Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study

The role of the greater trochanter pain syndrome in lumbar degenerative disc disease surgery

PURPOSE

Greater trochanter pain syndrome (GTPS) is highly discussed during spine surgeons, accompanies lumbar pain and complicates differential diagnosis. The aim is to raise awareness among physicians and demonstrate the lumbar spine degenerative diseases (LSDD) association with GTPS.

METHODS

A retro-prospective analysis enrolled 172 patients with LSDD with GTPS signs. Group I - retrospective (n = 112), group II - prospective (n = 60). Patients of group II with the confirmed diagnosis clinically and by the ultrasound recieved a GCS injection (Betamethasone 2 mg\ml + 5 mg\ml - 1.0). Also the VAS, X-ray and SPSS Statistics package were used.

RESULTS

112 patients in group I, 89 (79.5%) had increased pain in the hip early postOp to 7.8 points by VAS. All patients required trigger point injections of GCS and 68 (77%) received a repeat injection. 76 from 112 patients were tracked for long-term results, and recurrence of GTPS was detected in five people who treated conservatively for three months without dynamics. They were identified GTPS by ultrasound. During the injection, 39 from 43 (90%) patients noted pain reduction to 2.1 by VAS, but symptoms of radiculopathy or spinal stenosis persisted. Two patients (5%) did not note any changes. Two patients (5%) noted complete pain regression and refused the surgery.

CONCLUSION

Timely detection of GTPS among spinal surgeons influences tactics and, in some cases, allows one to avoid unnecessary surgical interventions. In turn, ignoring the symptoms of GTPS in the preoperative period can lead to pain intensification in the greater trochanter after surgery for degenerative diseases of the spine.

What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review

BACKGROUND

Cortico-Steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain.

OBJECTIVES

To identify factors that influence improvements in pain for patients with GTPS treated with CSI.

DESIGN

Systematic review.

METHODS

A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion if they investigated factors that influenced changes in pain experienced by patients with GTPS who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk Of Bias 2 (ROB2) tools were used to assess bias.

RESULTS

The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores.

CONCLUSIONS

Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance.

Ultrasound-guided bursal injections

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Lateral Trochanteric Pain Following Primary Total Hip Arthroplasty: Incidence and Success of Nonoperative Treatment

BACKGROUND

Our study aimed at quantifying the overall incidence of lateral trochanteric pain (LTP) following total hip arthroplasty (THA) and risk based on surgical approach. The success of conservative treatment and potential risk factors for failure of conservative treatment were evaluated.

METHODS

This is a retrospective review of patients who underwent primary THA between 2010 and 2019 and had a postoperative diagnosis of ipsilateral LTP. Chart review revealed patient demographics/comorbidities, preoperative diagnosis, surgical approach, femoral components, and nonoperative treatment modalities. Radiographic analysis was performed to measure leg length discrepancy, femoral offset, and femoral head lateralization.

RESULTS

The incidence of LTP following primary THA was 1.70% (573/33,761) with an average time to diagnosis of 27.3 months. The direct anterior approach demonstrated the highest risk and the direct lateral demonstrated the lowest risk for LTP (P < .001). Also, 82.4% (472/573) were diagnosed greater than 6 months postoperatively (P < .001). Of 573 patients, 95 (16.6%) were treated with physical therapy, home exercises, or oral medications with a success rate of 96.8% (92/95). Remaining 478 (83.4%) were treated with corticosteroid injection (CSI). And 89.5% (428/478) of the CSI cohort demonstrated clinical improvement with 3 or less CSIs. Risk factors for failure of conservative treatment were depression (P = .034), kidney disease (P = .040), and osteoporosis (P = .007).

CONCLUSION

Postoperative LTP after THA is rare with an incidence of 1.70%. The direct anterior approach presented higher risk of LTP. Non-CSI modalities and CSIs were both successful treatment options. In patients with depression, kidney disease, and osteoporosis, conservative treatment may be less efficacious.

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.

Diagnosis and surgical treatment of patients with femoral vein compression from hip joint synovial cyst

OBJECTIVE

In this study, the diagnosis and treatment of patients with femoral vein compression from a synovial cyst of the hip joint were investigated.

