Tears of the gluteus medius or minimus tendon insertion at the greater trochanter commonly accompany or mimic GTPS. The relative frequency of these tears has given them the moniker “rotator cuff tears of the hip”. The Hip Lag Sign demonstrates high sensitivity (89.5%) and specificity (96.6%) for identifying hip abductor tears. (5)
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Strains of the gluteus medius tendon may be present in nearly one-fourth of the elderly population. (6-8) Gluteal tears progress much like rotator cuff tears- beginning as interstitial partial anterior tears and progressing to full thickness tears. (9,10) Successful management of GTPS and its associated pathology requires three steps.
1. Differentiate The Structural Problem
The most classic physical finding of GTPS is tenderness to palpation over the greater trochanter. (11) Tenderness along the posterior aspect of the greater trochanter may indicate gluteus medius involvement, while discomfort at the anterior aspect may suggest a contribution from the gluteus minimus. (12) Resisted testing can help distinguish contractile tissue involvement from simple bursitis. (12) Resisted abduction is likely to reproduce GTPS complaints, particularly those associated with gluteus medius tendon involvement. (13)
The FABER test may help differentiate hip from sacroiliac problems. (14) The Thomas test can help identify excessive psoas hypertonicity. Ober’s test may be used to assess for iliotibial band contracture.
2. Assess for Hidden Functional Deficits
Clinicians should assess for biomechanical deficits that may contribute to GTPS, including leg length discrepancy, foot hyperpronation, and lower crossed syndrome. Most importantly, clinicians must assess for the presence of hip abductor weakness; which is central to GTPS as an etiologic factor and a source of ongoing symptoms.
The gluteus medius serves as a primary hip abductor with innervation from the superior gluteal nerve (L4-S1). (15) The muscle originates from the posterior surface of the iliac crest and inserts at two sites on the greater trochanter – the lateral facet and the superior posterior facet. (16) Hip abductor weakness manifests functionally by allowing the contralateral pelvis to drop during single leg stance activities, including ambulation. This causes excessive thigh adduction and medial rotation, creating significant biomechanical disadvantages at the knee and hip, particularly increased tension of the iliotibial band and compression of the greater trochanteric bursa. (17)
Functional orthopedic testing for hip abductor weakness would include the Trendelenburg sign, overhead squat test, and single leg squat test. The presence of an “uncompensated” pelvic drop upon Trendelenburg maneuver suggests gluteus medius weakness. Long-standing weakness may result in a “compensated” response of lateral trunk flexion over the stance leg. Patients with significant gluteus medius tendinopathy or tearing may report pain on Trendelenburg testing. (18)
3. Restore Balance
The differentiation of specific structural contributors to GTPS is challenging. (19) Fortunately, most of these problems arise from common functional deficits. The goal of treatment should be correct faulty mechanics and to prevent future overload. This process requires a focused home exercise program that aims to resolve underlying functional imbalances – like hip abductor weakness. With the right plan, conservative treatment of GTPS can exceed a 90% success rate. (20)
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9. Connell DA, Bass C, Sykes CA, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003;13(6):1339-1347.
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12. Snider RK, Trochanteric bursitis. In: Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:299-303
13. . Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. Sep 2011;21(5):447-53.
14. Bartlett MD, Wolf LS, Shurtleff DB, Stahell LT. Hip flexion contractures: a comparison of measurement methods. Arch Phys Med Rehabil. 1985;66(9):620-625.
15. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92.
16. Robertson WJ, Gardner MJ, Barker JU, Boraiah S, Lorich DG, Kelly BT. Anatomy and dimensions of the gluteus medius tendon insertion. Arthroscopy. 2008;24(2):130-136.
17. Markley G. Greater Trochanteric Pain Syndrome. Presentation- Illinois Chiropractic Society National Convention. September 2013, Chicago, IL.
18. Smart GW, Taunton JE, Clement DB. Achilles tendon disorders in runners – a review. Med Sci Sports Exerc 1980;12(4):231-243
19. Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. Sep 2011;21(5):447-53.
20. Brooker AJ. The surgical approach to refractory trochanteric bursitis. Johns Hopkins Med J. 1979;145:98–100.
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
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