Chiropractic Care Guide for Gluteus Medius Tendinopathy

Explore effective approaches to treat gluteus medius tendinopathy through chiropractic care to alleviate pain and enhance mobility.

Abstract

As a clinician with dual licensure in chiropractic and advanced practice nursing, specializing in functional and integrative medicine, I encounter complex musculoskeletal conditions daily. This post offers an in-depth clinical narrative that takes you through the assessment and treatment of a common yet often misunderstood issue: persistent hip pain. We will explore the case of a 57-year-old gentleman presenting with a two-month history of localized left hip pain, focusing on the diagnostic process that led to the identification of gluteus medius tendinopathy. I will explain the anatomical and biomechanical factors contributing to this condition, also known as Greater Trochanteric Pain Syndrome (GTPS), and detail the therapeutic injection procedure performed to alleviate his symptoms. This case illustrates how our clinic, Injury Medical Clinic PA, integrates various disciplines to provide comprehensive care. We will discuss the collaborative dynamic between myself and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD, a board-certified internist with over 40 years of experience. Her medical oversight is foundational to our multidisciplinary model, which combines my expertise in chiropractic, functional medicine, and rehabilitation with her profound knowledge of internal medicine. This synergy ensures a safe, effective, holistic approach to patient care that addresses not only structural symptoms but also underlying physiological imbalances. We will explain the rationale behind our integrative protocols, showing how chiropractic adjustments, soft tissue therapies, and targeted rehabilitation complement medical interventions to restore function, reduce pain, and prevent recurrence.

Our Integrative Care Model: A Synergy of Disciplines

At Injury Medical Clinic PA, our philosophy is rooted in the understanding that the human body is an interconnected system. A problem in one area, such as the hip, is rarely isolated. It often involves a cascade of biomechanical compensations, neuromuscular imbalances, and sometimes, underlying systemic inflammation. To address this complexity, we have cultivated a truly multidisciplinary environment.

As a Doctor of Chiropractic (DC) and an Advanced Practice Registered Nurse (APRN) certified as a Family Nurse Practitioner (FNP-BC), I bridge the gap between structural and medical care. I can perform detailed musculoskeletal examinations, deliver chiropractic adjustments to restore spinal and pelvic alignment, and also manage patient care from a primary and functional medicine perspective.

The invaluable collaboration with Dr. Maria Guadalupe Cardenas, MD anchors this model. As our Medical Director and Collaborative Physician, Dr. Cardenas brings an extraordinary depth of knowledge from her four decades as a board-certified internist. She provides essential medical oversight for our practice, ensuring all treatment plans meet the highest standards of safety and effectiveness. This is particularly crucial in cases like personal injury, where complex medical histories and comorbidities are common. Dr. Cardenas reviews patient cases, consults on diagnostic findings, and provides medical direction for procedures within the scope of advanced practice nursing, such as the therapeutic injection detailed in this post.

Our team approach integrates:

• Medical Oversight (Dr. Cardenas, MD): Ensuring diagnostic accuracy, managing comorbidities, and providing a foundation of established medical protocols.
• Chiropractic Care (Dr. Jimenez, DC): Focusing on spinal and pelvic alignment, nerve function, and biomechanical integrity.
• Advanced Practice Nursing (Dr. Jimenez, APRN): Administering medical treatments like injections, prescribing medications when necessary, and managing overall patient health.
• Functional Medicine: Investigating and addressing root causes of inflammation, metabolic dysfunction, and nutritional deficiencies that can contribute to chronic pain and poor healing.
• Rehabilitation and Physical Therapy: Designing customized exercise programs to strengthen weak muscles, stretch tight structures, and restore proper movement patterns.
• Personal Injury Care: Providing comprehensive documentation, diagnosis, and treatment for patients injured in accidents, navigating the complexities of their recovery.

This collaborative structure allows us to offer a seamless patient experience, where every aspect of health is considered and addressed under one roof. Patients benefit from the collective expertise of multiple professionals working in unison toward a common goal: optimal health and recovery.

