REF-1390 · Mellor et al., 2018 · BMJ · Paper · PubMed · Free full text

Does outer-hip tendon pain need a steroid jab or just time?

In 204 adults aged 35-70 (mostly women, not runners), education plus exercise beat both at 8 weeks and on global change at a year; at a year, pain no different from the jab's.

Main caveat: Not runners. Middle-aged and older community volunteers, 82% women, moderate pain, long symptom duration; activity was not running-specific.
strong evidenceMeasured on non-athletes and recreational people

Mellor and colleagues randomised 204 community volunteers aged 35-70 with more than three months of lateral hip pain of at least 4 of 10, a physiotherapist's clinical diagnosis of gluteal tendinopathy and MRI evidence of increased intratendinous signal in the gluteus medius and minimus tendons, to one of three strategies: education about tendon load management plus exercise (EDX; 14 individual physiotherapy sessions over 8 weeks, handouts and a DVD, and a daily home programme of 4-6 exercises targeting the hip abductors and dynamic control of adduction), one ultrasound-guided corticosteroid injection (CSI), or a wait-and-see approach (WS; one physiotherapy session with general information, advice to continue activity and reassurance that the condition resolves over time).

At 8 weeks, global success ("moderately better" or more on an 11-point rating of change) was reported by 51/66 EDX, 38/65 CSI and 20/68 WS participants — every group differed from the others — and pain over the past week was 1.5, 2.7 and 3.8 of 10.

At 52 weeks, 51/65 EDX, 36/63 CSI and 31/60 WS reported success: EDX remained better than both, the injection no longer differed from waiting, and pain no longer differed between EDX and the injection (2.1 vs 2.3 of 10), though both stayed below wait-and-see (3.2). No serious adverse event was reported and adherence to the exercise diary was above 80% each week.

Strength measured at 8 weeks changed little, and the authors suggest that much of the benefit may come from the education — avoiding positions and movements that compress the gluteal tendons against the greater trochanter and progressing tendon load gradually.

Our reading: a well-run trial showing that for this tendon the active load-education-plus-exercise package beats both a jab and waiting, in middle-aged and older women rather than in runners; a "do not wait-and-see a tendon" line, which the base does not yet carry, could rest on it, labelled as a transfer.

Protocol

Design: multicentre, parallel, three-group pragmatic RCT; computer-generated schedule by an independent off-site organisation, stratified by site; sealed opaque envelopes; statistician blind to allocation; physical tests (hip abductor torque, active abduction lag) at baseline and 8 weeks by a physiotherapist blinded to group; other outcomes by postal questionnaire. Ethics: Universities of Queensland (#2012000930) and Melbourne (ID 1238598).
Participants: n = 204 randomised (EDX 69, CSI 66, WS 69), enrolled March 2013 to September 2015; 167 women (81.9%); age 54.8 (SD 8.8) y; BMI 27.4 (5.1); symptom duration median 24 months (IQR 8-48), more than 12 months in 63.2%; unilateral in 77.0%; pain 4.9 (1.0) of 10; VISA-G 59.9 (12.5).
Inclusion: age 35-70; lateral hip pain for more than three months; pain at least 4/10; clinical diagnosis by a physiotherapist confirmed on MRI (increased intratendinous T2 signal in gluteus minimus and medius). Exclusion: low back, sciatic or groin pain above 2/10; corticosteroid injection within 12 months; current physiotherapy; total hip replacement; neurological conditions.
EDX: 14 individual sessions over 8 weeks (60 min first, 30 min after) with a registered physiotherapist; education on tendon care, "particularly on appropriate amounts and gradual progression of tendon loading" (handouts, DVD), with emphasis on avoiding postures and movements that compress the gluteus medius and minimus tendons against the greater trochanter; home programme of targeted hip abductor strengthening and dynamic control of adduction during function, 4-6 exercises daily (details in web appendix table S2, not read).
CSI: one ultrasound-guided injection by an experienced radiologist (1 mL betamethasone 5.7 mg/mL or 1 mL triamcinolone acetonide 40 mg/mL, with local anaesthetic).
WS: one session with a physiotherapist: general information about the condition, possible risk factors, advice on continuing activity, reassurance that it resolves over time.
Primary outcomes: global rating of change in the hip (11 points, success = "moderately better" to "very much better") and average hip pain over the past week (0-10), at 8 and 52 weeks. Sample size: 67 per group to detect a 30% difference in success between each treatment and WS at 8 weeks (Dunnett procedure, 15% loss allowed).
Follow-up: 189 (92.6%) at 52 weeks — EDX 65/69 (94%), CSI 63/66 (95%), WS 61/69 (88%); four CSI participants sought physiotherapy or chiropractic and two WS participants had an injection by 52 weeks.
Funding and interests: a National Health and Medical Research Council (NHMRC) programme grant (#631717); K. Bennell holds an NHMRC principal research fellowship and P. Hodges an NHMRC senior principal research fellowship; the funders had no role in design, conduct, analysis, interpretation, manuscript or the decision to submit.Competing interests (ICMJE forms): support from the NHMRC for the submitted work; no financial relationships with any organisation that might have an interest in it; no other relationships or activities that could appear to have influenced it.

