It started as mild tightness and has now progressed to debilitating butt pain. Rest, physical therapy, and medications did not help. Your trainer thinks you injured your gluteus medius. What is the gluteus medius? What are the different types of gluteus medius injuries? What causes gluteus medius pain? What are the symptoms of gluteus medius tendonitis and tendon tears? How is the diagnosis made? What are the traditional treatment options? What regenerative options exist? What are the consequences of not treating gluteus medius pain? Let’s dig in.
What Is the Gluteus Medius? (Butt Muscle)
Gluteus medius pain comes from the top of the butt, where the gluteus medius is located.
The gluteus medius is one of the major muscles in your buttock and hip (1). There are three gluteal muscles you have probably heard about: They layer one upon the another much like a layer cake. The gluteus minimus is closest to the body followed by the gluteus medius and then the larger gluteus maximus
Gluteus Minimus
The gluteus minimus is the smallest of the three gluteal muscles. It is a small triangular muscle that lies underneath its bigger brother, the gluteus medius. It functions to stabilize the hip, rotate the thigh, and move the hip in an outward direction.
Gluteus Medius
A powerful muscle that starts at the backside of your waist bone ( Aka the iliac crest) and travels downward in the diagonal fashion towards the outside aspect of your hip. It then attaches onto the outer boney outcropping of the hip which is called the greater trochanter. A tendon attaches the gluteus medius to the boney surface. This is important as the tendon can become irritated or injured and become a source of pain. The gluteus medius muscle stabilizes the hip and pelvis, helps bend the hip upward (flexion), and rotates the leg inward and outward. Approximately one-third of the muscle is covered by the larger, gluteus maximus muscle.
Gluteus Maximus
The Gluteus maximus is the largest and outermost of the three gluteal muscles. It stabilizes the hip joint as well as extends and rotates outwardly the hip joint. This large muscle starts on the waist bone and attaches to the boney prominence on the outside of the hip in addition to the iliotibial band (ITB)
Are there Different Types of Gluteus Medius Tendon Injuries? (Inflammation and Tears)
Yes, there are different types of gluteus medius tendon injuries. Tendons are thick pieces of connective tissue that connect muscle to bone. They are susceptible to inflammation, injury, and tears. Inflammation of a tendon is called tendinitis. To learn more about this condition please click here. Tendon tears can be classified into three broad groups (2).
Partial Thickness Tear
This type of tear only involves only a portion of the tendon.
Full-Thickness Tear without Retractions
A full-thickness tear also known as a complete tear extends across the entire tendon. The fibers of the tendon however are held together by some of the remaining, non-torn tendon fibers.
Full-Thickness Tear with Retractions
Snapped Rubber Band: Ends are Physically Separated
A full-thickness tear with retractions is a serious injury where the tear involves all tendon fibers and they are pulled apart. Think of a rubber band that breaks under tension. The ends become physically separated. So too with a full-thickness tendon tear with retraction.
Causes of Gluteus Medius Pain & Injuries
Gluteus medius pain can arise from a number of different injuries. The two most common causes of gluteus medius pain are tendonitis and tendon tears.
Tendonitis AKA inflammation of the tendon can be caused by a number of different factors. Common examples include repetitive activity, overuse, poor posture, and poor technique (3).
Tears in the gluteus medius tendon are commonly seen in runners and other high-impact athletes in sports such as such as basketball and soccer. The exact cause of the tears is unclear however there is evidence to support that it is a degenerative and progressive process (4). This is similar to tears in the rotator cuff tendons in the shoulder. Other factors that are associated with gluteus medius pain and dysfunction include:
Patients with poor gluteal and hip muscle strength as this places increased stress on the tendon
Patients with low back nerve irritation as this leads to reduced strength and more muscle tightness and dysfunction (5)
The incidence of gluteus medius tears peaks around the seventh decade of life (6)
More common in women (6)
Degenerative Scoliosis
Degenerative Scoliosis, also known as Adult-onset Scoliosis, is a medical condition that involves a side bending in the spine. The bending can be mild, moderate, or severe with side-bending to either the right or the left. The term degenerative means generalized wear and tear and is common as we get older. Degenerative scoliosis is the curvature of the spine that occurs as a result of degeneration of the discs, small joints, and building blocks. The Degenerative Scoliosis curve is often located in the low back and forms a ‘C” shape. There is a convex and a concave side. The convex side is the open side where it curves outward.