METHODS

A retrospective study was conducted to review hospital records from March 2010 to July 2017 of patients with femoral vein compression from a synovial cyst of the hip joint. The diagnostic procedure, duplex ultrasound results, computed tomography (CT), and magnetic resonance imaging (MRI) were recorded. The method and treatment outcomes were also documented.

RESULTS

Fifteen patients with femoral vein compression resulting from a synovial cyst of the hip joint were identified. The mean age was 47.5 years, and nine of the patients (60%) were female. All patients had unilateral lower extremity edema. In 11 patients (73.3%), the mass in the groin area could not be palpated; 2 (13.3%) patients had venous insufficiency; and 2 (13.3%) patients had venous thrombosis. All patients received a duplex ultrasound examination, 4 (26.7%) patients received CT, and 11 (73.3%) patients received MRI. One patient received a duplex ultrasound-guided percutaneous needle aspiration; however, the cyst recurred 1 month later. The remaining 14 patients received surgical excision and had no cyst recurrence during the follow-up period (mean, 22.6 months).

CONCLUSIONS

Duplex ultrasound should be selected as the first choice for screening of synovial cyst of the hip joint with femoral vein compression. Moreover, it can be used as the first choice for follow-up of these patients. MRI or CT can provide more anatomic information for surgical treatment. Surgical excision of the cyst is the preferred treatment method, with a lower rate of cyst recurrence compared with needle aspiration.

Greater trochanteric pain syndrome and gluteus medius and minimus tendinosis: nonsurgical treatment

Greater trochanteric pain syndrome (GTPS) affects 10–25% of people in developed countries. The underlying etiology for GTPS is most commonly the tendinosis or a tendon tear of the gluteus medius, minimus or both at the greater trochanter; the inflammation of the tendon is not a major feature. We critically evaluated conservative treatment, for which we reviewed 76 publications, grading them according to four levels of evidence. We identified a wide variety of conservative treatment options: home therapy (insoles, walking sticks/crutches, orthotic devices, stretching exercises and preventive measures); physiotherapy (massage and stretching exercises); infiltrations (corticosteroids and local anesthetics); image-guided infiltrations (fluoroscopy and ultrasound); shockwave therapy; platelet-rich plasma injection; and drug therapy. Severe complications associated with infiltrations are extremely rare, as are those associated with shockwave therapy. The most effective treatments were infiltrations with corticosteroids and shockwave therapy. We propose a graded treatment schedule for patients with GTPS.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

PRP IN THE TREATMENT OF TROCHANTERIC SYNDROME: A PILOT STUDY

OBJECTIVE

To compare the efficacy of platelet rich plasma (PRP) against corticosteroid on the treatment of trochanteric pain syndrome .

METHODS

From July 2011 to November 2012, eighteen patients (20 hips) with trochanter pain syndrome were randomized in two groups and treated with platelet rich plasma or triamcinolone infiltration guided by ultrasound. Pain and function were evaluated prior to the intervention and after 10, 30 and 60 days, through the Facial Expressions Scale for Pain and the Western Ontario McMaster and Harris Hip Score questionnaires. Inter-group analysis was performed by Student t-test and intragroup analysis by ANOVA, followed by Bonferroni post hoc test. Statistical significance was set at p <0.05 .

RESULTS

There was no difference between the groups. The triamcinolone group showed pain reduction (p=0.004) and improved function (p=0.036) through the Harris Hip Score questionnaire at 10, 30 and 60 days after treatment, when compared with the pre- intervention period. The platelet rich plasma group showed no statistical improvement in any of the variables .

CONCLUSION

Up to 60 days, PRP infiltration has no influence on pain relief and function improvement in trochanteric syndrome treatment. Level of Evidence II, Prospective Comparative Study.

Ultrasound-Guided Hip Procedures

This article describes the techniques for performing ultrasound-guided procedures in the hip region, including intra-articular hip injection, iliopsoas bursa injection, greater trochanter bursa injection, ischial bursa injection, and piriformis muscle injection. The common indications, pitfalls, accuracy, and efficacy of these procedures are also addressed.

