Greater trochanteric pain syndrome or gluteal tendopathy can be a real pain in the butt. Well, maybe not quite in the butt, more like the outside of the hip, but it's a super common condition I see in my sports med clinic where we have this outside hip pain. And if you've had it, you know it can be very, very annoying. It can also be challenging to rehab. So today I'm gonna talk through my entire process of how I think about rehabbing this condition, and I'm gonna give you a template to follow, and just kind of a general formula of how we think about rehabbing any condition really, but specifically for this lateral hip pain. So let's dive in and get started. Welcome back everybody to the Building Life and pulling out these podcasts. Thanks so much for stopping by, really appreciate it. We haven't had the chance to meet yet. My name is Jordan Wrenke. I'm a dual board certified physician in family and sports medicine. And the goal of this podcast is to keep you active and healthy for life through actionable evidence and form education. And today we're talking all about how to set up a rehab program. Today we're talking about greater trochanteric pain syndrome, but really this is kind of a general heuristic and framework. And so I'm gonna walk you through a program that I kind of created for lateral hip pain or this greater trochanteric pain syndrome, and walk you through my logic behind it. And then hopefully you can either, you know, take that and use it or kind of implement it into other problems that you have. But that's just once again, going through how I think about rehab and I hope you enjoy it. So I did create this kind of cheat sheet for me, just so I could have talking points. This will be linked below in the description. And essentially we're talking about greater trochanteric pain syndrome, how to get better and understanding it. So first things first, this is not gonna be a diagnosis lecture. I have a much longer video about greater trochanteric pain syndrome, and I'll link to it here in the show notes and also in the YouTube video. But overall, this is that pain you have in the outside of your hip. A lot of times people think it's bursitis and we've kind of moved past that. We think it's more of this tendinopathy of the glute tendons, specifically the glute med, glute minimus. And when we have this tendinopathy, we have to treat it like a tendinopathy. You know, the old answer used to be just do steroids, steroids, steroids, and that gets better for a little bit, but not longterm. So we really have to think about loading these tendons. But the first thing is we kind of have to offload it a little bit. So understanding that when are they painful? Well, it hurts when you lay on it, when you are sitting for long periods or if you have your legs crossed, if you're going upstairs, if you're walking for a long time, those are all reasons we may have pain. And so I kind of think about throughout this entire rehab process, kind of having these golden rules. So how do we avoid irritation? So first things first, avoiding compressive and irritating positions. So specifically, if you are sleeping on your painful side, don't do that. Don't lay on that side. A lot of times tendons specifically don't like compressive loads. And compressive means when we push on them. So tendons don't necessarily like that, whether it's the Achilles or, you know, the greater trochanter, they don't like that. So when you cross your legs across your body specifically, that is also another compressive load. So laying on it directly or pushing on it, it doesn't feel good. If you cross your body while sleeping, meaning like you're laying and your legs are kind of crossed, that can irritate you. Those are things we even want to think about. So avoid it if possible. If you do lay on the opposite side, put some pills between your knees to keep your hips nice and level. So our legs aren't going in. When your hip goes in towards the middle of your body, it's called adduction or adduction, that can compress the tendon as well. So big things are try to not sleep on that painful side. And if you sleep on the other side, try to keep some pills between your knees to keep your hips kind of neutral. Or maybe just on your back, back with something between you, like find something that's comfortable, but not on that side, that would be very helpful. From a sitting perspective, don't cross your legs. People love crossing that. But once again, when we cross that body, we're doing that adduction, that can really compress on that tendon, doesn't feel good. So try to avoid crossing your legs and don't try to sit too deep. If your knees are higher than your hips, try to avoid that 'cause that can lead compression as well. So those are the big things. Get up and move around, that's very helpful as well. Don't just sit there. And standing, don't just hang on the hip. Meaning if you're hanging there and just hang out to one side, all your weight is through that tendon, that might irritate you as well. These are all like recommendations, right? Nothing I'm gonna tell you today, nothing I tell you at all is like, you have to follow. Like this is the Bible of rehab. This is just, hey, kind of my thought process through that. So take it or leave it, you can do what you want. But that can be helpful if you're not standing