Spontaneous avulsion or rupture of the gluteus medius and minimus tendons
may be an unrecognized source of debilitating pain in the lateral part of the
hip1-3.
Because of the difficulty in diagnosing the condition on the basis of routine
history and physical examination, patients who present with ruptures of the
gluteus medius or minimus tendons are often diagnosed as having greater
trochanteric pain syndrome, which is a term used to denote trochanteric
bursitis1,4.
Patients with pain in the lateral part of the hip are often treated for
bursitis, and therefore a ruptured tendon may go undiagnosed. As radiographic
findings are generally absent, it may be necessary to acquire magnetic
resonance images to make an accurate
diagnosis2,5-7.
Common conditions associated with greater trochanteric pain syndrome
include degenerative diseases of the lumbar spine, arthritis of the hip,
pelvic obliquity, iliotibial band and abductor tendinitis, and difference in
the lengths of the lower
limbs4,8,9.
The cause of tendinosis and ruptures of the gluteus medius and minimus tendons
is uncertain, but may be related to local mechanical trauma or predisposing
systemic
conditions10,11.
The gluteus medius and minimus are part of the abductor apparatus. They can be
considered analogous to the rotator cuff of the shoulder and thus are
predisposed to rupture in a similar
manner12-14.
We report the clinical presentation, radiographic findings, and surgical
management of a patient diagnosed with bilateral spontaneous ruptures of the
gluteus medius and minimus tendons. Our patient is unique in that she was
young and had bilateral ruptures, yet she had no known predisposing condition
for tendon rupture. In addition, the ruptures occurred five years apart. Our
patient was informed that data concerning the case would be submitted for
publication.
A forty-two-year-old woman presented to our institution with a seven-month
history of atraumatic, moderate-to-severe debilitating pain in the lateral
aspect of the right hip. In the months preceding presentation, the condition
had been treated as trochanteric bursitis by her primary care physician.
Treatment had included nonsteroidal anti-inflammatory drugs, several cortisone
injections, and physical therapy. After failure of nonoperative treatment,
narcotics were prescribed for pain control and the patient was referred to us
for evaluation.
On evaluation, the patient had no history of any medical problems nor did
she have any predisposing conditions that would cause tendon rupture. She also
had no history of related trauma, lumbar spine disease, or contralateral hip
pain. Her lifestyle was moderately active.
On examination, the patient weighed 68 kg and was 173 cm tall. She had
normal spine movement, an even pelvis, and no limb-length discrepancy. She had
an antalgic gait and a positive Trendelenburg sign. There was mild tenderness
over the right subcutaneous trochanteric bursa and severe tenderness over the
insertion of the gluteus medius and minimus tendons. No palpable lesions were
noted. There was full, symmetric range of motion of both hips and no groin
pain with provocative maneuvers. There was weakness and trochanteric pain with
resisted hip abduction and flexion as well as mild tightness but no snapping
of the iliotibial band. Straight-leg-raising was unrestricted and pain free,
and the deep tendon reflexes were normal.
Plain radiographs did not demonstrate bone avulsion or calcification
adjacent to the greater trochanter or within the substance of the gluteal
tendons. There was no sclerosis of the greater trochanter or degenerative
disease of the hip. To rule out any abnormality related to the greater
trochanter, magnetic resonance images of the pelvis were acquired, including a
coronal T1-weighted image, a coronal short tau inversion recovery image, an
axial T1-weighted image, a sagittal T2-weighted fast-spin-echo image with fat
saturation, and small-field-of-view coronal proton-density-weighted images
with fat saturation. The images revealed focal edema surrounding the insertion
of the gluteus medius and minimus tendons with rupture of the gluteus minimus
and at least a partial tear of the gluteus medius. The musculature and
tendinous insertions of the left hip were within normal limits
(Fig. 1).
Surgical reattachment was offered to the patient because of the severe
debilitating symptoms and failed nonoperative treatment, and the patient
agreed.
A longitudinal incision was made over the right hip, and the tensor fasciae
latae was incised in line with its fibers. The subcutaneous trochanteric bursa
was noted to be normal. The anterior portion of the gluteus medius tendon was
noted to be partially avulsed from the greater trochanter, and the tendon was
released anteriorly to expose the gluteus minimus tendon. The majority of the
gluteus minimus was found to be avulsed. Several sutures were placed in the
free end of this tendon, and it was repaired back to the greater trochanter
through interosseous drill holes. The repair was augmented with use of an
orthobiologic patch (Restore Orthobiologic Soft Tissue Implant; DePuy
OrthoTech, Warsaw, Indiana). The patch was unwrapped, reconstituted, cut to
fit the repaired area, and then sutured under slight tension to the gluteus
minimus and the trochanteric remnant with 2-0 Vicryl sutures (polyglactin;
Ethicon, Somerville, New Jersey). The anterior portion of the gluteus medius
tendon was then advanced and repaired back to the cuff of tendon, which had
remained attached to the greater trochanter. Interosseous sutures were also
used to secure the repair of the gluteus medius tendon. The wound was closed
in layers.
The patient was discharged home on the next day and had no postoperative
complications. After two weeks of protected weight-bearing with use of two
crutches, she was started on resistance-free abduction exercises and graduated
to one crutch. At five weeks, the pain and limp were gone and she had full
return of abduction and flexion strength. By four months after the operation,
she was symptom-free and able to walk 3 km without difficulty.
Five years later, she presented with a four-month history of spontaneous
progressive lateral pain and weakness of the left hip and no history of
trauma. The physical examination was similar to that at the time of her
previous presentation except that the limp and Trendelenburg sign were not as
pronounced. As before, magnetic resonance imaging revealed a rupture of the
gluteus minimus tendon and possible tear of the gluteus medius tendon
(Fig. 2). The right hip was
normal.
Because of her previous history, nonoperative as well as surgical treatment
was offered to the patient, and she opted for surgical treatment. Surgical
repair was performed with use of the same technique as in the first operation.
Six months after surgery, the patient was walking without pain, crutches, or a
limp.
Although rupture of the gluteus tendons is considered to be an uncommon
injury, unilateral ruptures have been reported recently in both the
orthopaedic and radiographic
literature2,5,6.
However, in our literature review, we found no mention of spontaneous
bilateral ruptures or a description of surgical repair.
The characteristic findings of gluteus medius and minimus ruptures are
similar to those of trochanteric bursitis and may lead to the wrong diagnosis.
This may result in prolonged treatment with nonsteroidal anti-inflammatory
drugs, cortisone injections, and physical therapy, leading to improvement in
some patients but lingering symptoms with intractable pain and hip weakness in
most12,14-16.
Patients usually present with chronic lateral pain in the hip, often
associated with a disabling limp and no history of trauma. They may describe a
grinding sensation and have difficulty climbing stairs. On examination, there
often will be exquisite tenderness over the insertion of the gluteus medius
tendon and occasionally over the trochanteric
bursa8,9,17.
The two most reliable clinical signs are the Trendelenburg sign and pain on
resisted hip abduction, both of which are reported to have greater than 70%
specificity and sensitivity for diagnosing this condition. Pain on resisted
hip internal rotation is a helpful sign but is not as
reliable1.
Conditions such as fibromyalgia, mechanical low back pain, lumbar spinal
stenosis, lumbar radiculopathy and femoral nerve irritation, stress fracture,
and osteonecrosis may mimic this condition and should be considered in the
differential
diagnosis1,9.
A variety of systemic conditions (Table
I) may predispose to degenerative changes in the tendon, and these
changes may lead to eventual rupture of the tendon
6,18.
It has been postulated that pelvic morphology, a high valgus angle of the
knee, and leg-length discrepancy predispose patients biomechanically to injury
as the greater trochanter impinges on a tight iliotibial band. Tension within
the iliotibial band may result in frictional trauma to the gluteal tendons,
just as the acromial process causes trauma to the rotator cuff in the
shoulder2,6,8,9,12,14.
An alteration in gait is likely a predisposing factor and may play a role in
causation as
well2.
The clinical diagnosis of gluteus medius or minimus tendon rupture alone is
often difficult. Plain radiographs are usually not helpful but may show
calcification within the gluteal tendons or a bone avulsion. Tendinous
calcification has been reported in up to 40% of patients diagnosed with
greater trochanteric bursitis; however, other studies have found radiographic
signs to be less common. For example, Schapira et al. found positive signs in
only nine of seventy-two
patients19.
Scintigraphic findings typically consist of nonspecific uptake at the lateral
aspect of the greater trochanter. However, some researchers have suggested
that bone scan findings may indicate gluteal tendinitis and not bursitis
because of the characteristic appearance of a short linear band of increased
uptake confined to the superior and lateral aspects of the greater trochanter
on early blood-pool or delayed
images20.
Tendinitis, tears, and ruptures of the gluteal tendons are most accurately
diagnosed by magnetic resonance imaging, with coronal T1-weighted images with
fat saturation and axial fast-spin-echo T2-weighted images. These techniques
may reveal calcification within the tendons and edema within the muscle and
adjacent
compartments2.
Ultrasound can also be a useful aid in detecting gluteal injuries, as
described by Connell et
al.21.
The overall prevalence of descriptions of the gluteus medius and minimus
tendons is unknown, as is the prevalence of clinically important
symptoms4,7.
Howell et al.22
found degenerative tears of the gluteus medius or minimus in 20% of 176
patients undergoing total hip arthroplasty, and Bunker et
al.13 reported a
22% prevalence of tears in a prospective study of fifty consecutive patients
with femoral neck fractures. The percentage of symptomatic patients in these
two studies was not known.
Gluteus tendon ruptures, if diagnosed early, can be treated nonoperatively
by unloading the involved hip with crutches or a cane, prescribing
nonsteroidal anti-inflammatory drugs, and having the patient undergo physical
therapy once the acute symptoms have subsided. Local corticosteroid injections
are often used, but their effect on the tendinopathy is not clear. Surgical
management may be necessary if the patient fails to respond to nonoperative
treatment. Operative treatment should include conjoined tendon
débridement, transosseous fixation, and possibly augmentation with
soft-tissue graft material. The latter could include autograft, allograft, or
xenograft.
In conclusion, gluteus medius and minimus tears are often misdiagnosed or
underrecognized and may be more common than previously appreciated. Disruption
of the gluteus medius and minimus should be included in the differential
diagnosis of patients who present with acute or chronic hip pain. ?