Correlation of MRI findings with clinical findings of trochanteric pain syndrome

Sonographic pathoanatomy of greater trochanteric pain syndrome

AIMS

To identify and highlight pertinent US features that could serve as imaging biomarkers to describe different patient phenotypes, within Great Trochanteric Pain Syndrome (GTPS) clinical diagnosis.

MATERIALS AND METHODS

Using ultrasound we evaluated eighty-eight clinically diagnosed patients with GTPS, for tendon matrix changes and calcium deposits in the gluteus medius (superoposterior and lateral aspects) and in the gluteus minimus. Peritrochanteric examination included fascia lata, trochanteric bursa, cortical irregularities and the presence of enthesophytes. The association of pathological changes with pain and functionality was evaluated using multivariate regression models.

RESULTS

Out of the 88 patients, 86 examinations (97.7%) detected gluteus medius tendinopathy, and 54 patients (61.4%) had gluteus minimus tendinopathy in addition. Calcium deposits were present in 97.7% of patients, associated with tenderness (p = 0.009), and most often located in the gluteus medius rather than in the gluteus minimus (p = 0.014); calcifications were associated with tendon thickness (p = 0.042), hypoechogenicity (p = 0.005) and the presence of partial tears (p = 0.030). Bursa swelling occurred in 36 patients (40.9%); multivariate regression models predicted less pain in patients with bursa distension (p = 0.008) and dysfunction in patients with gluteal muscle atrophy (p = 0.001) and loss of fibrillar pattern in the gluteus medius (p = 0.002).

CONCLUSION

GTPS involves both degenerative calcifying gluteal tendinopathy and alterations in the peritrochanteric space associated with physical function and pain. The severity of GTPS can be assessed using ultrasound imaging biomarkers.

An EDucation and eXercise intervention for gluteal tendinopathy in an Irish setting: a protocol for a feasibility randomised clinical trial (LEAP-Ireland RCT)

Background

Gluteal tendinopathy (GT) is a degenerative tendon condition characterised by pain over the greater trochanter of the hip. A randomised controlled trial (RCT) in Australia found that 14 sessions of EDucation on load management plus eXercise (EDX) delivered over 8 weeks resulted in greater improvements in global rating of change and pain outcomes at 8 and 52 weeks, compared with corticosteroid injection or 'wait and see'. Typically, 5-6 physiotherapy sessions are provided in public and private physiotherapy settings in Ireland, therefore, the aim of this study is to examine the feasibility of conducting a future definitive RCT to investigate effectiveness of 6 sessions of the EDX programme compared to usual care.

Methods

We will randomly allocate 64 participants with GT to physiotherapist-administered EDX or usual care. The EDX intervention (EDX-Ireland) will be delivered in 6 sessions over 8 weeks.To determine feasibility of an RCT, we will assess recruitment and retention and outcome measure completion. The health status outcomes to be assessed at baseline, 8 weeks and 3 months include: Global Rating of Change, pain severity, the Victorian Institute of Sport Assessment-Gluteal Questionnaire (VISA-G), the Patient-Specific Functional Scale, the Pain Catastrophizing Scale, Patient Health Questionnaire (PHQ), Pain Self-Efficacy Questionnaire, the EQ-5D-5L, the Central Sensitisation Inventory and hip abductor muscle strength. We will explore acceptability of the EDX-Ireland intervention from the perspective of patients and treatment providers, and the perspective of referrers to the trial. A Study Within A Trial will be also applied to compare recording of exercise adherence using app-based technology to paper diaries.

Discussion

There is a need to establish effective treatments for GT that potentially can be implemented into existing health systems. The findings of this feasibility trial will inform development of a future definitive RCT.

Registration

The trial is registered prospectively on ClinicalTrials.gov ( NCT05516563, 27/10/2022).

Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To estimate the effectiveness of exercise at end of treatment and long-term follow-up compared to a control condition or other conservative treatments in patients with Greater Trochanteric Pain Syndrome (GTPS).

METHODS

Databases were searched September 2021 and updated September 2023. Randomized controlled trials (RCT) comparing exercise interventions for patients with GTPS, to a control condition; corticosteroid injection; shock wave therapy; or other types of exercise programs were included. Risk of bias was assessed using the ROB2 tool. Meta-analyses were performed using a random-effects model. The certainty of the evidence was rated by the GRADE approach.

RESULTS

Six RCTs including a total of 733 patients with GTPS were included. Three trials compared exercise to sham exercise or wait-and-see control groups, two trials compared exercise to corticosteroid injection, two trials compared exercise to shockwave therapy, and one trial compared exercise to another type of exercise. Meta-analyses showed that in the long term, exercise slightly reduces hip pain and disease severity, while slightly improving patient-reported physical function and global rating of change compared to a control condition. No serious adverse events were reported. Compared to corticosteroid injection, exercise improves long-term global rating of change.

CONCLUSION

The current evidence supports a strong recommendation for exercise as first line treatment in patients clinically diagnosed with GTPS. Compared to corticosteroid injection, exercise is superior in increasing the likelihood that a patient experiences a meaningful global improvement. These results are based on few trials and a moderate number of patients.

REGISTRATION

This review was prospectively registered in the PROSPERO database of systematic reviews (ID: CRD42021261380). CONTRIBUTION OF PAPER.

The Utilization of Diagnostic Musculoskeletal Ultrasound in the Evaluation of Gluteus Medius Tendon Pathology: A Perspective for Rehabilitation Providers

Gluteus medius tendon pathology, encompassing tendinopathy and tears, is a significant source of lateral hip pain and functional impairment. Traditional diagnostic approaches have relied on clinical examination and magnetic resonance imaging (MRI). However, the advent of diagnostic musculoskeletal ultrasound (MSKUS) has transformed the evaluation process. Musculoskeletal ultrasound has emerged as a highly valuable diagnostic tool in the evaluation of gluteus medius tendon pathology, offering a non-invasive, cost-effective, and dynamic assessment method. This modality provides real-time visualization of soft tissue, enabling the detailed examination of tendon structure, vascularity, and associated musculature. For rehabilitation providers, understanding the application, strengths, and limitations of diagnostic MSKUS can enhance clinical decision-making, facilitate targeted therapeutic interventions, and potentially expedite the recovery process. This article reviews the application of MSKUS in diagnosing gluteus medius tendon pathology and its implications for rehabilitation practice. This should help to equip rehabilitation professionals with knowledge to better integrate this diagnostic tool into their clinical repertoire.

