Sports Injuries

For individuals and athletes with a gluteal contusion with severe bruising, can a healthcare provider determine if there are any other injuries to underlying structures, including muscle or tendon tears?

Gluteal Contusion

A gluteal contusion is an injury, in this case, a bruise to the buttocks' gluteal muscles caused by damage to muscle fibers and blood vessels. A buttock bruise is caused by direct bodily impact, typically from falls, automobile collisions, accidents, bumping into something, or being struck by an object or person. Like all bruises, a gluteal bruise most often results in pain and visible discoloration of the skin at the injury site, varying in severity from grade I to grade III, with higher-graded bruises requiring more time to heal. Most butt bruises can heal on their own with time and rest, but if bruising is severe, individuals may require physical therapy to restore full muscle function.

Symptoms

A contusion is a muscle injury that can affect the body's skeletal muscles. A gluteal contusion can be painful, with a black and blue mark that changes color over time. Other symptoms may include: (Mount Sinai, 2024)

• Tenderness to touch over the injury site
• Increased pain with contraction of the glutes
• Swelling
• Discomfort with sitting

Causes

A contusion occurs from direct trauma and forceful impact on the gluteal muscles, causing damage to underlying blood vessels, muscle fibers, and sometimes bone, resulting in bleeding under the skin. (MedlinePlus, 2016) Direct impacts to the gluteal muscles that can cause a contusion include:

• Falls
• Car accidents
• Direct hits to the buttocks from a piece of sports equipment or person. 
• Bumping into furniture, a door, or a counter. 
• Intramuscular injections into the gluteal muscles.
• Individuals who take blood thinners or anticoagulant medication have an increased risk of bruising from direct contact injuries.

Diagnosis

A gluteal contusion is usually diagnosed through a physical examination and is generally straightforward to diagnose based on physical appearance, symptoms, and type of injury. Contusions can be graded based on the severity according to the following criteria (Fernandes, T. L. et al., 2015)

Grade I

• An injury that affects only a small amount of muscle fibers, resulting in minimal pain, tenderness, and possible swelling.
• Causes minimal or no loss of strength in the affected muscle or range of motion limitations.
• Muscle use is typically unaffected.

Grade II

• An injury that causes significant damage to muscle fibers, resulting in increased pain and impaired muscle contraction.
• A small muscle defect can be felt to the touch.
• Discoloration increases over the first few days after injury.

Grade III

• An injury that involves extensive muscle fiber damage and bleeding across an entire area of a muscle that results in severe, and sometimes total, loss of muscle function.
• Causes severe pain and significant discoloration of the skin.

1. When contusions are larger, deeper, and involve significant blood pooling and swelling, they are called hematomas.
2. If the bruising is severe, a diagnostic ultrasound, CT scan, or MRI may be used to determine whether any underlying structures are damaged.

Treatment

Contusions are generally mild injuries. Treatment typically involves rest to allow the muscles to heal from the bleeding and the bruising to dissipate.

• Applying ice to the injury site can help relieve pain and inflammation.
• If the bruising is severe, significant physical activity like sports, dancing, running, jumping, and weight lifting should be avoided until the muscles heal. (Mount Sinai, 2024)
• With more severe bruising, contraction and stretching of the glutes are painful and can require longer healing and recovery time.
• Physical therapy rehabilitation may be needed for more significant injuries to restore muscle function.

Prognosis

A mild injury usually heals on its own with time and rest. More significant injuries take longer to heal and may require physical therapy to build strength and range of motion if muscle function is affected.

Healing Time and Recovery

Healing and recovery times for gluteal contusions vary depending on the severity of the injury (Fernandes T. L. et al., 2015)

Grade I

• Minor injuries that cause minimal discomfort typically heal fully in five days to two weeks.

Grade II

• During the first two to three days, contusions develop, increasing discoloration under the skin, and complete healing can take two to three weeks.
• Return to sport is typically resumed after a month.

Grade III

• Contusions can take up to four to six weeks to heal, often requiring rehabilitation to restore muscle strength and range of motion.

Injury Medical Chiropractic and Functional Medicine Clinic

At Injury Medical Chiropractic and Functional Medicine Clinic, we passionately focus on treating patients’ injuries and chronic pain syndromes. We focus on improving ability through flexibility, mobility, and agility programs tailored to the individual. We use in-person and virtual health coaching and comprehensive care plans to ensure every patient’s personalized care and wellness outcomes. Our providers use an integrated approach to create personalized care plans that include Functional Medicine, Acupuncture, Electro-Acupuncture, and Sports Medicine principles. Our goal is to relieve pain naturally by restoring health and function to the body. If he feels the individual needs other treatment, they will be referred to a clinic or physician best suited for them as Dr. Jimenez has teamed up with the top surgeons, clinical specialists, medical researchers, and premier rehabilitation providers to provide our community with the best clinical treatments.

