PM R XXX (2015) 1-5
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Case Presentation
Atypical Cause of Lateral Hip Pain Due to Proximal Gluteus Medius Muscle Tear: A Report of 2 Cases Priyesh Mehta, DO, Raj Telhan, MD, Alissa Burge, MD, James Wyss, MD, PT Introduction Proximal tears of the gluteus medius muscle are a rare phenomenon. When reported, they most commonly occur at its distal attachment at the musculotendinous junction or at its insertion on the greater trochanter. The tears may be acute and associated with a traumatic injury or chronic degeneration. We report here 2 cases of traumatic tears of the gluteus medius muscle at its proximal attachment on the iliac crest. Case Presentation Case 1 A 35-year-old active woman presented with left-sided hip pain of 2 months’ duration. She was previously in good health until she went to sit down in a chair and slipped, landing directly on her left buttock and pelvis. She reported stiffness across her low back and left side of her hip. In addition, she had tenderness along the iliac crest. Her pain was exacerbated by running, walking, and sleeping on her left side. She denied any previous hip or back injuries as well as symptoms of numbness, paresthesia, weakness, or radiating pain. She did not undergo any specific treatments before her initial office visit. Findings of the physical examination revealed normal hip, knee, and ankle alignment. Her gait was mildly antalgic on the left. She was able to sit to stand without discomfort and heel walk and toe walk without any significant difficulty. There was no swelling, erythema, or ecchymosis around the back and hip. Muscle bulk was normal. With palpation, she was tender to touch along the anterior and proximal gluteus medius muscle just below its origin on the iliac crest. Active and passive hip range of motion was diminished predominantly in internal rotation. Strength in hip flexion, extension, internal, and external rotation was 5/5. Resistance to left hip abduction was 4/5 and reproduced her pain. Lower limb neurologic examination was symmetric and intact
for reflexes and sensation, and dural tension testing was negative. Distal pulses were normal and symmetric bilaterally. Radiographs of bilateral hips were unremarkable. Magnetic resonance imaging of the left hip revealed a full-thickness tear of the anterior aspect of the gluteus medius at its iliac origin, with surrounding soft tissue edema (Figure 1). Initial treatment consisted of physical therapy (hip range of motion, closed chain exercise strengthening program, myofascial release of pelvic, abdominal and gluteal muscles, and core stabilization) to alleviate pain, facilitate healing of the left gluteus medius injury, and most importantly to restore strength and function. At 4 weeks, she was able to progress to stationary bicycle and aquatic exercises. At 8 weeks, she was able to return to her regular activities without pain. Case 2 A 53-year-old woman was referred by an orthopedist hip specialist for right lateral hip pain that had persisted for 10 weeks. She reported onset of symptoms while performing dance exercises consisting of hip abduction and adduction movements and recalled that these symptoms worsened after completion of the exercises. After initial onset, the patient experienced significant right hip pain that was achy in nature, and she had difficulty resuming her daily activities. She denied previous injury to the hip or back, numbness, paresthesia, weakness, or radiating pain. Her initial treatment included relative rest, ice, topical and oral antiinflammatory medications, and physical therapy that led to no significant pain relief or restoration of function. On physical examination, she had a mild antalgic gait on the right. She was able to sit and stand without discomfort as well as heel and toe walk without any significant difficulty. There was no swelling, erythema, or ecchymosis around the back and hip. Muscle bulk was normal. Palpation of the gluteus medius tendon near the iliac crest was tender to touch. Active and passive hip
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.05.017
2
Hip Pain Due to Gluteus Medius Muscle Tear
Figure 1. Coronal (A) and axial (B) short tau inversion recovery (STIR) images demonstrate focal soft-tissue edema (red arrows) within the proximal gluteus medius muscle belly at its proximal origin upon the iliac crest (white arrowheads). Corresponding axial proton density image demonstrates focal tear of the gluteus medius origin (yellow arrow) at the iliac crest (white arrowhead).
range of motion was normal. Strength of the hip was maintained in all planes except resisted hip abduction was 4/5 and reproduced pain at the iliac crest. Distal knee and ankle reflexes were both 2þ bilaterally. There was no adverse neural tension with a seated slump test. Sensation was intact in the L2-S2 dermatomes bilaterally. Distal pulses were normal and symmetric bilaterally. Radiographs of bilateral hips were unremarkable. Magnetic resonance imaging of the left hip had been obtained previously and revealed a partial tear of the gluteus medius at the iliac crest (Figure 2).
