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

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.

The Association between the Extent of the Osteoarthritic Meniscus Degeneration and Cigarette Smoking-A Pilot Study

Background and Objectives: The negative effects of smoking on the musculoskeletal system were presented by many authors, although the relationship between smoking and osteoarthritis remains unclear. The aim of this paper was to investigate the negative effects of smoking on meniscal tissue in osteoarthritic knees by microscopic examination, by adapting the Bonar scoring system and its modifications. Materials and Methods: The study involved 34 patients with varus knees, from whom 65 samples of knee menisci were obtained. The mean age in the studied group was 65.385 years. The smoking status of the patients concluded that there were 13 smokers and 21 nonsmokers. Results: Among smokers, the mean classical Bonar score was 8.42 and the mean modified Bonar score was 6.65, while nonsmokers were characterized by scores of 8.51 and 7.35, respectively. There was a statistically significant negative correlation between the number of cigarettes and the collagen in the medial meniscus (p = 0.0197). Moreover, in the medial meniscus, the modified Bonar score correlated negatively with the number of cigarettes (p = 0.0180). Similarly, such a correlation was observed between the number of cigarettes and the modified Bonar score in the lateral meniscus (p = 0.04571). Furthermore, no correlation was identified between the number of cigarettes and the classical Bonar score in the lateral meniscus. There was a statistically significant difference in the collagen variable value between the smokers and nonsmokers groups (p = 0.04525). Conclusions: The microscopic investigation showed no differences in the menisci of smokers and nonsmokers, except for the collagen, which was more organized in smokers. Moreover, the modified Bonar score was correlated negatively with the number of cigarettes, which supports the role of neovascularization in meniscus pathology under the influence of tobacco smoking.

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.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

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.

Imaging in Hip Arthroplasty Management Part 2: Postoperative Diagnostic Imaging Strategy

Hip arthroplasty (HA) is a frequently used procedure with high success rates, but 7% to 27% of the patients complain of persistent postsurgical pain 1 to 4 years post-operation. HA complications depend on the post-operative delay, the type of material used, the patient’s characteristics, and the surgical approach. Radiographs are still the first imaging modality used for routine follow-up, in asymptomatic and painful cases. CT and MRI used to suffer from metallic artifacts but are nowadays central in HA complications diagnosis, both having their advantages and drawbacks. Additionally, there is no consensus on the optimal imaging workup for HA complication diagnosis, which may have an impact on patient management. After a brief reminder about the different types of prostheses, this article reviews their normal and pathologic appearance, according to each imaging modality, keeping in mind that few abnormalities might be present, not anyone requiring treatment, depending on the clinical scenario. A diagnostic imaging workup is also discussed, to aid the therapist in his imaging studies prescription and the radiologist in their practical aspects.

Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.

PURPOSE

To clarify the relationship between FI and surgical outcomes for hip abductor tears.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.

RESULTS

A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score (P > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair (P > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005).

CONCLUSION

Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.

Advances in Microscopic Studies of Tendinopathy: Literature Review and Current Trends, with Special Reference to Neovascularization Process

Tendinopathy is a process of chaotic extracellular matrix remodeling followed by increased secretion of enzymes and mediators of inflammation. The histopathological assessment of tendinous tissue is crucial to formulate the diagnosis and establish the severity of tendon degeneration. Nevertheless, the microscopic analysis of tendinous tissue features is often challenging. In this review, we aimed to compare the most popular scales used in tendon pathology assessment and reevaluate the role of the neovascularization process. The following scores were evaluated: the Bonar score, the Movin score, the Astrom and Rausing Score, and the Soslowsky score. Moreover, the role of neovascularization in tendon degeneration was reassessed. The Bonar system is the most commonly used in tendon pathology. According to the literature, hematoxylin and eosin with additional Alcian Blue staining seems to provide satisfactory results. Furthermore, two observers experienced in musculoskeletal pathology are sufficient for tendinopathy microscopic evaluation. The control, due to similar and typical alterations in tendinous tissue, is not necessary. Neovascularization plays an ambiguous role in tendon disorders. The neovascularization process is crucial in the tendon healing process. On the other hand, it is also an important component of the degeneration of tendinous tissue when the regeneration is incomplete and insufficient. The microscopic analysis of tendinous tissue features is often challenging. The assessment of tendinous tissue using the Bonar system is the most universal. The neovascularization variable in tendinopathy scoring systems should be reconsidered due to discrepancies in studies.