A Clinical Case Study: The 57-Year-Old Gentleman with Left Hip Pain

On the morning of September 15, 2026, a 57-year-old gentleman entered my examination room. He had been grappling with a persistent, nagging pain in his left hip for the past two months. This wasn’t a generalized ache; it was specific, localized, and significantly impacting his daily life. My first step, as always, is to listen intently to the patient’s story and then use my hands to translate their words into anatomical reality.

The Diagnostic Power of Palpation

Palpation, the art of examining the body by touch, is a cornerstone of musculoskeletal diagnosis. It is far more than simply “pressing on the sore spot.” It is a dynamic process of assessing tissue texture, identifying trigger points, evaluating temperature changes, and, most importantly, precisely recreating the patient’s specific pain.

I asked him to show me where he was uncomfortable. He pointed to the side of his hip, near the prominent bony landmark known as the greater trochanter. This is the large bump you can feel on the outside of your upper thigh, where several powerful hip muscles attach.

As I began my physical examination, I gently but firmly palpated the region. My goal was to pinpoint the exact anatomical structure responsible for his symptoms. I started directly over the greater trochanter itself. Pressure there often elicits pain in trochanteric bursitis, where the fluid-filled sac that cushions the bone becomes inflamed. However, he reported only mild tenderness there.

I then shifted my fingers slightly posterior (toward the back) and superior (toward the top) of the trochanter. This is a critical area because it marks the insertion point of the gluteus medius and gluteus minimus muscles. These muscles are part of the hip abductor group, responsible for lifting the leg out to the side and, crucially, for stabilizing the pelvis when we walk, run, or stand on one leg.

“How about here?” I asked, applying focused pressure.

“Some,” he replied, indicating we were getting warmer.

I moved my fingers slightly, exploring the tissue. “Further down?”

“Yes, right there!” he exclaimed. “Right in there.”

This is the “aha” moment in a physical exam—the moment of concordant pain reproduction. This means the pressure I applied exactly replicated the quality and location of the pain he experiences daily. This is a powerful diagnostic indicator, suggesting that the structure beneath my fingers is the primary source of the problem.

“Does that exactly replicate the pain that you’re having today?” I confirmed.

“Slowly, yes. Yeah. Yes,” he affirmed, the gradual onset of the familiar ache confirming my findings.

I took a surgical marker and placed an “X” directly on the spot. We had identified our target. Based on the location—posterior and superior to the greater trochanter—and the precise reproduction of his pain upon palpation of the tendinous insertion, my primary working diagnosis was gluteus medius tendinopathy.

Understanding Gluteus Medius Tendinopathy and Greater Trochanteric Pain Syndrome (GTPS)

For many years, pain in this lateral hip region was almost universally diagnosed as “trochanteric bursitis.” The assumption was that the bursa was the inflamed, painful structure. However, modern research, including advanced imaging studies like MRI and ultrasound, has revealed a more complex picture. Leading researchers have shown that in most cases, the primary pathology lies not in the bursa but in the tendons of the gluteus medius and minimus muscles (Grimaldi et al., 2015). This condition is more accurately termed tendinopathy, a degenerative process within the tendon involving collagen fiber disorganization, increased ground substance, and neurovascular ingrowth, rather than simple inflammation (“tendinitis”).

The bursa may become secondarily inflamed from irritation as the unhealthy tendon rubs over it, but the root of the problem lies within the tendon itself. For this reason, the broader, more inclusive term Greater Trochanteric Pain Syndrome (GTPS) is now preferred in the medical literature. GTPS encompasses a range of pathologies including:

• Gluteus Medius/Minimus Tendinopathy: The most common cause.
• Tendon Tears: Ranging from small partial-thickness tears to complete ruptures.
• Trochanteric Bursitis: Often a secondary finding.
• External Snapping Hip (Coxa Saltans Externa): Where the iliotibial (IT) band snaps over the greater trochanter.

The Biomechanics of Pelvic Stability

To understand why the gluteus medius is so vulnerable, we must appreciate its vital role. Imagine walking. As you lift your right foot to take a step, your left leg supports your entire body weight. What stops your right hip from dropping down? It’s the powerful contraction of the gluteus medius and minimus on your left (stance) side. They act as the primary stabilizers of the pelvis in the frontal plane.

