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

Sonographic pathoanatomy of greater trochanteric pain syndrome

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Discussion

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

Registration

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

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

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

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

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

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

Effects of Hip Pain Diagnostic Labels and Their Explanations on Beliefs About Hip Pain and How to Manage It: An Online Randomized Controlled Trial

OBJECTIVES: To compare the effects of diagnostic labels and their explanations on people's beliefs about managing hip pain. DESIGN: Online randomized controlled trial involving 626 participants. METHODS: Participants aged ≥45 years with and without hip pain considered a hypothetical scenario (initial doctor consultation for hip pain). They were randomized to receive a diagnostic label and explanation of (1) hip osteoarthritis, (2) persistent hip pain, or (3) hip degeneration. Primary outcomes were the beliefs (1) exercise would damage the hip and (2) surgery is necessary at some stage (scales, 0 = definitely would not/unnecessary, 10 = definitely would/necessary). Secondary outcomes included beliefs about other treatments and care providers. RESULTS: Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain believed exercise was less damaging (mean difference -1.3 [95% CI: -1.9, -0.7] and -1.8 [-2.3, -1.2], respectively) and surgery less necessary (-1.5 [-2.1, -1.0] and -2.2 [-2.7, -1.6], respectively). Compared to hip osteoarthritis, participants who were allocated to persistent hip pain believed surgery was less necessary (-0.7 [-1.2, -0.1]), but not that exercise was less damaging (-0.5 [-1.1, 0.1]). Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain were less concerned about their hip and believed exercise and care from an exercise and sports physician, rheumatologist, or physiotherapist would be more helpful, and care from an orthopaedic surgeon less helpful. CONCLUSIONS: People who were allocated a diagnostic label and explanation of hip osteoarthritis or persistent hip pain believed exercise was less damaging and surgery less necessary for a hip problem than hip degeneration. J Orthop Sports Phys Ther 2023;53(11):673-684. Epub 5 October 2023. doi:10.2519/jospt.2023.11984.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

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

Clinical reasoning in managing chronic hip pain: One in two Australian and New Zealand physiotherapists diagnosed a case vignette with clinical criteria for hip OA as hip OA. A cross-sectional survey

OBJECTIVES

Using a case vignette of an adult (George) presenting with hip pain consistent with hip OA, this study aimed to describe: (a) whether physiotherapists make diagnoses and identify bodily structures using either patient history and/or physical examination findings; (b) which diagnoses and bodily structures physiotherapists attribute to the hip pain; (c) how confident physiotherapists were in their clinical reasoning using patient history and physical examination findings; (d) what treatments physiotherapists would offer to George.

METHODS

We conducted a cross-sectional online survey of physiotherapists in Australia and New Zealand. We used descriptive statistics to analyse closed questions and content analysis for open-text responses.

RESULTS

Two hundred and twenty physiotherapists completed the survey (39% response-rate). After receiving the patient history, 64% diagnosed George's pain and 49% of these as hip OA; 95% attributed George's pain to a bodily structure(s). After receiving the physical examination, 81% diagnosed George's hip pain and 52% of these as hip OA; 96% attributed George's hip pain to a bodily structure(s). Ninety-six percent of respondents were at least somewhat confident in their diagnosis after the patient history, and 95% were similarly confident after the physical examination. Most respondents offered advice (98%) and exercise (99%), but fewer offered treatments for weight loss (31%), medication (11%), and psychosocial factors (<15%).

DISCUSSION

About half of the physiotherapists that diagnosed George's hip pain made a diagnosis of hip OA, despite the case vignette including clinical criteria for a diagnosis of OA. Physiotherapists offered exercise and education, but many physiotherapists did not offer other clinically indicated and recommended treatments, such as weight loss and sleep advice.

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.

Evaluating the contribution of fat infiltration in anterior gluteus minimus muscle to walking ability in female with unilateral hip osteoarthritis and candidates for total hip arthroplasty

BACKGROUND

The purpose of this study is to investigate the relationship between gait and fat infiltration in anterior and posterior gluteus minimus in the patients with hip osteoarthritis.

METHODS

Ninety-one female patients who were diagnosed as the unilateral hip osteoarthritis, classified into Kellgren-Lawrence global scoring system grades 3 or 4, and candidate for total hip arthroplasty were retrospectively reviewed. The horizontally cross-sectional regions of interest for the gluteus medius and anterior and posterior gluteus minimus were manually circumscribed in a single transaxial computed tomography image and muscle density of those regions were obtained. The gait was assessed as the step and speed with the 10-Meter Walk Test. The multiple regression analysis was used to compare the step and speed with age, height, range of motion in flexion, the muscle density of anterior gluteus minimus in the affected side, and that of gluteus medius muscle in both affected and unaffected sides.

FINDINGS

Multiple regression analysis for step revealed that the muscle density of anterior gluteus minimus in the affected side and height were the independent predictors for step (R² = 0.389, p < 0.001). That for speed identified the muscle density of anterior gluteus minimus in the affected side as the only factor determining speed (R² = 0.287, p < 0.001).

INTERPRETATION

The fatty infiltration of anterior gluteus minimus muscle in affected side can be a predictor for the gait in in female with unilateral hip osteoarthritis and candidates for total hip arthroplasty.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Beyond the Hip Labrum: A Pictorial Review

Magnetic resonance arthrography and 3T magnetic resonance imaging of the hip are a technique commonly performed in young, physically active patients presenting with pain relating to the hip, with the focus on assessing for the presence of labral tears and femoroacetabular impingement. Abnormal signal within the labrum can be misleading, however, as labral tears are a frequent incidental finding and have been identified in a large proportion of the asymptomatic population. A range of extralabral conditions can cause hip-related pain in young patients, including pathology related to the bones, joints, and periarticular soft tissues. It is vital that the radiologist is aware for these pathologies and examines for them even in the presence of a confirmed labral tear. In this article, we review a range of common extralabral pathologies responsible for hip pain and highlight review areas that aid in their diagnosis.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Towards defining muscular regions of interest from axial magnetic resonance imaging with anatomical cross-reference: a scoping review of lateral hip musculature

Background

Measures of hip muscle morphology and composition (e.g., muscle size and fatty infiltration) are possible with magnetic resonance imaging (MRI). Standardised protocols or guidelines do not exist for evaluation of hip muscle characteristics, hindering reliable and valid inter-study analysis. This scoping review aimed to collate and synthesise MRI methods for measuring lateral hip muscle size and fatty infiltration to inform the future development of standardised protocols.

Methods

Five electronic databases (Medline, CINAHL, Embase, SportsDISCUS and AMED) were searched. Healthy or musculoskeletal pain populations that used MRI to assess lateral hip muscle size and fatty infiltration were included. Lateral hip muscles of interest included tensor fascia late (TFL), gluteus maximus, gluteus medius, and gluteus minimus. Data on MRI parameters, axial slice location, muscle size and fatty infiltrate measures were collected and analysed. Cross referencing for anatomical locations were made between MRI axial slice and E-12 anatomical plastinate sections.

Results

From 2684 identified publications, 78 studies contributed data on volume (n = 31), cross sectional area (CSA) (n = 24), and fatty infiltration (n = 40). Heterogeneity was observed for MRI parameters and anatomical boundaries scrutinizing hip muscle size and fatty infiltration. Seven single level axial slices were identified that provided consistent CSA measurement, including three for both gluteus maximus and TFL, and four for both gluteus medius and minimus. For assessment of fatty infiltration, six axial slice locations were identified including two for TFL, and four for each of the gluteal muscles.

Conclusions

Several consistent anatomical levels were identified for single axial MR slice to facilitate muscle size and fatty infiltration muscle measures at the hip, providing the basis for reliable and accurate data synthesis and improvements in the validity of future between studies analyses. This work establishes the platform for standardised methods for the MRI assessment of lateral hip musculature and will aid in the examination of musculoskeletal conditions around the hip joint. Further studies into whole muscle measures are required to further optimise methodological parameters for hip muscle assessment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05439-x.

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.

Exercise With Low-Loads and Concurrent Partial Blood Flow Restriction Combined With Patient Education in Females Suffering From Gluteal Tendinopathy: A Feasibility Study

Introduction

To date, there exists no gold standard conservative treatment for lateral hip pain due to tendinopathy of the gluteus medius and/or minimus tendon (GT), a condition often complicated by pain and disability. Higher loads during everyday activities and exercise seems to be contraindicated with GT. The purpose of this study was to evaluate the feasibility of exercise with low-loads concurrent partial blood flow restriction (LL-BFR) and patient education for patients present GT.

Methods

Recruitment took place at three hospitals in the Central Denmark Region. The intervention consisted of daily sessions for 8 weeks with one weekly supervised session. From week three patients exercised with applied partial blood flow restriction by means of a pneumatic cuff around the proximal thigh of the affected leg. Throughout the intervention patients received patient education on their hip condition. Sociodemographic and clinical variables were collected at baseline. The feasibility of LL-BFR was conducted by adherence to the exercise protocol and drop-out rate. Patient reported outcome measures (The Victorian Institute of Sport Assessment-Gluteal Questionnaire, EuroQol - 5 Dimensions-Visual Analogue Scale, Oxford Hip Score, Copenhagen Hip and Groin Outcome Score), maximal voluntary isometric hip abduction-, hip extension, and knee extension strength (Nm/kg) measured using a handheld dynamometer, and functional capacity tests (30 second chair-stand test and a stair-climb test) was conducted as secondary outcomes.

Results

Sixteen women with a median (IQR) age of 51 (46–60) years were included. Median (IQR) Body Mass Index was 26.69 (23.59–30.46) kg/m2. Adherence to the total number of training sessions and the LL-BFR was 96.4 and 94.4%, respectively. Two patients dropped out due to (i) illness before initiation of LL-BFR and (ii) pain in the affected leg related to the LL-BFR-exercise. At follow-up both pain levels and patient-reported outcome measures improved. Isometric hip abduction-, hip extension-, and knee extension strength on both legs and functional performance increased. Conclusion: LL-BFR-exercise seems feasible for treatment of GT. At follow-up, a high adherence and low drop-out rate were observed. Further, patients reported clinically relevant reductions in pain, and showed significant increases in isometric hip and knee strength.

Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties

OBJECTIVE

Evaluate properties of outcome measures for gluteal tendinopathy.

DESIGN

Multistage scoping/systematic review.

DATA SOURCES

Cochrane, PubMed, Embase, Scopus, Web of Science, PEDro, CINAHL, SPORTDISCUS were searched (December 2021) to identify measures used to evaluate gluteal tendinopathy. Measures were mapped to the core health domains for tendinopathy. Medline, CINAHL, Embase and PubMed were searched (December 2021) for studies evaluating measurement properties of gluteal tendinopathy outcome measures captured in the initial search. Both reviews included studies that evaluated a treatment in participants with gluteal tendinopathy, diagnosed by a professional. Consensus-based-Standards for the Selection of Health Instruments methodology were followed-including bias assessment and synthesis of findings.

RESULTS

Six studies reported on the Victorian Institute of Sport Assessment-Gluteal Tendinopathy (VISA-G). One study reported on the Hip Outcome Score (HOS)-activities of daily living (ADL) and Sport.The VISA-G had moderate-quality evidence of sufficient construct validity (known group) and responsiveness (pre-post intervention), low-quality evidence of sufficient reliability, measurement error, comprehensibility and insufficient construct validity (convergent), and very low-quality evidence of sufficient comprehensiveness, relevance and responsiveness (comparison with other outcome measures).Both the HOS(ADL) and HOS(Sport) had very low-quality evidence of sufficient reliability, relevance and insufficient construct validity and comprehensiveness. The HOS(ADL) had very low-quality evidence of sufficient comprehensibility and insufficient measurement error. The HOS(Sport) had very low quality evidence of inconsistent comprehensibility and sufficient measurement error.

CONCLUSION

Rigorously validated outcome measures for gluteal tendinopathy are lacking. The VISA-G is the preferred available option to capture the disability associated with gluteal tendinopathy.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

ACTRN12614001157662 (Australian New Zealand Clinical Trials Registry).

FABREX: A NEW CLINICAL TEST FOR DIAGNOSIS GLUTEAL TENDINOPATHY

Objective:

This study aims to describe a simple and accurate semiological method executing a specific maneuver with the lower limb to direct the semiological investigation towards the tendinopathies in the gluteus medius and minimus.

Methods:

Fifty patients participated in the study, with a mean age of 44.1 ± 13 years, with persistent pain on the side of the hip for more than three months. To compare the FABREX (proposed test) and Lequesne semiological tests, in the diagnosis of tendinopathies in the gluteus medius and minimus, Magnetic Resonance Imaging (MRI) was adopted as the gold standard.

Results:

FABREX presented high sensitivity and moderate specificity for tendinopathy in the gluteus medius and high sensitivity and specificity for tendinopathy in the gluteus minimus.

Conclusion:

The proposed test, when positive, can be used to determine the diagnosis of gluteal tendinopathies (high specificity). Moreover, it has high sensitivity, excluding the diagnosis when negative. This study represents the initial step for validating the FABREX test, and can therefore be considered a simple and accurate procedure to identify patients with or without gluteal tendinopathies. Level of Evidence III, Case Control Study.

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

OBJECTIVE

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

DESIGN

Double-blinded randomized controlled trial.

SETTING

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

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

How do middle-aged and older adults with chronic hip pain view their health problem and its care? A protocol for a systematic review and qualitative evidence synthesis

INTRODUCTION

Chronic hip pain in middle-aged and older adults is common and disabling. Patient-centred care of chronic hip pain requires a comprehensive understanding of how people with chronic hip pain view their health problem and its care. This paper outlines a protocol to synthesise qualitative evidence of middle-aged and older adults' views, beliefs, expectations and preferences about their chronic hip pain and its care.

METHODS AND ANALYSIS

We will perform a qualitative evidence synthesis using a framework approach. We will conduct this study in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and the Enhancing Transparency in Reporting the synthesis of Qualitative research checklist. We will search MEDLINE, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE and PsycINFO using a comprehensive search strategy. A priori selection criteria include qualitative studies involving samples with a mean age over 45 and where 80% or more have chronic hip pain. Two or more reviewers will independently screen studies for eligibility, assess methodological strengths and limitations using the Critical Appraisal Skills Programme qualitative studies checklist, perform data extraction and synthesis and determine ratings of confidence in each review finding using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. Data extraction and synthesis will be guided by the Common-Sense Model of Self-Regulation. All authors will contribute to interpreting, refining and finalising review findings. This protocol is registered on PROSPERO and reported according to the PRISMA Statement for Protocols (PRISMA-P) checklist.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review as primary data will not be collected. The findings of the review will be disseminated through publication in an academic journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

PROSPERO registration number: CRD42021246305.

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.

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

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

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMMON THERAPEUTIC EXERCISES THAT GENERATE HIGHEST MUSCLE ACTIVITY IN THE GLUTEUS MEDIUS AND GLUTEUS MINIMUS SEGMENTS

Background

The gluteus medius (GMed) and gluteus minimus (GMin) muscle segments demonstrate different responses to pathology and ageing, hence it is important in rehabilitation that prescribed therapeutic exercises can effectively target the individual segments with adequate exercise intensity for strengthening.

Purpose

The purpose of this systematic review was to evaluate whether common therapeutic exercises generate at least high ( > 40% maximum voluntary isometric contraction (MVIC)) electromyographic (EMG) activity in the GMed (anterior, middle and posterior) and GMin (anterior and posterior) segments.

Methods

Seven databases (MEDLINE, EMBASE, CINAHL, AusSPORT, PEDro, SPORTdiscus and Cochrane Library) were searched from inception to May 2018 for terms relating to gluteal muscle, exercise, and EMG. The search yielded 6918 records with 56 suitable for inclusion. Quality assessment, data extraction and data analysis were then undertaken with exercise data pooled into a meta-analysis where two or more studies were available for an exercise and muscle segment.

Results

For the GMed, different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all segments. The dip test, and isometric standing hip abduction are other options to target the anterior GMed segment, while isometric standing hip abduction can be used for the posterior GMed segment. For the middle GMed segment, the single leg bridge; side-lying hip abduction with hip internal rotation; lateral step-up; standing hip abduction on stance or swing leg with added resistance; and resisted side-step were the best options for generating at least high activity. Standing isometric hip abduction and different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all GMin segments, while side-lying hip abduction, the dip test, single leg bridge and single leg squat can also be used for targeting the posterior GMin segment.

Conclusion

The findings from this review provide the clinician with confidence in exercise prescription for targeting individual GMed and GMin segments for potential strengthening following injury or ageing.

Level of Evidence

Level 1.

What is known about the subject

Previous reviews on GMed exercises have been based on single electrode, surface EMG measures at middle GMed segment. It is not known whether these exercises effectively target the other segments of GMed or the GMin at a sufficient intensity for strengthening.

What this study adds to existing knowledge

This review provides the clinician with confidence in exercise prescription of common therapeutic exercises to effectively target individual GMed and GMin segments for potential strengthening.

Quantitative Imaging of Body Composition

Body composition refers to the amount and distribution of lean tissue, adipose tissue, and bone in the human body. Lean tissue primarily consists of skeletal muscle; adipose tissue comprises mostly abdominal visceral adipose tissue and abdominal and nonabdominal subcutaneous adipose tissue. Hepatocellular and myocellular lipids are also fat pools with important metabolic implications. Importantly, body composition reflects generalized processes such as increased adiposity in obesity and age-related loss of muscle mass known as sarcopenia.In recent years, body composition has been extensively studied quantitatively to predict overall health. Multiple imaging methods have allowed precise estimates of tissue types and provided insights showing the relationship of body composition to varied pathologic conditions. In this review article, we discuss different imaging methods used to quantify body composition and describe important anatomical locations where target tissues can be measured.

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

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

"It's just like a needle going into my hip, basically all of the time". The experiences and perceptions of patients with Greater Trochanteric Pain syndrome in the UK National Health Service

BACKGROUND

Greater Trochanteric Pain syndrome (GTPS) is a condition causing lateral hip pain, which can be both persistent and debilitating. Data suggests that NHS patients with GTPS often have complex presentations with greater risk of developing persistent pain. No research to date has looked to understand the lived experience of patients with GTPS.

OBJECTIVES

This data may help inform a programme of intervention development for testing in a future randomised controlled trial. Hence, this qualitative study aimed to provide insight into the experiences and perceptions of patients suffering with GTPS.

DESIGN

Qualitative study using semi-structured interviews.

METHODS

Ten patients diagnosed with GTPS in consultant-led clinic at one NHS Hospital. Patients were identified from the physiotherapy waiting list and approached via a postal letter. Once informed consent was gained, semi-structured telephone interviews were conducted, transcribed verbatim and analysed using the Framework Method.

RESULTS

Data were analysed with reference to five pre-determined themes (1) living with persistent pain; (2) understanding the problem and pain; (3) experiences of previous treatment; (4) beliefs about activity and exercise; (5) the future.

CONCLUSION

The participants with GTPS, interviewed in this study commonly suffered from debilitating pain, affecting them during activity and at rest. They were confused about the diagnoses they were given and the meaning of their pain in relation to activity. Furthermore, participants were often either uncertain or pessimistic about their potential to recover.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov Identifier: NCT03720587.

Gluteus medius muscle pathologies - A case series & pictorial review

Introduction

Gluteus medius lesions are rare and can present with lateral hip pain. We present a spectrum of pathologies involving the gluteus medius and discuss the imaging features.

Material and methods

A search of our oncology database at tertiary orthopaedic oncology service was performed. The imaging features of these were analysed.

Results

There were nine cases involving the gluteus medius, which included soft tissue sarcomas, lipomas, infection and trauma with an average age of 62 years.

Conclusion

Gluteus medius lesions are rare and one should be aware of these as these can present as lateral hip pain.

Deep learning for automated segmentation of pelvic muscles, fat, and bone from CT studies for body composition assessment

OBJECTIVE

To develop a deep convolutional neural network (CNN) to automatically segment an axial CT image of the pelvis for body composition measures. We hypothesized that a deep CNN approach would achieve high accuracy when compared to manual segmentations as the reference standard.

MATERIALS AND METHODS

We manually segmented 200 axial CT images at the supra-acetabular level in 200 subjects, labeling background, subcutaneous adipose tissue (SAT), muscle, inter-muscular adipose tissue (IMAT), bone, and miscellaneous intra-pelvic content. The dataset was randomly divided into training (180/200) and test (20/200) datasets. Data augmentation was utilized to enlarge the training dataset and all images underwent preprocessing with histogram equalization. Our model was trained for 50 epochs using the U-Net architecture with batch size of 8, learning rate of 0.0001, Adadelta optimizer and a dropout of 0.20. The Dice (F1) score was used to assess similarity between the manual segmentations and the CNN predicted segmentations.

RESULTS

The CNN model with data augmentation of N = 3000 achieved accurate segmentation of body composition for all classes. The Dice scores were as follows: background (1.00), miscellaneous intra-pelvic content (0.98), SAT (0.97), muscle (0.95), IMAT (0.91), and bone (0.92). Mean time to automatically segment one CT image was 0.07 s (GPU) and 2.51 s (CPU).

CONCLUSIONS

Our CNN-based model enables accurate automated segmentation of multiple tissues on pelvic CT images, with promising implications for body composition studies.

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

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Rehabilitation Exercises for the Gluteus Minimus Muscle Segments: An Electromyography Study

CONTEXT

The gluteus minimus (GMin) muscle consists of 2 uniquely oriented segments that have potential for independent function and have different responses to pathology and aging. For healthy young adults, it is unknown that which rehabilitation exercises specifically target the individual segments.

OBJECTIVE

To quantify segmental GMin activity for 6 common lower-limb rehabilitation exercises in healthy young adults and determine if significant differences exist in segmental activity levels between the exercises.

METHOD

Six common lower-limb rehabilitation exercises were performed by 10 healthy young adults with fine-wire electromyography (EMG) electrodes inserted into the anterior and posterior segments of the GMin muscle.

MAIN OUTCOME MEASURES

Electromyography signals were recorded, and median normalized exercise activity levels were reported and compared for each GMin segment across the 6 exercises.

RESULTS

High activity levels were generated in the anterior segment by the resisted hip abduction-extension exercise (51% maximum voluntary isometric contraction [MVIC]), whereas for the posterior segment, high activity levels were produced by the single-leg bridge (49% MVIC), the side-lie hip abduction (43% MVIC), the resisted hip abduction-extension exercise (43% MVIC), and the single-leg squat (40% MVIC). There were significant differences (P < .05) in the median electromyography activity levels for the anterior GMin segment but not for the posterior GMin segment across some of the exercises with large effect sizes.

CONCLUSION

Targeted rehabilitation exercises graded by exercise intensity can be prescribed specifically for the anterior and posterior GMin segments to aid in restoration of hip function following injury or aging.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

DESIGN

Cross-sectional observational study of physiotherapists.

METHODS

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

RESULTS/FINDINGS

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

CONCLUSION

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

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.

Current trends in sport and exercise hip conditions: Intra-articular and extra-articular hip pain, with detailed focus on femoroacetabular impingement (FAI) syndrome

Musculoskeletal conditions, such as hip pain are leading causes of pain and disability. Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals. Hip and groin pain may have intra-articular and extra-articular causes. Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. There are also a number of extra-articular causes of pain, which include musculotendinous conditions, extra-articular impingements and the clinical entities of groin pain described in the Doha agreement. This chapter will describe these, with a detailed focus on FAI syndrome. Specifically, it addresses: 1. What is and what causes FAI syndrome; 2. How do I diagnose FAI syndrome; and 3. What is the evidence-based approach to managing FAI syndrome?

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

Cross-sectional study.

METHODS

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

RESULTS

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

CONCLUSION

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

Does Dynamic Tape change the walking biomechanics of women with greater trochanteric pain syndrome? A blinded randomised controlled crossover trial

OBJECTIVES

There is considerable debate among clinicians as to whether sports tape can provide mechanical support and pain relief. People with greater trochanteric pain syndrome (GTPS) have increased adduction moment, adduction angle and pelvic obliquity, likely contributing to the continuation of the pathology. We aimed to see if Dynamic Tape^® could control these movements and reduce pain.

METHODS

Fifty women with GTPS participated in a three-dimensional gait analysis. Each participant performed three walking trials: baseline, and two subsequent trials, with active and sham applications of Dynamic Tape. The order of active and sham taping was randomised. Differences in kinetic and kinematic data were analysed using mixed model linear regressions for each condition. Pain scores were obtained before and immediately after walking trials.

RESULTS

Hip adduction moment was reduced at first peak by both active (p < 0.001) and sham tape (p = 0.028), with no between group difference; at second peak by the active taping (p < 0.001), with a between-group difference (p < 0.001). Adduction angle was reduced at first peak by both active (p < 0.001) and sham taping (p = 0.026), with the active taping producing a larger effect (p = 0.004); at mid-stance by active taping (p = 0.003), with a between-group difference (p = 0.002); there was no reduction at second peak. Internal rotation was reduced at the first (p < 0.001) and second peaks (p < 0.001), and mid-stance by the active taping alone (p < 0.001). Pelvic obliquity was reduced at the first peak (p = 0.019), mid-stance (p < 0.001) and second peak (p < 0.001) by the active tape, with a between-group difference at mid-stance (p = 0.03). Both the active and sham taping resulted in a clinically meaningful pain reduction.

CONCLUSION

Dynamic Tape produced a mechanical effect and a meaningful reduction in pain in women with GTPS. The extent that placebo or somatosensory input may have had on these results is not clear.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12617001611314.

A survey of physiotherapy practice (2018) in the United Kingdom for patients with greater trochanteric pain syndrome

PURPOSE

Greater Trochanteric Pain syndrome (GTPS) is a debilitating condition causing lateral hip pain. It affects up to 23.5% of women and 8% of men between 50 and 75 years old. Sufferers report comparable quality of life and functional performance to patients with end stage osteoarthritis of the hip. Understanding of optimal management strategies for GTPS remains limited. Hence, the purpose of this cross-sectional survey was to describe current UK physiotherapy practice so as to understand current practice and inform the systematic development of a physiotherapy intervention.

METHODS

An online survey was developed and distributed via Twitter, the interactive Chartered Society of Physiotherapy website, Musculoskeletal Association of Chartered Physiotherapists and the professional networks of the authors via email. Responses were collected over a four-week period, this was finalised in April 2018.

RESULTS

A total of 409 surveys were submitted; 382 were eligible for use. Nearly all physiotherapists were either somewhat, or very confident diagnosing (372/382; 97.4%) and treating (372/382; 97.4%) patients with GTPS. The management strategies most commonly used were: education on load management (377/381; 98.7%) and self-management strategies (375/381; 98.4%). Strengthening exercises (376/382; 98.4%) were commonly used and targeted to the hip abductors (355/379; 93.7%). Most frequently these exercises were delivered using a combination of home exercise programme (380/380; 100%) and one-to-one exercise sessions (344/377; 91.2%).

CONCLUSION

The data from this large survey highlights that physiotherapists in the UK most commonly use education on load management and self-management strategies, alongside strengthening exercises targeting the hip abductors for patients with GTPS.

Gluteus Minimus and Gluteus Medius Muscle Activity During Common Rehabilitation Exercises in Healthy Postmenopausal Women

Study Design Controlled laboratory study, cross-sectional. Background The gluteus medius (GMed) and gluteus minimus (GMin) provide dynamic stability of the hip joint and pelvis. These muscles are susceptible to atrophy and injury in individuals during menopause, aging, and disease. Numerous studies have reported on the ability of exercises to elicit high levels of GMed activity; however, few studies have differentiated between the portions of the GMed, and none have examined the GMin. Objectives To quantify and rank the level of muscle activity of the 2 segments of the GMin (anterior and posterior fibers) and 3 segments of the GMed (anterior, middle, and posterior fibers) during 4 isometric and 3 dynamic exercises in a group of healthy, postmenopausal women. Methods Intramuscular electrodes were inserted into each segment of the GMed and GMin in 10 healthy, postmenopausal women. Participants completed 7 gluteal rehabilitation exercises, and average normalized muscle activity was used to rank the exercises from highest to lowest. Results The isometric standing hip hitch with contralateral hip swing was the highest-ranked exercise for all muscle segments except the anterior GMin, where it was ranked second. The highest-ranked dynamic exercise for all muscle segments was the dip test. Conclusion The hip hitch and its variations maximally activate the GMed and GMin muscle segments, and may be useful in hip muscle rehabilitation in postmenopausal women. J Orthop Sports Phys Ther 2017;47(12):914-922. Epub 15 Oct 2017. doi:10.2519/jospt.2017.7229.

Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study

QUESTION

What are the functional differences between people with greater trochanteric pain syndrome (GT), hip osteoarthritis (OA) or an asymptomatic population as measured by walking, Time Up and Go, single leg standing and strength?

DESIGN

Cross sectional study with blinded measurers.

PARTICIPANTS

38 participants with GT, 20 with end stage hip OA and 21 asymptomatic healthy control (AS) participants. All participants were women.

OUTCOME MEASURES

Pain (numeric rating scale), Walking speed (m/s), cadence (steps/min) and step length (m) measured via the 10m walk test and the Timed Up and Go; balance via single leg stance (s) duration; and hip abduction, adduction, medial and lateral rotation strength, standardized to body mass (BM) via the body mass average index (BMavg), measured via a wall mounted dynamometer.

RESULTS

The two symptomatic groups reported similar pain levels (p=0.226), more pain then the AS group (p<0.000). Compared to the AS participants, participants with GT or hip OA demonstrated lower walking speed (10mwt and TUG, p<0.001), lower cadence and shorter duration single leg stance on the affected leg (p<0.05). Participants with GT or hip OA also demonstrated bilaterally weaker hip abduction than the AS group (p≤0.005). Compared to AS and GT participants, participants with hip OA demonstrated adduction weakness on the affected side (p=0.008 and p=0.002 respectively).

CONCLUSION

There is a significant level of dysfunction and impairments associated with GT and hip OA. As activity limitations do not appear to be differentiated by structural impairments, we suggest that pain, rather than the underlying pathology may be the driving impairment that leads to walking and single leg standing dysfunction.

Kinematics and kinetics during stair ascent in individuals with Gluteal Tendinopathy

BACKGROUND

Individuals with gluteal tendinopathy commonly report lateral hip pain and disability during stair ascent. This study aimed to compare kinematics and kinetics between individuals with and without gluteal tendinopathy during a step up task.

METHODS

35 individuals with unilateral gluteal tendinopathy and 35 pain-free controls underwent three-dimensional motion analysis of stance phase during stair ascent. An analysis of covariance was performed to compare hip, pelvis and trunk kinematic and kinetic variables between groups. A K-means cluster analysis was performed to identify subgroups from the entire group (n=70) based on the characteristics of the external hip adduction moment. Finally, a Newcombe-Wilson test was performed to evaluate the relationship between group and cluster codes and a 3×2 ANOVA to investigate the differences in kinematics between groups and cluster codes.

FINDINGS

Individuals with gluteal tendinopathy exhibited a greater hip adduction moment impulse during stair ascent (ES=0.83), greater internal rotation impulse during the first 50% stance phase (ES=0.63) and greater contralateral trunk lean throughout stance than controls (ranging from ES=0.67-0.93). Three subgroups based on hip adduction moment characteristics were identified. Individuals with GT were 4.5 times more likely to have a hip adduction moment characteristic of a large impulse and greater lateral pelvic translation at heel strike than the subgroup most likely to contain controls.

INTERPRETATION

Individuals with GT exhibit greater hip adduction moment impulse and alterations in trunk and pelvic kinematics during stair ascent. Findings provide a basis to consider frontal plane trunk and pelvic control in the management of gluteal tendinopathy.

Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain

PURPOSE

Gluteal tendinopathy (GT) is a source of lateral hip pain, yet common clinical diagnostic tests have limited validity. Patients with GT are often misdiagnosed, resulting in inappropriate management, including surgery. This study determined the diagnostic utility of clinical tests for GT, using MRI as the reference standard.

METHODS

65 participants with lateral hip pain were examined to evaluate the ability of clinical tests to detect MRI-determined GT (an increase in intratendinous signal intensity on T2-weighted images). Palpation of the greater trochanter and several clinical pain provocation tests applying compressive and tensile loads on the gluteal tendons were investigated. MRI of the painful hip was examined by a radiologist, blind to clinical findings.

RESULTS

Pain reported within 30 s of standing on the affected limb conclusively moves a (nominal) 50% pretest probability of GT presence on MRI to a post-test probability of 98% (specificity 100%, positive likelihood ratio ∼12), whereas no pain on palpation (80% sensitivity) would rule out its presence. 20 participants (31%) had GT on MRI but clinically negative (ie, not positive on palpation and another test).

CONCLUSIONS

Keeping in mind that the sample size was small (ie, possibly underpowered for indices of diagnostic utility with low precision), the results of this study indicate that a patient who reports lateral hip pain within 30 s of single-leg-standing is very likely to have GT. Patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected GT.