Because of the lack of improvement with the conservative care described previously, the patient and referring physician decided to proceed with an intratendinous autologous platelet-rich plasma (PRP) injection. The injection was performed with ultrasonography guidance of the proximal right anterior gluteus medius. The site of the injection was cleansed, and subcutaneous anesthesia was provided with 1% lidocaine through a 25-gauge needle. With ultrasonography guidance, a sterile, 3.5-inch, 22-gauge needle was inserted into the site of the proximal gluteus medius tendon near its
Figure 2. (A) Coronal short tau inversion recovery image demonstrates focal soft-tissue edema (red arrow) along the gluteus medius origin at the iliac crest (white arrowhead). (B) Axial PD image demonstrates corresponding partial tear of the proximal gluteus medius muscle (yellow arrow) at the iliac crest (white arrowhead).
P. Mehta et al. / PM R XXX (2015) 1-5
interface with the iliac crest followed by injection of a total of 4 mL of autologous PRP. The patient experienced no complications from the procedure. She was instructed to use ice and Tylenol (McNeil Consumer Healthcare, Fort Washington, PA) for pain until her follow-up visit. At 2 weeks, the patient reported significant pain relief and gradually returned to activity, such as dancing, without any significant pain. She was given a physical therapy exercise program to further restore flexibility and strength to the right gluteus medius. At 10 weeks, she was able to return to her regular activities painfree. She remains pain-free and without any functional restrictions at 2 years after injection. Discussion Anatomically, the gluteus medius muscle has attachments to the iliac crest and gluteal line proximally and greater trochanter distally [1]. The fibers converge to a strong flattened tendon, which is inserted into the oblique ridge on the lateral surface of the greater trochanter. Cadaveric models indicate that the muscle bulk has 3 equal distinct parts comprising the fanshaped orientation. At its origin, one fiber layer is located on the posterior-inferior edge of the sharp lip of the iliac crest. In addition, deep fascicles compromise a second layer and begin at the gluteal fossa and extend from the posterior sacroiliac ligaments to a point at the anterior superior iliac spine anteriorly. The third layer is located on the deep surface of the gluteal aponeurosis, which covers both gluteus maximus and the superior portion of gluteus medius. Orientation of the gluteus medius muscle fibers are unique with anterior and middle fibers running almost vertically from the anterior iliac crest to the top of the trochanter whereas the posterior fibers are more parallel to the femoral neck [1]. The gluteus medius muscle plays a role in hip girdle muscle synergy with attachments to the gluteal aponeurosis fascia, which represents a broad continuum of fibrous tissue about the buttock, hip, and thigh with attachments to the latissimus dorsi and distal iliotibial band [2]. Functionally, the gluteus medius is described as a strong abductor and medial rotator of the thigh. It plays a pivotal role during the stance phase of gait and prevents dropping of the pelvis on the unsupported side. Hip injuries, specifically those involving the lateral hip and pelvis, can pose significant diagnostic and therapeutic challenges. A complete history and physical examination help confirm the source of pain, but differential diagnoses can remain broad. Some of the common causes of lateral hip pain include hip pointer syndrome, greater trochanter bursitis, and gluteus medius tendinopathy [3]. In addition, proximal iliotibial band strain involving the proximal attachment of the iliotibial band to the iliac crest has been described in
3
the literature as a cause of lateral hip pain and must remain on the differential diagnosis. Often, proximal iliotibial band strains and gluteus medius tendinopathies coexist with each other as both structures are susceptible to strain with heightened abductor forces. The proximal iliotibial band, however, is less likely subject to complete tear because it shares thick fascial connections to the gluteus maximus and tensor fascia latae muscles [4]. Injuries of the gluteus medius tendon more commonly occur at its distal attachment on the greater trochanter and are recognized as a common cause of lateral hip pain. Symptomatic tendinosis and tears of the gluteus medius of the greater trochanter are similar to tears of the muscle insertions in the rotator cuff. Similar to the shoulder, a pattern of injury and degeneration is initiated with tendonitis, tendinosis, and eventual tear of the