Building a Stronger Body

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research studies or studies supporting our posts. We provide copies of supporting research studies that are available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how they may assist in a particular care plan or treatment protocol; therefore, to discuss the subject matter above further, don't hesitate to contact Dr. Alex Jimenez or us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Mount Sinai. (2024). Bruise. https://www.mountsinai.org/health-library/injury/bruise

MedlinePlus. (2016). Bruises. Retrieved from https://medlineplus.gov/bruises.html

Fernandes, T. L., Pedrinelli, A., & Hernandez, A. J. (2015). MUSCLE INJURY - PHYSIOPATHOLOGY, DIAGNOSIS, TREATMENT AND CLINICAL PRESENTATION. Revista brasileira de ortopedia, 46(3), 247–255. https://doi.org/10.1016/S2255-4971(15)30190-7

Gluteus medius and minimus tendinopathy are painful and debilitating disorders in athletes. Chiropractor, Dr. Alexander Jimenez looks at the identification and rehabilitation options for this kind of injury...

No matter the condition that is overall of an athlete, the fact is that there are instances when their sport's demands exceeds the movement and stability available during the kinetic chain of joints and the muscles utilized to execute that movement. Pattern compensation can occur if any weakness exists in almost any plane of motion and injury might be the outcome.

An illness that can arise from this and similar situations is gluteal tendinopathy (either medius or minimum). The mixture of overuse and inherent weakness of the gluteus medius and minimis can lead to stress, tearing, or degeneration of the muscles or their various tendons, inducing tendinopathy in the athlete.

Hip Anatomy

A schematic view of gluteus medius and minimus can be viewed in Figure 1. The gluteus medius originates in the ilium inferior to the iliac crest and spans to the lateral and superior surfaces of the greater trochanter. Medius has two insertions: the superoposterior facet and the aspect. Of the two, the aspect includes a bigger area of insertion. Medius is a main hip abductor; the hip, while the posterior fibers help in external rotation is internally rotated by its anterior fibres. In weight bearing positions, these muscles keep the pelvis out of falling.

Gluteus minimus is a fan-shaped muscle lying to gluteus medius, and has the anterior and poor lines, as well as a source from the ilium and also the border of the greater sciatic notch. Gluteus minimus (in association with different muscles) chiefly abducts the hip when the hip is in extension and also a most important purpose of this muscle is to help reestablish the head of the femur in the acetabulum when an person is walking.

Indicators Of GlutealTtendinopathy

Tendinopathy is characterised by lateral hip pain in the shared insertion on the greater trochanter of the femur, and is often associated with higher trochanteric bursitis(1). Typically patients will complain of a dull and bronchial lateral hip pain, which can be aggravated abduction and by weight bearing under load.

To help distinguish the underlying muscular pathology (ie whether gluteus medius or minimus tendinopathy lies), medius tendinopathy often poses as tenderness along the anterior aspect of the greater trochanter in the tendinous insertion, whereas pain in the anterior part of the greater trochanter indicates the difficulties are more likely to be credited to gluteus minimus. In addition testing might be useful to help differentiate muscular from bursal pathology.

In some patients, however may present masquerading as other ailments, which then can lead to mismanagement and misdiagnosis of the condition. This is partly due to descriptions of the gluteus minimus are not always true and treatment protocols are not always unique to the pathology. Additionally, referred pain from the gluteus minimus can be acute as well as its source is relatively concealed; pain may be felt at the lateral and posterior element of the lower limb as far as the outer ankle and upward into the buttock, imitating sciatica(two). Palpation of the trigger point that is profound is not easy.

Diagnosis & Testing

When it comes to examining patients with suspected gluteal tendinopathy, a comprehensive and stepwise approach to the evaluation is recommended. This strategy should consist of taking a history from the patient, an inspection of the hip, palpation, followed by evaluations of range of movement, stability, and strength in all planes of motion. Areas and joints around the hip area (eg SI joint, lumbar spine) should also be analyzed. Gait patterns should be observed, noting any discrepancy and compensations due to weakness, in addition to heel strike and avoidance patterns. An MRI scan and/or ultrasound imaging is strongly suggested in case avulsion is suspected.