The Trendelenburg sign describes this action. If these muscles are weak or their nerve supply is compromised, the opposite side of the pelvis will drop during the swing phase of gait. A person with significant gluteus medius weakness will exhibit a characteristic “waddling” or Trendelenburg gait, lurching their upper body over the stance leg to maintain balance.

Even in individuals without a visible gait deviation, subtle weakness or overuse can place enormous strain on the gluteus medius tendon. Repetitive tensile and compressive forces during walking, running, climbing stairs, or even prolonged standing can cause micro-trauma. Over time, if this micro-trauma outpaces the body’s ability to repair the tissue, degenerative tendinopathy develops. This is why GTPS is often considered an overuse or repetitive strain injury.

Contributing Factors to GTPS often include:

• Biomechanical Issues: Leg length discrepancy, excessive foot pronation (flat feet), or altered gait mechanics can increase stress on the hip abductors.
• Muscle Imbalances: Weakness in the core and gluteal muscles, combined with tightness in opposing muscle groups like the hip flexors and IT band, creates dysfunctional movement patterns.
• Structural Variations: A wider pelvis (more common in women, who have a higher incidence of GTPS) increases the angle at which the IT band crosses the trochanter, potentially increasing compressive forces on the underlying tendons (Fearon et al., 2010).
• Activity Changes: A sudden increase in the intensity, duration, or type of physical activity (e.g., starting a new running program) can overload the tendons.
• Systemic Factors: Conditions like rheumatoid arthritis, metabolic syndrome, and hormonal changes can affect tendon health and healing capacity.

The Therapeutic Injection: Rationale and Procedure

Having identified the gluteus medius tendon insertion as the pain generator, the next step was to formulate a treatment plan. For acute, debilitating pain that has not responded to initial conservative measures, a targeted therapeutic injection can be a highly effective intervention.

The goals of the injection are twofold:

1. Diagnostic Confirmation: Injecting a local anesthetic (numbing medicine) into the suspected structure should provide significant, albeit temporary, pain relief. If the patient’s concordant pain is eliminated or dramatically reduced within minutes of the injection, it confirms that we have targeted the correct anatomical source. This is a powerful diagnostic tool.
2. Therapeutic Effect: The injection typically includes a corticosteroid, a potent anti-inflammatory medication. While tendinopathy is primarily degenerative, it often has a secondary inflammatory component, particularly in the surrounding bursa and tissues, that contributes to pain. The steroid helps quell this local inflammation, breaking the pain cycle and creating a window for effective rehabilitation.

Preparation for the Procedure

Safety and sterility are paramount. Before any procedure that breaks the skin, meticulous preparation is essential to minimize infection risk.

1. Site Cleansing: I began by prepping the marked area on the patient’s hip. I used several alcohol swabs to degrease the skin and remove surface contaminants. Next, I made two passes with swabs soaked in povidone-iodine, a broad-spectrum antiseptic. This “painting” of the area ensures a sterile field for the injection.
2. Topical Anesthesia: To make the procedure as comfortable as possible, I used a vapocoolant spray. I gave him a “free spray” of ethyl chloride over the area. This substance evaporates instantly on contact with the skin, causing rapid, intense cooling that temporarily numbs superficial nerve endings. It feels very cold, as the patient noted, but it significantly reduces the sharp sensation of the needle piercing the skin.

Performing the Injection: A Tactile Approach

With the site prepped and numbed, I was ready to proceed. The needle I used was long enough to reach the tendon’s deep insertion on the bone.

“Okay. Now I feel it enter the muscle,” I noted, providing a running commentary to keep the patient informed and at ease.

As the needle advanced through the layers of skin, subcutaneous fat, and the dense fascia lata, the resistance I felt through the syringe changed. When it entered the muscle belly of the gluteus maximus or tensor fasciae latae, the resistance was minimal. As it approached the deeper, more fibrous gluteus medius tendon, the resistance increased.

“I feel it enter the tendon, right there.”

This tactile feedback is crucial. An experienced practitioner can feel the subtle changes in tissue density. The tendon feels grittier and more resistant than muscle or fat.