muscle of the hip, most commonly being the gluteus medius [5]. Gluteus medius muscle tears at its origin on the iliac crest, however, also should be included in the differential diagnosis of a patient that presents with lateral hip pain, especially if the patient presents with pain limited with active and passive hip abduction and tenderness below the iliac crest. Although the true incidence and prevalence of gluteus medius tears are not known, studies suggest that tears occur in up to 25% of late middle-aged women and 10% of similarly aged men. Its increased prevalence in women has been reported, possibly secondary to the wider female pelvis [1,5]. When gluteus medius tendon ruptures occur, they commonly are traumatic in origin. Tears can be interstitial, partial thickness or full thickness with partial-thickness tears the most common [6,7]. To our knowledge, there are no case reports of symptomatic proximal gluteus medius muscle tears reported in the literature. Although it is unknown how the patients in this case report sustained this unusual injury, there are a few possible contributing factors. First, the wider female pelvis lends women to altered biomechanical forces on the hip girdle [1,5]. Biomechanical and cadaveric studies indicate that the abductor force requirement to balance the pelvis is determined by the weight of the patient as well as the pelvic moment arm (PMA) and gluteus medius moment arm (GMA); the distance from the pubic symphyses to the center of the hip joint and the distance from the gluteus medius insertion on the greater trochanter to the center of the hip joint, respectively. It has been shown that a greater PMA/GMA ratio results in a greater theoretical force per unit area on the gluteus medius, resulting in inefficient hip mechanics and likely injury [8]. Both patients in our case study have large PMA/GMA ratios, increasing the overall gluteal force and indicating a possible susceptibility to injury. Second, both patients’ activity levels make them susceptible to gluteus medius injury. Activities such as running and
4
Hip Pain Due to Gluteus Medius Muscle Tear
dancing, both often resulting in predominant hip flexor and hip abductor activation, can result in muscle imbalance causing abnormal length, strength, and motor recruitment of the gluteus medius and tensor fascia latae [9]. Often, a motor pattern fault involving habitual preference of the iliopsoas in performing hip flexion and the tensor fascia latae in performing hip abduction movements can result in posterior gluteus medius disuse weakness and atrophy. When the gluteus medius muscle is overloaded or susceptible to a high magnitude of stress such as trauma (eg, fall), this can result in gluteus medius tendinosis or tear [9]. Overall management of gluteus medius tendon injury to the proximal or distal attachment remains relatively similar [10]; however, certain factors play an important role in treating proximal gluteal medius muscle tears. Because of an increased PMA/GMA ratio, attention must be given to elements of the kinetic chain (ie, spine, knee, and ankle) biomechanics because alterations at these joints can predispose patients to gluteal tendon disruption. Physical therapy programs often are initiated with closed chain exercises such as wall squat slide or squat machine repetitions. Studies indicate that a squat machine and feet placed forward is the preferred protocol compared with a wall squat protocol for maximal gluteus activation and isolation [11]. In addition, injuries to the proximal gluteal medius can impact the gluteal aponeurosis. This fascia has fascicles that run continuous with the superficial fibers of the thoracolumbar aponeurosis, as well as lateral fibers of the fascial insertion of the latissimus dorsi and posterior ilium. Special attention must be made to treatment of the gluteal aponeurosis for proximal gluteus medius tears because it plays an integral part in maintaining hip girdle muscle synergy. An exercise prescription using myofascial modalities to the gluteal aponeurosis and maintaining alignment of the lumbosacral joints, sacroiliac joints and pelvic girdle muscles can assist in the healing of proximal gluteal tendon injuries [2]. Most patients tend to show improvements after a course of physical therapy. Additional treatment modalities, however, can help in refractory cases. PRP injections have been proposed as a promising alternative for treating tendinopathies [12,13]. PRP is considered an ideal autologous blood product that promotes the body’s own natural healing. A multicenter retrospective review reported treatment of gluteus medius tendinopathies with PRP in 16 patients reported an overall 81% of the subjects reporting moderate-to-complete resolution of pain symptoms [13]. In a recent randomized controlled trial, Hamid et al [14] found PRP with rehabilitation to treat partial hamstring muscle tears had statistically significant greater return to play and reduced pain scores compared with those treated with rehabilitation alone [14]. This study supports the potential role for PRP to treat both muscle and tendon tears. Case 2 was a patient with a partial tear of the