Key Results

Global rating of change, success (number/total, %; risk difference with 95% CI and number needed to treat; table 2):

WeekEDXCSIWSEDX vs WSCSI vs WSEDX vs CSI
437/64 (58)38/66 (58)13/66 (20)38.8 (23.7 to 54.0)38.0 (22.9 to 53.0)0.9 (−15.9 to 17.6), ns
8 (primary)51/66 (77)38/65 (58)20/68 (29)49.1 (34.6 to 63.5); NNT 2.0 (1.6 to 2.9)29.2 (13.2 to 45.2); NNT 3.4 (2.2 to 7.6)19.9 (4.7 to 35.0); NNT 5.0 (2.9 to 21.1)
1243/58 (74)39/65 (60)21/64 (33)39.9 (24.2 to 55.7)26.0 (9.7 to 42.3)13.9 (−2.4 to 30.3), ns
2645/61 (74)34/64 (53)23/61 (38)37.0 (20.9 to 53.1)15.4 (−1.4 to 32.3), ns21.6 (5.5 to 37.7)
52 (primary)51/65 (78)36/63 (57)31/60 (52)26.8 (11.3 to 42.3); NNT 3.7 (2.4 to 8.8)6.4 (−10.7 to 23.6), ns20.4 (4.9 to 35.9); NNT 4.9 (2.8 to 20.6)

Pain over the past week, 0-10 (mean, SD; adjusted mean difference with 95% CI):

WeekEDXCSIWSEDX vs WSCSI vs WSEDX vs CSI
42.7 (1.6)2.4 (2.0)4.1 (1.9)−1.4 (−2.02 to −0.73)−1.8 (−2.43 to −1.17)0.4 (−0.21 to 1.07), ns
8 (primary)1.5 (1.5)2.7 (2.4)3.8 (2.0)−2.2 (−2.89 to −1.54)−1.2 (−1.85 to −0.50)−1.0 (−1.72 to −0.37)
261.8 (1.9)2.6 (2.2)3.1 (2.4)−1.2 (−2.00 to −0.37)−0.6 (−1.38 to 0.26), ns−0.6 (−1.41 to 0.16), ns
52 (primary)2.1 (2.2)2.3 (1.9)3.2 (2.6)−1.1 (−1.93 to −0.33)−0.9 (−1.68 to −0.07)−0.3 (−1.06 to 0.55), ns
Secondary outcomes (from the text; supplementary table not read): at 8 weeks EDX beat WS on all secondary outcomes except active abduction lag and the Active Australia activity survey, and beat CSI on function, quality of life, self-efficacy, pain frequency and clinically important pain reduction (at least 2/10, a post hoc dichotomy); by 52 weeks EDX and CSI differed only in pain frequency (less with EDX).
Safety and adherence: no serious adverse event reported by any participant or practitioner; weekly adherence to the EDX home programme always above 80% (diary).
Strength: the limitations paragraph reports "a small but significant difference in torque" between EDX and WS; the discussion says "measures of muscle strength did not differ between groups at eight weeks" — the paper says both.

Mechanisms

Measured: large early improvements with both active treatments; the injection's advantage over waiting faded by 26-52 weeks while education plus exercise kept its lead on global change; hip abductor torque changed little or not at all at 8 weeks.
Authors' interpretation: with little change in strength, "the mechanism underpinning the benefits of education plus exercise might well be more in the education aspect" — avoiding postures and movements that compress the gluteus medius and minimus tendons against the greater trochanter and gradually progressing tendon load; the exercises may also have improved motor control (not measured), given direct analgesia or improved tendon structure.A previous home-exercise trial that did poorly had no load-management advice and non-specific exercises.
Inference: the package that worked combines the two elements the Achilles guideline puts first (REF-1380) — take out the provoking (here compressive) load and load the tendon progressively — and it cites this trial for that; the trial cannot separate education from exercise.

