Gluteus Medius Tears – Not Just Trochanteric Bursitis
By: Anil K. Gupta, M.D., M.B.A. and Jacob Maier, M.S.
Greater trochanteric pain syndrome (GTPS), a spectrum of pathology that manifests as lateral hip pain, affects an estimated 1.8 in 1000 patients per year.1 While typically attributed to trochanteric bursitis, recent research has shown that GTPS, especially cases recalcitrant to conservative treatment, often involves some degree of injury to the gluteus medius (GM) tendon. First described in the late 1990s, GM tears range from low-grade partial-thickness tears to complete tendon avulsion from the greater trochanter. Similarities in the pathogenic mechanism, presentation, radiographic findings and surgical repair techniques have earned GM tears the nickname, “rotator cuff tears of the hip.”2 As our knowledge of GM tears has improved over the past decade, so have treatment options and outcomes for patients suffering from GTPS. This review aims to explore the presentation, diagnosis, treatment and outcomes for GM tendon pathology, focusing primarily on the surgical management options.
The hallmark of GTPS is lateral hip pain, which often has an insidious onset. However, falls or other acute trauma can also be causes.3,4 Other symptoms of gluteal pathology include pain with rising from a seated position, with prolonged standing, with hip rotation and pain at night. In the case of full-thickness GM tears, abductor weakness will be prominent. Consequently, these patients demonstrate gait abnormalities, a positive Trendelenburg sign and/or an inability to overcome resisted abduction.3,5 Ortiz-Declet et al. described an exam maneuver that has excellent accuracy in predicting GM tears.6 The patient flexes the symptomatic hip to 90 degrees, externally rotates 10 degrees, flexes the knee to 90 degrees and then must attempt to externally rotate against resistance from the examiner. Recreation of pain or weakness indicates a positive test.
Often, symptoms resolve with conservative management only. Rest, nonsteroidal anti-inflammatories (NSAIDs) and physical therapy are the first lines of treatment. A corticosteroid injection can also be considered in patients with severe pain on initial presentation.7 While injections alone provide excellent short-term relief, physical therapy and home exercise have demonstrated better long-term outcomes.8 Shockwave therapy (SWT) has shown some success in treating lower extremity tendon injuries, with long-term results similar to physical therapy.8–11 SWT has the potential to be a great option for patients that fail other conservative therapies, but further studies are necessary.
Patients that fail conservative treatment often require imaging to evaluate for gluteal pathology. Ultrasound and magnetic resonance imaging (MRI) are effective imaging studies to evaluate for abductor pathology. An ultrasound can be easily done during a clinic visit and is relatively inexpensive. However, it is difficult to assess deep tissues and bony structures; it also requires extensive training and a skilled operator. GM tears are better appreciated on MRI, specifically the coronal cuts, where tear thickness and atrophy is demonstrated best.12 Furthermore, both the greater and lesser trochanter are visible in the coronal plane, providing a consistent landmark for evaluation.12 Visible tendon retraction has traditionally been the indicator for GM tears on MRI, but Cvitanic et al. demonstrated that T2 focal hyperintensities -which are usually considered signs of tendinitis - more commonly indicate GM tearing.13 Both modalities have limitations regarding diagnosing specific pathology; for example, a partial-thickness tear versus a full-thickness tear.14 For this reason, a physician experienced in hip pathology should read the imaging.
Regenerative medicine may have a role in treating GM tears, as ultrasound-guided platelet-rich plasma (PRP) injections have been an effective conservative treatment for bursitis and tendinopathy.2 Patients that received a PRP injection demonstrated significantly better clinical improvement of chronic tendinopathy compared to controls receiving a single corticosteroid injection.15 Similarly, stem cell therapy has proven to be effective in treating chronic tendon degeneration. A small pilot study by Bucher et al. showed acceptable clinical outcomes in patients with GTPS treated with autologous tenocyte injection, but failed to find significant improvements on post-injection MRI.16 While encouraging, further research is necessary; this is because these early studies excluded patients with high-grade partial or full-thickness GM tendon tears.