gluteus medius muscle who chose PRP when her pain was refractory to conservative treatment. Persistent symptoms of pain and weakness limiting daily activities can warrant surgical intervention. Open surgical techniques have been reported for gluteus medius tears noted during femoral neck fracture fixation and total hip arthroplasty as well as endoscopic techniques primarily for distal abductor tendon repair; however no surgical evidence is reported for tears at the iliac crest [15,16]. Conclusion Proximal gluteus medius tears near the iliac crest attachment are an uncommon occurrence but should nevertheless be carefully considered in the differential diagnosis for patients presenting with lateral hip pain. A female propensity to a wider pelvis may result in altered distribution of gluteal medial muscle force on the hip as well as muscle imbalance, seen in activities such as running and dancing increasing the likelihood of this unusual injury. Treatment for these injuries remains conservative. Patients tend to do well with a period of relative rest, a course of physical therapy with closed chain exercises, and attention to the gluteal aponeurosis, and in cases refractory to conservative care, autologous PRP injection can be considered as a treatment option. References 1. Robertson WJ, Gardner MJ, Barker JU, Lorich DG. Anatomy and dimensions of the gluteus medius tendon insertions. Arthroscopy 2008;24:130-136. 2. Huang BK, Campos JC, Michael Peschka PG, et al. Injury of the gluteal aponeurotic fascia and proximal iliotibial band: Anatomy, pathologic conditions, and MR imaging. Radiographics 2013;33: 1437-1452. 3. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: Differential diagnosis and treatment options. Sports Health 2010;2:191-196. 4. Sher I, Umans H, Downie SA, Tobin K, Arora R, Olson TR. Proximal iliotibial band syndrome: What is it and where is it? Skeletal Radiol 2011;40:1553-1556. 5. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc 2010;18:113-119. 6. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br 1997;79:618-620. 7. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty 2001;16:121-123. 8. Woyski D, Olinger A, Wright B. Small insertion area and inefficient mechanics of the gluteus medius in females. Surg Radiol Anat 2013;35:713-719. 9. Bewyer DC, Bewyer KC. Rational for treatment of hip abductor pain syndrome. Iowa Orthop J 2003;23:57-60. 10. Williams BS, Cohen SP. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg 2009; 108:1662-1670. 11. Yoo WG. Effects of individual strengthening exercises on subdivisions of the gluteus medius in a patient with sacroiliac joint pain. J Phys Ther Sci 2014;26:1501-1502.
P. Mehta et al. / PM R XXX (2015) 1-5 12. Alosousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet rich plasma and its application in trauma and orthopaedic surgery: A review of literature. J Bone Joint Surg Br 2009; 91:987-996. 13. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasoundeguided platelet rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM R 2013;5:169-175. 14. Hamid M, Ali M, Yusof A, Yusof A, George J, Lee LP. Platelet rich plasma injections for the treatment of hamstring
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injuries: A randomized control trial. Am J Sports Med 2014;42: 2410-2418. 15. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip. Arthroscopy 2007;23:1246e11246e5. 16. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endsocopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747.
Disclosure P.M. Department of Rehabilitation Medicine, Harkness Pavilion, 1st Floor, Room 180, New York Presbyterian Hospital, 180 Fort Washington Avenue, New York, NY 10032. Address correspondence to: P.M.; e-mail: [email protected] Disclosure: nothing to disclose R.T. Department of Anesthesia, University of Virginia School of Medicine, Charlottesville, VA Disclosure: nothing to disclose
A.B. Department of Radiology, Hospital for Special Surgery, New York, NY Disclosure: nothing to disclose J.W. Department of Rehabilitation, Hospital for Special Surgery, New York, NY Disclosure: nothing to disclose Submitted for publication March 18, 2014; accepted May 23, 2015.
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Case Presentation
Atypical Cause of Lateral Hip Pain Due to Proximal Gluteus Medius Muscle Tear: A Report of 2 Cases Priyesh Mehta, DO, Raj Telhan, MD, Alissa Burge, MD, James Wyss, MD, PT Introduction Proximal tears of the gluteus medius muscle are a rare phenomenon. When reported, they most commonly occur at its distal attachment at the musculotendinous junction or at its insertion on the greater trochanter. The tears may be acute and associated with a traumatic injury or chronic degeneration. We report here 2 cases of traumatic tears of the gluteus medius muscle at its proximal attachment on the iliac crest. Case Presentation Case 1 A 35-year-old active woman presented with left-sided hip pain of 2 months’ duration. She was previously in good health until she went to sit down in a chair and slipped, landing directly on her left buttock and pelvis. She reported stiffness across her low back and left side of her hip. In addition, she had tenderness along the iliac crest. Her pain was exacerbated by running, walking, and sleeping on her left side. She denied any previous hip or back injuries as well as symptoms of numbness, paresthesia, weakness, or radiating pain. She did not undergo any specific treatments before her initial office visit. Findings of the physical examination revealed normal hip, knee, and ankle alignment. Her gait was mildly antalgic on the left. She was able to sit to stand without discomfort and heel walk and toe walk without any significant difficulty. There was no swelling, erythema, or ecchymosis around the back and hip. Muscle bulk was normal. With palpation, she was tender to touch along the anterior and proximal gluteus medius muscle just below its origin on the iliac crest. Active and passive hip range of motion was diminished predominantly in internal rotation. Strength in hip flexion, extension, internal, and external rotation was 5/5. Resistance to left hip abduction was 4/5 and reproduced her pain. Lower limb neurologic examination was symmetric and intact
for reflexes and sensation, and dural tension testing was negative. Distal pulses were normal and symmetric bilaterally. Radiographs of bilateral hips were unremarkable. Magnetic resonance imaging of the left hip revealed a full-thickness tear of the anterior aspect of the gluteus medius at its iliac origin, with surrounding soft tissue edema (Figure 1). Initial treatment consisted of physical therapy (hip range of motion, closed chain exercise strengthening program, myofascial release of pelvic, abdominal and gluteal muscles, and core stabilization) to alleviate pain, facilitate healing of the left gluteus medius injury, and most importantly to restore strength and function. At 4 weeks, she was able to progress to stationary bicycle and aquatic exercises. At 8 weeks, she was able to return to her regular activities without pain. Case 2 A 53-year-old woman was referred by an orthopedist hip specialist for right lateral hip pain that had persisted for 10 weeks. She reported onset of symptoms while performing dance exercises consisting of hip abduction and adduction movements and recalled that these symptoms worsened after completion of the exercises. After initial onset, the patient experienced significant right hip pain that was achy in nature, and she had difficulty resuming her daily activities. She denied previous injury to the hip or back, numbness, paresthesia, weakness, or radiating pain. Her initial treatment included relative rest, ice, topical and oral antiinflammatory medications, and physical therapy that led to no significant pain relief or restoration of function. On physical examination, she had a mild antalgic gait on the right. She was able to sit and stand without discomfort as well as heel and toe walk without any significant difficulty. There was no swelling, erythema, or ecchymosis around the back and hip. Muscle bulk was normal. Palpation of the gluteus medius tendon near the iliac crest was tender to touch. Active and passive hip
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.05.017
2
Hip Pain Due to Gluteus Medius Muscle Tear
Figure 1. Coronal (A) and axial (B) short tau inversion recovery (STIR) images demonstrate focal soft-tissue edema (red arrows) within the proximal gluteus medius muscle belly at its proximal origin upon the iliac crest (white arrowheads). Corresponding axial proton density image demonstrates focal tear of the gluteus medius origin (yellow arrow) at the iliac crest (white arrowhead).
range of motion was normal. Strength of the hip was maintained in all planes except resisted hip abduction was 4/5 and reproduced pain at the iliac crest. Distal knee and ankle reflexes were both 2þ bilaterally. There was no adverse neural tension with a seated slump test. Sensation was intact in the L2-S2 dermatomes bilaterally. Distal pulses were normal and symmetric bilaterally. Radiographs of bilateral hips were unremarkable. Magnetic resonance imaging of the left hip had been obtained previously and revealed a partial tear of the gluteus medius at the iliac crest (Figure 2).
Because of the lack of improvement with the conservative care described previously, the patient and referring physician decided to proceed with an intratendinous autologous platelet-rich plasma (PRP) injection. The injection was performed with ultrasonography guidance of the proximal right anterior gluteus medius. The site of the injection was cleansed, and subcutaneous anesthesia was provided with 1% lidocaine through a 25-gauge needle. With ultrasonography guidance, a sterile, 3.5-inch, 22-gauge needle was inserted into the site of the proximal gluteus medius tendon near its
Figure 2. (A) Coronal short tau inversion recovery image demonstrates focal soft-tissue edema (red arrow) along the gluteus medius origin at the iliac crest (white arrowhead). (B) Axial PD image demonstrates corresponding partial tear of the proximal gluteus medius muscle (yellow arrow) at the iliac crest (white arrowhead).
P. Mehta et al. / PM R XXX (2015) 1-5
interface with the iliac crest followed by injection of a total of 4 mL of autologous PRP. The patient experienced no complications from the procedure. She was instructed to use ice and Tylenol (McNeil Consumer Healthcare, Fort Washington, PA) for pain until her follow-up visit. At 2 weeks, the patient reported significant pain relief and gradually returned to activity, such as dancing, without any significant pain. She was given a physical therapy exercise program to further restore flexibility and strength to the right gluteus medius. At 10 weeks, she was able to return to her regular activities painfree. She remains pain-free and without any functional restrictions at 2 years after injection. Discussion Anatomically, the gluteus medius muscle has attachments to the iliac crest and gluteal line proximally and greater trochanter distally [1]. The fibers converge to a strong flattened tendon, which is inserted into the oblique ridge on the lateral surface of the greater trochanter. Cadaveric models indicate that the muscle bulk has 3 equal distinct parts comprising the fanshaped orientation. At its origin, one fiber layer is located on the posterior-inferior edge of the sharp lip of the iliac crest. In addition, deep fascicles compromise a second layer and begin at the gluteal fossa and extend from the posterior sacroiliac ligaments to a point at the anterior superior iliac spine anteriorly. The third layer is located on the deep surface of the gluteal aponeurosis, which covers both gluteus maximus and the superior portion of gluteus medius. Orientation of the gluteus medius muscle fibers are unique with anterior and middle fibers running almost vertically from the anterior iliac crest to the top of the trochanter whereas the posterior fibers are more parallel to the femoral neck [1]. The gluteus medius muscle plays a role in hip girdle muscle synergy with attachments to the gluteal aponeurosis fascia, which represents a broad continuum of fibrous tissue about the buttock, hip, and thigh with attachments to the latissimus dorsi and distal iliotibial band [2]. Functionally, the gluteus medius is described as a strong abductor and medial rotator of the thigh. It plays a pivotal role during the stance phase of gait and prevents dropping of the pelvis on the unsupported side. Hip injuries, specifically those involving the lateral hip and pelvis, can pose significant diagnostic and therapeutic challenges. A complete history and physical examination help confirm the source of pain, but differential diagnoses can remain broad. Some of the common causes of lateral hip pain include hip pointer syndrome, greater trochanter bursitis, and gluteus medius tendinopathy [3]. In addition, proximal iliotibial band strain involving the proximal attachment of the iliotibial band to the iliac crest has been described in
3
the literature as a cause of lateral hip pain and must remain on the differential diagnosis. Often, proximal iliotibial band strains and gluteus medius tendinopathies coexist with each other as both structures are susceptible to strain with heightened abductor forces. The proximal iliotibial band, however, is less likely subject to complete tear because it shares thick fascial connections to the gluteus maximus and tensor fascia latae muscles [4]. Injuries of the gluteus medius tendon more commonly occur at its distal attachment on the greater trochanter and are recognized as a common cause of lateral hip pain. Symptomatic tendinosis and tears of the gluteus medius of the greater trochanter are similar to tears of the muscle insertions in the rotator cuff. Similar to the shoulder, a pattern of injury and degeneration is initiated with tendonitis, tendinosis, and eventual tear of the