on one side. And then stretching, this is a big one. Everyone loves doing essentially pigeon pose, right? Your legs across your body or your figure eight, whatever you wanna call it, where your leg is across your body, that's not gonna be good long-term for that healing. Just because it's once again gonna bring that compressive load onto the greater trochanter over on the outside of the hip. So avoid that for a little bit. I know it feels good for a little bit, it feels good for a second, but it's not helping long-term. So avoid those cross body positions. So these kind of go all throughout the entire rehab principle. If you're having flares, really remember to go back to the golden rules. And the next I have the stoplight approach. So a stoplight approach, the way I explain this is that this gives you a target for when you're doing exercises or any sort of activity, whether it's okay or not. So I'm not saying any specific activity is good or bad, but it kind of gives you some guidelines. There's green light, yellow light, red light. Green light is if your pain is zero to three out of 10. And when I mean where your pain is, it's either during the activity or up through the next 24 hours. So we're looking for a full day. If you feel good while you're doing it, but the next day you're really sore, that might've been a little too much. And so something to think about. Green light is zero to three out of 10. It means, hey, good. And you can do that and then you feel fine, continue with that, maybe increase up the next time. So no worries. Yellow is when we get into like that four to six-ish range, four to five, maybe, kind of it's up for debate. It doesn't matter. The idea is that it's not like, ow, take your breath away pain, but like, ooh, that's kind of sore pain. And for here, I want you to think about, okay, maybe I'll need to tweak the activity I'm doing, the amount I'm doing, something, but I don't necessarily need you to continue to stop. I just kind of probably wouldn't want to repeat that time and time and time again. But that's kind of yellow is that caution of, hey, I'm not doing damage necessarily, but it doesn't feel great. What can I tweak there? And red is like the take your breath and be like, ow, that really hurts pain. That doesn't really help in a rehab process. So we kind of want to avoid that. So that's kind of how I think about that. You know, it's variable, whether it's for yellow is four to five or four to six, I don't really care, whatever you use, use it. Just have an understanding that we don't want you just having tons of pain, but yeah, a little bit of pain in rehab is to be expected. That's another thing I'll repeat. Having a little bit of pain during a rehab process is to be expected. The goal is hopefully take it down and then move up from there. So that's kind of how I think about all rehab. So this is the phase overview of this program, specifically. You could literally just take this program and swap out and say rotator cuff or Achilles or plantar fascia, 'cause the general idea is the same. That's what I'm trying to teach you is this heuristic, but this is generally what I think about. The first phase is getting you out of pain, right? So the timeline for that is one to four weeks and take a while. I'm using it when the hip is really irritated, flared up. And the goal here is to reduce pain, learn good habits, calm things down and really yeah, get there. You do these daily typically, 'cause they're just kind of bringing pain down and ideas that we're doing mostly isometric things here. Isometric is when you're having a contraction that is not moving. So if you think about for this one specifically, you're gonna be sitting in the ground, you can have your knees with a band around them and then just pushing out into the band, but they're not moving. That's an isometric contraction. We find that isometrics can be very helpful for pain. They're actually have an analgesic property where the analgesic means it kind of brings your pain level down. So we do these in the acute phase to kind of calm things down. And this can take one to four weeks, depending on how flared up you are, everyone's mileage is gonna vary. Then we go on to the phase two, which is building up the strength of the tendon and the tolerance. So tendons like load. I'll say that time and time again, but they're kind of like Goldilocks. They too little load, they're not great too much. They get angry. We've got to find that right amount of load. And as I mentioned before, they like tensile load, which means stress kind of through the tendons, but not necessarily from a pushing force. So compression forces when they're pushing on it, they don't like that, but when they're getting pulled on and using it, that they like. So they like that and that's kind of helps them build their adaptation to get stronger. And the phase two is all about building up the tolerance of those tendons to get stronger. And so this can take a long time. Up to six to 12 weeks. So quite a bit of time and it's gonna be flexible, right? So for you, maybe you've been tolerating up and feeling good and it's been four weeks, five weeks, in six weeks, you feel great. That's awesome. You can progress. Some people may need to take longer. The goal here is that you have less overall soreness and can tolerate these activities. You're gonna get your stronger in your hips and core and glutes and all those things. I'm doing these typically every other day or three times a week. 