Disorders that affect and weaken the connective tissues such as tendons and ligaments. It is a hereditary disorder which means you are born with it. EDS has many different signs and symptoms which can vary significantly depending upon the type of EDS and its severity. It most commonly affects the skin, joints, and blood vessels. Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. In most cases Ehlers-Danlos syndrome is inherited. That is to say that you are born with it. The two main ways EDS is inherited are: autosomal dominant inheritance and autosomal recessive inheritance…
Failed Back Surgery Syndrome also called failed back is a clinical condition in which patients who have undergone low back surgery continue to have pain and dysfunction. Said another way the surgery that was intended to reduce pain and increase function FAILED. That is right, the surgery failed. You had the surgery, struggled with the pain postoperatively, diligently participated in physical therapy and yet the pain and limitation are still there. Unfortunately, this occurs frequently. Estimates range from 20-40% of patients who undergo low back surgery will develop Failed Back Surgery Syndrome. Pain is the most common symptom of Failed Back Surgery Syndrome…
Tendinopathy is a group of tendon disorders. The most common form of Tendinopathy is Tendinosis (1). Tendinosis is a degenerative condition that is characterized by collagen degeneration and micro-trauma in the tendon due to repetitive overloading. Gluteal Tendinopathy is a clinical condition in which there is moderate to severe debilitating pain due to injury of the Gluteal tendons. It is the most common Tendinopathy in the lower leg (2) and is more common in women (3). In most cases, physical examination alone is sufficient to diagnose Gluteal Tendinopathy. If symptoms continue despite conservative care, other studies may be warranted which include ultrasound and MRI.
Hamstring tendinopathy, a condition that causes pain and tenderness in the hamstring tendons, represents a common but often misunderstood musculoskeletal issue. It typically occurs in athletes and individuals engaged in high-intensity activities but isn’t limited to them. This condition, including its more specific form, high hamstring tendinopathy, can significantly impact daily and athletic performance, making understanding its nuances critical.
A tear in the hip labrum can cause a number of different symptoms. The most common is anterior hip or groin pain which may radiate down to the level of the knee (3). Pain develops gradually and typically is dull in character made worse with walking, pivoting and running. Hip labral tears are easily seen on MRI. Unfortunately, it’s importance as a source of pain must be questioned. Why? Research has demonstrated that many patients with no hip pain have labral tears on MRI (4-5). In one study, Duthon et al demonstrated that 69% of patients without hip pain had labral tears.
Ligaments are connective tissue structures that connect bone to bone. They help provide stability for joints such as the hip. There are four main hip ligaments that help to keep the hip in its natural socket. If these ligaments are injured, then they may cause pain directly.
Most often, they cause the hip to become unstable, leading to more stress and injury to other parts of the hip such as the labrum, cartilage, and/or bone.
Disc herniation, disc protrusion, overgrowth of the facet joint, and thickening of the ligaments can result in nerve root compression or irritation, causing symptoms of sciatic compression. Some causes of sciatic compression can be interrelated with the following conditions: Degenerative disc disease, Spinal stenosis, damage or injuries to the discs, spondylolisthesis, piriformis syndrome, osteoarthritis. The symptoms of sciatica include pain in the lower back, buttock, and down your leg, numbness and weakness in low back, buttock, leg, and/or feet, pain increase with movement, “Pins and needles” feeling in your legs, toes, or feet., loss of bowel control, and incontinence. Sciatica can be treated…
The sacroiliac joints reside between the sacrum (the tailbone segment of the spinal column) and the prominent wing-like iliac bones that form the pelvic girdle. There are two SI joints, one on the left and one on the right (highlighted in red in the image above), and along with the symphysis pubis joint at the front of the structure, they are critical for transferring forces and energy back and forth between the spine and the lower limbs. There are a number of reasons that an SI joint can become painful and inflamed, leading to SI joint syndrome. Trauma, such as a fall injury to the tail bone or a forced injury from a car accident for example, obviously can create problems in the SI joint…
Gluteus Medius Tendonitis and Tendon Tear Symptoms (Pain!!)