Unfortunately, there's no definitive test to rule tendinopathy outside or in. But, there are quite a few different tests that can be quite helpful when assessing a patient. These are as follows:

• Trendelenburg test the functional power of gluteus medius. The patient stands unsupported on a single leg. If the pelvis tilts towards the unsupported leg, then this indicates abductor weakness about the stance leg;
• Ober's test -- that the individual lies on the unaffected hip. The symptomatic knee and hip have been held in a flexed position. The hip is abducted and long to centre the iliotibial band over the greater trochanter, and then passively adducted. Pain in This Procedure suggests a tight, contracted or inflamed tensor fasciae latae and iliotibial band;
• Thomas test -- that the patient lies supine And retains the leg at the knee- to-chest place while the leg is kept completely extended on the exam table. If the thigh is elevated off the desk, the test is positive, indicating hip flexor tightness;
• Ely's test -- the patient lies in a prone position, together with the examiner flexing the knee and bringing the heel toward the buttock. If the heel can't touch the buttocks, then the hip of the side rises from the desk, or the patient feels pain or tingling at the back or thighs, the test is positive suggesting rectus femoris tightness.

In a 2008 study investigated the diagnostic reliability for gluteal tendinopathy of two additional tests: the 30-second single leg stance test and also the resisted external derotation test(5). In the single leg stance test, the individual accounts on one leg for 30 minutes with individual's hands held by the examiner to limit trunk influence. The test is deemed favorable if pain is experienced at any given time point. From the outside derotation test (see Figure 2), the patient lies in the supine position with the hip flexed to 90 degrees and brought into end range external rotation (or the point of pain). The individual is then asked to return to neutral. Reproduction of pain is considered a positive test.

The hip is flexed 90°, and the individual is asked to return the leg into the axis of the table against immunity. When the pain is replicated the test result is positive.

The reliability value of these tests is considered high. In the analysis, two groups of patients were compared with both the evaluations -- a target group of 17 patients who were suffering from hip pain anterior, lateral, or posterior to the greater trochanter or involving the thigh, along with a pain-free control group of 19 patients.

In the single-leg, the target group stance reproduced immediate, early, and spontaneous pain in 5 patients, 7, and 5 . The external derotation that was resisted generated pain lying in the supine position. In one of both of these patients, pain has been produced from the position. In the control group, 38 hips were analyzed with only one outcome. Following the tests, MRI imaging was carried, showing tendinopathy and/or bursitis of the gluteus medius and/or minimus tendons.

Statistical analysis showed excellent sensitivity and specificity, with 100 percent and 97.3%, respectively, for its single-leg stance test and 88% and 97.3percent, respectively, for its resisted external derotation test in the supine position. For the latter test, the sensitivity increased to 94\% with results that were positive in the prone position in the case of negative effects in the supine position.

Management & Treatment

As with tendinopathies, the main goal is the reduction of pain and dysfunction before progressing to eccentric training. Although no research on the advantages of eccentric training have been carried out especially on gluteal tendinopathy, there's good evidence in the literature because of this particular rationale, where the therapy of the achilles tendon, patellar tendon, along with lateral epicondylitis are strongly supported(6,7). There are no theoretical reasons why the principles can't be implemented in the treatment of gluteal tendinopathy.

A particularly useful example of training that is gluteal that is bizarre is the 'short fallout'. Here, the patient rolls towards the affected side then externally rotates the unaffected side, then loading the affected side, and then gradually resists the resistance band to the starting position (see Figure 3). Table 1 shows that a three- stage rehab plan based upon the principles outlined above.

Overview

Gluteal tendinopathy is a painful requirement to get an athlete and its diagnosis is not always straightforward. However, a stepwise and comprehensive test in clinic, which includes applicable and tests like the 30-second Single leg stance test and the resisted derotation test will help clinicians arrive at a diagnosis. As with other tendinopathies, that is approached by a rehab focuses on the reduction of pain and dysfunction, followed by a progression to eccentric training that is therapeutic is likely to yield good results.

References
1. Clin J Sport Med. 2011;21(5):447-453
2. Movement, stability and low back pain. New York: Churchill Livingstone; 1997. p.53-71
3. Eur Radiol. 2003; 13: 1339-1347
4. Surg Radiol Anat. 2004; 26: 433-446
5. Arthritis & Rheumatism 2008; 59(2) 241–246
6. Brit J of Sports Med. 2013;47(9):536-544
7. Am J Sports Med. 1998;26(3):360-366
8. Int J Sports Phys Ther. Nov 2014; 9(6): 785–797