'Cause we are gonna do some stuff where we're gonna start getting a little harder. I want you to kind of build up and let your body kind of have a chance to recovery. And yeah, we're doing a lot of these things. The focus of this intensity is working about a five or six out of 10 with something called the RPE. So rating perceived exertion. Want you to work hard, but not too crazy, but you should be challenged by these exercises. And it's gonna take a while. And we really focus on tempo here. So tempo is three seconds for the concentric, three seconds for eccentric. What I mean by that is, let's say you're doing a squat, right? When you're going down on the squat, that's gonna be three seconds down. Maybe you can hold for a second on the bottom and then three seconds back up. It's really challenging to do anything that long, but we find that tendons really like that load. They like that tempo. So we call that heavy, slow resistance, HSR. Sometimes you hear about eccentrics, which is just the lowering. I find HSR to be a little easier 'cause you just go down slow and back up slow. So that's kind of what we're focusing on here. But this second phase is all about building you up. And the third phase, the third phase is gonna be getting you back to doing the things you want to do. So whether it's hiking or running or jumping and stuff like that, just general ideas. That's once you're ready, once your body is ready for that load and we can introduce it. I think a lot of people skip that middle part where they kind of calm it down, feels better, try to go back to what they're doing. And that's where we kind of have this irritation. Your tendons take time to get ready. So you need to slowly build things up over time. That's what that second phase is all about. And it's really important 'cause you're building the tolerance of the tendons. So that's the third phase is getting you back to doing things like running and jumping. And typically we'll do these not every day. We're gonna kind of mix them around our strengths. So strength two, three times a week, your specific activities one to three times a week, kind of mixing them on off days. So I wouldn't have to do the same things, but these are gonna be challenging workouts. So we're gonna continue to progress with our strength with an RPE rating and perceived exertion of around seven or eight, meaning, hey, I want you to be working hard here in pretty darn challenging. RPE eight means after your end of your last set or your last rep, you should be able to do about two ish more meaning, hey, I could have probably done two more, but that's about it. That's the general idea. The main thing I want you to think about is you have to work hard. That's what I want. I don't want this to be easy, but that's what we think about. That's kind of what it is. And once you've slowly built things up, you can get out of there and continue to go. So just taking a kind of scroll on here. As I mentioned, phase one, the big thing is calming thing down. And how do we do that? Well, the first thing is isometrics. So what I have here is isometrics are those contractions. As I mentioned before, where we're contracting without resistance and specifically here, we're gonna work on a couple of different directions. So first things first is glutes. So you're literally just laying on your back, squeezing your glutes. You're doing that for a little bit to start. It's like five to 10 seconds, but then eventually I want you to get up to go in 30 to 45 seconds. That seems to be the amount of time that it takes to kind of really start getting pain reduction improvements. So eventually you're just gonna be squeezing for 30 to 45 seconds and performing three to five reps of those and have one, two sets as well. So you're gonna do two sets, a goal and kind of work up to hopefully two or three sets, doing 45 second holds, doing multiple times, that's the goal. Then we have a knee squeezes where you're gonna be essentially laying on your back and squeezing your knees together. That's adduction. Same idea, we're gonna slowly build up. And at the end we have a hip abduction one. So you can do this either on your back or going into a wall, or you can do it with a band. There's a whole different ways to do this. Another thing is these are just random exercises that I just put in there. And they're kind of ones that are in throughout the literature and the physical therapy world. And I put them in there, but there's literally so many exercises you could plug in for any of these things. This is once again, just a general like a framework that I use, but I just kind of put some example exercises in. And so none of these exercises are magic. That's for sure. You could do other things and they may or may not work for you, but this is just once again, a general idea of how I think about this. And so that's really our phase one. We are trying to just initially calm things down moving on and going up from there. So then phase two, when they say, when am I ready for phase two? When your pain is considerably better, right? We're kind of chilling out more in that zero to three and that's daily stuff, just kind of