Evaluation of Abductor Tendons of the Hip
Lateral side hip pain is a common complaint of patients in an orthopaedic clinic and many conditions can present in such fashion. Referred pain from the lumbar spine, as well as intra-articular pathology need to be considered as explanations for the patient’s complaint. Once these are excluded from the differential, peritrochanteric causes of pain may be entertained. The most common causes of peritrochanteric pain are external coxa sultans, trochanteric bursitis, calcific tendonitis, and gluteus medius and minimus tendon tears.
The true incidence of tears of the gluteus medius and minimus tendons is unknown. Bunker, et al, have reported that 22% of patients undergoing operative intervention for femoral neck fractures have tears of the gluteus medius or minimus tendons. Howell, et al, have reported tears of the hip abductors in 20% of patients undergoing primary total hip arthroplasty.
Anatomically, the greater trochanter consists of four facets: the anterior, lateral, posteriosuperior, and posterior facets. The gluteus minimus attaches to the anterior facet and may function as a hip flexor, abductor, or internal and external rotator depending on the position of the hip. The gluteus medius attaches to the lateral and posteriosuperior facets and functions as an abductor and internal rotation of the hip. The posterior facet is devoid of any muscular attachment.
Tears of the abductor tendons are usually of a degenerative nature but may also be traumatic. They start from the undersurface anteriorly and progress posteriorly to involve the full thickness of the tendon.
Patients will typically present with the complaint of pain laterally over the trochanter. The pain is usually described as sharp in nature. They may mention an inability to lay on the affected side because of pain, and exhibit pain with extended walking and difficulty going up stairs.
As always, we begin the physical exam with evaluation of the patient’s gait which may show the patient to have a trendelenburg pattern and they may even display a trendelenburg sign on a single leg stance. On inspection atrophy is not normally seen. Range of motion is noted but typically normal. On provocative maneuvers during ROM assessment patients may note pain laterally. Patients will have tenderness with palpation over the lateral and/or anterior facets of the greater trochanter. Weakness of abduction and resisted external rotation with the hip at 900 flexion will also be noted.
Once evaluated for lateral side hip pain that is suspected to originate from the peritrochanteric space, conservative treatment is warranted and should consist of rest from aggravating activities, NSAID, physical therapy, and corticosteroid injection. Patients with pain that is refractory to this treatment warrant further work up with magnetic resonance imaging. Caution should be observed when evaluating MRI of the hip as there is a high prevalence of tendonopathy of the abductor tendons of the hip and certainly not all are symptomatic.
Patients that have undergone extensive non-operative treatment may warrant operative intervention. Good and excellent results may be expected with open or arthroscopic repair in well selected patients.
References
- Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg BR. 1997;79:618-620.
- Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips with osteoarthritis. J Arthroplasty. 2001;16(1):121-123.
- Robertson WJ, Gardner MJ, Barker JU, Boraiah S, Lorich DG, Kelly BT. Anatomy and Dimensions of the Gluteus Medius Tendon Insertion. Arthroscopy. 2008,24(2):130-136.
- Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic Repair of the Gluteus Medius Tendon Tear of the hip. Am J Sports Med. 2009;37:743-747.
- Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT. Arthroscopic Anatomy and SurgicalvTechniques for the Peritrochanteric Space Disorders in the Hip. Arthroscopy. 2007,23:1246e1-1246e5.
- Domb BG, Botser I, Giordano BD. Outcomes of Endoscopic Gluteus Medius Repair with Minimum 2-Year Follow-up. Am J Sports Med. 2013,20:1-10.
- Domb BG, Nasser RM, Botser IB. Partial-Thickness Tears of the Glutius Medius: Rationale and Trans-Tendinous Endoscopic Repair. Arthroscopy. 2010,26:1697-1705.
Submitted by:
Ricardo J. Rodriguez, MD
Baton Rouge, LA