To further confirm my position, I used a subtle technique. “If you just slide down with your fingers along the sides of the syringe, right when it starts to slip, that’s where you know you’ve got increased resistance.” This describes the haptic feedback. When injecting into a low-resistance space like a bursa or muscle belly, the plunger depresses easily. When the needle tip is in a dense, pathological tendon, the back pressure is significant, and it’s much harder to inject the fluid.

“So I believe I’m there,” I stated, confident in my anatomical position. “Let me give you a little injection there.”

I slowly depressed the plunger, injecting a small amount of the solution (a mixture of a local anesthetic like lidocaine or bupivacaine and a corticosteroid).

“Okay. Does that actually feel like the pain that you have?” I asked immediately.

“Yes,” he confirmed.

This is another critical diagnostic sign, known as a provocation response. Injecting fluid into the tight, inflamed space of the tendinopathy temporarily increases the pressure, which can briefly but precisely replicate the patient’s familiar pain. Combined with the subsequent relief from the anesthetic, this provides dual confirmation of correct needle placement.

The Fanning Technique

The gluteus medius tendon doesn’t insert as a single point; it has a broad, fan-shaped insertion on the greater trochanter. To ensure the medication distributes across the entire pathological area, not just one small pocket, I used a fanning technique.

“Okay. No. Okay. I’m going to fan it just a little bit.”

Without withdrawing the needle completely from the skin, I angled it slightly superiorly and injected a portion of the medication. Then I redirected it slightly inferiorly and anteriorly, delivering more solution.

“Kay. Give you a little bit right here.”

This creates a “fan” of medication that bathes the entire tendinous footprint. It’s more effective than a single-bolus injection for treating diffuse tendinopathies.

“Let me do it one more time, and advance right there.”

With the final medication deposition, the procedure was complete. “Injection is in. Right, I’m out. The needle is out.”

Immediate Post-Procedure Assessment

The moments immediately following the injection are vital for assessment.

First, I applied firm pressure to the injection site and massaged the area. “Now, let me massage the area here. So, want to massage that in?” This helps disperse the medication within the tissues and can alleviate some immediate post-injection discomfort.

The patient experienced noticeable discomfort during the injection, which is not uncommon when treating an already painful, inflamed tendon. The fluid pressure itself can be quite painful.

The true test, however, was the post-procedure palpation. I returned to the very same spot that I had marked earlier—the spot that had caused him significant pain during the initial exam.

“Okay. We are done… Does this hurt? What I’m doing right now.”

“Just a little,” he replied.

“Okay. Because this is the area that I pressed when you came in,” I reminded him. I then palpated the surrounding areas again for comparison. “So let me press over the outside part of the hip bone.”

“That’s okay.”

“How about here?” I asked, returning to the primary spot.

“Just a little tender.”

“Is it… is it less than it was earlier?” I asked, needing confirmation.

“Yes, it was.”

“Okay. All right. So that’s a good sign,” I concluded. “That means that the numbing medicine is in the right spot for that, so I’m encouraged by that.”

This immediate, significant reduction in palpation tenderness confirmed the injection’s diagnostic value. The local anesthetic had successfully numbed the pain-generating fibers within the gluteus medius tendon insertion. This gave us high confidence in our diagnosis of GTPS originating from gluteus medius tendinopathy.

I finished by cleaning the site one last time and applying a simple adhesive bandage. “Let me just go ahead and put a Band-Aid on it, and then we’re done.”

The Integrative Chiropractic and Rehabilitation Plan: Beyond the Injection

The injection is not a cure; it is a powerful tool to break the cycle of pain and inflammation. It creates a therapeutic window, typically lasting a few weeks to several months, during which the patient can focus on the most critical part of recovery: corrective rehabilitation guided by an integrative framework. This is where our clinic’s synergy truly shines.

The injection provides pain relief, allowing the patient to perform exercises and receive manual therapies that would otherwise be too painful. Our goal is to use this window to address the underlying biomechanical and neuromuscular deficits that led to the tendinopathy in the first place. Without this comprehensive approach, the pain is likely to return once the effects of the steroid wear off. As a chiropractor and functional medicine practitioner, I immediately focus on restoring function.