existing. I'm not talking about going upstairs or running or doing things you wanna do. Like that's probably still gonna be painful, but like day to day activities, we've hopefully calmed it down there. That's what we're thinking about. And then you can comfortably do these isometrics for multiple sets for long holds of 30, 45 seconds. And you feel good with the golden rules, meaning, hey, I can kind of tolerate things here and I can understand how to titrate things and move things so I'm not feeling as bad. That's when we can move on to phase two. And this is where we build it up again. Same thing is here. We're gonna do this three times a week, general, kind of general template. You could do more, you could do every other day. You could do four days. Once again, nothing I'm telling you is like magic. Nothing I'm telling you is like set in stone. This is just like, hey, this is, I tried to make this as easy as possible to follow along. Like for someone just like at home to do this or with like a minimal exercise equipment, just you can do this and yeah. But I just want to have that general idea. And then we had those two. And then so it's string exercises. First, we'll start off with bridges. So bridges, you're laying in the ground, just lifting your hips up. This is where we start to incorporate that tempo, right? So three seconds up, kind of hold the top three seconds down really focusing on slow and controlled activities. And I start with body weight here, but at any time you're like, this is way too easy. Then you can absolutely start adding on weight. I talk about different progressions as well, but we're gonna kind of start off building up, right? So we start two sets of eight to 10 reps, hopefully getting up to three-ish sets, 15 to 20 reps. That's what it is. And then we have banded walks. We're essentially working on our outer hip musculature when we're walking with a resistance band around our legs, really slow walks. Once again, everything's slow 'cause it just makes it harder. That's like my way of tricking people. If you go slow, it's really challenging and you don't think about the weight you're doing. Some people who are really, really strong, if they're doing a slow tempo, it's completely different and they don't worry about the weight they lifted. If you tell someone who loves lifting a specific weight and then you say, "Hey, I want you to do like 75% of that weight at the same speed." They're gonna be like, "Ah, I don't feel good." Or like, "I wanna lift more." But if you just completely slow down the tempo, it's like an entirely different lift. You have to figure out like, what is their normal for them? And it's very challenging. So that's why I like tempo. But yeah, I do some banded walks here and then we can add in specific abduction exercises, working the outside muscles. So you can either do standing or side lying with bands. It's totally up to you. It doesn't matter. Once again, all these are arbitrary. And yeah, that's kind of the general idea. And then mini squats. We start to introduce squats. Usually we start a little slow to start. We're not going all the way down. I think we kind of work our way back up as well. Yeah, so that's kind of how I think about these squats. And it's just a general strength, right? These are general strength and you might be able to progress fast. If you're a high level athlete, like that's probably not gonna be enough. You're probably gonna have to use load on the bar. So you're gonna have, let's say you squat 315. Maybe you're only gonna be able to do 135 with the plate. Like it's one of those things where you just gotta calm it down, find where it doesn't feel bad, follow the pain rules and slowly build from there. That's the general idea of this entire section. And so nothing's magic. How do we progress to phase two or phase three, I'm sorry, is when we're hitting these goal, tempos, reps, sets, feeling challenged as well, but really feeling pretty darn good and our day-to-day is not too bad. That's when we can kind of move on there. And yeah, overall those are big things. And then phase three, this is when we start to get into some jumping plyometrics. This is kind of actually optional, depends on your life, right? If you're just like, hey, I just hang out in the gym and I do some lifting and I do some cardio that's not bothered and my hip doesn't bother me. Then you don't necessarily have to do this, but if you're like, hey, I'm an athlete or I'm a runner, I wanna get back to it, then it's probably a good idea to introduce some of those more ballistic and jumping things in a controlled environment first. And so, yeah, we're gonna continue on to get strong and then we'll add in things as well. So once again, I keep going with bridges 'cause I think bridges are helpful for the glutes. You can do hip thrusts. You can do so many different things. You can do stagger stands. You can do single leg. You can add on weights on the bar, put a bar across your head, you can do bands. There's so many things. Once again, I just wanna like throw this out there that you can do that. It's just kind of giving you a general idea of what you could follow. And yeah, and then we have banded walks for longer. I think it may get more challenging. I just like those. I think they're light. They're not too stressful, but they're