Symptoms vary depending upon the type and the severity of the gluteus medius injury. Common symptoms include:
Pain and tenderness on the outside of the hip or buttock. One study demonstrated that 46% of studied patients with chronic buttock pain had a gluteus medius tear on MRI.(7).
Swelling or inflammation
Difficulty sitting or walking
Limp while walking
Decreased hip range of motion
Pain is often worse when lying on the affected side.
Pain at night, sometimes preventing sleep
Diagnosis ( Physical Examination, X-ray and Ultrasound)
Diagnosis of a gluteus medius injury requires completion of a history and physical examination and selection of appropriate studies. Pain in the outer aspect of the hip and buttock is typically gradual in nature.
Physical Examination
Positive Trendelenburg Test
Pain over the outer aspect of the hip along with a reduced range of motion is common. The Trendelenburg test is the most sensitive and specific physical exam finding for this condition (9). The test requires the patient to stand on one leg for 30 seconds. A positive Trendelenburg test occurs when the patient is unable to maintain their pelvis level to the floor. The pelvis on the non-standing leg drops as illustrated in the picture to the right. This occurs due to gluteus medius and minimus weakness or injury. The gluteus medius muscle is colored red.
Studies
X-ray is helpful as it can exclude hip osteoarthritis and fracture. Radiographic signs of gluteus medius injury include bone irregularities on the greater trochanter. In-office ultrasound is very helpful in evaluating the integrity of the gluteal tendons (8). Ultrasound can identify inflammation of the tendon as well as different types of tendon tears. At the Centeno-Schultz Clinic patients with hip pain or restricted range of motion undergo ultrasound evaluation. When not available, MRI is the next appropriate study.
Treatment Options for Gluteus Medius Pain and Injuries (Conservative, Steroids & Surgery)
Treatment will depend upon the severity of the injury and underlying medical conditions. Treatment options include conservative care, steroids, and surgery.
Conservative Care
When appropriate, conservative care should always be the first-line treatment. The goal is to reduce pain, minimize intramuscular bleeding, control the inflammatory response and improve strength and flexibility. Treatment options include rest, physical therapy, chiropractic care, gentle stretching, dry needling, and ultrasound.
Injections
Steroid injections are often recommended for patients who do not respond to conservative treatment. Steroids have many different brands and names which include dexamethasone, methylprednisolone, betamethasone, and cortisone. Steroids are powerful anti-inflammatory agents that have a significant number of side effects. These include injury to cartilage, tendons, and ligaments. To learn more about the harmful effects of steroids please click here.
Surgery
Surgery is rarely indicated with the exception of when a patient has sustained a full-thickness tendon tear with retractions. In this condition, the tendon is completely torn with two physical ends that are separated.
Regenerative Treatment Options for Gluteus Medius Pain (PRP and Bone Marrow Concentrate)
PRP is rich in growth factors that can increase blood flow and promote healing. PRP has been demonstrated to be superior to steroids for the treatment of hamstring injuries (10).
Bone Marrow Concentrate (BMC) Injections
Stem cells are your body’s own powerhouses for healing. At the Centeno-Schultz Clinic, we are experts in the treatment of buttock and hip pain with both PRP and bone marrow concentrate (which contains stem cells). In 2005 we were the first clinic in the world to inject BMC into the low back disc for severe back pain. We have published extensively on the benefits and use of PRP and BMC for common orthopedic conditions. To review our list of publications please click here.