Our integrative plan for this patient would involve the following components:

1. Chiropractic Assessment and Care

The hip does not exist in isolation. Its function is inextricably linked to the pelvis and the lumbar spine. A common contributor to GTPS is dysfunction within the sacroiliac (SI) joints or lumbar facet joints.

• Spinal and Pelvic Alignment: I would perform a thorough chiropractic evaluation to assess for subluxations (misalignments) in the lumbar spine and pelvis. A rotated ilium or a sacral misalignment can alter the mechanics of the entire lower extremity. For example, an anteriorly rotated ilium on the affected side can functionally lengthen the leg, increasing tension in the gluteus medius and IT band. It can also inhibit (weaken) the gluteal muscles through altered nerve signaling.
• Chiropractic Adjustments: Using specific, gentle adjustments, I would aim to restore proper motion and alignment in any restricted lumbar spine and pelvic joints. By improving joint mechanics, we can normalize nerve flow to the gluteal muscles (via the superior gluteal nerve, L4-S1) and reduce compensatory strain on the hip abductors. Restoring a level pelvic foundation is paramount for balanced weight-bearing and gait.

2. Targeted Soft Tissue and Myofascial Release

Tendinopathy is often accompanied by trigger points, adhesions, and hypertonicity (excessive tightness) in the surrounding musculature. These tissues must be addressed directly.

• Gluteus Medius/Minimus: I would use techniques like deep tissue massage, Active Release Technique (ART), or instrument-assisted soft tissue mobilization (IASTM) to break down fibrous adhesions within the muscle bellies of the gluteus medius and minimus. This improves blood flow, reduces muscle tightness, and restores the muscle’s ability to contract and lengthen properly.
• Tensor Fasciae Latae (TFL) and IT Band: The TFL muscle, located on the front and side of the hip, blends into the dense, fibrous IT band. Tightness in this complex is common in GTPS, as it can increase compressive load on the gluteal tendons where they pass under the IT band at the greater trochanter (Grimaldi et al., 2017). Releasing the TFL muscle and the fascial restrictions along the IT band is crucial.
• Hip Flexors and Quadriceps: Tight hip flexors (iliopsoas and rectus femoris) can cause an anterior pelvic tilt, which can lead to reciprocal inhibition. This neurological phenomenon suggests that when a muscle on one side of a joint is tight and overactive, the opposite muscle (the antagonist) can become neurologically inhibited and weak. In this case, tight hip flexors can contribute to weak, underactive glutes, forcing the smaller gluteus medius to work overtime and leading to breakdown.

3. A Phased Rehabilitation Program

Rehabilitation is the cornerstone of long-term success. The program must be progressive and tailored to the individual’s healing stage.

• Phase 1: Isometric Loading and Pain Management (First 1-2 Weeks Post-Injection): Immediately after the injection, the goal is to begin loading the tendon without irritating it. Isometric exercises, where the muscle contracts without changing length (no movement), are ideal.

• Example: Lying on the non-painful side with a pillow between the knees, the patient gently presses the top knee into the pillow and holds for 30-45 seconds. This activates the gluteus medius without moving the hip joint. Isometrics have been shown to have an analgesic (pain-relieving) effect on tendons (Rio et al., 2015).
• Education: During this phase, we educate the patient on activity modification. This includes avoiding sleeping on the affected side, avoiding crossing the legs, and avoiding standing with all the weight shifted onto one hip (“hip hanging”). These positions compress the tendon and impede healing.

• Phase 2: Isotonic Strengthening (Weeks 2-6): As pain subsides, we progress to isotonic exercises, where the muscle contracts through a range of motion. The focus remains on strengthening the gluteus medius and its synergists.

• Examples: Clamshells (with proper form to avoid substitution), side-lying leg lifts, standing hip abduction with a resistance band, and bridges. The key is slow, controlled movement that emphasizes activating the correct muscles. Start with low resistance and repetitions, then gradually increase as tolerated.

• Phase 3: Functional and Weight-Bearing Strengthening (Weeks 6-12 and beyond): This phase aims to reintegrate the strengthened muscles into functional, everyday movements.