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.

Superior Gluteal Reconstruction Results in Promising Outcomes for Massive Abductor Tendon Tears

Purpose

To evaluate the 1-year outcomes of a small patient series following open gluteus medius/minimus repair with human dermal allograft incorporated into the repair construct using a double-row repair.

Methods

Data from consecutive patients undergoing a superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy by a single fellowship trained surgeon from January 2018 to May 2019 were collected and analyzed. Baseline demographic data and magnetic resonance imaging were collected preoperatively. Clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Score-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were recorded at 1-year postoperatively.

Results

A total of 8 patients underwent open superior gluteal reconstruction for severe hip abductor deficiency. The mean age and body mass index were 62.6 ± 7.3 years and 29.6 ± 5.3 kg/m², respectively. The majority of patients were female (N = 7, 87.5%). Three (37.5%) patients had undergone previous endoscopic gluteus medius repair and presented for revision surgery. All patients had full-thickness tears with gluteus medius and gluteus minimus involvement. Patients were evaluated at an average of 11.5 ± 1.7 months from the initial surgical intervention and reported a mean HOS-ADL of 82.9 ± 24.3, HOS-SS of 73.2 ± 37.3, mHHS of 83.6 ± 17.1, iHOT-12 of 63.9 ± 27.4, VAS Pain of 30.0 ± 23.1, and VAS Satisfaction of 87.1 ± 17.0. There was no evidence of retears in this patient cohort as defined by physical examination findings and/or corroborating magnetic resonance imaging.

Conclusions

Superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy is a technique that demonstrates promising 1-year postoperative outcomes in both primary and revision patients.

Level of Evidence

Level IV, therapeutic case series.

Modern Suture Anchor Techniques for Gluteus Medius Tear Repair With Concomitant Total Hip Arthroplasty Using the Direct Anterior and Posterior Approaches

Gluteus medius (GM) tears are currently a well-established source of pain and disability. However, their role in primary total hip arthroplasty (THA) in the setting of osteoarthritis (OA) has been underexamined in the literature. The purpose of this study was to report on short-term patient-reported outcome measurements (PROMs) for patients who underwent concomitant primary THA and GM repair. Data were prospectively collected from September 2011 and June 2017. Inclusion criteria were primary THA along with concomitant GM repair and complete follow-up for the Harris Hip Score, Forgotten Joint Score 12, Veterans RAND 12-item Health Survey both Physical and Mental, 12-item Short Form Survey both Physical and Mental (SF-12 P and SF-12 M), visual analog scale for pain, and patient satisfaction. Patients were excluded if they did not have follow-up. Thirty patients (30 hips) were included. Mean follow-up was 24.2±19.3 months. Twenty-nine (96.7%) patients were female. Mean age was 65.2±7.4 years. Mean body mass index was 31.1±5.9 kg/m². The posterior approach was used for 16 (53.3%) cases and the anterior approach for the remaining 14 (46.7%). Two (6.7%) patients had a less than 25% tear, 7 (23.3%) had a 25% to 50% tear, 14 (46.7%) had a greater than 50% tear, and 7 (23.3%) had a full-thickness tear. All PROMs except SF-12 M demonstrated significant improvement at latest follow-up. Patients who underwent THA with either the anterior or the posterior approach with concomitant GM repair using modern suture anchor techniques reported favorable PROMs at short-term follow-up. [Orthopedics. 2021;44(5):e653-e660.].

Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background:

Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain.

Purpose:

To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed.

Results:

A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation).

