Heavy slow resistance training combined with patient education in patients with gluteal tendinopathy: a feasibility study

Key Points

1. A heavy slow resistance training intervention combined with patient education is safe and feasible in patients with gluteal tendinopathy, in terms of adherence, drop-outs, adverse events and lateral hip pain tolerability.
2. Several participants showed meaningful changes in lateral hip pain intensity and in disability severity.
3. Improvements in hip muscle strength were observed, with abductor strength improvements noteworthy, given the known deficits in patients with gluteal tendinopathy.

INTRODUCTION

Gluteal tendinopathy (GT) is a persistent and disabling condition characterized by moderate to severe lateral hip pain (LHP) (1-3). GT is one of the most common lower-limb tendinopathies in clinical practice, affecting up to 24% of middle-aged women. Exercise is currently the recommended first-line treatment for GT and it is combined with patient education (1). Heavy slow resistance training (HSR), involving high-load, low-velocity isotonic muscle contractions, has demonstrated meaningful improvements in pain and physical function in Achilles and patellar tendinopathy. However, in GT, a traditional repetition-maximum (RM)-based HSR program with linear load progression remains unexamined. Therefore, preliminary feasibility research is beneficial before initiating a larger trial.

The primary aim of this study was to investigate the feasibility of combining HSR with patient education in patients with GT in terms of adherence, drop-outs, adverse events and LHP tolerability. A secondary purpose was to evaluate changes in LHP, patient-reported outcomes, functional performance and hip muscle strength.

Gluteal Tendinopathy is one of the most common lower-limb tendinopathies in clinical practice, affecting up to 24 % of middle-aged women.

The hip abduction exercise, even though it loads the symptomatic tendons most, still had high adherence, suggesting it is well-tolerated and often preferred by people with gluteal tendinopathy.

METHODS

Design: Single-group, interventional feasibility trial.

Participants: Participants who met the following criteria were included in the study: (1) age ≥18 years; (2) persistent LHP for more than six weeks; (3) tenderness on palpation of the greater trochanter; (4) reproduction of LHP during diagnostic clinical tests (30-second single-leg stance and resisted hip abduction); and (5) normal passive hip range of motion.

Intervention: Participants completed 30 sessions over 12 weeks (five sessions per two weeks), alternating between two and three weekly sessions. Each session comprised a 10-min submaximal ergometer warm-up and five exercises targeting major hip muscles, with emphasis on agonistic or synergistic hip abductor activation (see Video 1). In the first session, participants performed one set of each exercise to determine training loads. In subsequent sessions, loads were adjusted to reach a 12RM. Participants received education on aggravating and easing factors specific to GT.

VIDEO 1 – HEAVY SLOW RESISTANCE TRAINING INTERVENTION

Feasibility outcomes

Intervention feasibility was measured through treatment adherence (session adherence and program adherence), number of dropouts, adverse events, and lateral hip pain tolerability (LHP).

Secondary outcomes

At follow-up, participants rated their perceived change in hip condition across pain, daily activities, and quality of life using a Global Rating of Change scale. Lateral hip pain intensity was measured with an 11-point Numerical Rating Scale (NRS) for night pain, and during functional tests. Disability was assessed using the Victorian Institute of Sport Assessment–Gluteal (VISA-G). The Nine-step timed stair climb test and thirty-second chair stand test were used to measure functional performance. Maximal isometric hip muscle strength was measured using an isokinetic dynamometer.

RESULTS

Feasibility outcomes

Session adherence ranged from 98 to 100%, exceeding the adherence in similar musculoskeletal studies. The high intervention (program) adherence indicates that participants not only attended but closely followed the prescribed exercise protocol. The drop-out rate was 5% and considered low compared to the 0-33% in related studies. The most frequent adverse events were knee and groin pain or discomfort. Median pain tolerability (i.e. no or tolerable pain) was 100 % at all three timepoints (before sessions, during HSR, and 24h after sessions). The trajectory of the LHP tolerability indicates a gradual increase over time in the proportion of participants experiencing no LHP before sessions, during HSR, and 24h after sessions.

Functional and strength outcomes

The improvements across all secondary outcomes warrant further investigation in a future randomized controlled trial investigating the effects of HSR in GT. Several participants exceeded minimal important changes thresholds for LHP, and changes in VISA-G corresponded to large effect sizes. Improvements in hip muscle strength were observed, with abductor strength improvements noteworthy, given the known deficits in patients with GT. Participants reduced their time on the Nine-Step Timed Stair Climb Test by an average of 0.8 seconds and increased their repetitions on the Thirty-Second Chair Stand Test by an average of 2.3.

LIMITATIONS

Caution is warranted when interpreting these findings, as this study was a feasibility trial. The absence of a passive control group prevents causal inference, making it difficult to distinguish between treatment effects, placebo effects, contextual factors, and regression towards the mean. The lack of blinding among participants, trainers and testing assessors may have introduced performance bias. Finally, the sample may reflect a population highly motivated to improve their condition, introducing potential selection bias.

CLINICAL IMPLICATIONS

This study demonstrates that a HSR and patient education intervention, including isotonic abduction exercises with progressive external loading, is safe and feasible in patients with GT. The high adherence, low drop-out rate, and well-tolerated LHP justify and inform a future well-powered randomized controlled trial investigating the effectiveness of this intervention in GT.

The high content adherence further indicates that participants not only attended but closely followed the prescribed exercise protocol. Notably, the hip abduction exercise, despite placing the greatest force on the symptomatic tendons, had among the highest content adherence among exercises in the program, indicating that can be a tolerable/preferable exercise by patients with GT. Treatment discontinuation was not directly related to the intervention but due to lack of time, a common barrier to exercise-based rehabilitation in musculoskeletal conditions that should be considered by clinicians when treating those with GT.

Most adverse events in the study were transient and short-lasting, most likely reflecting typical responses in individuals unaccustomed to exercise. However, knee and groin symptoms were common during hip adduction. Given that this exercise has potentially limited relevance for GT management, it could be reconsidered or replaced with better-tolerated alternatives in future programs. Study findings demonstrate that pain was well-tolerated, with nearly all participants reporting no or tolerable LHP before, during, and 24 h after HSR sessions. In fact, reports of no LHP gradually increased over time across all three time points.

+STUDY REFERENCE

Grigat J, Kjeldsen T, Jørgensen S, Mechlenburg I, Dalgas U (2025) Heavy slow resistance training combined with patient education in patients with gluteal tendinopathy: A feasibility study. Musculoskelet Sci Pract, 80:103425, Epub ahead of print.

SUPPORTING REFERENCE

1. Mellor R, Grimaldi A, Wajswelner H, et al. Exercise and load modification versus corticosteroid injection versus 'wait and see' for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomised clinical trial. BMC Musculoskelet Disord 2016;17:196 [published Online First: 20160430]
2. Nasser AM, Fearon AM, Grimaldi A, et al. Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties. Br J Sports Med 2022;56(15):877-87 [published Online First: 20220408]
3. Grimaldi A, Ganderton C, Nasser A. Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence. Musculoskelet Sci Pract 2025;76:103253 [published Online First: 20250103]