• Examples: Bodyweight squats (ensuring the knees track over the toes and don’t collapse inward), lunges, single-leg balance exercises, and eventually, step-ups and single-leg deadlifts. These exercises challenge the gluteus medius in its crucial role as a pelvic stabilizer during weight-bearing activities. We would also incorporate core-strengthening exercises like planks and bird-dogs, as a stable core provides a solid base for hip movement.

• Phase 4: Return to Sport/Activity: For active individuals, the final phase involves sport-specific drills that replicate the demands of their chosen activity, ensuring the hip can tolerate the loads without a recurrence of pain.

4. Functional Medicine Considerations

As a Certified Functional Medicine Practitioner (CFMP, IFMCP), I also look beyond the local musculoskeletal issue to consider systemic factors that may be hindering the healing process. Chronic, low-grade inflammation is a major driver of poor tendon health and chronic pain.

• Anti-Inflammatory Diet: I would counsel the patient on adopting a diet rich in whole foods, phytonutrients, and healthy fats while minimizing pro-inflammatory processed foods, refined sugars, and industrial seed oils. Foods rich in omega-3 fatty acids (like wild-caught fish), turmeric, ginger, and leafy greens can help modulate the body’s inflammatory response.
• Nutrient Support: Certain nutrients are critical for collagen synthesis and tissue repair. These include Vitamin C, zinc, manganese, and amino acids like proline and glycine. If dietary intake is insufficient, targeted supplementation may be beneficial.
• Gut Health: The gut microbiome profoundly affects systemic inflammation. Dysbiosis or “leaky gut” can be a hidden source of inflammation that impairs recovery from musculoskeletal injuries.
• Metabolic Health: Conditions like insulin resistance and metabolic syndrome are strongly associated with poorer tendon health and an increased risk of tendinopathy (Gaida et al., 2016). Assessing and addressing these metabolic issues can be a key component of a long-term solution.

Conclusion: A Holistic Path to Healing

This 57-year-old gentleman’s case clearly illustrates our clinical philosophy at Injury Medical Clinic PA. The journey began with a precise, hands-on diagnostic process that pinpointed gluteus medius tendinopathy as the source of his discomfort. We confirmed this with a diagnostically and therapeutically successful injection, performed under established medical protocols overseen by our Medical Director, Dr. Maria Cardenas.

However, this medical procedure was not the end of the story; it was the beginning of true recovery. The relief it provided opened the door to a comprehensive, integrative treatment plan. This plan combines chiropractic structural correction, targeted release of dysfunctional soft tissues, the systemic approach of functional medicine, and a progressive, evidence-based rehabilitation program.

By addressing painful symptoms with an injection, correcting underlying biomechanical faults with chiropractic adjustments, and rebuilding strength and resilience through rehabilitation, we move beyond temporary fixes. We empower the patient with the tools and functional capacity to prevent recurrence and achieve lasting health. This is the essence of integrative medicine—a patient-centered, collaborative approach that honors the complexity of the human body and leverages the strengths of multiple disciplines to guide the patient on their journey from pain to performance.

References

Fearon, A. M., Cook, J. L., Scarvell, J. M., Neeman, T., Cormick, W., & Smith, P. N. (2010). Greater trochanteric pain syndrome: defining the clinical syndrome. British Journal of Sports Medicine, 44(8), 1-5. bjsm.bmj.com/content/48/8/649.long

Gaida, P. J., Ashe, M. C., Bass, S. L., & Cook, J. L. (2016). Is adiposity an under-recognized risk factor for tendinopathy? A systematic review. Arthritis Care & Research, 78(5), 669–677. onlinelibrary.wiley.com/doi/abs/10.1002/acr.22729

Grimaldi, A., Mellor, R., Hodges, P., Bennell, K., Wajswelner, H., & Vicenzino, B. (2015). Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine, 45(8), 1107–1119. link.springer.com/article/10.1007/s40279-015-0336-5

Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2017). Utility of clinical tests in diagnosing gluteal tendinopathy: a systematic review. British Journal of Sports Medicine, 51(3), 187-197. bjsm.bmj.com/content/51/3/187

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283. bjsm.bmj.com/content/49/19/1277

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