patients

Patients with lateral hip or sitting-bone pain should expect education and a graded exercise programme as first-line care, and should be aware that corticosteroid injections offer only short-term relief with potential long-term harm to tendon health.

For clinicians

Clinicians should use a structured clinical assessment combining history, palpation, and active loading tests to diagnose hip tendinopathies, and should prioritize education and progressive exercise over injection-based treatments based on the LEAP trial evidence.

For readers

This review consolidates diagnostic and management evidence for two common but frequently mismanaged hip tendinopathies, highlighting a clear evidence-practice gap in favor of active over passive treatment approaches.