Acute Traumatic Tear of Gluteus Medius and Minimus Tendons in a Patient Without Antecedant Peritrochanteric Hip Pain

Abstract

Morphologic similarities between the abductor mechanisms of the hip and shoulder have given rise to the term rotator cuff tear of the hip. Although the true incidence of gluteus medius and minimus tears in the general population is unknown, the association between these tears and recalcitrant lateral hip pain has been described as greater trochanteric pain syndrome. Historically, tears of the gluteus medius and minimus have been thought to be attritional, and associated with chronic peritrochanteric pain, found incidentally during fracture fixation or hip arthroplasty, or with failure of abductor repair following arthroplasty utilizing the anterolateral approach. The literature supports favorable clinical outcomes with operative repair utilizing either endoscopic or open techniques. To our knowledge, there has never been a reported case of an acute traumatic tear of the gluteus medius and minimus that occurred without antecedant peritrochanteric hip pain. In this case, the patient was treated with acute open repair of the gluteus medius and minimus tendons within 3 weeks of injury and excellent clinical results were obtained at 6-month follow-up. Of note, the patient was notified and gave consent for his case to be used in publication.

Introduction

Morphologic similarities between the abductor mechanisms of the hip and shoulder have given rise to the term rotator cuff tear of the hip. ¹ Although the true incidence of gluteus medius and minimus tears in the general population is unknown, the association between these tears and recalcitrant lateral hip pain has been described as greater trochanteric pain syndrome. ² Historically, tears of the gluteus medius and minimus have been thought to be attritional, and associated with chronic peritrochanteric pain, found incidentally during fracture fixation or hip arthroplasty, or with failure of abductor repair following arthroplasty utilizing the anterolateral approach. ^{1 –5} The literature supports favorable clinical outcomes with operative repair utilizing either endoscopic or open techniques. ^1,3,6 To our knowledge, there has never been a reported case of an acute traumatic tear of the gluteus medius and minimus that occurred without antecedant peritrochanteric hip pain. In this case, the patient was treated with acute open repair of the gluteus medius and minimus tendons within 3 weeks of injury, and excellent clinical results were obtained at 6-month follow-up. Of note, the patient was notified and gave consent for his case to be used in publication.

Case Report

Presenting Complaint

A 72-year-old male was referred to our institution for evaluation of an acute right lateral hip injury. Three weeks prior to his evaluation, he was climbing up stairs in an auditorium when he attempted to execute a step-up to a level approximately equivalent to the height of 3 normal steps, leading with his right leg. In the middle of this step-up, he felt a sharp pain in his lateral right hip muscles and nearly lost his balance. After an hour, the pain had subsided and he could walk normally without a limp and assumed he had “pulled a muscle.”

Five days later during a particularly forcible golf swing, he experienced severe right lateral hip pain, was unable to continue, and had increasingly severe pain through the rest of the day, being unable to bear weight on the right leg by evening. He obtained crutches and had to be minimally weight bearing to ambulate without pain. He denied any prior history of injury or symptoms related to the hip. There was no known history of back pain or lower extremity weakness. He further denied any constitutional symptoms, dysesthesia throughout his injured extremity, or any mechanical symptoms such as catching, clicking, or locking. He denied any subjective sense of instability, giving way, or buckling.

Physical Examination

Upon initial evaluation, the patient was noted to have peritrochanteric tenderness and significant ecchymosis from the peritrochanteric region distal to the popliteal fossa (see Figure 1). He had a positive Trendelenburg sign and exhibited objective weakness on manual strength testing of resisted abduction in both supine and lateral decubitus positions with the knee flexed to minimize contribution of the iliotibial (IT) band. Range of motion was relatively well preserved and he did not demonstrate any positive findings for anterior acetabular rim impingement on provocative maneuvering. Neurovascular examination was normal.

Figure 1.

Image of patient’s posterior–lateral thigh on operative day demonstrating significant ecchymosis from injury.

The patient’s past medical history did not reveal any medical comorbidities or connective tissue disorders. He did not have any family history or musculoskeletal or connective tissue disorders.