Conclusion:

There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

[Avulsion injuries of the gluteus medius and gluteus minimus muscles]

Avulsion injuries of the gluteus medius and gluteus minimus muscles represent a diagnostic and therapeutic challenge. Such injuries are rarely to be expected in high-energy trauma. Degenerative damage or iatrogenic injuries in the context of hip surgery are more frequently identified as the cause. Clinically, in addition to lateral hip pain, limping is an important finding and depends on the extent of the tendon damage. In addition to the medical history and clinical examination, imaging by means of sonography and, above all, magnetic resonance imaging (MRI, possibly with artifact-reduced sequences in the presence of an endoprosthesis) are diagnostically groundbreaking. Therapeutically, a stepwise approach is indicated according to the extent of rupture and quality of the gluteal tendon and muscle tissues. Specific conservative training regimens, mini-open/endoscopic anatomic reconstruction techniques in cases of gluteal muscle integrity and muscle transfer techniques as salvage option with chronic mass ruptures are available. The common goal is the restoration of everyday occupational and private activities to regain the quality of life.

Pertrochanteric Calcifications in Patients With Greater Trochanteric Pain Syndrome: Description, Prevalence, and Correlation With Intraoperatively Diagnosed Hip Abductor Tendon Injuries

BACKGROUND

Pertrochanteric calcifications can be found in patients with greater trochanteric pain syndrome (GTPS). A systematic description of the types and prevalence of these calcifications has not been undertaken. Furthermore, there is conflicting evidence regarding their association with abductor tendon injuries.

PURPOSE

(1) To describe the various types and prevalence of pertrochanteric calcifications in patients presenting for the surgical management of recalcitrant GTPS. (2) To evaluate the association of the various calcifications with intraoperatively diagnosed hip abductor tendon injuries, including tendinosis, partial-thickness tears, and full-thickness tears.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients undergoing surgical management for GTPS, in isolation or as an ancillary procedure during hip arthroscopy for femoroacetabular impingement, between April 2008 and February 2020 were included. Of these, 85 procedures were isolated treatment of GTPS and the remaining 628 were ancillary to hip arthroscopy. Radiographs were scrutinized for the presence of pertrochanteric calcifications. The hip abductor tendon status was intraoperatively classified as intact, partial-thickness tear, or full-thickness tear. The prevalence and correlation of the various radiographic findings in relation to the intraoperatively classified tendon condition were analyzed via the odds ratio (OR).

RESULTS

Surgery was performed on 713 hips with recalcitrant GTPS. No tear was found in 340 hips (47.7%), 289 hips (40.5%) had a partial-thickness tear, and 84 hips (11.8%) had a full-thickness tear. Radiographically, 102 hips (14.3%) demonstrated proximally directed enthesophytes, and 34 (4.8%) had distally directed enthesophytes. In addition, 75 hips (10.5%) had amorphous calcifications, 47 (6.6%) had isolated ossicles, and 110 (15.4%) had surface irregularities. The presence of any calcification was associated with partial-thickness tears (OR, 1.67 [95% CI, 1.21-2.21]; P = .002) and full-thickness tears (OR, 6.40 [95% CI, 3.91-10.47]; P < .001). Distally directed enthesophytes (OR, 10.18 [95% CI, 3.08-33.63]; P < .001) and proximally directed enthesophytes (OR, 8.69 [95% CI, 4.66-16.21]; P < .001) were the findings with the highest OR for the presence of any type of tear. Distally directed enthesophytes were the findings with the highest OR for a full-thickness tear (OR, 15.79 [95% CI, 7.55-33.06]; P < .001). Isolated ossicles were the findings with the highest OR for a partial-thickness tear (OR, 1.73 [95% CI, 0.96-3.13]; P = .070).

CONCLUSION

Pertrochanteric calcifications were common radiographic findings in patients with GTPS and can help guide management in these patients. Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear, and increasing size of the findings was associated with more severe tendon injuries.