Practical Application

Does outer-hip tendon pain need a steroid jab or just time? In 204 adults aged 35-70 (mostly women, not runners), education plus exercise beat both at 8 weeks and on global change at a year; at a year, pain no different from the jab's.
Do not wait it out: with one advice session and reassurance, 29% felt better at 8 weeks and 52% at a year, against 77% and 78% with 8 weeks of education plus exercise (A, RCT; transfer to runners).
An injection's lead over waiting fades: after one corticosteroid injection 58% felt better at 4 and 8 weeks, but by 52 weeks it no longer differed from waiting on global change (6.4 percentage points, −10.7 to 23.6), though its pain stayed slightly below waiting's (−0.9, −1.68 to −0.07) and did not differ from education plus exercise.
The education was about load: the right amount and gradual progression of tendon loading, and avoiding positions and movements that press the tendon against the bony point of the hip; the specific positions are in the trial's appendix (not read here). Not from this paper; the base's own practice: for a runner, the same order applies to the running that provokes the pain — swap it out, then rebuild under a pain limit (SYNTH-73; REF-1380).
For a runner, a transfer: the trial says nothing about running load, hills, speed or a return-to-run schedule; those are practice.
What it is good for as a source: that an active education-plus-exercise package beats waiting and outlasts an injection for a lower-limb tendinopathy, in a large pre-registered trial. What it does not show: which component worked, effects in young athletes or runners, the effect of continued running, or that strength gains are the mechanism.

Limitations

Not runners. Middle-aged and older community volunteers, 82% women, moderate pain, long symptom duration; activity was not running-specific.
Unblinded participants, self-reported primary outcomes. Participants knew their treatment and one arm got no treatment; the global rating may reflect less frequent pain and better quality of life rather than pain intensity (the authors' reading).
Unequal attention. EDX had 14 sessions with a physiotherapist; CSI one procedure; WS one session. The contact itself could explain part of the benefit.
Multiple comparisons. No adjustment for secondary outcomes and time points (exploratory); the three primary comparisons would survive a Bonferroni correction, per the authors.
Reporting that does not add up: the abstract gives the 52-week pain differences against wait-and-see as "1.13 (−1.93 to −0.33); 0.87 (−1.68 to −0.07)" — positive numbers with negative intervals; the Results text gives −1.13 and −0.87, so the signs in the abstract are wrong. The paper both reports a small significant torque difference between EDX and WS and says strength did not differ between groups.
Funding and interests: public (NHMRC programme grant and fellowships); no financial relationships with interested organisations declared. No device maker, platform or federation is named.
How this entry was checked and changed
Why this level

a pre-registered RCT with 204 randomised and 189 (92.6%) followed to 52 weeks (rubric: large pre-registered RCT, 100 or more). Caveats that do not lower the design level but limit the reading: participants were not blinded to their treatment and both primary outcomes are self-reported against a no-treatment arm, and contact time differed by design (14 physiotherapy sessions vs one injection vs one session). Read from the full text (Europe PMC, CC BY-NC 4.0); the web appendix (exercise and education details, adherence, secondary outcomes) was not read

Full text (checked 2026-10-28)
Of 204 randomised participants (including 167 women; mean age 54.8 years (standard deviation 8.8)), 189 (92.6%) completed 52 week follow-up (full text)
Success on the global rating of change at eight weeks: 51/66 EDX, 38/65 CSI, and 20/68 WS; EDX vs WS risk difference 49.1% (95% confidence interval 34.6% to 63.5%), number needed to treat 2.0 (1.6 to 2.9) (full text)
At 52 weeks: 51/65 EDX, 36/63 CSI, and 31/60 WS; EDX better than CSI (20.4% (4.9% to 35.9%)); CSI did not differ from WS (6.4% (−10.7% to 23.6%; P=0.46)) (full text)
Pain at 8 weeks: 1.5 (1.5) EDX, 2.7 (2.4) CSI, 3.8 (2.0) WS; at 52 weeks no difference between EDX and CSI (mean difference −0.26 (−1.06 to 0.55)) (full text)
Education plus exercise: 14 individual sessions over eight weeks; home programme of 4-6 exercises to be performed daily; education to avoid movements and positions that compress the gluteus medius and minimus tendons against the greater trochanter (full text)
No participant or practitioner reported a serious adverse event; weekly adherence always more than 80% (full text)
Funding: NHMRC programme grant (#631717); the funders had no role in design, conduct, analysis or reporting (full text)