Imaging Studies

Anteroposterior (AP) and cross-table radiographs were initially obtained and demonstrated a concentric femoroacetabular joint without evidence of joint space narrowing, subluxation, dislocation, fracture, other osseous or soft tissue abnormalities. A noncontrast magnetic resonance imaging (MRI) examination was also obtained due to clinical suspicion of an acute disruption of the gluteus medius. Magnetic resonance imaging was performed at high field strength (3.0 T). Axial proton-density-weighted images and coronal Short T1 inversion recovery (STIR) images were obtained with a large field of view through the entire pelvis. Coronal proton-density-weighted images and coronal intermediate-weighted fat-suppressed images were then obtained with a slightly smaller field of view predominantly through the right hemipelvis. Sagittal and axial intermediate-weighted fat-suppressed images were then obtained with an even smaller field of view through the right hip. The images showed a full thickness insertional tear of the right gluteus medius and minimus tendons onto the greater trochanter with more than 3 cm of retraction and associated mild soft tissue edema. No acute osseous abnormality was seen (see Figure 2).

Figure 2.

Coronal fat-suppressed magnetic resonance imaging (MRI) of right hip demonstrating high-grade insertional tear of gluteus medius tendon with surrounding hematoma in gluteus medius muscle belly.

Treatment options were discussed with the patient and included nonoperative management and open versus endoscopic repair. After informing the patient of all potential treatments, it was jointly determined that he would benefit from open repair. It was believed that this treatment method would result in the most predictable return of strength, endurance, balance, and likely prevent persistent lateral-sided hip pain associated with chronic retracted injury to the gluteus medius and minimus.

Operative Technique

After obtaining standard informed consent the patient was brought to the operating room and placed supine on the standard operating room table. After induction of general endotracheal anesthesia, he was turned to the left lateral decubitus position on a well padded peg board. All bony prominences were well padded and a pneumatic compression device was placed on his well leg. After standard preparation of the operative extremity and sterile draping, a lateral skin incision centered over the greater trochanter was used to develop the interval between subcutaneous tissue and underlying IT band. The IT band was split longitudinally in line with its fibers, and appropriate retractors were placed, permitting visualization of the vastus ridge and lateral facet of the greater trochanter. A superficial layer of disorganized fibrous scar tissue was initially viewed on entry into the peritrochanteric space. However, on entry into this thin layer, a large seroma was expressed revealing a bare footprint at the lateral and anterior facets of the greater trochanter. A small portion of the gluteus medius insertion at the superoposterior facet remained intact on careful inspection. The hip was internally rotated, exposing the trochanteric bursa at the posterior facet. This was excised in its entirety. The short external rotators were visualized and appeared intact. The sciatic nerve was not visualized or exposed.

The extremity was then externally rotated revealing the anterior trochanteric facet at the former insertion site of the gluteus minimus. Residual soft tissue remnants were thoroughly debrided off the footprint of the gluteus medius and minimus using a rongeur and round burr, promoting a favorable biologic healing response. The retracted gluteus medius and gluteus minimus tendons were identified. There were no visible degenerative changes in either tendon. Two double loaded 5.5-mm titanium suture anchors were then placed into the peripheral zones of the footprint (Arthrex Inc, Naples, Florida). Sutures were passed in a running locking fashion throughout the periphery of the crescent-shaped tear in the gluteus medius and minimus (see Figure 3). Next, a 3.0-mm PEEK SutureTak was placed into the more posterior aspect of the footprint for additional fixation at the posterosuperior insertion site (Arthrex Inc). Sutures were tied with the leg held in slight abduction (10°-15°) to limit tension at the repair site. On completion of the repair, the hip was gently brought through a broad physiologic range of motion and rotation. The footprint of the gluteus medius was intact and stable throughout this range of motion. The IT band layer was closed using Vicryl absorbable sutures placed in figure 8 fashion (Ethicon Inc, Somerville, New Jersey). A running subcuticular closure of the skin was finally completed.

Figure 3.

Intraoperative photo demonstrating suture placement through the gluteus medius and minimus tendons and their reapproximation back to the insertion site on the greater trochanter.