Current and future advances in practice: tendinopathies of the hip

Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy

Gluteal tendinopathy (GT) is common and can be debilitating and challenging to manage. A lack of condition specific and appropriate outcome measures compromise evidence synthesis for treatment and limits clinical guideline development. Our objective was to develop a core outcome measurement set for GT (COS-GT). Participants were patients with GT and expert health professionals (HPs). A scoping review identified measures used in GT research, which were mapped to the nine International Scientific Tendinopathy Symposium Consensus core domains, and included in two surveys of HPs. The first survey identified the feasible and true measures for each domain. The second survey refined the list which a patient focus group then considered. Meeting online, HPs reached consensus (agreement ≥70%) on the most appropriate COS-GT measures. 34 HPs and seven patients were recruited. 57 measures were mapped to the nine core domains. Six measures did not proceed past survey one. Of those that progressed, none had adequate clinimetric properties for a COS-GT. Thus, participants decided on interim measures: the global rating of change, pain at night, time to pain onset with single limb stance, pain with stair walking, pain self-efficacy and hip abduction strength. HP participants additionally recommended that pain over the last week, the European Quality of Life-5 dimensions-5 levels and the Victorian Institute of Sport Assessment-Gluteal be considered in clinical trials, as they currently provide best easures of the relevant tendinopathy domains. In conclusion this interim COS-GT should guide outcome measure selection in clinical practice and future research trials in patients with GT.

Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis

The objective of this review was to evaluate the effect of exercise on pain intensity, function, and quality of life in individuals with gluteal tendinopathy. Searches were carried out in PUBMED, EMBASE, CINAHL, Cochrane Library, and PEDro databases. Randomized or quasi-randomized controlled trials were included. Five studies met the eligibility criteria, comparing exercise-based interventions with minimal interventions and/or corticosteroid injections. Three studies, involving 383 participants, were included in the quantitative analysis. Meta-analyses showed that exercise is superior to minimal intervention for function in short-term [mean difference (MD) = 10.24; 95% confidence interval (95%CI) = 5.98, 14.50) and long-term (MD = 6.54; 95%CI = 1.88, 11.21]). However, no difference was observed for quality of life in the short [standardized mean difference (SMD) = 0.33; 95%CI = -0.29, 0.94] and long-term (SMD = 0.11; 95%CI = -0.16, 0.37). The effect of exercise was no different from that of corticosteroid injections for pain intensity in the short (MD = 1.25; 95%CI = -3.56, 6.05) and long-term (MD = -1.37; 95%CI = -3.72, 0.98]). In conclusion, exercise is superior to minimal interventions for function in the short- and long-term in individuals with gluteal tendinopathy. Exercise and corticosteroid injections had similar effects on pain intensity, however, exercise showed a higher treatment success rate when compared to corticosteroid injections in this population. The GRADE analysis revealed that the certainty of the evidence ranges from low to very low, therefore, large high-quality randomized controlled trials are recommended.PROSPERO registration number: CRD42021242853.

Diagnostic Accuracy of Clinical Tests for Assessing Greater Trochanteric Pain Syndrome: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to evaluate the accuracy of clinical tests that are used to diagnose greater trochanteric pain syndrome (GTPS) in clinical practice. DESIGN: Diagnostic test accuracy systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CINAHL, AMED, and SPORTDiscus were searched using key words mapped to diagnostic test accuracy for GTPS. STUDY SELECTION CRITERIA: Studies with published or derivable diagnostic accuracy data were included. DATA SYNTHESIS: Risk of bias was assessed using the QUADAS-2 tool, and certainty of evidence, via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MetaDTA "R" random-effects models were used to summarize individual and pooled data including sensitivity, specificity, likelihood ratios, and pretest/posttest probabilities. RESULTS: From a database yield of 858 studies, 23 full texts were assessed. We included 6 studies for review, involving 15 tests and 272 participants (314 hips). Overall certainty of evidence ranged from very low to moderate. Meta-analysis of 6 tests revealed sequenced test clusters able to significantly shift pretest-posttest probability for or against a GTPS diagnosis. In people reporting lateral hip pain, a negative gluteal tendon (GT) palpation test followed by a negative resisted hip abduction test significantly reduced the posttest probability of GTPS from 59% to 14%. In those with a positive GT palpation test followed by a positive resisted hip abduction test, the posttest probability of GTPS significantly shifted from 59% to 96%. CONCLUSION: The value of magnetic resonance imaging for diagnosing GTPS is debated. We have identified a straightforward, clinically useful diagnostic test cluster to help confirm or refute the presence of GTPS in people reporting lateral hip pain. J Orthop Sports Phys Ther 2024;54(1):1-24. Epub 10 August 2023. doi:10.2519/jospt.2023.11890.

High-resolution ultrasound in the evaluation of the adult hip

This paper reviews ultrasound of the hip, which is a commonly requested examination for symptomatic hip issues. This includes both intra-articular and extra-articular causes of hip pain. Ultrasound is easily accessible, lacks radiation exposure, and allows for evaluation of the contralateral hip as well as assessment of dynamic maneuvers. Ultrasound can be used to guide interventional procedures. Ultrasound of the hip can be challenging due to the deep location of structures and complex anatomy. Typically, high-frequency transducers are used to examine the hip, however the choice of ultrasound transducer depends on the patient's body habitus, with lower frequency transducers required to penetrate deep structures in obese patients. It is important to have an approach to ultrasound of the hip which includes assessment of the anterior, lateral, posterior, and medial aspects of the hip. The technique and relevant anatomy of each of these compartments are discussed as well as the use of Doppler examination of the hip. Several dynamic maneuvers can be performed to help determine the cause of hip pathology in various locations, and these are described and illustrated. Ultrasound is useful for guided procedures about the hip, and these indications will be reviewed.

Diagnostic Value of an Additional Sequence (Large-Field Coronal Stir) in a Routine Lumbar Spine MR Imaging Protocol to Investigate Lumbar Radiculopathy

OBJECTIVE

Lumbar radiculopathy mainly originates in the spine (lumbar disc herniation or spine osteoarthritis) but can sometimes be explained by extra-spinal nerve compression or confused with referred pain mimicking radiculopathy. Our main objective was to demonstrate the clinical benefit of the large-field coronal STIR (coroSTIR) sequence in the etiological assessment of lumbar radiculopathy with a duration of more than six weeks.

MATERIALS AND METHODS

Six hundred consecutive lumbar MRI scans performed using the same protocol were retrospectively reviewed. Two musculoskeletal radiologists independently assessed the coroSTIR sequence for the presence of extra-spinal anomalies (ESA) that could explain or contribute to the lumbar radiculopathy. The presence of an ESA was then correlated with sex, age, topography and lateralization of radiculopathy, history of vertebral surgery, as well as the presence of a spinal cause explaining the symptoms. Extra-spinal incidentalomas (ESI) with potential clinical impact visible only on the coroSTIR sequence were also systematically reported.

RESULTS

An extra-spinal cause was detected on the coroSTIR sequence in 68 cases (11.3%), mainly gluteal tendinobursitis (30.9%), congestive hip osteoarthritis (25%), degenerative sacroiliac arthropathy (14.7%), or inflammatory sacroilitis (7.3%). Their prevalence was significantly correlated in multivariate regression with age (58 years vs. 53 years, p = 0.01), but not with the type of radiating pain (sciatica or cruralgia). The presence of ESI was also frequent (70 cases, 11.7%), including some potentially severe diagnoses (38% of tumor or pseudo-tumor mass requiring further assessment or monitoring).