Cystic lesion around the hip joint

This article presents a narrative review of cystic lesions around the hip and primarily consists of 5 sections: Radiological examination, prevalence, pathogenesis, symptoms, and treatment. Cystic lesions around the hip are usually asymptomatic but may be observed incidentally on imaging examinations, such as computed tomography and magnetic resonance imaging. Some cysts may enlarge because of various pathological factors, such as trauma, osteoarthritis, rheumatoid arthritis, or total hip arthroplasty (THA), and may become symptomatic because of compression of surrounding structures, including the femoral, obturator, or sciatic nerves, external iliac or common femoral artery, femoral or external iliac vein, sigmoid colon, cecum, small bowel, ureters, and bladder. Treatment for symptomatic cystic lesions around the hip joint includes rest, nonsteroidal anti-inflammatory drug administration, needle aspiration, and surgical excision. Furthermore, when these cysts are associated with osteoarthritis, rheumatoid arthritis, and THA, primary or revision THA surgery will be necessary concurrent with cyst excision. Knowledge of the characteristic clinical appearance of cystic masses around the hip will be useful for determining specific diagnoses and treatments.

The running athlete: stress fractures, osteitis pubis, and snapping hips

CONTEXT

Pelvic stress fractures, osteitis pubis, and snapping hip syndrome account for a portion of the overuse injuries that can occur in the running athlete.

EVIDENCE ACQUISITION

PUBMED SEARCHES WERE PERFORMED FOR EACH ENTITY USING THE FOLLOWING KEYWORDS: snapping hip syndrome, coxa sultans, pelvic stress fracture, and osteitis pubis from 2008 to 2013. Topic reviews, case reports, case series, and randomized trials were included for review.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Collectively, 188 articles were identified. Of these, 58 were included in this review.

CONCLUSION

Based on the available evidence, the majority of these overuse injuries can be managed non-operatively. Primary treatment should include removal from offending activity, normalizing regional muscle strength/length imbalances and nutritional deficiencies, and mitigating training errors through proper education of the athlete and training staff.

STRENGTH OF RECOMMENDATION TAXONOMY

C.

Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: greater trochanter bursa versus subgluteus medius bursa

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of corticosteroid injections into the greater trochanteric bursa as opposed to the subgluteus medius bursa in patients with greater trochanteric pain syndrome.

MATERIALS AND METHODS

We retrospectively reviewed 183 injections (149 performed in women, 34 performed in men; age range 23-90 years; median, 53 years) performed for treatment of greater trochanteric pain syndrome. A 10-cm visual analog scale survey was used to assess pain level before the procedure and 14 days after the procedure. A 3-mL corticosteroid solution was injected into either the greater trochanteric bursa or the subgluteus medius bursa under direct ultrasound guidance. Procedure images were retrospectively reviewed to determine the site of injection. Diagnostic images obtained at the time of the procedure were also reviewed for findings of tendinopathy, bursitis, and enthesopathy. Statistical analysis of differences in pain reduction was performed, as was analysis for association between pain relief and demographic variables of age, sex, previous injections, and ultrasound findings.

RESULTS

Sixty-five injections met the inclusion criteria; 56 performed in women and nine performed in men (age range, 30-82 years; median, 53 years). Forty-one injections were into the greater trochanteric bursa and 24 into the subgluteus medius bursa. There was a statistically significant difference in pain reduction between greater trochanteric bursa and subgluteus medius bursa injections with a median pain reduction of 3 as opposed to 0 (p < 0.01). There was no statistically significant association between pain relief and demographic variables or ultrasound findings.

CONCLUSION

Corticosteroid injections into the greater trochanteric bursa may be more effective than injections into the subgluteus medius bursa for treatment of greater trochanteric pain syndrome.

Trochanteric area pain, the result of a quartet of bursal inflammation

Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients’ use of the term “hip” can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of “hip” pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.

Greater trochanteric pain syndrome

Originally defined as "tenderness to palpation over the greater trochanter with the patient in the side-lying position," greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans.

Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment

We examined the efficacy of corticosteroid injection as treatment for postarthroplasty trochanteric bursitis and the risk factors for failure of nonoperative treatment. There were 32 (4.6%) cases of postsurgical trochanteric bursitis in 689 primary total hip arthroplasties. Of the 25 hips with follow-up, 11 (45%) required multiple injections. Symptoms resolved in 20 (80%) but persisted in 5. We found no statistically significant differences between patients who did and did not develop trochanteric bursitis, or between those who did and did not respond to treatment. There was a trend toward younger age and greater limb-length discrepancy in nonresponders. In conclusion, (1) corticosteroid injection(s) for postoperative trochanteric bursitis is effective; and (2) nonoperative management may be more likely to fail in young patients and those with leg-length discrepancy.

Musculoskeletal injection

Patients commonly present to primary care physicians with musculoskeletal symptoms. Clinicians certified in internal medicine must be knowledgeable about the diagnosis and management of musculoskeletal diseases, yet they often receive inadequate postgraduate training on this topic. The musculoskeletal problems most frequently encountered in our busy injection practice involve, in decreasing order, the knees, trochanteric bursae, and glenohumeral joints. This article reviews the clinical presentations of these problems. It also discusses musculoskeletal injections for these problems in terms of medications, indications, injection technique, and supporting evidence from the literature. Experience with joint injection and the pharmacological principles described in this article should allow primary care physicians to become comfortable and proficient with musculoskeletal injections.

Musculoskeletal injection

Patients commonly present to primary care physicians with musculoskeletal symptoms. Clinicians certified in internal medicine must be knowledgeable about the diagnosis and management of musculoskeletal diseases, yet they often receive inadequate postgraduate training on this topic. The musculoskeletal problems most frequently encountered in our busy injection practice involve, in decreasing order, the knees, trochanteric bursae, and glenohumeral joints. This article reviews the clinical presentations of these problems. It also discusses musculoskeletal injections for these problems in terms of medications, indications, injection technique, and supporting evidence from the literature. Experience with joint injection and the pharmacological principles described in this article should allow primary care physicians to become comfortable and proficient with musculoskeletal injections.

Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

OBJECTIVE

To determine whether fluoroscopic guidance improves outcomes of injections for greater trochanteric pain syndrome.

DESIGN

Multicentre double blind randomised controlled study.

SETTING

Three academic and military treatment facilities in the United States and Germany.

PARTICIPANTS

65 patients with a clinical diagnosis of greater trochanteric pain syndrome.

INTERVENTIONS

Injections of corticosteroid and local anaesthetic into the trochanteric bursa, using fluoroscopy (n=32) or landmarks (that is, "blind" injections; n=33) for guidance.

PRIMARY OUTCOME MEASURES

0-10 numerical rating scale pain scores at rest and with activity at one month (positive categorical outcome predefined as >or=50% pain reduction either at rest or with activity, coupled with positive global perceived effect). Secondary outcome measures included Oswestry disability scores, SF-36 scores, reduction in drug use, and patients' satisfaction.

RESULTS

No differences in outcomes occurred favouring either the fluoroscopy or blind treatment groups. One month after injection the average pain scores were 2.7 at rest and 5.0 with activity in the fluoroscopy group compared with 2.2 and 4.0 in the blind injection group. Three months after the injection, 15 (47%) patients in the blind group and 13 (41%) in the fluoroscopy group continued to have a positive outcome.

CONCLUSION

Although using fluoroscopic guidance dramatically increases treatment costs for greater trochanteric pain syndrome, it does not necessarily improve outcomes.

TRIAL REGISTRATION

Clinical trials NCT00480675.

Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis

This article presents a simple technique for fascia lata lengthening that is less aggressive, can be performed under local anaesthetic with little morbidity and disability, and has excellent results. Eleven patients (13 hips) were enrolled in this study. Mean age was 54.6 years, there was one man and ten women. Outcomes were assessed by using a visual analog pain scale, Harris hip score and Lickert scale (satisfaction). There was a mean follow-up time of 43 months (range 15-84). All patients were scored by the Harris hip scale with a mean improvement from 61 (range 48-77) to 91 (range 76-95) after surgery. The mean visual analogue scale (VAS) score improved from 83 (range 60-99) to 13 (range 0-70). We had 12 of 13 patients reporting a good result. Mean surgical time was 15 min, and only one seroma was reported as a complication. No inpatient management was needed. In conclusion, distal "Z" lengthening of the fascia lata appears to be a good alternative for treatment of this condition.

Lateral hip pain: findings from magnetic resonance imaging and clinical examination

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVES

To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology.

BACKGROUND

LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem.

METHODS AND MEASURES

Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance imaging (MRI) studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined.

RESULTS

Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large.

CONCLUSIONS

The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MRI as a diagnostic reference standard. This factor, together with the imprecise point estimates of the likelihood ratios, means that no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology.

Morphology of the bursae associated with the greater trochanter of the femur

BACKGROUND

Abnormalities of the bursae in the vicinity of the greater trochanter have been implicated in the pathogenesis of lateral hip pain. The purpose of the present study was to investigate the detailed morphology of the bursae associated with the greater trochanter of the femur.

METHODS

The bursae deep to the tendons of each of the gluteal muscles were examined in eighteen embalmed human hips with use of macrodissection and histological techniques. The specimens were obtained from eight female and seven male donors who had had a mean age of seventy-eight years at the time of death.

RESULTS

A total of 106 bursae were identified in ten different locations, with an average of six bursae per hip. As many as four bursae were present beneath the gluteus maximus muscle and the fascia lata, including those normally thought of as the "trochanteric" bursae and the gluteofemoral bursa. Two bursae typically were found beneath the tendon of the gluteus medius muscle: the anterior subgluteus medius bursa and the piriformis (posterior subgluteus medius) bursa. In the majority of cases, a single bursa was located deep to the gluteus minimus tendon, although two different bursae were identified: the subgluteus minimus bursa and the secondary subgluteus minimus bursa. All of these bursae demonstrated a synovial lining, which was predominantly areolar in type.

CONCLUSIONS

The present study revealed that numerous bursae are intimately associated with the greater trochanter and that at least two bursae are associated with each of the gluteal tendons.

The impact of obesity on the musculoskeletal system

Obesity is associated with a range of disabling musculoskeletal conditions in adults. As the prevalence of obesity increases, the societal burden of these chronic musculoskeletal conditions, in terms of disability, health-related quality of life, and health-care costs, also increases. Research exploring the nature and strength of the associations between obesity and musculoskeletal conditions is accumulating, providing a better understanding of underlying mechanisms. Weight reduction is important in ameliorating some of the manifestations of musculoskeletal disease and improving function.

Lateral hip pain: does imaging predict response to localized injection?

Lateral hip pain is a common complaint in patients with a history of lower back pain from spinal disease. These patients often are diagnosed and treated for trochanteric bursitis because of localized pain and tenderness in the lateral hip. We presumed numerous scintigraphic features could provide diagnostic criteria for diagnosing gluteus medius tendinitis and trochanteric bursitis. A study was designed to assess the scintigraphic criteria for diagnosis of trochanteric bursitis and to evaluate the relationship of trochanteric bursitis to gluteus medius tendinitis and lumbar degenerative disease in predicting relapse after injection. We evaluated 97 patients with greater trochanteric pain syndrome to find a correlation between trochanteric bursitis, gluteus medius tendinitis, and spinal degenerative disease using scintigraphy and magnetic resonance imaging. We also evaluated predictors for responding to trochanteric injection of local anesthetic/glucocorticoid injection. We found a correlation between lumbar degenerative disease, gluteus medius tendinopathy, and trochanteric bursitis. Of these, 30 of 48 patients (63%) responded to injection of local anesthetic and glucocorticoids. The major predictor of relapse of pain after injection in 18 patients was the presence of moderate to severe lumbar degenerative disease seen on scintigraphic imaging. We propose a mechanistic model of the greater trochanteric pain syndrome to explain the interrelationship and response to therapy. Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis.