Management of the greater trochanteric pain syndrome: a systematic review

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.

An Unconventional Solution for Persistent Lateral Hip Prosthetic Friction Syndrome (LHPFS) after Revision Total Hip Arthroplasty

We report on a 77-year-old male patient, who presented with excessive bone loss at the area of the greater trochanter after several hip revision surgeries resulting in a persistent friction syndrome caused directly by the rough surface and sharp edges of the prosthetic shoulder of a well-fixed Wagner-type revision stem. Surgery was performed by creating a cemented neotrochanter with an attached polyester patch around the proximal lateral shaft and performing a Z-plasty of the iliotibial tract. Twelve months postoperatively, the patient reported a reduction in subjective pain of 50% and improvement of the Harris Hip Score from 45 to 75 points. Without a definition in the current literature, the authors propose the term "lateral hip prosthetic friction syndrome" (LHPFS) to describe this medical condition.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS.

METHODS

To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs.

RESULTS

Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma.

DISCUSSION

There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

The conservative management for improving Visual Analog Scale (VAS) pain scoring in greater trochanteric pain syndrome: a Bayesian analysis

BACKGROUND

Greater trochanteric pain syndrome (GTPS) possesses a harmful influence on quality of life. Numerous conservative management modalities with varying success have been proposed for patients with GTPS. However, it is not clear which treatment is more effective for reducing pain. The purpose of this Bayesian analysis was to assess the current evidence for the effectiveness of conservative treatments on improving Visual Analog Scale (VAS) pain scoring of GTPS and to determine the most effective treatment protocol.

METHODS

A comprehensive study search was performed from inception until July 18, 2022, via the electronic databases PubMed, the Cochrane Library, and Web of Science for potential research. The risk of bias assessment for the included studies was independently performed based on the Cochrane Collaboration Risk of Bias Tool. Bayesian analysis was conducted by using ADDIS software (v1.16.5). The DerSimonian-Laird random effects model was used to perform the traditional pairwise meta-analysis.

RESULTS

Eight full-text articles with a total of 596 patients with GTPS were included in the analysis. In comparing ultrasound-guided platelet-rich plasma application (PRP-U) to ultrasound-guided corticosteroid injection (CSI-U), patients who received PRP therapy experienced reduced pain as the VAS decreased significantly (MD, -5.21; 95% CI, -6.24 to -3.64). VAS score in group of extracorporeal shockwave treatment (ESWT) was significant improved than that in exercise (EX) group (MD, -3.17; 95% CI, -4.13 to -2.15). There were no statistically significantly different VAS scores between the CSI-U group and the CSI under landmark (CSI-B) group. The treatment efficacy rankings of the different treatments on improving VAS scores showed that the most likely efficacious treatment was PRP-U (99%) followed by ESWT (81%), CIS-U (58%), usual care (48%), CIS-B (54%), and EX (84%).

CONCLUSION

Bayesian analysis revealed that PRP injection and ESWT are relatively safe and effective in the treatment of GTPS. More multicenter high-quality randomized clinical trials with large sample sizes are still needed in the future to provide further evidence.

Endoscopic treatment of gluteus medius tendon tear

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

The effect of corticosteroid injection in the treatment of greater trochanter pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Background

corticosteroid injection (CSI) has been used to treat greater trochanter pain syndrome (GTPS) for many years. However, so far, the efficacy of CSI in the treatment of GTPS is still controversial. Therefore, the aim of this review is to evaluate the effectiveness of CSI in comparison with sham intervention, nature history, usual care, platelet-rich plasma (PRP), physiotherapy/exercise therapy, dry needling, or other nonsurgical treatment for improvements in pain and function in GTPS.

Methods

PubMed (Medline), Embase, Cochrane Library were searched from their inception until April 2021. Randomized controlled trails (RCTs) comparing CSI to nonsurgical treatment were included. Data on the effect of CSI on pain and function were extracted and checked by two review authors independently. The treatment effect was analyzed in the short term, medium term, and long term.

Results

Eight RCTs (764 patients) were included. This review suggests CSI may be superior to usual care and ‘wait and see,’ ESWT, but may not be superior to exercise, PRP, dry needling, and sham intervention in short-term pain or function improvement. In terms of medium-term pain or function improvement, CSI may be superior to usual care and ‘wait and see,’ but may not be superior to PRP. In terms of long-term pain or function improvement, CSI may be inferior to PRP and ESWT, but it may be superior to usual care and ‘wait and see’ at 12 months.

Conclusions

Due to the small sample size and lack of sufficient clinical studies, current evidence is equivocal regarding the efficacy of CSI in the treatment of GTPS. Considering the limitations, more large-sample and high-quality RCTs are needed to prove the therapeutic effect of CSI on GTPS.

Trial registration

PROSPERO registration number: CRD42021247991. Registered 09 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03175-5.

Editorial Commentary: It Is Imperative to Fix Symptomatic Hip Gluteus Medius Tears at Time of Femoroacetabular Impingement: Why Ignore This Pain in the Butt?