The Bonar Score in the Histopathological Assessment of Tendinopathy and Its Clinical Relevance-A Systematic Review

This study aimed to perform a comprehensive systematic review, which reports the role of the Bonar score in the histopathological assessment of tendinopathy and its clinical relevance. To identify all of the studies that reported relevant information on the Bonar scoring system and tendinopathy, an extensive search of the major and the most significant electronic databases (PubMed, Cochrane Central, ScienceDirect, SciELO, Web of Science) was performed. A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The extracted data included—year of study, geographical location, type of the study, radiological modifications, gender, number of patients, region of tendinopathy, mean age, control group, characteristics of the Bonar score and alterations in the scale, mean Bonar score, number of investigators, area of tendon investigation, clinical and radiological implications. An extensive search of the databases and other sources yielded a total of 807 articles. Eighteen papers were finally included in this systematic review, and of these, 13 original papers included the clinical and radiological implications of tendinopathy. Radiological evaluation was present in eight studies (both magnetic resonance imaging (MRI) and ultrasound (US)). The clinical implications were more frequent and present in 10 studies. Using the Bonar score, it is easy to quantify the pathological changes in tendinous tissue. However, its connection with clinical and radiological evaluation is much more complicated. Based on the current state of knowledge, we concluded that the neovascularization variable in the Bonar system should be reconsidered. Ideally, the microscopic assessment score should follow the established classification scale with the radiological and clinical agreement and should have a prognostic value.

Relationship between long head of the biceps tendon histopathology and long-term functional results in smokers. A time to reevaluate the Bonar score?

Aim

The purpose of this study was to investigate whether there is an association between smoking, the extent of the degeneration process in the biceps tendinopathy, including cells and extracellular matrix (ECM) alterations, and long-term surgical results.

Methods

This study comprised 40 consecutive patients admitted for shoulder arthroscopy due to symptomatic biceps tendinopathy and classified into three groups based on smoking status: active smokers, former smokers, and non-smokers. According to the classical Bonar score criteria, the histopathologic evaluation of the harvested intra-articular portion of the tendon was done. The follow-up examination was based on the American Shoulder and Elbow Surgeons Score (ASES).

Results

A cohort of 32 patients was enrolled in the final follow-up examination; mean 37.56 months. Histopathological evaluation according to the classical Bonar score revealed degeneration of the tendinous tissue in each group but there was no correlation between the extent of degeneration, smoking indexes and the ASES. After revision of Bonar scale within the vascularity criterion, we found a correlation between the extent of degeneration of tendinous tissue, smoking data, ASES score, and the severity of rotator cuff injury.

Conclusion

In this paper, we indicate the ambiguous role of the neovascularization in the biceps tendinopathy, and it was used for modification of the classical Bonar score. Consequently, recalculated, modified Bonar score was correlated positively with smoking indexes and functional outcomes. Furthermore, the morphological alterations of rotator cuff tendons also correlated positively with the extent of biceps tendon degeneration, measured according to the modified scoring system.

Repair of Symptomatic Partial Gluteus Medius Tear During Total Hip Arthroplasty Through the Direct Anterior Approach

Gluteus medius (GM) tears are a well-established source of pain and disability. Considering previous studies, which have reported rates of incidental GM tears in 20% of patients undergoing primary total hip arthroplasty (THA) and a 3-fold greater rate in elderly female patients, additional focus should be placed on identifying treatment options. The direct anterior approach (DAA) for primary THA has gained popularity within the past few years. However, there has been a paucity in the literature on how to address symptomatic and partial GM tears through this approach. The purpose of this Technical Note is to describe a method to repair partial GM tears during primary THA using the DAA.

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.

Mid-Term Outcomes of Endoscopic Gluteus Medius Repair With Concomitant Arthroscopic Labral Treatment: A Propensity-Matched Controlled Study

PURPOSE

To report mid-term outcomes of patients who underwent endoscopic gluteus medius (GM) repair with arthroscopic labral treatment and to compare them with a control cohort of patients who underwent arthroscopic labral treatment without an endoscopic GM repair.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent primary hip arthroscopy between February 2008 and August 2013. Patients were included if they underwent arthroscopic labral treatment, endoscopic GM repair, and had preoperative with minimum 5-year follow-up for the following patient-reported outcomes: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sports Specific Subscale (HOS-SSS). Propensity score matching was used to create a control cohort of patients who underwent primary arthroscopic labral treatment without GM repair.

