Pain over the lateral aspect of the hip (outer aspect) is quite a common clinical
problem. It could be due to a number of reasons, including pain from the lower back
as well as hip arthritis. One of the common causes is trochanteric bursitis and is
usually treated by pain killers and local steroid injections.
It is now being recognised that in a small proportion of the cases, the pain may
be due to tear in the abductor muscles of the hip (gluteus minimus/gluteus medius
- the muscle which hold the pelvis level during single-leg stance) at their insertion
into the greater trochanter. This is now considered to be similar to the “rotator
cuff tear” of the shoulder and occurs due to chronic attrition. While the shoulder
rotator cuff problems have been well recognised for a long time and the treatment
is well evolved, the diagnosis and management of the “hip abductor problem” is still
The clinical diagnosis is based on the location of pain, temporary response to steroid
injection, weakness of abductors, positive Trendelenberg test, pain during passive
abduction etc., although not all signs may be present.
When a clinical diagnosis is suspected, further investigation is required to evaluate
the problem. Either ultrasound or MRI scan can be done. MRI scan is probably better
as the ultrasound interpretation is dependant on the person who does the ultrasound.
The management depends on the symptoms and the MRI findings. Although the long term
results of repairing such an abductor tear is not known (as the condition is being
recognised as a cause of hip pain only recently and the awareness about this condition
among health professionals including orthopaedic surgeons is still scarce), recent
studies have shown favourable short term results following surgical repair of the
abductor tear. However, if there is significant fatty degenerative changes and wasting
of the muscles, the results are likely to be less than optimal. Hence it is important
to understand that the results may not be always successful.
The surgical treatment involves a open repair procedure although with advances in
key hole surgery it is also possible to do the repair through key hole procedure.
After the surgery, the repair should be protected with partial weight bearing with
crutches for about 6 weeks.
The following are some relevant selected scientific references:
1. Surgical repair of chronic tears of the hip abductor mechanism.
Hip Int. 2009 Oct-Dec;19(4):372-6.
Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G.
Avon Orthopaedic Centre, Bristol, UK.
Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common
cause of this pain is trochanteric bursitis. This usually improves with conservative
treatment. In a few cases it doesn't settle and warrants further investigation and
treatment. We present a series of 28 patients who underwent MRI scanning for such
pain, 16 were found to have a tear of their abductors. All 16 underwent surgical
repair using multiple soft tissue anchors inserted into the greater trochanter of
the hip to reattach the abductors. There were 15 females and 1 male. All patients
completed a self-administered questionnaire pre-operatively and 1 year post-operatively.
Data collected included: A visual analogue score for hip pain, Charnley modification
of the Merle D'Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg
and SF36 scores.Of the 16 patients who underwent surgery 5 had a failure of surgical
treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection
which required debridement. In the remaining 11 patients there were statistically
significant improvements in hip symptoms. The mean change in visual analogue score
was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5 (p=0.00085).
The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients
who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.We
conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric
pain that should be further investigated with MRI scanning. Surgical repair is a
successful operation for reduction of pain and improvement of function. However there
is a relatively high failure rate.
2. Advanced techniques in hip arthroscopy.
Instr Course Lect. 2009;58:423-36.
Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS.
Twin Cities Orthopaedics, Minneapolis, Minnesota, USA.
The indications for hip arthroscopy are expanding as the understanding of hip disease
increases. Improved instrumentation and technical skills also have facilitated the
ability to treat some hip disorders arthroscopically. Femoroacetabular impingement
(FAI) is increasingly recognized as a disorder that can lead to progressive intra-articular
chondral and labral injury. Although FAI is usually treated through an open approach,
limited-open and all-arthroscopic approaches have been described. Various arthroscopic
techniques allow treatment of labral and acetabular rim pathology as well as peripheral
compartment femoral head-neck abnormalities. Early outcomes of limited-open and all-arthroscopic
treatment of FAI are only beginning to be reported but appear to compare favorably
with those of open dislocation procedures. Although labral tears traditionally have
been treated with simple débridement, concerns have been raised about the consequences
of removing the labrum. Modified portal placement and hip-specific suture anchors
are now being used in an effort to repair some labral tears. Snapping hip disorders
typically are treated nonsurgically. For persistent symptoms, arthroscopic release
is successful, compared with open release, and allows additional evaluation of the
hip joint during surgery. Diagnosis and management of traumatic and atraumatic hip
instability continue to be challenging. Hip arthroscopy has been shown to be effective
in the treatment of hip instability in some patients. The extra-articular peritrochanteric
space is receiving increased attention. The arthroscopic anatomy has been well defined,
but the treatment of greater trochanteric pain syndrome and arthroscopic repair of
abductor tendon tears are only beginning to be reported. Improved techniques and
longer-term outcomes studies will further define the optimal role of hip arthroscopy.
3. Endoscopic repair of gluteus medius tendon tears of the hip.
Am J Sports Med. 2009 Apr;37(4):743-7.
Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT.
Hospital for Special Surgery, New York, NY 10021, USA.
BACKGROUND: Tears of the gluteus medius tendon at the greater trochanter have been
termed "rotator cuff tears of the hip." Previous reports have described the open
repair of these lesions. HYPOTHESIS: Endoscopic repair of gluteus medius tears results
in successful clinical outcomes in the short term. STUDY DESIGN: Case series; Level
of evidence, 4. METHODS: Of 482 consecutive hip arthroscopies performed by the senior
author, 10 patients with gluteus medius tears repaired endoscopically were evaluated
prospectively. Perioperative data were analyzed on this cohort of patients. There
were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients
had persistent lateral hip pain and abductor weakness despite extensive conservative
measures. Diagnosis was made by physical examination and magnetic resonance imaging
and was confirmed at the time of endoscopy in all cases. At the most recent follow-up,
patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys.
RESULTS: At an average follow-up of 25 months (range, 19-38 months), all 10 patients
had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip
abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100),
and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse
complications after abductor repairs. Seven of 10 patients said their hip was normal,
and 3 said their hip was nearly normal. CONCLUSION: With short-term follow-up, endoscopic
repair of gluteus medius tendon tears of the hip appears to provide pain relief and
return of strength in select patients who have failed conservative measures. Further
long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.
4. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders
in the hip.
Arthroscopy. 2007 Nov;23(11):1246.e1-5.
Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.
Hospital for Special Surgery, New York, New York 10021, USA.
Disorders of the lateral or peritrochanteric space (often grouped into the greater
trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external
snapping iliotibial band, and gluteus medius and minimus tears, are now being treated
endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of
the hip and describe surgical techniques for the treatment of these entities. Proper
portal placement is key in understanding the peritrochanteric space and should be
first oriented at the gluteus maximus insertion into the linea aspera, as well as
the vastus lateralis. When tears of the gluteus medius and minimus are encountered,
suture anchors can be placed into the footprint of the abductor tendons in a standard
arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric
bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius
and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial
band release, and decompression of the peritrochanteric space and suture anchor tendon
repair to the greater trochanter, respectively.
The following video shows Mr.Ganapathi performing an arthroscopic assessment of an abductor tear and mini-open repair of the abductor tear using suture anchors