The hip can have a multitude of different pathologies leading to different symptoms. Greater trochanteric pain syndrome, historically attributed to bursitis, has been largely found to be associated with lesions of the gluteus medius and minimus tendons, and the prevalence of gluteus medius pathology in patients with femoroacetabular impingement (FAI) is as high as one-third of the FAI population. If a patient is found to have significant clinical symptoms of both FAI and a gluteus medius tear, it is imperative to fix both pathologies. The most important diagnostic predictor in hip arthroscopy is not magnetic resonance imaging but a well-executed history and physical exam. We use a quadrant approach: the medial quadrant accounts for adductor bursitis, adductor tears, pudendal neuralgia, or sports hernias. The posterior quadrant may account for a hamstring tear, lumbar radiculopathy, ischiofemoral impingement, or in rare cases piriformis syndrome. The anterior quadrant accounts for more intraarticular pathologies including FAI, Labral tears, osteoarthritis, avascular necrosis, or iliopsoas bursitis. The lateral quadrant would include greater trochanteric pain syndrome, gluteus medius and minimus tears, external snapping hip syndrome and iliotibial band syndrome. By using this systematic approach and using the magnetic resonance imaging to confirm the diagnosis, we may accurately determine patients' hip pathologies.

Hip Gluteus Medius Tears Are Associated With Lower Femoral Neck-Shaft Angles and Higher Acetabular Center-Edge Angles

PURPOSE

1) To assess the possible relationship between the morphology of femur or acetabulum and the gluteus medius pathology. 2) To analyze the outcome of isolated arthroscopic treatment of femoroacetabular impingement (FAI) for patients with radiographic gluteus medius tear.

METHODS

We performed a retrospective study of FAI patients who underwent arthroscopy between January 2016 to December 2019. Demographic data, such as sex, age, body mass index (BMI), symptom duration, were collected. Radiographic parameters, including alpha angle, lateral center-edge angle (LCEa), femur neck-shaft angle (NSa), gluteus medius pathology, were also collected. Exclusion criteria were previous hip conditions, such as osteoarthritis (Tönnis grade > 1), rheumatoid arthritis, ankylosing spondylitis, snapping hip, previous surgery on the ipsilateral hip, or incomplete data. We followed up these patients with radiographic gluteus medius tear. No surgical procedure for gluteus medius was performed. The minimum follow-up period was 13 months. Patient-reported outcomes, such as modified Harris Hip score (mHHS), visual analog scale (VAS), and patient acceptable symptom state (PASS), as well as physical examination data, including tenderness at the greater trochanter, abductor weakness, limping gait, and positive Trendelenburg sign or test, were gathered preoperatively and postoperatively.

RESULTS

A total of 569 hips (314, 55.2% male) were collected eventually, with a mean age of 36.5 ± 10.4 years (range: 13.0 to ∼65.0). Gluteus medius pathology was found in 209 (36.7%) hips, including 41 (7.2%) partial-thickness tears and 10 (1.8%) complete tears. The NSa of the normal, tendinosis, partial tear, and complete tear groups was 133.8 ± 4.7°, 130.6 ± 3.8°, 129.4 ± 3.9°, and 129.6 ± 3.4°, respectively (P < .001). The LCEa of each group was 31.7 ± 35.7°, 33.3 ± 6.5°, 34.9 ± 6.8°, and 33.7 ± 8.1°, respectively (P = .004). On multivariable logistic regression analysis, lower NSa and higher LCEa were identified as risk factors for developing gluteus medius pathology (P < .001). For patients with gluteus medius tear, two cases were lost to follow-up and two cases had incomplete data. The mean follow-up period of the remaining 47 hips was 29.5 ± 12.9 (range: 13 to 59) months. The mHHS improved from 54.8 ± 19.1 to 90.1 ± 6.7 points (P < .001), and VAS decreased from 6.8 ± 1.6 to 3.0 ± 1.6 points (P < .001). Forty-two cases met the threshold of PASS, with a rate of 89%. The abductor strength increased from 4.1 ± 1.00 to 4.6 ± .7 grades (P = .002). However, for patients with a completely torn gluteus medius, improvement of abductor strength was not significant statistically (3.4 ± .9 to 3.9 ± .9, P = .234).

CONCLUSION

There was a correlation between lower NSa/higher LCEa and gluteus medius pathology. Isolated arthroscopic treatment of FAI for patients with radiographic gluteus medius tear can gain satisfactory patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic case series, IV.

Endoscopic fascia lata release for treatment of gluteal tendinopathy: a prospective study with a follow-up of 6 months to 1 year

Greater trochanteric pain syndrome (GTPS) is clinically defined as greater trochanter pain with mechanical characteristics. The most common diagnosis is gluteal tendinopathy. Most cases of gluteal tendinopathy resolve with conservative management. In case of refractory pain endoscopic surgical treatment can resolved symptoms. This article presents a prospective study of endoscopic proximal fascia lata release associated to trochanteric bursectomy for recalcitrant trochanteric pain syndrome. 33 patients (35 hips) with refractory pain during more than six months were included. All patients were treated by endoscopic iliotibial band release and bursectomy according to Ilizaliturri. Outcomes were assessed by using Harris hip score and Womac hip score. Patients were follow-up until one year after surgery. The mean age was 53.7 years old, there was 9 men and 24 women. There were two bilateral cases in the female group. The average duration of conservative treatment was 20 months (CI95 9 to 31 months). 68% of patients were satisfied of the surgery with disappearance of pain after surgery. WOMAC and Harris hip score significantly improved after surgery until 6 months (respectively from 67 to 29 and from 40 to 76 - p<0.05). No complication was reported. Age, body mass index and duration of conservative treatment did not influence surgical results. This study showed that the endoscopic ilio tibial band (ITB) release and trochanteric bursectomy is simple, safe and easily reproductible but future prospective studies with a larger number of patients are required.

Greater trochanteric pain syndrome: focused shockwave therapy versus an ultrasound guided injection: a randomised control trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a common problem with an incidence of 1.8-5.6 per 1000 population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential non-invasive management option for this difficult presentation.

METHOD

We ran a prospective, 2-arm, single-blinded, randomised control trial comparing focused shockwave therapy (f-ESWT) to an ultrasound guided corticosteroid injection. Primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris Hip Score (HHS) and Trendelenburg test for function; SF-36 for quality of life (QoL); and a Likert scale question for subjective assessment of symptom improvement.

RESULTS

104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image-guided injection. 11 patients were lost to follow-up. There were no significant differences in baseline scores between groups.At 3 months, pain, function and QoL scores had improved in both groups but were not statistically significant. The Trendelenburg test was significantly improved in the f-ESWT group with 80% patients being negative compared to 20% at baseline (p < 0.001).At 12 months, across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 37.1 versus 55.0 (p = 0.007, 95% confidence interval [CI], 6.3-30.8), HHS 69.7 versus 57.5 (p = 0.002, 95% CI, -20.0 to -4.6) and SF-36 52.4 versus 47.7 (p = 0.048, 95% CI, -9.31 to -0.04). The improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline (p < 0.001).

CONCLUSIONS

We have shown f-ESWT is an effective treatment for patients with GTPS. We would advocate f-ESWT as an effective non-invasive treatment modality for this challenging patient population.Trial Registration No. ISRCTN8338223.

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.

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.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique

BACKGROUND

Greater trochanteric pain syndrome encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and lateral snapping hip (LSH). Surgical options for LSH range from open surgery to endoscopic surgery, including a diamond-shaped cut or a simple transversal release to gluteus maximus tendon release. Resection of an area of proximal iliotibial band (ITB) and step-cut or z-plasty lengthening have not proven superior to transverse release of the ITB. Therefore, making a complete and effective transverse cut guided by ultrasound may represent a potential advance over endoscopic surgery.

PURPOSE

In this case series study, we describe how to perform proximal release of the ITB guided by ultrasound.

METHODS

The surgical technique-either z-plasty or transverse section of the ITB-was first validated on 10 cadaver specimens and then used in clinical practice. Fourteen patients (5 males and 9 females) were operated from 2014 to 2018. Mean age was 43 years (29-62).

RESULTS

The snap resolved in all patients, as verified actively during the surgical procedure as the patient has only local anesthesia. The VAS score for sports activity improved from 7 (5-9) before surgery to 0 (0-2) after 1 year. The HSS score improved from 58 points (47-72) to 96 at 1-2 years. There were no complications other than minor hematomas nor recurrences.

CONCLUSION

Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. It can be performed under local anesthesia in an outpatient setting with minimal aggressiveness. It is relatively easy, quick, and painless; no stitches are required. Weight bearing is immediate, and patients usually need crutches for only 2-3 days. Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless.

COMPARISON BETWEEN CONCENTRATED BONE MARROW ASPIRATE AND CORTICOID IN GLUTEAL TENDINOPATHY

OBJECTIVE

To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies.

METHODS

48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections.

RESULTS

40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference.

CONCLUSION

BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.

Radiofrequency Microdebridement as an Adjunct to Arthroscopic Surgical Treatment for Recalcitrant Gluteal Tendinopathy: A Double-Blind, Randomized Controlled Trial

Background:

Recalcitrant greater trochanteric pain is increasingly recognized as an indication for surgical intervention. The arthroscopic approach has become rapidly more common than the open alternative.

Hypothesis:

Patients undergoing radiofrequency microdebridement (RFMD) as an adjunct to arthroscopic gluteal bursectomy (AGB) and iliotibial band release (ITBR) will experience better functional improvement than AGB and ITBR alone at 1 year.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 33 patients with failed nonoperative treatment of gluteal tendinopathy were randomly allocated to undergo AGB/ITBR or AGB/ITBR + RFMD. Full-thickness tears were excluded. The primary outcome measure was the modified Harris Hip Score (mHHS) at 52 weeks. Secondary outcome measures included the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and 12-item Short Form Health Survey (SF-12), which were evaluated at 0, 6, 12, 24, and 52 weeks. Statistical significance was defined as P < .05.

Results:

A total of 33 participants (33 hips; 30 female and 3 male; mean age, 58 years) were randomized; 16 patients underwent AGB/ITBR + RFMD, and 17 underwent AGB/ITBR. Participants’ functionality improved in both groups at all time intervals. The mean mHHS score improved from 57.49 ± 10.61 to 77.76 ± 18.40 (P = .004) and from 58.98 ± 12.33 to 79.96 ± 18.86 (P = .001) at 52 weeks in the AGB/ITBR and AGB/ITBR + RFMD groups, respectively, although there was no statistically significant difference between groups. There were no device-related adverse events.

Conclusion:

AGB/ITBR led to significant improvements in patients with recalcitrant gluteal tendinopathy. In this small RCT, the addition of RFMD showed no additional benefit to AGB/ITBR but provided a safe adjunct for the surgical management of recalcitrant gluteal tendinopathy.

Registration:

NCT01562366 (ClinicalTrials.gov identifier).

Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice

OBJECTIVES

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

DESIGN

Cross-sectional observational survey of physiotherapists.

METHODS

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons 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 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

CONCLUSION

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up

BACKGROUND

A previously published trial showed that patients with chronic gluteal tendinopathy achieved greater clinical improvement at 12 weeks when treated with a single platelet-rich plasma (PRP) injection than those treated with a single corticosteroid injection (CSI).

PURPOSE

This follow-up study was conducted to determine whether there would be a sustained long-term difference in the modified Harris Hip Score (mHHS) at 2 years for a leucocyte-rich PRP (LR-PRP) injection in the treatment of chronic gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This trial included 80 patients randomized 1:1 to receive LR-PRP or CSI intratendinously under ultrasound guidance. Patients had a mean age of 60 years, a 9:1 ratio of women to men, a mean body mass index of 27, and a mean length of symptoms >15 months. No patients had full-thickness tears of the gluteal tendons. An open-labeled extension allowed patients to receive crossover treatment after 3 months. The main outcome measure was the mHHS.

RESULTS

The mean mHHS improved significantly at 12 weeks in the PRP group (74.05; SD, 13.92) as compared with the CSI group (67.13; SD, 16.04) ( P = .048). At 24 weeks, the LR-PRP group (77.60; SD, 11.88) improved further than the CSI group (65.72; SD, 15.28; P = .0003). Twenty-seven patients were deemed to have failed the CSI treatment at 16 to 24 weeks, with an exit score of 59.22 (SD, 11.54), and then had treatment with LR-PRP. The crossover group improved with the LR-PRP: from 59.22 (SD, 11.22) at baseline to 75.55 (SD, 16.05) at 12 weeks, 77.69 (SD, 15.30) at 24 weeks, and 77.53 (SD, 14.54) at 104 weeks. The LR-PRP group retained 38 of 39 patients to 52 weeks and continued to improve. Their baseline scores of 53.77 (SD, 12.08) improved to 82.59 (SD, 9.71) at 104 weeks ( P < .0001).

CONCLUSION

Among patients with chronic gluteal tendinopathy and a length of symptoms >15 months, a single intratendinous LR-PRP injection performed under ultrasound guidance results in greater improvement in pain and function than a single CSI. The improvement after LR-PRP injection is sustained at 2 years, whereas the improvement from a CSI is maximal at 6 weeks and not maintained beyond 24 weeks.

REGISTRATION

ACTRN12613000677707 (Australian New Zealand Clinical Trials identifier).

Focused extracorporeal shock wave therapy for greater trochanteric pain syndrome with gluteal tendinopathy: a randomized controlled trial

OBJECTIVES:

To investigate if focused extracorporeal shock wave therapy (f-ESWT) is an effective treatment in a population affected by greater trochanteric pain syndrome (GTPS).

DESIGN:

Randomized controlled trial, with blind outcome assessors.

SETTING:

Outpatients, University Hospital.

SUBJECTS:

A total of 50 patients affected by GTPS with gluteal tendinopathy.

INTERVENTIONS:

The study group was assigned to receive f-ESWT, the control group received ultrasound therapy (UST).

MAIN MEASURES:

We assessed hip pain and lower limb function by means of a numeric rating scale (p-NRS) and the Lower Extremity Functional Scale (LEFS scale), respectively. The first follow-up evaluation (2M-FUP) was performed two months after the first treatment session, the second (6M-FUP) was carried out six months later.

RESULTS:

The mean age of the population was 61.24 (9.26) years. A marked prevalence of the female sex was recorded (44 subjects, 86%). The statistical analysis showed a significant pain reduction over time for the study group and the control group, the f-ESWT proving to be significantly more effective than UST ( P < 0.05) at the 2M-FUP (2.08 vs 3.36) and at the 6M-FUP (0.79 vs 2.03). A marked improvement of the LEFS total score was observed in both groups as well, but we found no statistical differences in the comparisons between groups.

CONCLUSION:

Our findings support the hypothesis that f-ESWT is effective in reducing pain, both in the short-term and in the mid-term perspective. We also observed a functional improvement in the affected lower limb, but, in this case, f-ESWT showed not to be superior to UST.

Effect of a Collagen-Based Compound on Morpho-Functional Properties of Cultured Human Tenocytes

Background: Greater Trochanter Pain Syndrome (GTPS) is the main reason for recalcitrant lateral hip pain. Gluteus medius and minimus tendinopathy plays a key role in this setting. An injectable medical compound containing collagen type I (MD-Tissue, Guna) has been produced with the aim to counteract the physiological and pathological degeneration of tendons. In this study we aimed at characterizing the effect of this medical compound on cultured human gluteal tenocytes, focusing on the collagen turnover pathways, in order to understand how this medical compound could influence tendon biology and healing. Methods: Tenocytes were obtained from gluteal tendon fragments collected in eight patients without any gluteal tendon pathology undergoing total hip replacement through an anterior approach. Cell proliferation and migration were investigated by growth curves and wound healing assay, respectively. The expression of genes and proteins involved in collagen turnover were analysed by real-time PCR, Slot blot and SDS-zymography. Results: Our data show that tenocytes cultured on MD-Tissue, compared to controls, have increased proliferation rate and migration potential. MD-Tissue induced collagen type I (COL-I) secretion and mRNA levels of tissue inhibitor of matrix metalloproteinases (MMP)-1 (TIMP-1). Meanwhile, lysyl hydroxylase 2b and matrix metalloproteinases (MMP)-1 and -2, involved, respectively, in collagen maturation and degradation, were not affected. Conclusions: Considered as a whole, our results suggest that MD-Tissue could induce in tenocytes an anabolic phenotype by stimulating tenocyte proliferation and migration and COL-I synthesis, maturation, and secretion, thus favouring tendon repair. In particular, based on its effect on gluteal tenocytes, MD-Tissue could be effective in the discouraging treatment of GTPS. From now a rigorous clinical investigation is desirable to understand the real clinical potentials of this compound.

US Assessment of Sports-related Hip Injuries

Traumatic and overuse hip injuries occur frequently in amateur and professional athletes. After clinical assessment, imaging plays an important role in diagnosis and in defining care management of these injuries. Ultrasonography (US) is being increasingly used in assessment of hip injuries because of the wide availability of US machines, the lower cost, and the unique real-time imaging capability, which allows both static and dynamic evaluation as well as guidance of point-of-care interventions such as fluid aspiration and steroid injection. Accurate diagnosis of hip injuries is often challenging, given the complex soft-tissue anatomy of the hip and the wide spectrum of injuries that can occur. To conduct a skillful US evaluation of hip injuries, physicians must have pertinent knowledge of the normal anatomy and should make judicious use of surface anatomy landmarks while using a compartmentalized diagnostic approach. In this article, common sports-related injuries of the anterior, lateral, and posterior hip compartments are discussed. This review includes assessment of joint effusion, acetabular labral tear, acute and chronic tendon injuries including tendinopathy, partial and full-thickness tears, snapping hip syndromes, relevant US-guided procedures, and some other conditions such as Morel-Lavallée lesion and perineal nodular induration. Principles of care management and current knowledge on imaging findings that may affect return to activity are also presented. Using an oriented US examination technique and having knowledge of the normal hip anatomy will help physicians characterize US findings of common sports-related hip injuries and make accurate diagnoses. Online supplemental material is available for this article. ^©RSNA, 2018.

A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a painful condition characterised by pain around the greater trochanter usually affecting middle-aged women. The majority of patients will improve with conservative management such as physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs); however, if this fails then more invasive treatments including corticosteroid injections and surgery may be required. Platelet-rich plasma (PRP) is an autologous blood product, which has a higher concentration of growth factors postulated to provide enhanced healing and anti-inflammatory properties. There have been numerous studies on PRP's efficacy in musculoskeletal soft tissue conditions with similar pathology to GTPS, with varying results, most promising being in plantar fasciopathy and patellar tendinopathy. Corticosteroids are the established second-line treatment, but do not always work long term. PRP may be a suitable alternative to corticosteroid in GTPS with longer-term effects; however, there are very limited reports. The Hip Injections PRP Vs Placebo (HIPPO) trial aims to assess the ability of PRP to improve symptoms and function in patients with GTPS.

METHODS/DESIGN

HIPPO is a single-centre, double-blind randomized placebo-controlled study in patients with a radiologically confirmed diagnosis of gluteus medius or minimus tendinopathy with swelling within the tendon insertion with or without bursitis. We aim to randomise 102 patients with GTPS to either the PRP or placebo (normal saline injection) treatment arm. Participants will receive one ultrasound (US) guided PRP/placebo injection into the trochanteric bursa and surrounding gluteus medius/minimus tendons. The primary outcome measure is the International Hip Outcome Tool-12. Secondary outcome measures will include a visual analogue score for pain, the three-level version of the EuroQol five-dimensional questionnaire and the modified Harris Hip Score. Outcomes will be measured at baseline, 3, 6 and 12 months. Participants will have the option at 6 months to have a repeat blinded injection or cross over to PRP. Analyses of primary and secondary outcomes will be made according to the intention-to-treat principle. The trial reporting will comply with Consolidated Standards of Reporting Trials (CONSORT) guidelines.

DISCUSSION

The HIPPO study has been designed to test the hypothesis that PRP is effective in treating GTPS in patients who have failed conservative management and to assess the duration of effect of PRP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03479190 . Registered on 27 March 2018.

The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review

This review aims to determine whether platelet-rich plasma (PRP) has any role in improving clinical outcomes in patients with symptomatic greater trochanteric pain syndrome (GTPS). A search of NICE healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE and AMED databases) was conducted from their year of inception to April 2018 with the keywords: ‘greater trochanteric pain syndrome’ or ‘GTPS’ or ‘gluteus medius’ or ‘trochanteric bursitis’ and ‘platelet rich plasma’ (PRP). A quality assessment was performed using the JADAD score for RCTs and MINORS for non-RCT studies. Five full-text articles were included for analysis consisting of three RCTs and two case series. We also identified four additional studies from published conference abstracts (one RCT and three case series). The mean age in 209 patients was 58.4 years (range 48–76.2 years). The majority of patients were females and the minimum duration of symptoms was three months. Diagnosis was made using ultrasound or MRI. Included studies used a variety of outcome measures. Improvement was observed during the first 3 months after injection. Significant improvement was also noted when patients were followed up till 12 months post treatment. PRP seems a viable alternative injectable option for GTPS refractory to conservative measures. The current literature has revealed that PRP is relatively safe and can be effective. Considering the limitations in these studies, more large-sample and high-quality randomized clinical trials are required in the future to provide further evidence of the efficacy for PRP as a treatment in GTPS.

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.

SPECT/CT in Postoperative Painful Hip Arthroplasty

Consecutive milestones in hip arthroplasty design and surgical technique have contributed to the successful and cost-effective intervention this procedure has become today in maintaining mobility and quality of life in patients with osteoarthritis, fracture, or other hip conditions. With the increasing prevalence of hip joint replacements, the need for improved diagnostic imaging tools to guide revision surgery has risen in parallel. Over the last few years, promising data have emerged on the potential role of bone SPECT/CT imaging in the assessment of patients with recurrent pain after arthroplasty. This review summarizes the trends in hip arthroplasty surgery (partial vs total arthroplasty; cemented vs cementless arthroplasty; resurfacing arthroplasty) and prosthesis design (bearing materials; stem designs) over the last decade. In particular, the impact on the biomechanics and interpretation of bone SPECT/CT findings is discussed, with emphasis on integrative reporting in the following frequently encountered conditions: lysis/aseptic loosening, septic loosening, heterotopic ossification, periprosthetic fracture, tendinopathies, and adverse local tissue reactions. Based on the available literature data, bone SPECT/CT is increasingly being used as second-line imaging modality when conventional investigations are nondiagnostic. Further outcome research is warranted to examine whether this technique could be used earlier in patient management.

Editorial Commentary: Hip Trochanteric Bursitis and Femoroacetabular Impingement: The Arthroscope Is Only the Tool

Lateral hip pain is debilitating, with pain located at or around the greater trochanter, and trochanteric bursitis is one of the conditions that are part of the greater trochanter pain syndrome. At times, trochanteric bursitis coexists with femoroacetabular impingement. In such cases, the arthroscope is used as a soft tissue endoscope facilitating debridement of the bursa and functional lengthening of the fascia lata. Coupled with appropriate femoroacetabular impingement treatment and rehabilitation, the procedure allows predictable functional results.

Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial

OBJECTIVES

The aim of the current study was to determine the effects of education with targeted or sham exercise on pain and function in postmenopausal women with greater trochanteric pain syndrome (GTPS).

BACKGROUND

Conservative management of GTPS is poorly described, and to date, there have been no studies on education with exercise as an intervention for GTPS. Ninety-four postmenopausal women with GTPS were recruited to participate in this study.

MATERIALS AND METHODS

Participants were randomized to receive one of two 12-week exercise programs (GLoBE vs. sham). Participants received education on avoiding tendon compression with appropriate activity modification. The Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G) was examined at baseline, 12, and 52 weeks. Secondary outcomes included hip pain and function questionnaires (Hip dysfunction and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), and Lateral Hip Pain questionnaire), a global rating of change in symptom questionnaire, and a quality of life measure (Assessment of Quality of Life [AQoL]-8D). Differences between groups were analyzed using intention to treat with analysis of covariance, per-protocol analysis, and responder analysis.

RESULTS

Responders to the GLoBE intervention had significantly better VISA-G, HOOS, OHS, and lateral hip pain questionnaire scores compared to responders in the sham group. However, intention to treat analyses showed no between-group differences for the GLoBE intervention and sham exercise groups. Significant improvement in VISA-G score was found for both programs at 12- and 52-weeks time points (p < 0.001).

CONCLUSION

Lack of treatment effect was found with the addition of an exercise program to a comprehensive education on GTPS management. The improved outcomes of the responders in the GLoBE group indicate that there may be a subgroup of patients with a GTPS diagnosis that benefit from a GLoBE intervention program.

High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for evaluation of degenerative lumbar pathologies

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a relatively common diagnosis among the general population.

OBJECTIVE

We aim to determine the prevalence of GTPS among patients who presented to the spine clinic.

METHODS

Medical records of patients who were evaluated in the spine clinic were reviewed over a 12-month period (4/1/2016 to 3/31/2017). Patient demographics, presenting symptomatology, physical examination findings, presence or absence of GTPS, medical imaging findings, and interventions were recorded analyzed. Statistical analysis was performed using SPSS Statistics 23.0 (Chicago, IL). Statistical significance is defined as p < 0.05.

RESULTS

A total of 273 consecutive patients (145 women, 128 men) were evaluated for degenerative lumbar pathologies by a single spine surgeon over the study period. The average patient age was 61.9 years. Overall, there were 138/273 patients (50.5%) with GTPS (Group I), while 135/273 patients (49.5%) did not have GTPS (Group II). There were 73 patients in Group I received trochanteric injection for GTPS treatment and subsequently returned to clinic for follow-up, and there were 36/73 (49.3%) patients reporting improvement in their symptoms after trochanteric injection. There was a statistically significant predilection for presence of GTPS in the female gender (60% vs 32.8%, p = <0.01). There was no statistically significant difference in the prevalence of low back pain, buttock, thigh or groin pain between the two groups.

CONCLUSION

GTPS is a very common but often unrecognized or misdiagnosed condition. Accurate diagnosis and differentiation of GTPS from lumbar spinal pathologies are essential in avoiding potential unnecessary spinal procedures.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection

BACKGROUND

Gluteus medius/minimus tendinopathy is a common cause of lateral hip pain or greater trochanteric pain syndrome.

HYPOTHESIS

There would be no difference in the modified Harris Hip Score (mHHS) between a single platelet-rich plasma (PRP) injection compared with a corticosteroid injection in the treatment of gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

There were 228 consecutive patients referred with gluteal tendinopathy who were screened to enroll 80 participants; 148 were excluded (refusal: n = 42; previous surgery or sciatica: n = 50; osteoarthritis, n = 17; full-thickness tendon tear, n = 17; other: n = 22). Participants were randomized (1:1) to receive either a blinded glucocorticoid or PRP injection intratendinously under ultrasound guidance. A pain and functional assessment was performed using the mHHS questionnaire at 0, 2, 6, and 12 weeks and the patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) at 12 weeks.

RESULTS

Participants had a mean age of 60 years, a ratio of female to male of 9:1, and mean duration of symptoms of >14 months. Pain and function measured by the mean mHHS showed no difference at 2 weeks (corticosteroid: 66.95 ± 15.14 vs PRP: 65.23 ± 11.60) or 6 weeks (corticosteroid: 69.51 ± 14.78 vs PRP: 68.79 ± 13.33). The mean mHHS was significantly improved at 12 weeks in the PRP group (74.05 ± 13.92) compared with the corticosteroid group (67.13 ± 16.04) ( P = .048). The proportion of participants who achieved an outcome score of ≥74 at 12 weeks was 17 of 37 (45.9%) in the corticosteroid group and 25 of 39 (64.1%) in the PRP group. The proportion of participants who achieved the MCID of more than 8 points at 12 weeks was 21 of 37 (56.7%) in the corticosteroid group and 32 of 39 (82%) in the PRP group ( P = .016).

CONCLUSION

Patients with chronic gluteal tendinopathy >4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. Registration: ACTRN12613000677707 (Australian New Zealand Clinical Trials Registry).

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.

August 2017 Letters to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Manual Therapy: More Than Elaborate Swordplay" with Authors' Response "Comparing Dry Needling to Corticosteroid Injection for Greater Trochanteric Pain Syndrome" with Authors' Response J Orthop Sports Phys Ther 2017;47(8):580-585. doi:10.2519/jospt.2017.0204.

Autologous Tenocyte Injection for the Treatment of Chronic Recalcitrant Gluteal Tendinopathy: A Prospective Pilot Study

BACKGROUND

Gluteal tendinopathy is a common cause of lateral hip pain, and existing conservative treatment modalities demonstrate high symptom recurrence rates. Autologous tenocyte injection (ATI) is a promising cell therapy that may be useful for the treatment of gluteal tendinopathy.

PURPOSE

To investigate the safety and effectiveness of ATI, specifically in patients with chronic recalcitrant gluteal tendinopathy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve female patients with a clinical and radiological diagnosis of gluteal tendinopathy were recruited. Patients demonstrated a mean duration of symptoms of 33 months (range, 6-144 months), had undergone a mean 3.2 prior corticosteroid injections (range, 2-5), and had failed to respond to existing conservative treatments including physiotherapy and injections. In an initial procedure, tendon cells were harvested from a needle biopsy of the patella tendon and propagated in a certified Good Manufacturing Practice (GMP) laboratory. In a secondary procedure, a single injection of 2 mL autologous tenocytes (2-5 × 106 cells/mL) suspended in patient serum was injected into the site of the pathological gluteal tendons under ultrasound guidance. Patients were assessed pre- and postinjection (3, 6, 12, and 24 months) using the Oxford Hip Score (OHS), a visual analog pain scale (VAS), the Short Form-36 (SF-36), and a satisfaction scale. Magnetic resonance imaging (MRI) was undertaken at 8.7 months (range, 6-12 months) postinjection.

RESULTS

Molecular characterization of autologous tendon cells showed a profile of growth factor production in all cases, including platelet-derived growth factor α, fibroblast growth factor β, and transforming growth factor β. The OHS (mean, 24.0 preinjection to 38.9 at 12 months [14.9-point improvement]; 95% CI, 10.6-19.2; P < .001), VAS (mean, 7.2 preinjection to 3.1 at 12 months [4.1-point improvement]; 95% CI, 2.6-5.6; P < .001), and SF-36 (mean, 28.1 preinjection to 43.3 at 12 months [15.2-point improvement]; 95% CI, 9.8-20.5; P < .001) significantly improved to 12 months postinjection, sustained to 24 months. Eight patients were satisfied with their outcomes. Significant MRI-based improvement could not be demonstrated in the majority of cases.

CONCLUSION

ATI for gluteal tendinopathy is safe, with improved and sustained clinical outcomes to 24 months.

Platelet-Rich Plasma Injections With Needle Tenotomy for Gluteus Medius Tendinopathy: A Registry Study With Prospective Follow-up

BACKGROUND

Gluteal tendinopathy is a prevalent condition that can be associated with significant pain and disability. To date, no studies have prospectively assessed the efficacy of intratendinous platelet-rich plasma (PRP) injections as a minimally invasive treatment for gluteus medius tendinopathy.

PURPOSE

To prospectively assess the efficacy of intratendinous PRP injections as treatment for chronic recalcitrant gluteus medius tendinopathy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During the study period between July 2011 and November 2015, data were collected from the Hospital for Special Surgery Center for Hip Preservation Outcomes Registry on participants who underwent ultrasound-guided intratendinous PRP injections for recalcitrant gluteus medius tendinosis and/or partial tears of the tendon associated with moderate to severe lateral hip pain for longer than 3 months. All participants were assessed pre- and postinjection with 4 outcome measures: modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL), Hip Outcome Score-Sport-Specific subscale (HOS-Sport), and the International Hip Outcome Tool-33 (iHOT-33). Demographic data, including age, sex, height, weight, body mass index, and smoking status, were also collected.

RESULTS

A total of 21 patients were included in the study, with a mean follow-up of 19.7 months (range, 12.1-32.3 months). The mean improvements from preinjection to postinjection follow-up were 56.73 to 74.17 for mHHS, 68.93 to 84.14 for HOS-ADL, 45.54 to 66.72 for HOS-Sport, and 34.06 to 66.33 for iHOT-33. All mean outcome measure improvements were clinically and statistically significant (P < .001). Length of follow-up was positively correlated with improvements in HOS-ADL (P = .021) and HOS-Sport (P = .004) scores. No adverse events were observed during or after the procedure.

CONCLUSION

In this registry study with prospective follow-up, we found ultrasound-guided intratendinous PRP injections to be a safe and effective treatment option for chronic recalcitrant gluteus medius tendinopathy due to moderate to severe tendinosis and/or partial tendon tears. Well-powered randomized controlled studies are warranted to confirm our findings and further define the ideal candidates for this treatment.

Endoscopic Trochanteric Bursectomy and Iliotibial Band Release for Persistent Trochanteric Bursitis

Lateral hip pain associated with trochanteric bursitis is a common orthopedic condition, and can be debilitating in chronic or recalcitrant situations. Conservative management is the most common initial treatment and often results in resolution of symptoms and improved patient outcomes. These modalities include rest, activity modification, physical therapy, anti-inflammatory medication, or corticosteroid injections. However, there is a subset of patients in which symptoms persist despite exhaustive conservative modalities. For these patients, trochanteric bursectomy is a surgical option to address persistent pathology. Previous literature indicates that both open and arthroscopic surgical techniques can be used to address the inflamed bursa and results in good patient outcomes. However, recent advances in hip arthroscopy have allowed for improvements in minimally invasive techniques to address intracapsular and extracapsular pathology of the hip, including recalcitrant trochanteric bursitis. The purpose of this manuscript is to describe our technique for a minimally invasive arthroscopic trochanteric bursectomy.

Does menopausal hormone therapy (MHT), exercise or a combination of both, improve pain and function in post-menopausal women with greater trochanteric pain syndrome (GTPS)? A randomised controlled trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is pathology in the gluteus medius and minimus tendons and trochanteric bursa that causes debilitating tendon pain and dysfunction, particularly in post-menopausal women. Limited evidence in clinical studies suggests hormone changes after menopause may have a negative effect on tendon. This protocol describes a randomised controlled trial comparing the effectiveness of menopausal hormone therapy (MHT) and exercise therapy in reducing pain and dysfunction associated with GTPS in post-menopausal women.

METHOD

One hundred and sixteen post-menopausal women will be recruited and randomised to receive one of two exercise programs (sham or targeted intervention exercise) and transdermal creams (MHT cream containing oestradiol 50mcg and norethisterone acetate 140mcg or placebo cream). Interventions will be 12-weeks in duration and outcomes will be examined at baseline, 12-weeks and 52-weeks. The primary outcome measure will be the VISA-G questionnaire and secondary outcomes measures will include three hip pain and function questionnaires (Hip dysfunction and Osteoarthritis Outcome Score, Oxford Hip Score, Lateral Hip Pain questionnaire), a global change in symptom questionnaire (using a 15-point Likert scale) and a quality of life measure (AQoL-8D questionnaire). Data will be analysed using the intention to treat principle.

DISCUSSION

This study is the first randomised controlled trial to compare the effectiveness of menopausal hormone therapy therapy alone, and with the combination of exercise therapy, to treat pain and dysfunction associated with GTPS. This study has been pragmatically designed to ensure that the interventions in this study can be integrated into policy and clinical practice if found to be effective in the treatment of GTPS in post-menopausal women. If successful, there is potential for this treatment regimen to be explored in future studies of other persistent tendon conditions in the post-menopausal population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001157662 Registered 31 October 2014.

Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management

Synopsis Gluteal tendinopathy is now believed to be the primary local source of lateral hip pain, or greater trochanteric pain syndrome, previously referred to as trochanteric bursitis. This condition is prevalent, particularly among postmenopausal women, and has a considerable negative influence on quality of life. Improved prognosis and outcomes in the future for those with gluteal tendinopathy will be underpinned by advances in diagnostic testing, a clearer understanding of risk factors and comorbidities, and evidence-based management programs. High-quality studies that meet these requirements are still lacking. This clinical commentary provides direction to assist the clinician with assessment and management of the patient with gluteal tendinopathy, based on currently limited available evidence on this condition and the wider tendon literature and on the combined clinical experience of the authors. J Orthop Sports Phys Ther 2015;45(11):910-922. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5829.

Return to Sport After Tibial Shaft Fractures: A Systematic Review

CONTEXT

Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods.

OBJECTIVE

To determine the current evidence for the treatment of and return to sport after tibial shaft fractures.

DATA SOURCES

OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014.

STUDY SELECTION

Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis.

RESULTS

A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01).

CONCLUSION

The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.

Return to sports after stress fractures of the tibial diaphysis: a systematic review

INTRODUCTION

This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs).

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport.

AREAS OF CONTROVERSY

The best time to return to sport and the optimal management modalities for TDSFs remain undefined.

GROWING POINTS

Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TDSFs.

Shockwave treatment for musculoskeletal diseases and bone consolidation: qualitative analysis of the literature

Shockwave treatment is an option within orthopedics. The exact mechanism through which shockwaves function for treating musculoskeletal diseases is unknown. The aim of this study was to make a qualitative analysis on the effectiveness of shockwave treatment among patients with musculoskeletal pathological conditions and pseudarthrosis. Searches were conducted in the Cochrane Library, Medline and Lilacs databases. Thirty-nine studies that reported using shockwave treatment for musculoskeletal diseases were found. Their results varied greatly, as did the types of protocol used. The studies that evaluated the effectiveness of shockwave treatment for lateral epicondylitis, shoulder tendinopathy, knee osteoarthrosis, femoral head osteonecrosis and trochanteric bursitis reported inconsistent results for most of their patients. Those that evaluated patients with calcifying tendinopathy, plantar fasciitis, Achilles tendinopathy, patellar tendinopathy and pseudarthrosis showed benefits. Shockwave treatment is a safe and non-invasive method for chronic cases in which conventional techniques have been unsatisfactory and should be used in association with other treatment methods for tendinopathy. Further quality studies are needed.