RESULTS

There were a total of 46 patients with GM repair eligible for the current study, of whom 43 (93.5%) had 5-year follow-up. The average follow-up time was 73.4 months. At minimum 5-year follow-up, all PROs significantly improved (P < .001). Among the entire GM repair cohort, rates for achieving the patient acceptable symptomatic state (PASS) for mHHS, HOS-SSS, and international Hip Outcome Tool (iHOT-12) were 74.4%, 51.9%, and 71.8%, respectively. Rates for reaching a minimal clinically important difference for mHHS, NAHS, and HOS-SSS were 79.5%, 89.7%, and 73.1%, respectively. When the GM repair cohort was matched, there were 37 cases in the GM repair cohort and 78 in the control cohort. The GM repair cohort outcomes compared satisfactorily to the control cohort for mHHS (82.3 vs 82.6), NAHS (81.9 vs 82.3), and HOS-SSS (66.3 vs 67.5). Rates of achieving minimal clinically important difference and PASS for mHHS, NAHS, HOS-SSS, and iHOT-12 were also favorable.

CONCLUSIONS

Endoscopic GM repair with arthroscopic labral treatment results in safe, durable, and significant improvement in PROs at a minimum 5-year follow-up. The outcomes compared favorably with a control cohort without GM tears.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Lower Limb Tendinopathy Tissue Changes Assessed through Ultrasound: A Narrative Review

Tendinopathy is a common disease that affects athletes, causing pain and dysfunction to the afflicted tendon. A clinical diagnose is usually combined with imaging and, among all the existing techniques, ultrasound is widely adopted. The aim of this review is to sum up the existing evidence on ultrasound as an imaging tool and guide for treatments in lower limbs tendinopathy. Using three different databases—PubMed, MEDLINE and CENTRAL—a literature search has been performed in May 2020 combining MeSH terms and free terms with Boolean operators. Authors independently selected studies, conducted quality assessment, and extracted results. Ultrasound imaging has a good reliability in the differentiation between healthy and abnormal tendon tissue, while there are difficulties in the identification of tendinopathy stages. The main parameters considered by ultrasound imaging are tendon thickness, hypoechogenicity of tendon structure and neovascularization of the tendon bound tissue. Ultrasound-guide is also used in many tendinopathy treatments and the available studies gave encouraging results, even if further studies are needed in this field.

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.

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.

An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS)

PURPOSE

To evaluate how physiotherapists across three countries (Australia, New Zealand (NZ) and Ireland) diagnose greater trochanteric pain syndrome (GTPS) using clinical tests and imaging findings, and how physiotherapists update their knowledge regarding GTPS.

DESIGN

Cross-sectional observational study of physiotherapists.

METHODS

An online survey was distributed to registered physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; medians and interquartile ranges were calculated for numerical data. Comparisons between the three countries were made using Chi-squared analyses for nominal/ordinal data and Kruskal Wallis tests for numerical data. Statistical significance was set at p < 0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists; 61% were female and 79.8% worked in private practice. Most respondents were very confident in diagnosing GTPS (67.9%) and incorporated a range of symptoms and tests, including validated tests, in their diagnosis. However, many physiotherapists were not commonly using some available validated diagnostic tests (e.g. FABER and FADER-R). Approximately 30% of physiotherapists used imaging to inform assessment, with ultrasound being most preferred. Physiotherapists rated hands-on experience as most valuable for updating their knowledge of GTPS, followed by courses.

CONCLUSION

While most clinicians appear to be using current evidence in their assessment of patients with GTPS, a proportion use suboptimal methods and/or a limited range of diagnostic tests, suggesting that despite their confidence in diagnosis, further knowledge translation may be required. Future research should determine the best methods of facilitating knowledge acquisition and translation of research into practice.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).