Surgical intervention is indicated for patients who have persistent pain and disability as well as fail conservative treatment. Endoscopic bursectomy is a popular procedure for bursitis with low-grade partial-thickness tears, where lateral pain is the most prominent symptom. However, a bursectomy alone does not address degeneration of the GM tendon and can lead to a suboptimal outcome. Coulomb et al. examined the outcomes of patients undergoing bursectomy and debridement only of the partial-thickness GM tears and found only modest outcomes.17 These outcomes were inferior to those of GM tendon repair. For this reason, many surgeons prefer to do a takedown and repair for low-grade pathology.
Endoscopic repair is an effective treatment option for high-grade partial-thickness tears and full-thickness tears. An initial study evaluating outcomes of endoscopic repair showed 100% resolution of pain and recovery of abductor strength.4 Further studies have continued to show excellent outcomes for endoscopic repair of full-thickness tendon tears.18,19 Regarding technique, using an approach that splits the iliotibial band (ITB) improves intraoperative visualization and may improve modified Harris Hip Scores and lower failure rates.20
ITB release is effective in relieving symptoms in patients with bursitis.21 However, there are no studies to date that examine outcomes of GM repair with ITB release. Indications for an ITB release at the time of GM repair are associated with snapping hip syndrome with a positive Thomas (hula-hoop) test, or a positive Ober test on physical exam indicating a tight ITB. Considering that ITB friction can contribute to GTPS and that patients refractory to conservative treatment demonstrated thicker ITBs, future research should look at outcomes of GM repair with ITB release.22
Open repair is typically indicated during complete avulsion and significant retraction of the abductor tendons from the greater trochanter, which would make visibility and tissue mobilization difficult by endoscopic means. Open repair for full-thickness tendon tears result in excellent outcomes, with pain and strength improvements similar to endoscopic technique.23–25 However, open procedures have a slightly higher rate of retears (8% vs. 0) and wound complications such as hematoma and infection (3% vs. 0).23,24,26
Chronic tears with fatty degeneration are less amenable to suture anchor repair alone. Thaunat et al. found a correlation between increased fatty infiltration and decreased functional outcomes postoperatively.27 Bogunovic et al. applied the Goutallier/Fuchs Rotator Cuff Classification scale to GM tendon pathology and found great results in predicting outcomes of endoscopic repair.12 The scale classifies muscles based on the amount of fatty infiltration relative to muscle tissue. In this study, 29% of patients with Grades 3 or 4 fatty infiltration failed endoscopic repair, while none of those patients with Grades 1 or 2 fatty infiltration experienced postoperative failure. The patients with failed repairs were treated with gluteus maximus transfers, which demonstrated significant improvement in patient-reported outcomes after combined gluteus maximus and tensor fascia latae transfers for irreparable full-thickness tears.28
For severe chronic and atrophic tears, tendon augmentation with an allograft tissue is another option. In these procedures, the GM tendon is anchored down to the greater trochanter and the allograft tendon is sewn over the repair to add strength. Augmentation options include the Achilles tendon and quadriceps tendon allografts, both of which have shown success in alleviating pain and restoring abductor strength.29–31 More recently, studies have shown that using an acellular human dermal matrix allograft and other biosynthetic grafts to strengthen the repair construct often result in success.8,10,11,19
The postoperative rehabilitation typically lasts around 12 weeks. Immediately following surgery, patients are placed in an abduction brace with touchdown weight bearing and gentle range of motion permitted. Active abduction is restricted, especially in an open-chain fashion. Around six weeks postoperatively, active range of motion and strengthening may begin. Gait normalization is the key component of rehabilitation from weeks six to 12. From this point on the abduction brace is discontinued and the patient begins to steadily increase ambulation.4,32 Full release to unrestricted activity can vary from three to six months depending on the chronicity and severity of the tear.
As the understanding of the role GM tears play in trochanteric pain has developed over recent years, many acceptable options for managing these tears have emerged. Still, further studies are required to establish the best treatment options for various cases. For partial-thickness tears, these authors prefer takedown and repair over endoscopic bursectomy alone. We believe endoscopic repair is best for high-grade partial-thickness and full-thickness tears while reserving allograft augmentation for massive chronic atrophic tears.
References
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