CONCLUSIONS

Considering its acceptable acquisition time, the detection of a significant number of potentially symptom-related extra-spinal anomalies, and the discovery of a non-negligible number of extra-spinal incidentalomas with potential clinical impact, the coronal STIR should be performed systematically in routine MRI for lumbar radiculopathy.

Imaging of common hip pathologies in runners

Running is an increasingly popular sport and form of exercise. Because of the importance of the hip in the biomechanics involved with running, forming the primary connection between the axial and appendicular skeleton of the lower extremities, accurate diagnosis and reporting of hip pathology are vital for appropriate management. This review provides an overview of the most common hip pathologies and injuries encountered in runners. Radiologic studies, primarily conventional radiography and magnetic resonance imaging (MRI) provide useful diagnostic information and should be used in combination with clinical findings to help guide therapeutic management.

A Review of Abductor Tendon Tears: The Hidden Lesion of the Hip

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Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years.

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Abductor tendon tears are becoming a more recognized cause of lateral hip pain in patients without hip osteoarthritis.

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Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies.

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Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

An evolved understanding of the pathophysiology of greater trochanteric pain syndrome has led to a number of proposed nonoperative management strategies. The objective of this review was to compare the efficacy of the various nonoperative treatments for greater trochanteric pain syndrome (GTPS).

DESIGN

Systematic review and network meta-analysis.

SETTING

PubMed, Embase, CENTRAL, SCOPUS, and Web of Science were searched to January 2020.

PATIENTS

Patients undergoing nonoperative treatment for GTPS.

INTERVENTIONS

Nonoperative treatment strategies for GTPS including injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs and extracorporeal shockwave therapy.

MAIN OUTCOME MEASURES

Pain and functional outcomes. Bayesian random-effects model was performed to assess the direct and indirect comparison of all treatment options.

RESULTS

Thirteen randomized controlled trials and 1034 patients were included. For pain scores at 1 to 3 months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both 1 to 3 months and 6 to 12 months. No proposed therapies significantly outperformed the no treatment control group for pain scores at 6 to 12 months. Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months.

CONCLUSION

Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.

Asymptomatic gluteal tendinosis does not influence outcome in arthroscopic treatment of femoroacetabular impingement syndrome

PURPOSE

To compare outcomes after arthroscopy in FAIS patients with preoperative asymptomatic gluteal tendinosis (GT) to a control group with no gluteal tendinosis.

METHODS

A retrospective analysis was performed using data from FAIS patients who had arthroscopy between 2016 and 2018. Asymptomatic GT was diagnosed using hip MRI without clinical symptoms. Patients with asymptomatic GT were 1:1 propensity-score matched to patients without GT. Patient-reported outcomes (HOS-ADL, iHOT-12, mHHS), VAS scores, radiographic measures, performed procedures, complications, and revision surgery were compared and analyzed for both groups.

RESULTS

A total of 105 asymptomatic GT hips and 105 hips without GT were found using propensity-score matching. When compared to preoperative levels, both groups demonstrated significant improvements in PROs and VAS scores at the final follow-up. Besides, there were no significant differences in preoperative scores, final outcome scores, or score improvements between the groups. Patients in the GT group were significantly less likely to achieve the MCID for the VAS score (72.4% vs 83.8%, p = 0.045). However, there were no other differences in the rate of meeting the PASS and MCID between the study and the control groups.

CONCLUSION

It was demonstrated in this study that FAIS patients with asymptomatic gluteal tendinosis can expect to experience similar good short-term patients-reported outcomes as compared with patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome? A 2 × 2 Factorial Randomized Clinical Trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a debilitating chronic condition, most prevalent in postmenopausal women. A positive association between high estrogen levels and tendon health may exist, and postmenopausal women have reduced estrogen. Menopausal hormone therapy (MHT) may reduce the incidence of tendon abnormality, particularly when combined with exercise.

PURPOSE

To determine the effect of MHT and exercise on tendon pain and function in postmenopausal women with GTPS.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Postmenopausal women (N = 132; n = 12, lost to follow-up) with GTPS were randomized into MHT and placebo transdermal cream groups combined with tendon-specific or sham exercise. All groups received education about avoiding gluteal tendon compression and load management throughout 12 weeks of intervention. The primary outcome was the Victorian Institute of Sport Assessment for gluteal tendinopathy (VISA-G), and secondary outcomes were measured at baseline and at 12 and 52 weeks. The Global Rating of Change was assessed at 12 and 52 weeks. A linear mixed-effects model was used to assess differences. Body mass index (BMI) was included as a covariate.

RESULTS

All participant groups improved over time (baseline vs 12 weeks, P < .001; baseline vs 52 weeks, P < .001). There was no difference among exercise groups measured by all outcomes (VISA-G: baseline, P = .97, mean difference [MD] = 0.10; 12 weeks, P = .49, MD = 2.15; 52 weeks, P = .32, MD = -3.08). There was a significant interaction effect between cream and BMI; therefore, the population was stratified by BMI levels (<25, <30, ≥30). The MHT groups (with exercise and education) had significantly better VISA-G outcomes (baseline, P = .04, MD = -11.20, 95% CI = -21.70 to -0.70; 12 weeks, P < .001, MD = -20.72, 95% CI = -31.22 to -10.22; 52 weeks, P = .002, MD = -16.71, 95% CI = -27.21 to -6.22) and secondary measure scores as compared with placebo at all time points when BMI was <25.

CONCLUSION

MHT or placebo combined with tendon-specific or sham exercise plus education reduced pain and increased function for this population. For women with a BMI <25, MHT with any exercise plus education was better than placebo. A targeted exercise or sham exercise strategy is effective when prescribed with education about avoiding gluteal tendon compression and load management.

REGISTRATION

ACTRN12614001157662 (Australian New Zealand Clinical Trials Registry).

Three Sessions of Radial Extracorporeal Shockwave Therapy Gives No Additional Benefit Over "Minimal-Dose" Radial Extracorporeal Shockwave Therapy for Patients With Chronic Greater Trochanteric Pain Syndrome: A Double-Blinded, Randomized, Controlled Trial

OBJECTIVE

To investigate the outcomes following 3 weekly sessions of radial extracorporeal shockwave therapy (rESWT) in patients with chronic greater trochanteric pain syndrome (GTPS) presenting to an NHS Sports Medicine Clinic in the United Kingdom.

DESIGN

Double-blinded randomized controlled trial.

SETTING

A single NHS Sports Medicine Clinic, in the United Kingdom.

PATIENTS

One hundred twenty patients in an NHS Sports Medicine clinic presenting with symptoms of GTPS who had failed to improve with a minimum of 3 months of rehabilitation were enrolled in the study and randomized equally to the intervention and treatment groups. Mean age was 60.6 ± 11.5 years; 82% were female, and the mean duration of symptoms was 45.4 ± 33.4 months (range, 6 months to 30 years).