muscle of the hip, most commonly being the gluteus medius [5]. Gluteus medius muscle tears at its origin on the iliac crest, however, also should be included in the differential diagnosis of a patient that presents with lateral hip pain, especially if the patient presents with pain limited with active and passive hip abduction and tenderness below the iliac crest. Although the true incidence and prevalence of gluteus medius tears are not known, studies suggest that tears occur in up to 25% of late middle-aged women and 10% of similarly aged men. Its increased prevalence in women has been reported, possibly secondary to the wider female pelvis [1,5]. When gluteus medius tendon ruptures occur, they commonly are traumatic in origin. Tears can be interstitial, partial thickness or full thickness with partial-thickness tears the most common [6,7]. To our knowledge, there are no case reports of symptomatic proximal gluteus medius muscle tears reported in the literature. Although it is unknown how the patients in this case report sustained this unusual injury, there are a few possible contributing factors. First, the wider female pelvis lends women to altered biomechanical forces on the hip girdle [1,5]. Biomechanical and cadaveric studies indicate that the abductor force requirement to balance the pelvis is determined by the weight of the patient as well as the pelvic moment arm (PMA) and gluteus medius moment arm (GMA); the distance from the pubic symphyses to the center of the hip joint and the distance from the gluteus medius insertion on the greater trochanter to the center of the hip joint, respectively. It has been shown that a greater PMA/GMA ratio results in a greater theoretical force per unit area on the gluteus medius, resulting in inefficient hip mechanics and likely injury [8]. Both patients in our case study have large PMA/GMA ratios, increasing the overall gluteal force and indicating a possible susceptibility to injury. Second, both patients’ activity levels make them susceptible to gluteus medius injury. Activities such as running and
4
Hip Pain Due to Gluteus Medius Muscle Tear
dancing, both often resulting in predominant hip flexor and hip abductor activation, can result in muscle imbalance causing abnormal length, strength, and motor recruitment of the gluteus medius and tensor fascia latae [9]. Often, a motor pattern fault involving habitual preference of the iliopsoas in performing hip flexion and the tensor fascia latae in performing hip abduction movements can result in posterior gluteus medius disuse weakness and atrophy. When the gluteus medius muscle is overloaded or susceptible to a high magnitude of stress such as trauma (eg, fall), this can result in gluteus medius tendinosis or tear [9]. Overall management of gluteus medius tendon injury to the proximal or distal attachment remains relatively similar [10]; however, certain factors play an important role in treating proximal gluteal medius muscle tears. Because of an increased PMA/GMA ratio, attention must be given to elements of the kinetic chain (ie, spine, knee, and ankle) biomechanics because alterations at these joints can predispose patients to gluteal tendon disruption. Physical therapy programs often are initiated with closed chain exercises such as wall squat slide or squat machine repetitions. Studies indicate that a squat machine and feet placed forward is the preferred protocol compared with a wall squat protocol for maximal gluteus activation and isolation [11]. In addition, injuries to the proximal gluteal medius can impact the gluteal aponeurosis. This fascia has fascicles that run continuous with the superficial fibers of the thoracolumbar aponeurosis, as well as lateral fibers of the fascial insertion of the latissimus dorsi and posterior ilium. Special attention must be made to treatment of the gluteal aponeurosis for proximal gluteus medius tears because it plays an integral part in maintaining hip girdle muscle synergy. An exercise prescription using myofascial modalities to the gluteal aponeurosis and maintaining alignment of the lumbosacral joints, sacroiliac joints and pelvic girdle muscles can assist in the healing of proximal gluteal tendon injuries [2]. Most patients tend to show improvements after a course of physical therapy. Additional treatment modalities, however, can help in refractory cases. PRP injections have been proposed as a promising alternative for treating tendinopathies [12,13]. PRP is considered an ideal autologous blood product that promotes the body’s own natural healing. A multicenter retrospective review reported treatment of gluteus medius tendinopathies with PRP in 16 patients reported an overall 81% of the subjects reporting moderate-to-complete resolution of pain symptoms [13]. In a recent randomized controlled trial, Hamid et al [14] found PRP with rehabilitation to treat partial hamstring muscle tears had statistically significant greater return to play and reduced pain scores compared with those treated with rehabilitation alone [14]. This study supports the potential role for PRP to treat both muscle and tendon tears. Case 2 was a patient with a partial tear of the