really, really good. Then I've started throwing in some hamstring curls just to kind of round things out to make sure we're getting the whole lower body and posterior chain and then squats. We're kind of progressing them as well. Add weight, whether it's you're gonna do goblet, front squat, back squat, you can do single leg squats. There's just so many squats. We're just, once again, just trying to build up tolerance through that, those tendons. And so we're tolerating it. And then after there, a couple of activities, specific things we can do, one and two times a week in terms of you could run maybe once a week, kind of start off with run-walk intervals. So you're gonna run for one minute and walk for anywhere from like, honestly it could be 10 minutes or nine minutes. You do a one to nine ratio or 10% ratio and then go from there. That's a whole different discussion, whole different topic of returning to run. But I just want you to think about, hey, if you're doing this, start to run very, very gently, maybe do five minutes or a minute. And then the next time you try and you were good and it's in the green, you can do two minutes or six minutes, whatever you started with, like just very, very, very slowly incrementally go up. That's gonna think about don't jump it too fast. And then our plyometrics, we can do them. It's hops in place. You're hopping up and down, forward and back, side to side, or kind of doing drops as well as you're stepping off a low box or of a bench or anything like that. That's kind of what I think about. And another thing, and at any time at the end here, it says pain relief holds. Anytime like you're flared up, you can always do isometrics. Sometimes you have bad days and you have flares and isometrics make you feel better. Totally reasonable to do that as well. The main idea is that we're getting better over time. I tell people recovery is kind of like the stock market. Maybe you don't listen to whatever's happening in this current time when you're listening to this, but the stock market in general goes up over time, but there's good days and there's bad days. But that trend line is really what's important. And that's what I say I care about to my athletes is that I care about the trend lines. So over time, are we getting better? I usually draw a graph too. So on the Y axis is pain, on the X axis is time. And as long as it's like this, this slope going down, with my audio listeners, we're seeing a slope going down from up left to down right. As long as that slope's going down, meaning that pain's getting better, that's all I really care about. And some people that is quick, some people that's not, and that's okay, it's gonna be variable, but this is just general idea. And then we're kind of getting back to full activity if at all possible. And the big things here is you gotta be patient and consistent, right? This is gonna take time, it's gonna take effort. And this is not a no pain, no gain meaning, hey, I'm gonna push through like, no, listen to your body and adjust and pull things back as needed. Don't push through flare ups, we'll work around them and kind of get better. Focus really on the form and tempo, and remember to breathe, don't just hold your breath during exercises. And this is really just the starting point. This is the start of everything and it may not fix it for you that's the thing too, this template, there's no guarantee it's gonna do anything for you necessarily. Sometimes people follow things, a decently well-structured program, and they don't get better. And sometimes it needs just more either hands on or some tweaks and that's where a generic program that anybody gives you will never be the answer. This program will not be the answer for a probably decent amount of people 'cause that's just how our bodies work. Will it work for some people? Absolutely, because sometimes your body just needs a little bit of something to guide you in the right direction. It didn't work for them, but it won't work for everybody and that's okay, that's how it goes. I don't want you to get entirely frustrated saying, hey, this didn't work for me, like, oh, that's it. This just wasn't the right fit for you. I always kind of say rehabs like dating, you gotta find that right person. Maybe first program and first therapist you try, it wasn't quite right for you but then you find that right fit and that's awesome and that's magic. But sometimes it takes a couple of times to do that. So don't want you to get discouraged. But overall, this is my idea of how to rehab the outside of the hip, this greater trichontic pain syndrome. Once again, you can replace all these exercises with other things. I just wanna give an examples of how I think about structuring your rehab program and getting back there just 'cause yeah, there's sometimes it's hard to, if you're not in that all the time, you don't see it, it's hard to kind of understand and learn what that is. But thank you so much for stopping by. I really appreciate it, it means the world to me. If you like this, it would mean the world also if you share with a friend or if you liked it or commented on it, it just, any interaction is really, really helpful to me and means a lot. But thanks for stopping by, really appreciate it. Now get off your phone, get outside, have a great day. We'll see you next time.