INTERVENTIONS

Participants were randomized to receive either 3 sessions of ESWT at either the "recommended"/"maximally comfortably tolerated" dose or at "minimal dose." All patients received a structured home exercise program involving flexibility, strength, and balance exercises.

MAIN OUTCOME MEASURES

Follow-up was at 6 weeks, 3 months, and 6 months. Outcome measures included local hip pain, validated hip PROMs (Oxford hip score, non-arthritic hip score, Victorian Institute of Sport assessment questionnaire), and wider measures of function including sleep (Pittsburgh sleep quality index) and mood (hospital anxiety and depression scale).

RESULTS

Results were available for 98% of patients at the 6-month period. There were statistically significant within-group improvements in pain, local function, and sleep seen in both groups. However, fewer benefits were seen in other outcome measures, including activity or mood.

CONCLUSION

There were no time × group interaction effects seen between the groups at any time point, indicating that in the 3 sessions, the "recommended-dose" rESWT had no measurable benefit compared with "minimal dose" rESWT in this group of patients with GTPS. The underlying reason remains unclear; it may be that rESWT is ineffective in the treatment of patients with chronic GTPS, that "minimal dose" rESWT is sufficient for a therapeutic effect, or that a greater number of treatment sessions are required for maximal benefit. These issues need to be considered in further research.

Quantitative MRI in patients with gluteal tendinopathy and asymptomatic volunteers: initial results on T1- and T2*-mapping diagnostic accuracy and correlation with clinical assessment

OBJECTIVE

To determine if T1- and T2*-mapping of the gluteal tendons can discriminate between participants with and without clinical findings of gluteal tendinopathy (GT) and if they correlate with clinical assessment.

MATERIALS AND METHODS

This prospective study was conducted between January and December 2016. MRI of the hip included spin echo, short-T1 inversion recovery, variable-flip angle, and variable echo-time gradient echo sequences. MRI studies were reviewed independently by two radiologists. Two other readers segmented the gluteal tendons and T1, mono- (T2*_m) and bi-exponential T2* (short (T2*_s) and long (T2*_l) components) were computed.

RESULTS

Ten participants with GT (median age; interquartile range: 63 (57-67) years, all women) and 9 participants without GT (57 (55-59) years, 8 women) (P = 0.06) were enrolled. The sensitivity and specificity of reader 1 for disease classification were 40% (95% confidence interval (CI): 17-61%) and 70% (CI: 47-91%), and those of reader 2 were 70% (CI: 43-86%) and 80% (CI: 53-96%), with fair inter-reader agreement (Kappa = .38). T1 values could not discriminate between the two groups. The gluteal tendons T2*_m and T2*_s showed diagnostic accuracy ranging from .80 to .89. The posterior gluteus medius tendon T2*_m and T2*_s respectively showed sensitivity and specificity of 90%, and strong correlation (Spearman's rho = -.71; P = 0.02) with the Lower Extremity Functional Scale score.

CONCLUSION

Quantitative MRI could help gain new insight into healthy and diseased gluteal tendons to allow better diagnosis and treatment stratification for patients.

Gluteus minimus tendon: MR imaging features and patterns of tendon tearing

PURPOSE

To highlight the spectrum of pathology and patterns of gluteus minimus tendon tearing observed on MR imaging of the hip.

METHODS AND MATERIALS

Retrospective review of consecutive hip MRI exams with findings of gluteus minimus tendon (GMin) pathology. A total of 194 exams in 178 patients (148 female, mean age 61) were reviewed. MRI exams are assessed for GMin: tendinopathy, partial, or complete tendon tears. GMin muscular fatty atrophy, enthesopathic cortical irregularities of the greater trochanter (GT), and peri-trochanteric edema or bursal fluid collections were assessed in all cases. In all cases of complete GMin tendon tearing, position and relationship of GMin tendon were assessed relative to its normal insertion site and adjacent soft tissues.

RESULTS

Clinical indications for MR imaging included hip pain (n = 151), and weakness or altered gait (n = 13). Insertional GMin tendinopathy was seen in 72, partial tearing in 81, and complete tendon tearing in 40 cases. Complete tendon tearing without proximal retraction was observed in 38/40 cases with soft tissue continuity visualized between distal tendon fibers and the proximal vastus lateralis muscle. Peri-trochanteric bursal fluid (n = 61), osseous irregularities of the GT (n = 118), and fatty atrophy GMin (n = 102) were statistically associated with partial or complete GMin tendon tearing (p < 0.001).

CONCLUSIONS

The spectrum of GMin tendon pathology observed on MR imaging ranges from tendinopathy to complete tears. The majority of complete distal GMin tendon tears from the greater trochanter show continuity of distal tendon fibers with the proximal vastus lateralis, distally tethering and limiting proximal tendon retraction.

Platelet-rich plasma versus steroids injections for greater trochanter pain syndrome: a systematic review and meta-analysis

INTRODUCTION

Greater trochanter pain syndrome (GTPS) is characterized by a persistent and debilitating pain around the greater trochanter. GTPS can be caused by a combination of gluteus medius or minimus tendinopathy, snapping hip or trochanteric bursitis.

SOURCE OF DATA

Recent published literatures identified from PubMed, EMBASE, Google Scholar, Scopus.

AREAS OF AGREEMENT

Platelet rich plasma (PRP) and corticosteroids (CCS) injections are useful options to manage symptoms of GTPS.

AREAS OF CONTROVERSY

Whether PRP leads to superior outcomes compared to CCS injections is unclear.

GROWING POINTS

A systematic review and meta-analysis comparing PRP versus CCS in the management of GTPS was conducted.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP injections are more effective than CCS at approximately 2 years follow-up.

MR of tendons about the hip: A study in asymptomatic volunteers

PURPOSE

Tendon pathology around the hip is a common entity. The aim of this study was to detect tendon abnormalities around the hip in a population of asymptomatic volunteers.

MATERIALS AND METHODS

Fifty volunteers (100 hips) referred for non-musculoskeletal conditions were evaluated with an additional coronal STIR-weighted MRI imaging on a 1.5 MR unit. This group was composed of 27 women and 23 men with a mean age of 52 (19-91 years). The images were interpreted independently by 2 musculoskeletal radiologists. All tendons around the hip were given a score from 0 to 4, with a score 0 corresponding to no abnormality, score 1 to signal alteration around the tendon, score 2 to minimal signal abnormality in the tendon, score 3 partial tear and score 4 complete rupture. The trochanteric bursa was also evaluated and its size was measured. It was also given a score from 0 to 3 (0: no abnormality, 1: slight hypersignal, 2: bursitis < 10 mm, 3: bursitis ≥ 10 mm).