gluteus medius muscle who chose PRP when her pain was refractory to conservative treatment. Persistent symptoms of pain and weakness limiting daily activities can warrant surgical intervention. Open surgical techniques have been reported for gluteus medius tears noted during femoral neck fracture fixation and total hip arthroplasty as well as endoscopic techniques primarily for distal abductor tendon repair; however no surgical evidence is reported for tears at the iliac crest [15,16]. Conclusion Proximal gluteus medius tears near the iliac crest attachment are an uncommon occurrence but should nevertheless be carefully considered in the differential diagnosis for patients presenting with lateral hip pain. A female propensity to a wider pelvis may result in altered distribution of gluteal medial muscle force on the hip as well as muscle imbalance, seen in activities such as running and dancing increasing the likelihood of this unusual injury. Treatment for these injuries remains conservative. Patients tend to do well with a period of relative rest, a course of physical therapy with closed chain exercises, and attention to the gluteal aponeurosis, and in cases refractory to conservative care, autologous PRP injection can be considered as a treatment option. References 1. Robertson WJ, Gardner MJ, Barker JU, Lorich DG. Anatomy and dimensions of the gluteus medius tendon insertions. Arthroscopy 2008;24:130-136. 2. Huang BK, Campos JC, Michael Peschka PG, et al. Injury of the gluteal aponeurotic fascia and proximal iliotibial band: Anatomy, pathologic conditions, and MR imaging. Radiographics 2013;33: 1437-1452. 3. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: Differential diagnosis and treatment options. Sports Health 2010;2:191-196. 4. Sher I, Umans H, Downie SA, Tobin K, Arora R, Olson TR. Proximal iliotibial band syndrome: What is it and where is it? Skeletal Radiol 2011;40:1553-1556. 5. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc 2010;18:113-119. 6. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br 1997;79:618-620. 7. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty 2001;16:121-123. 8. Woyski D, Olinger A, Wright B. Small insertion area and inefficient mechanics of the gluteus medius in females. Surg Radiol Anat 2013;35:713-719. 9. Bewyer DC, Bewyer KC. Rational for treatment of hip abductor pain syndrome. Iowa Orthop J 2003;23:57-60. 10. Williams BS, Cohen SP. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg 2009; 108:1662-1670. 11. Yoo WG. Effects of individual strengthening exercises on subdivisions of the gluteus medius in a patient with sacroiliac joint pain. J Phys Ther Sci 2014;26:1501-1502.
P. Mehta et al. / PM R XXX (2015) 1-5 12. Alosousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet rich plasma and its application in trauma and orthopaedic surgery: A review of literature. J Bone Joint Surg Br 2009; 91:987-996. 13. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasoundeguided platelet rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM R 2013;5:169-175. 14. Hamid M, Ali M, Yusof A, Yusof A, George J, Lee LP. Platelet rich plasma injections for the treatment of hamstring
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injuries: A randomized control trial. Am J Sports Med 2014;42: 2410-2418. 15. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip. Arthroscopy 2007;23:1246e11246e5. 16. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endsocopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747.
Disclosure P.M. Department of Rehabilitation Medicine, Harkness Pavilion, 1st Floor, Room 180, New York Presbyterian Hospital, 180 Fort Washington Avenue, New York, NY 10032. Address correspondence to: P.M.; e-mail: [email protected] Disclosure: nothing to disclose R.T. Department of Anesthesia, University of Virginia School of Medicine, Charlottesville, VA Disclosure: nothing to disclose
A.B. Department of Radiology, Hospital for Special Surgery, New York, NY Disclosure: nothing to disclose J.W. Department of Rehabilitation, Hospital for Special Surgery, New York, NY Disclosure: nothing to disclose Submitted for publication March 18, 2014; accepted May 23, 2015.
