Education Plus Exercise, Single Corticosteroid Injection Effective in Long Term for Gluteal Tendinopathy

Education combined with exercise as well as a single corticosteroid injection may be more effective than a wait-and-see approach for alleviating gluteal tendinopathy-associated pain, according to a study published in The British Medical Journal.

Tendon load management education plus physiotherapy exercises may represent an alternative treatment strategy to the short-term benefits associated with corticosteroid injections for gluteal tendinopathy.

In this 3-arm single-blinded randomized clinical trial (Australian New Zealand Clinical Trials Registry identifier: ACTRN12612001126808), a total of 204 patients (mean age, 54.8 years; 81.9% women) were enrolled. Study participants with lateral hip pain for ≥3 months and gluteal tendinopathy confirmed clinically and by magnetic resonance imaging were randomly assigned to receive 14 sessions of education plus exercise over an 8-week period (n=69), a single corticosteroid injection (n=66), or no treatment (n=69).

Patients were assessed at baseline and at 4, 8, 12, 26, and 52 weeks, with 92.6% remaining at the 52-week follow-up. The primary outcomes were self-reported global rating of change in condition (global improvement) and pain intensity, assessed with an 11-point rating scale. Secondary outcomes evaluated additional measures of pain and disability.

At 8 weeks, participants in both the education plus exercise and corticosteroid injection groups had greater global improvement compared with those not receiving treatment (risk difference, 49.1% and 29.2%, respectively; 95% CI, 34.6%-63.5% and 13.2%-45.2%, respectively; P <.001). Education plus exercise had a greater success rate compared with corticosteroid injection (risk difference, 19.9%; 95% CI, 4.7%-35.0%; P =.010). Mean pain intensity scores at 8 weeks were reduced in the education plus exercise group and in the corticosteroid injection group compared with the no-treatment group (P <.001 for both), with the education plus exercise vs corticosteroid injection providing greater analgesic benefits (P =.003).

The greater benefits on global improvement associated with education plus exercise vs corticosteroid injection and vs no treatment were maintained at 52 weeks (global improvement: risk difference, 20.4%; 95% CI 4.9%-35.9%; P =.010 and risk difference, 26.8%; 95% CI 11.3%-42.3%; P <.001, respectively). At the 52-week follow-up, the analgesic benefits associated with the corticosteroid injection were no longer superior to no treatment, and those associated with either treatment were no longer visible after 1 year.  

Study strengths included a lack of major adverse events associated with either treatment and high retention rates. Study limitations included an exclusive focus on gluteal tendinopathy treatment, differences within groups regarding time and number of sessions spent with therapists, and lack of patient blinding to nature of treatment.

“Understanding and knowledge of appropriate management strategies could encourage patients to have a greater sense of self-efficacy and control over their condition, leading to improved quality of life,” concluded the study authors. “These results support the use of education plus exercise as an effective management approach for gluteal tendinopathy.”

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Reference

Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662.