RESULTS

High intratendinous signal was commonly found at the joined insertion of biceps femoris and semitendinosus (18% L, 20% R), the semimembranosus (24% L, 20% R), gluteus minimus (6% L, 11% R) and rectus femoris (9% L, 3% R). A small trochanteric bursa was seen in 33% of the volunteers on the left side and 32% on the right side. The interobserver correlation was very good with an intraclass correlation coefficient of 0.79 (CI: 0.74-0.85).

CONCLUSION

Slight signal alterations might be found in the insertions of the rectus femoris, hamstrings and gluteus minimus tendons. A small to moderate trochanteric bursitis might also be seen. This suggests that care should be taken when interpreting MR scans to attribute symptoms to these findings.

Greater trochanteric pain syndrome in women: Analysis of magnetic resonance, sagittal alignment, muscular strength and endurance of the hip and trunk

INTRODUCTION

There are many studies on the Greater Trochanteric Pain Syndrome (GTPS), however its relationship with radiographic and biomechanics parameters is not established.

OBJECTIVE

To compare the magnetic resonance images (MRI) of the hip, radiographic parameters of sagittal alignment (pelvic incidence, sacral slope and lumbar lordosis), muscular strength and endurance in women with and without GTPS.

METHODS

Forty women, age over 45, IMC <30 Kg/m2 and sedentary, were recruited and distributed in two groups: GTPS group (GTPSG, n = 20) and Control group (CG, n = 20). All participants underwent MRI scans and X-ray for sagittal alignment analysis in the hip and performed tests for muscular strength and endurance of the hip and trunk.

RESULTS

No differences were found between the GTPSG and CG for the frequency of tendinopathy (P = .30), peritendinitis (P = .10), bursitis (P = .68) and enthesitis (P = .15), however the gluteus medius tendon tear was more prevalent in GTPSG (P = .05). There were no differences in radiographic parameters for pelvic incidence (P > .05), sacral slope (P > .05) and lumbar lordosis (P > .05). The GTPSG showed lower strength of all hip muscle groups (abductors, adductors, flexors, extensors and rotators; P < .01 for all), as well as lower endurance in the Supine Bridge test and Prone bridge test (P < .01).

CONCLUSION

The results of the MRI and radiographic parameters did not differentiate women with and without GTPS. However, the evaluation of muscle strength and endurance can establish the difference between groups.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology

Greater trochanteric pain syndrome is a common cause of lateral hip pain, encompassing a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and external coxa saltans. Greater trochanteric pain syndrome is primarily a clinical diagnosis, and careful clinical examination is essential for accurate diagnosis and treatment. A thorough history and physical exam may be used to help differentiate greater trochanteric pain syndrome from other common causes of hip pain, including osteoarthritis, femoroacetabular impingement, and lumbar stenosis. Although not required for diagnosis, plain radiographs and magnetic resonance imaging may be useful to exclude alternative pathologies or guide treatment of greater trochanteric pain syndrome. The majority of patients with greater trochanteric pain syndrome respond well to conservative management, including physical therapy, non-steroidal anti-inflammatory drugs, and corticosteroid injections. Operative management is typically indicated in patients with chronic symptoms refractory to conservative therapy. A wide range of surgical options, both open and endoscopic, are available and should be guided by the specific etiology of pain. The purpose of this review is to highlight pertinent clinical and radiographic features used in the diagnosis and management of greater trochanteric pain syndrome. In addition, treatment indications, techniques, and outcomes are described.

Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review

PURPOSE

Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space.

METHODS

A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome.

RESULTS

A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg's test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised.

CONCLUSION

Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted.

LEVEL OF EVIDENCE

IV.

Hip Stability May Influence the Development of Greater Trochanteric Pain Syndrome: A Case-Control Study of Consecutive Patients

Background:

Greater trochanteric pain syndrome (GTPS) is thought to relate primarily to tendinosis/tendinopathy of the hip abductors. Previous studies have suggested that certain anatomic factors may predispose one to development of the condition.

Hypothesis:

It was hypothesized that intrinsic acetabular bony stability of the hip is related to the development of GTPS.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 198 consecutive patients diagnosed with GTPS were compared with 198 consecutive patients without clinical evidence of GTPS. Electronic health records of the included patients were examined; data recorded included patient age, sex, race, and body mass index (BMI). Standing anteroposterior radiographs were evaluated by 2 blinded examiners who measured the Tönnis angle, lateral center-edge angle (LCEA), and acetabular depth/width ratio (ADW) and assessed for the presence of a posterior wall sign. The number of dysplastic measures was recorded for each patient based on published norms. Associations between radiographic and patient variables versus the presence or absence of GTPS were determined. Factors with univariate associations where P < .20 were included in a binary logistic regression model to identify independent predictors of the presence of GTPS.

Results:

There was no difference between groups in terms of age, BMI, or race. There were significantly more women than men in the GTPS group (71% vs 30%; P < .001). Intraclass correlation coefficients were good for the LCEA (0.82) and Tönnis angle (0.82) and poor (0.08) for the ADW. Kappa was moderate for the presence of a posterior wall sign (0.51). An increased Tönnis angle, decreased ADW, and ADW <0.25 were significantly associated with the presence of GTPS. The binary logistic regression model identified an increased Tönnis angle (P < .010) and female sex (P < .001) as independent risk factors for GTPS.

Conclusion:

Based on this preliminary retrospective study, decreased intrinsic acetabular bony stability of the hip may be associated with an increased risk of GTPS.

Impact of fluoroscopic injection location on immediate and delayed pain relief in patients with greater trochanteric pain syndrome

OBJECT

The purpose of this study was to assess whether fluoroscopically guided corticosteroid injections into the extrabursal tissues, trochanteric (subgluteus maximus) bursa, or subgluteus medius bursa provide better immediate and short-term pain relief.

MATERIALS AND METHODS

All fluoroscopically guided corticosteroid injections performed over a 67-month period for greater trochanteric pain syndrome were retrospectively reviewed. Procedural images were reviewed by two musculoskeletal radiologists to determine the dominant injection site based on final needle positioning and contrast spread pattern, with discrepancies resolved by consensus. Statistical analysis of the association between pain score reduction and dominant injection site was performed.

RESULTS

One hundred forty injections in 121 patients met the inclusion criteria. The immediate and 1-week post-injection pain reduction was statistically significant for trochanteric bursa, subgluteus medius bursa, and non-bursal injections. However, there was no statistically significant difference in the degree of pain reduction between the groups. There was statistically significant increase in the 1-week post-injection mean pain score compared with immediate post-injection mean pain score in the subgluteus medius bursa and non-bursal injection groups (p < 0.01) but not in the trochanteric bursa group.

CONCLUSION

Fluoroscopy is frequently chosen over blind injection or ultrasound guidance for trochanteric steroid injections in patients with a high body mass index. Our results indicate that fluoroscopically guided steroid injections into the trochanteric bursa and subgluteus medius bursa significantly reduced immediate and 1-week post-injection pain scores, as do non-bursal injections. Steroid injection into the subgluteus medius bursa and non-bursal sites may be less effective in maintaining pain reduction at 1-week post-injection.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Hip abductor tendon tears: where are we now?

Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilising the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic injury during arthroplasty and chronic degenerative tendinopathy. Ultrasound and magnetic resonance imaging have provided limited clues regarding the pattern of disease and further work is required to clarify both the macro and microscopic pattern of disease. While surgery has been attempted over the last 2 decades, the outcomes are variable and the lack of high-quality studies have limited the uptake of surgical repair. Hip abductor tendon tears share many features with rotator cuff tears, hence, innovations in surgical techniques, materials and biologics may apply to both pathologies.

Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome: A Systematic Review

Ultrasound (US) assists in the determination of the pathology underlying greater trochanteric pain syndrome (GTPS); however, there exists no consensus regarding the US criteria used to define these pathologies. We aim to explore these US definitions and their associated prevalence. "Trochanteric bursitis" was defined in 10 studies (13 included studies) and was heterogeneously described. "Tendinopathy" was defined in 4 studies, while 7 studies defined "tendinosis." "Tendon tears" were defined in 8 studies, 6 of which distinguished between "partial- and full-thickness tears." Tendon pathology was most frequent in 5 studies (prevalence: 7%-93%), and bursitis in 2 studies (prevalence: 10%-75%); 3 studies had equal distribution. Methodological quality was limited in the descriptions of GTPS and US approaches. Together, we document the lack of standardized US definitions of the pathologies underlying GTPS. This may explain the heterogenous prevalence of US findings. Standardized definitions are needed to improve the reliability of future GTPS studies.

Spinopelvic parameters in greater trochanteric pain syndrome: a retrospective case-control study

PURPOSE

Greater trochanteric pain syndrome (GTPS) is a condition resulting in lateral hip pain, most commonly caused by tendinosis or tear of the gluteus medius and minimus tendons, and greater trochanteric bursitis. Our aim was to assess pelvic parameters and proximal femoral anatomy in patients suffering from surgical-stage GTPS compared with a control group.

METHODS

This retrospective, case-control study assessed 43 patients suffering from GTPS, matched according to age, gender, body mass index and level of sport and physical activity to 43 control patients, between 2013 and 2018. Pelvic parameters, including pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS), and proximal femoral anatomy, including femoral offset (FO) and neck-shaft angle (NSA), were measured using the EOS Imaging™ system.

RESULTS

GTPS patients had a significantly lower mean (± SD) SS than control patients (33.1 ± 10.4 vs. 39.6 ± 9.7°, respectively; p < 0.05). There was no significant difference in PT (21.3 ± 7.1 vs. 19.0 ± 7.2°), PI (53.5 ± 11.6 vs. 57.7 ± 10.5°), FO (40.4 ± 8 vs. 42.2 ± 6.8°) or NSA (125.1 ± 5.8 vs. 124.4 ± 4.7°). There was no difference in lower back pain symptoms in a subgroup analysis of GTPS patients.

CONCLUSIONS

Sacral slope was lower in patients with surgical-stage GTPS than in asymptomatic hip patients, using the EOS Imaging™ system.

Sonoanatomy and Pathology of the Gluteus Minimus Tendon

Gluteus minimus disorders are a potential source of greater trochanteric or anterior hip pain. Disorders of the gluteus minimus tendon most commonly occur in conjunction with gluteus medius tendon abnormalities but can also occur in isolation. Understanding the sonoanatomy of the gluteus minimus muscle-tendon unit is a prerequisite for recognizing and characterizing gluteus minimus tendon disorders, which, in turn, guides treatment for patients with greater trochanteric or anterior hip pain syndromes.

Primary Open Abductor Reconstruction: A 5 to 10-Year Study

BACKGROUND

Gluteal tears are recognized as the source of pain over the greater trochanter. We investigated the outcome of primary open abductor tendon reconstruction with a 5-10 year follow-up.

METHODS

One hundred sixty-five consecutive hips underwent an open abductor tendon reconstruction, with all tears confirmed preoperatively by magnetic resonance imaging. Oxford Hip Scores (OHS) were assessed at the initial visit, and at 5-10 years.

RESULTS

The average preoperative OHS was 22 (range 7-34) and average postoperative OHS was 40 a difference of 18 (P < .0001).

CONCLUSION

Surgical reconstruction of degenerate abductor tendons should be considered in the presence of a magnetic resonance imaging confirmed separation where clinical findings are consistent with the known tendon disruption. Open transosseous reconstruction reliably results in good pain relief at 5-10 years.

Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy

Background:

Gluteal tendinopathy is a common cause of lateral hip pain. Percutaneous ultrasonic tenotomy (PUT) has been used successfully for the treatment of tendinopathy of the elbow, knee, and ankle, but its use in the hip has not been described.

Purpose:

To evaluate the efficacy of PUT in patients who did not respond to nonsurgical management of gluteal tendinopathy.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 29 patients with gluteal tendinopathy (mean age, 62 years) who did not respond to nonsurgical treatment were enrolled in this prospective study and underwent ultrasound-guided PUT in an outpatient setting. Patients with a history of ipsilateral hip surgery were excluded. All patients initially underwent magnetic resonance imaging or a computed tomography arthrogram demonstrating tendinopathy and/or partial tearing of the gluteus minimus or medius tendon or both tendons. Outcomes were assessed with a visual analog scale (VAS) for pain, the Harris Hip Score evaluation, and the 12-Item Short Form Health Survey (SF-12) before the procedure and at subsequent follow-up visits or by telephone interviews at 3 weeks, 3 months, 6 months, and final follow-up (range, 18-30 months).

Results:

The mean final follow-up was at 22 months postoperatively. At final follow-up, VAS scores had improved from a preprocedural mean ± SD of 5.86 ± 1.73 to 2.82 ± 2.22 (P < .01). Harris Hip Scores improved from a preprocedural mean of 60.03 ± 10.86 to 77.47 ± 14.34 (P < .01). Total SF-12 scores improved from a mean of 29.93 ± 5.39 (51% optimal) to 34.41 ± 4.88 (64% optimal) (P < .01). No complications were reported. At final follow-up, when asked whether they would have the procedure again, 15 patients replied “yes definitely,” 3 replied “yes probably,” 3 replied “maybe,” 1 replied “likely not,” and 2 replied “definitely not.” There were 3 patients who eventually had hip abductor tendon repair, and their PUT procedures were considered failures.

Conclusion:

PUT is an effective treatment, with good results for patients with gluteal tendinopathy.

Trochanteric spurs and surface irregularities on plain radiography are not predictive of greater trochanteric pain syndrome

PURPOSE

Surface irregularities of the greater trochanter have been described as a potential radiographic sign of greater trochanteric pain syndrome (GTPS). We report a diagnostic accuracy study to evaluate the clinical usefulness of trochanteric surface irregularities on plain radiographs in the diagnosis of GTPS.

