Gluteal Tendinopathy, are Psychological Factors More Important than Strength?

Following on from the excellent LEAP Trial in Gluteal Tendinopathy which found exercise led to a roughly 80% success rate at 8 weeks we have intriguing research from the same group. For a long time in tendinopathy it’s been assumed that strength and tendon capacity are key. We might assume then that differences in strength would be associated with severity in tendinopathy, in gluteal tendinopathy (GT) it would appear that assumption is wrong…

Plinsinga et al. (2018) analysed baseline data from the 204 subjects recruited for the LEAP Trial (Mellor et al. 2018). The VISA-G tendon questionnaire was used to assess severity and classify participants into 3 subgroups; mild, moderate and severe. Average and worst pain scores were also assessed using a numeric scale. A number of psychological factors were then assessed alongside, physical activity levels, quality of life, BMI, waist girth and hip abductor strength. The authors then analysed the data to determine which of these factors was associated with severity in GT.

The results are somewhat surprising… there were no significant differences in hip abductor muscle torque between the groups. Strength deficits did not appear associated with severity. This finding may be further supported by the LEAP Trial which found that while symptoms differed significantly between the groups at 8 weeks, measures of abductor muscle strength did not.

Unlike muscle strength, psychological factors were associated with severity. The severe group had significantly higher pain catastrophizing and depression scores and lower pain self-efficacy than the mild and moderate severity groups. Females (which made up 82% of the participants) had significantly greater BMI in the severe group and waist girth was greater in the severe group compared to the mild severity group. The severe group also had significantly lower activity levels and quality of life scores.

With any research it is important to appraise the study and be aware of limitations. This is an excellent study but we do need to recognise the limits of its cross-sectional design, chiefly that we can’t determine causality. It isn’t clear if psychological factors led to increased severity or if increased severity resulted in psychological changes (such as depression and catastrophizing). In addition I’d urge caution in assuming that strength change is entirely irrelevant or that exercise is not important. The exercise intervention used successfully in the LEAP Trial aimed to change movement patterns to reduce provocative load as well as improving strength. This change in movement may be responsible for some of the improvements in symptoms reported in that study. It’s also important to note the population in this study and that different tendon sites may have different presentations, causes and treatment approaches.

Research from McAuliffe et al. (2017) highlights the impact achilles tendinopathy can have in someone’s life. We’ve discussed some of their findings in the video below, taken from part 1 in our webinar series on achilles pain.

 CLICK HERE to access the entire achilles webinar series and we’ll keep you updated with news and exclusive offers for our online courses.

What Plinsinga et al. (2017), McAuliffe et al. (2017) and also excellent work from Mallows et al. (2016) shows us is that we need to think beyond the tendon in tendinopathy. We need to recognise the impact it has on people’s lives and the fear that often goes with it. If we can recognise this, empathise with the patient and explain tendon pain in a positive way we can help provide a clear path forward towards their goals and a brighter future with less fear.

A first step is discussing tendinopathy with the patient, asking about how it affects their lives and what concerns they have. Tools like the pain catastrophizing scale may be useful in appraising their relationship with pain. The work of Plinsinga and colleagues highlights that depression may be a factor so it can help to talk about mood and mental wellbeing and direct people towards mental health services and resources if indicated. Our Tendon Health Questionnaire, TendonQ includes questions about mood and fear of damage as well as BMI which was found to be a factor in this study. Download it for free using the button below and find out more about it HERE.

Mallows et al. (2017) note that while load-based rehab is currently recommended for tendinopathy responses to this vary widely. They comment that the success of such a load-based approach depends on the person interpreting the pain response in a way that facilitates the ongoing use of exercises as a treatment strategy. Fear of damage isn’t conducive to this. They go on to discuss how we may broach this with patients;

“IT MAY BE USEFUL FOR THE CLINICIAN TO EXPLAIN PAIN IN TERMS OF SENSITIVITY, ENSURING THE PERSON IN PAIN UNDERSTANDS WHY HURT DOES NOT NECESSARILY EQUAL HARM AND WHY PAIN DURING REHAB SHOULD BE ACCEPTABLE” MALLOWS ET AL. (2017)

These recent studies in gluteal tendinopathy highlight the link between severity and psychological factors and that improvement can occur withoutincreases in strength pose a question… does the addition of an exercise programme lead to better outcomes than education alone in gluteal tendinopathy? In the next part in our gluteal tendinopathy series we’ll try to answer this question!…

This was originally posted on Tom Goom’s website. You can click here to read more blogs from them.