Stem cell treatments are appropriate for patients with ongoing gluteal pain who have failed to receive significant healing from PRP injections or those who have severe gluteus medius tendonitis and partial thickness tearing of the tendon. At the Centeno Schultz Clinic, you can be assured of the following:
Board Certified Fellowship trained physicians will perform all injections
BMC and PRP will be injected under direct visualization with ultrasound. This will ensure that cells will get into the injured tissue. Blind injections are beneath our standard of care as there is no assurance that the injected cells get into the targeted tissue.
Consequences of Not Treating Gluteus Medius Pain (Progression of Tear, Knee, Hip and Ankle Injuries Including Arthritis)
Gluteus medius pain is a warning sign that you have a problem that warrants further investigation. Think of it as the warning light in your car that illuminates as you are heading out of town for a three-day road trip. If ignored the potential consequences are significant. They include your car’s engine malfunctioning costing you thousands of dollars and quickly ending your weekend sojourn. So too with gluteus medius pain that is not treated. Potential consequences include:
Progression of injury from tendonitis to partial thickness tear.
Progression of partial thickness tear to complete tear with retractions. All nonsurgical treatment options are eliminated when this occurs.
Knee instability. Dysfunction of the iliotibial band can cause lateral knee instability
Knee osteoarthritis
Changes in the way you walk (gait)
Low back pain due to changes in the way you walk (gait)
Develop hip osteoarthritis (11). The gluteus medius stabilizes the hip and pelvis. Without this stability the hip is at risk for cartilage, labrum and tendon injury.
Ankle tendon, ligament and cartilage injuries including arthritis.
In Conclusion
The gluteus medius is one of the major muscles in your buttock and hip.
The buttock is compromised of three muscles that layer upon one another: the gluteus minimus, gluteus medius and gluteus maximus.
The gluteus medius stabilizes the hip and pelvis, bends the hip upward and rotates the leg inward and outward.
The gluteus medius muscle starts at the waist bone and travels downward until it’s tendon attaches to the outer boney prominence of the hip (greater trochanter). This tendon can be inflamed, injured or torn and a source of significant pain.
There are three broad groups of tendon tears: partial thickness, full thickness without retractions and full thickness with retractions.
Tendonitis and tendon tears are the most common cause of gluteus medius pain.
Gluteus medius tendonitis and tendon tear symptoms vary depending upon the severity. Common symptoms include pain of the outside of the hip/buttock, difficulty walking, reduced range of motion and pain when lying on the affected side.
Diagnosis of gluteus medius tendonitis and tendon tear starts with history and physical examination. X-ray can exclude fracture and in-office ultrasound can make the diagnosis.
Treatment options include conservative care, steroid injections and surgery.
Regenerative treatment options include PRP and stem cell injections. Not all clinics are the same. For best clinical results insist upon a fellowship trained physician who performs the injections under ultrasound guidance.
Gluteus medius pain is a warning signal that you have a problem that warrants further evaluation. If ignored the consequences can be significant and include progression of injury, knee instability, knee osteoarthritis, low back pain, hip osteoarthritis and ankle injury and pain.
If you or a loved one suffers from gluteus medius pain or dysfunction please schedule a new patient consultation where you can learn what regenerative treatment options are best for you.
5..Sadler S, Cassidy S, Peterson B, Spink M, Chuter V. Gluteus medius muscle function in people with and without low back pain: a systematic review. BMC Musculoskelet Disord. 2019;20(1):463. Published 2019 Oct 22. doi:10.1186/s12891-019-2833-4
6.Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001 Jan;16(1):121-3. doi: 10.1054/arth.2001.19158. PMID: 11172282.
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 Sep;44(9):2138-45. doi: 10.1002/1529-0131(200109)44:9<2138::AID-ART367>3.0.CO;2-M. PMID: 11592379.
8.Dawes AR, Seidenberg PH. Sonography of sports injuries of the hip. Sports Health. 2014;6(6):531-538. doi:10.1177/1941738114552801
9.Bewyer D, Chen J. Gluteus medius tendon rupture as a source for back, buttock and leg pain: case report. Iowa Orthop J. 2005;25:187-189.