METHODS

We retrospectively identified the anteroposterior pelvic radiographs of a consecutive group of 38 patients (representing a 27.5% series prevalence) diagnosed with GTPS (mean age 69.5 years ± 16.1 [standard deviation], 27 females, 11 males) based on clinical symptoms and a positive response to a local anaesthetic and steroid injection. A control group consisted of 100 patients (mean age 73 years ± 17.1 [standard deviation], 67 females, 33 males) with either hip osteoarthritis listed for hip arthroplasty (n = 50), or with an intracapsular neck of femur fracture (n = 50) both presenting between January and July 2017. Radiographs were cropped to blind observers to the presence of hip osteoarthritis or intracapsular fracture but included the trochanteric region. The radiograph sequence was randomised and separately presented to 3 orthopaedic surgeons to evaluate the presence of trochanteric surface irregularities.

RESULTS

The inter-observer correlation coefficient agreement was acceptable at 0.75 (95% CI, 0.60-0.84). Trochanteric surface irregularities including frank spurs protruding ⩾2 mm were associated with a 24.7% positive predictive value, 64.0% sensitivity, 25.7% specificity, 74.3% false-positive rate, 36.0% false-negative rate, and a 65.3% negative predictive value for clinical GTPS.

CONCLUSION

Surface irregularities of the greater trochanter are not reliable radiographic indicators for the diagnosis of greater trochanteric pain syndrome.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Hip abductor tendon pathology visualized by 1.5 versus 3. 0 Tesla MRIs

INTRODUCTION

Hip abductor tendinopathies are becoming increasingly recognized as clinically relevant disorders. However, knowledge about prevalence of abductor tendinopathies and associated disorders of adjacent hip articular and periarticular structures is limited. In this context, the relative diagnostic value of 1.5-T vs. 3.0-T MRI magnets has not been studied yet.

MATERIALS AND METHODS

Pelvic MRI scans of 1000 hips from 500 consecutive unselected patients (341 in 3.0-T/159 in 1.5-T magnets, with standardized scanning protocols over the entire study period) were analysed for the detection of abductor tendinosis, calcifying tendinitis, partial or full-thickness tears of the M. gluteus medius (GMed) and/or -minimus (GMin) and trochanteric bursitis (TB). The occurrence of these lesions was correlated to the presence of muscle atrophy (MA) of GMed/GMin, hip joint effusion (JE) and osteoarthritis (OA).

RESULTS

Peritrochanteric lesions were observed with a prevalence of 31.4% of all patients (22.3% of all hips). TB occurred almost exclusively in the presence of GMed/GMin tendinopathies. Compared to overall prevalence, patients with MA displayed lesions of GMed/GMin or TB in 70%, patients, with OA in 30% and with JE in 23%. These lesions occurred significantly more often ipsilateral to MA and OA than contralateral (MA: 76.8% vs. 23.2%, p < 0.001; OA: 64.4% vs. 35.6%, p = 0.03; JE: 62.7% vs. 37.3%, p = 0.08). Significantly more tendon lesions, in particular specific radiological diagnoses like partial/full-thickness tears, were detected by 3.0-T MRI than by 1.5 T (p = 0.019).

CONCLUSIONS

Peritrochanteric lesions are a prevalent pathology that should specifically be looked for, preferably by 3.0-T MRI, independent of concomitant hip joint pathology.

Do features of central sensitisation exist in Greater Trochanteric Pain Syndrome (GTPS)? A case control study

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS), which is commonly due to Gluteal Tendinopathy, refers to pain over the lateral hip that can become persistent and disabling. Central nervous sensitisation has been implicated in upper limb tendinopathy, but no studies have investigated if it plays a role in GTPS.

OBJECTIVES

To investigate if features of central sensitisation were present in people with GTPS.

METHODS

Eighteen people with GTPS were matched with 18 healthy controls in this cross-sectional study. The VISA-G and Central Sensitisation Inventory (CSI) self-report questionnaires were completed and pressure pain detection thresholds (PPDTs) at local and remote sites were measured in all participants. Data were analysed for between-group differences using Mann-Whitney U tests. Correlation between CSI and PPDTs were assessed using Pearson correlation co-efficients.

RESULTS

PPDT values were lower at local (symptomatic greater trochanter) and remote sites in the GTPS group, indicative of central sensitisation, resulting in statistically significant between-group differences. 44.4% of the GTPS group were classified as having symptoms of central sensitisation, based on the CSI.

CONCLUSION

There is preliminary evidence of central sensitisation in people with GTPS. Results need to be validated using other objective quantitative sensory testing measures in larger samples.

Responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), modified Harris hip and Oxford hip scores in patients undergoing hip abductor tendon repair

BACKGROUND

A lack of consensus exists on which patient-reported outcome measures (PROMs) best evaluate change following hip abductor tendon (HAT) repair.

OBJECTIVES

To compare the responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), Oxford Hip (OHS) and modified Harris Hip (mHHS) scores in patients undergoing HAT repair.

STUDY DESIGN

Prospective case series.

METHODS

56 patients underwent HAT repair and were evaluated pre-surgery and 3, 6 and 12 months post-operatively using the VISA-G, OHS, mHHS and a Global Rating of Change (GRC) scale. Internal and external responsiveness, the minimal clinically important change (MIC) and the presence of ceiling effects were evaluated. The extent to which VISA-G change was associated with mHHS and OHS change was investigated, as was the extent to which PROM changes were discriminatory for GRC improvement.

RESULTS

All PROMs demonstrated large standardized effect sizes (>1), with the VISA-G demonstrating responsiveness similar to the mHHS and OHS. At 12 months, the GRC correlated similarly with VISA-G (0.42, 95% CI: 0.17-0.61), mHHS (0.44, 95% CI: 0.17-0.61) and OHS (0.53, 95% CI: 0.31-0.70) changes. Using a GRC anchor of ≥4, an MIC of 29/100, 29/91 (32/100) and 16/48 (33/100) was observed for the VISA-G, mHHS and OHS, respectively. At 12 months ceiling effects existed for the mHHS (18/56, 32.1%) and OHS (13/56, 23.2%), but not VISA-G (1/56, 1.8%).

CONCLUSION

The VISA-G demonstrated acceptable responsiveness and was more resistant to ceiling effects, though demonstrated similar change scores and correlations with perceived improvement to the mHHS and OHS.

CLINICAL TRIAL REGISTRATION

This research trial is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12616001655437).

Identification and differentiation of gluteus medius tendon pathology using ultrasound and magnetic resonance imaging

BACKGROUND

It has been suggested that imaging findings play a role in directing treatment for Greater Trochanteric Pain Syndrome. Structural diagnoses associated with Greater Trochanter Pain Syndrome include gluteal tendinosis, and partial- or full-thickness gluteal tendon tears. However, few studies have compared imaging to confirmed tendon pathology observed during surgery.