Results and Rehabilitation

Postoperatively, the patient experienced an unremarkable recovery. He underwent a strict physical therapy program at an outpatient sports rehabilitation center starting on postoperative day 3. Weight bearing was protected for 12 weeks after surgery before allowing gradual progression to full weight bearing. Hip flexion was limited to 90° for 6 weeks. No active hip abduction or passive hip internal rotation was allowed for 8 weeks. No single leg stance was allowed for 12 weeks. At 3-month post surgery, the patient was pain free, full weight bearing, and working on active strengthening of his hip abductors. Postoperative radiographs demonstrated secure placement of suture anchors in the greater trochanter (see Figures 4 and 5).

Figure 4.

Postoperative Anteroposterior (AP) radiograph of patient’s right hip.

Figure 5.

Postoperative cross-table lateral radiograph of patient’s right hip.

Preoperative and postoperative outcome questionnaires including the Hip Outcome Score (HOS), modified Harris Hip Score (mHHS), and modified Hip Dysfunction and Osteoarthritis Score (mHDOS) were completed by the patient. Postoperative outcome measurements were performed at the 6 months of clinic visit. The patient experienced significant gains in all 3 outcome scores. He improved from a score of 22 to 97.6 in the HOS, 44.4 to a 98.6 in the mHDOS, and a 17 to a 93.5 in the mHHS.

Discussion

Greater trochanteric pain syndrome is frequently encountered by orthopedists and primary care physicians. Lateral hip pain can be caused by a variety of conditions including recalcitrant trochanteric bursitis, external snapping syndromes of the IT band, and gluteus medius and minimus injury. Nonoperative measures include rest, core and hip strengthening, stretching, and local steroid injection in attempt to reduce symptoms. Surgical bursectomies with possible IT band lengthening or release are usually reserved for refractory cases that had failed conservative measures. ² Complete symptom resolution and return to full activity has been achieved with operative management. ⁷

Although greater trochanteric bursitis is a common clinical diagnosis, partial and full thickness tears of the gluteus medius and minimus tendons are being increasingly recognized as a cause for lateral hip pain. Gluteus medius and minimus tendonopathy can be often overlooked as noted in a recent French survey where 45% of orthopedic surgeons were not aware tears could occur. ⁷ A recent study showed that 83% of patients presenting with lateral hip pain had findings consistent with gluteus medius pathology on MRI compared to only 8% with radiograph appreciable bursal inflammation. ⁸

Diagnosing gluteus medius tears can be clinically difficult due to the large overlap of symptoms and lack of plain radiograph findings. Along with lateral hip pain, a common complaint with gluteus medius tears is abductor weakness. This can manifest as weakness with single leg stance and a Trendelenburg gait. A Trendelenburg gait has been shown to have a sensitivity of 72.7% and specificity of 76.9% in detecting gluteus medius pathology in patients with lateral hip pain. Resisted abduction was also shown to have a sensitivity in the 70th percentile but a lower specificity. ⁸ Confirmatory diagnosis is usually achieved with the use of MRI.

The true incidence of gluteus medius/minimus tears in the general population is unknown, but previous studies have shown tears associated with fractures and osteoarthritis. Bunker et al ¹ demonstrated a 22% incidence in 50 patients with femoral neck fractures, and Howell et al ³ found an incidence of 20% in 176 total hip arthroplasty patients. Neither of these studies commented on the preoperative symptoms of the patients.

Open and arthroscopic management has been reported in the literature with complete resolution of pain and full recovery of strength. ^6,8 In a small case series of patients surgically treated for gluteus medius tears, 60% of patients were postulated to have had a traumatic event corresponding to the onset of symptoms, although the presence of hip pain prior to event was not mentioned. ⁵ All of the patients treated had failed conservative measures for at least 3 months. In retrospect, in this case history being reported, we believe the initial injury episode caused a partial tear of the gluteus medius and/or the gluteus minimus, which became a complete tear during the golf swing 5 days later. To our knowledge, this is the first documented case of a traumatic gluteus medius tear in a patient without previous hip pain, treated with acute surgical repair resulting in an excellent clinical outcome.

Conclusion

Greater trochanteric pain syndrome is a frequent diagnosis when a patient presents with lateral hip pain. With increased recognition of traumatic rupture of the gluteus medius/minimus as a cause of lateral hip pain, proper diagnosis and treatment can occur to avoid chronic pain that may not respond to conservative management. Treatment with open and endoscopic techniques has been described to have excellent short-term resolution in lateral hip pain and abductor weakness.