OBJECTIVE

To investigate the ability of magnetic resonance and ultrasound imaging to identify the presence of a pathological gluteus medius tendon in comparison to surgical and histological findings.

STUDY DESIGN

Cross-sectional study.

METHODS

26 participants undergoing gluteal tendon reconstruction surgery or hip arthroplasty were included. Prior to surgery, participants underwent both magnetic resonance (MR) (n = 23) and ultrasound (US) (n = 25) imaging. A radiologist (MR) and nuclear physicians (US) classified the gluteus medius tendon as normal, tendinosis (no tear), partial-thickness tear, or full-thickness tear.

RESULTS

Ultrasound identified 17 out of the 19 pathological gluteus medius tendons correctly. However, 5 of the 6 normal tendons were incorrectly identified as exhibiting pathology on ultrasound. Magnetic resonance rated 11 out of 17 pathological tendons as abnormal, with 4 out of 6 normal tendons identified correctly. Both imaging modalities were poor at identifying and differentiating between tendinosis and partial-thickness tears.

CONCLUSION

Both imaging modalities showed a reasonable ability to identify tendon pathology. While limited by sample size, these early findings suggest that both imaging modalities may be limited in identifying specific pathoanatomical diagnoses, such as partial-thickness tears. These limitations may misdirect treatment.

More tendon degeneration in patients with shoulder osteoarthritis

PURPOSE

Tendon disorders are a major problem in the general population. It is known that rotator cuff tendinopathy contributes to osteoarthritis (OA) of the shoulder. The aim of the study was to analyse the presence of tendinopathy in patients with shoulder OA and an intact rotator cuff, using a multimodal approach.

METHODS

Thirteen consecutive patients median age 67 (52-84) years, with OA of the shoulder, and 13 consecutive control patients, with a fracture of the proximal humerus, median age 70 (51-84) years, underwent an open biopsy procedure from the biceps and subscapularis tendon in conjunction with shoulder arthroplasty. In addition to a macroscopic evaluation, the samples underwent histologic, morphologic and ultrastructural analyses in light and transmission electron microscopy.

RESULTS

Macroscopic degeneration was found in 15 of 26 specimen in the OA group but in seven of 25 in the control group (p = 0.048). The histologic analysis revealed a non-significant difference for the total degeneration score (TDS) between the study groups. The morphologic evaluation of the samples revealed that the OA group had significantly more samples with non-homogeneous extracellular matrix (ECM), (p = 0.048). Ultrastructurally, the OA group revealed a significantly larger fibril diameter in the biceps tendon (p < 0.0001) but not in the subscapularis tendon compared with the control group.

CONCLUSION

A significantly worse macroscopic appearance and significantly more morphologically inhomogeneous ECM, indicating more tendon degeneration, were found in the OA group compared with the control group. This indicates that it could be beneficial to treat the tendinosis in an early stage to decrease symptoms from the OA.

STUDY DESIGN

Level of evidence, III.

Ultrasound Intervention of the Lower Extremity/Pelvis

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.

Radiographic Risk Factors and Signs of Abductor Tears in the Hip

PURPOSE

The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears.

METHODS

Between April 2008 and October 2015, patients with intraoperative diagnosis of partial- or full-thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5 years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior-posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses.

RESULTS

There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group (n = 58) versus the control group (n = 54; P = .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8 cm for abductor tears vs 14.3 cm for control; P < .001), body weight moment arm (11.1 cm vs 10.9 cm; P < .001), and abductor moment arm (7.8 cm vs 7.6 cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P = .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear.

CONCLUSIONS

Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Long-term outcome of low-energy extracorporeal shockwave therapy on gluteal tendinopathy documented by magnetic resonance imaging

Background

Previous outcome studies for extracorporeal shock wave therapy (ESWT) have included clinically diagnosed greater trochanteric pain syndrome (GTPS). The purpose of this study is to investigate outcome of ESWT on GTPS with gluteal tendinopathy documented by magnetic resonance imaging (MRI).

Methods

Medical records of 38 consecutive patients were retrospectively reviewed, who underwent ESWT for GTPS with MRI-documented gluteal tendinopathy (> 6 months). ESWT was conducted (1/week) when the Roles-Maudsley score (RMS) showed “Poor” or “Fair” grade after conservative treatment until RMS had reached “Good” or “Excellent” grade (treatment success) or until 12 treatments had been applied. Numeric rating scale (NRS) and RMS were evaluated before, 1 week after (immediate follow-up) and mean 27 months after ESWT program (long-term follow-up). Success rate was calculated at each follow-up point.

Results

Initial NRS (5.9 ± 1.6) significantly decreased at immediate (2.5 ± 1.5, p< 0.01) and long-term follow-up (3.3 ± 3.0, p< 0.01), respectively. Success rates were 83.3% (immediate) and 55.6% (long-term), respectively. There was no correlation among age, symptom duration and NRS.

Conclusion

Low-energy ESWT can be an effective treatment for pain relief in chronic GTPS with MRI-documented gluteal tendinopathy. However, its long-term effect appears to decrease with time.

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups

PURPOSE

To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI.

METHODS

Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB.

RESULTS

The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores.

CONCLUSIONS

The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB.

LEVEL OF EVIDENCE

Level III, retrospective matched case control study.

Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics

BACKGROUND

Gluteal tendinopathy (GT) and hip osteoarthritis (OA) are the most common causes of hip pain and associated disability in older adults. Pain and altered walking biomechanics are common to both conditions. This study aimed to compare three-dimensional walking biomechanics between individuals with unilateral, symptomatic GT and HOA.

METHODS

Sixty individuals with symptomatic unilateral GT confirmed by magnetic-resonance-imaging and 73 individuals with symptomatic unilateral HOA (Kellgren-Lawrence Grade ≥ 2) underwent three-dimensional gait analysis. Maximum and minimum values of the external sagittal hip moment, the first peak, second peak and mid-stance minimum of the hip adduction moment (HAM), sagittal plane hip excursion and hip joint angles, pelvic obliquity and trunk lean, at the three HAM time points during stance phase of walking were compared between groups.

RESULTS

Compared to individuals with HOA, those with GT exhibited a greater hip peak extension moment (P < 0.001) and greater HAM throughout the stance phase of walking (P = 0.01-P < 0.001), greater hip adduction (P < 0.001) and internal rotation (P < 0.01-P < 0.001) angles and lower hip flexion angles and excursion (P = 0.02 - P < 0.001). Individuals with HOA exhibited a greater forward trunk lean (P ≤ 0.001) throughout stance, and greater ipsilateral trunk lean in the frontal plane (P < 0.001) than those with GT.

CONCLUSION

Despite presence of pain in both conditions, hip kinematics and kinetics differ between individuals with symptomatic unilateral GT and those with symptomatic unilateral HOA. These condition-specific impairments may be targets for optimization of management of HOA and GT.