Published in BJSM Online First
on September 15, 2016 as 10.1136/
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.
Published by BioMed Central
Open Access Publisher, 30 April 2016,
17:196 DOI 10.1186/s12891-016-1043-6
EXERCISE AND LOAD MODIFICATION VERSUS CORTICOSTEROID INJECTION VERSUS ‘WAIT AND SEE’ FOR PERSISTENT GLUTEUS MEDIUS/MINIMUS TENDINOPATHY (THE LEAP TRIAL): A PROTOCOL FOR A RANDOMISED CLINICAL TRIAL
Methods: Two hundred one people with gluteal tendinopathy will be randomly allocated into one of three groups: (i) CSI; (ii) physiotherapist-administered load modification and exercise intervention; and (iii) wait and see approach. The CSI therapy will consist of one ultrasound (US) guided CSI around the affected tendons and advice on tendon care. Education about load modification will be delivered in physiotherapy clinics and the exercise programme will be both home-based and supervised. The group allocated the wait and see approach will receive basic tendon care advice and reassurance in a single session by a trial physiotherapist. Outcomes will be evaluated at baseline, 4, 8, 12, 26 and 52 weeks using validated global rating of change, pain and physical function scales, psychological measures, quality of life and physical activity levels. Hip abductor muscle strength will be measured at baseline and 8 weeks.
HIP ABDUCTOR MUSCLE WEAKNESS IN INDIVIDUALS WITH GLUTEAL TENDINOPATHY
Purpose. To compare hip abductor muscle strength between individuals with symptomatic, unilateral gluteal tendinopathy (GT) and asymptomatic controls.
Methods. Fifty individuals with GT aged between 35 and 70 years, and 50 sex- and age-comparable controls were recruited from the community. Maximal isometric strength (torque normalized to body mass) of the hip abductors was recorded in supine using an instrumented manual muscle tester. A two-way mixed analysis of covariance (ANCOVA), with covariates of self-reported pain during testing and pain limiting maximum effort, was used to compare hip abductor strength of the symptomatic and asymptomatic hip between GT and control individuals. Data were expressed as mean and standard deviation, with the pairwise comparisons expressed as mean differences and 95% confidence intervals.
GLUTEAL TENDINOPATHY: A REVIEW OF MECHANISMS, ASSESSMENT AND MANAGEMENT
Tendinopathy of the gluteus medius and gluteus minimus tendons is now recognized as a primary local source of lateral hip pain. The condition mostly occurs in mid-life both in athletes and in subjects who do not regularly exercise. Females are afflicted more than males. This condition interferes with sleep (side lying) and common weight-bearing tasks, which makes it a debilitating musculoskeletal condition with a significant impact. Mechanical loading drives the biological processes within a tendon and determines its structural form and load-bearing capacity. The combination of excessive compression and high tensile loads within tendons are thought to be most damaging. The available evidence suggests that joint position (particularly excessive hip adduction), together with muscle and bone elements, are key factors in gluteal tendinopathy. These factors provide a basis for a clinical reasoning process in the assessment and management of a patient presenting with localized lateral hip pain from gluteal tendinopathy. Currently, there is a lack of consensus as to which clinical examination tests provide best diagnostic utility. On the basis of the few diagnostic utility studies and the current understanding of the pathomechanics of gluteal tendinopathy, we propose that a battery of clinical tests utilizing a combination of provocative compressive and tensile loads is currently best practice in its assessment. Management of this condition commonly involves corticosteroid injection, exercise or shock wave therapy, with surgery reserved for recalcitrant cases. There is a dearth of evidence for any treatments, so the approach we recommend involves managing the load on the tendons through exercise and education on the underlying pathomechanics.
GLUTEAL TENDINOPATHY: INTEGRATING PATHOMECHANICS AND CLINICAL FEATURES IN ITS MANAGEMENT
Gluteal tendinopathy is now believed to be the primary local source of lateral hip pain, or greater trochanteric pain syndrome, previously referred to as trochanteric bursitis. This condition is prevalent, particularly among post-menopausal women, and has a considerable negative inﬂuence on quality of life. Improved prognosis and outcomes in the future for those with gluteal tendinopathy will be underpinned by advances in diagnostic testing, a clearer understanding of risk factors and comorbidities, and evidence-based management programs. High-quality studies that meet these requirements are still lacking. This clinical commentary provides direction to assist the clinician with assessment and management of the patient with gluteal tendinopathy, based on currently limited available evidence on this condition and the wider tendon literature and on the combined clinical experience of the authors.
Can local muscles augment stability in the hip? A narrative literature review
Hip pain and dysfunction are increasingly recognised as important causes of morbidity in younger and older adults. Pathology compromising the passive stability of the hip joint, including acetabular labral injury, may lead to increased femoral head translation, greater joint contact pressures and ultimately degenerative hip disease. Activation of hip muscles may play an important role in augmenting the stability in the normal and the passively unstable hip. Research at other joints suggests that the local, rather than global, muscles are well suited to provide subtle joint compression, limiting translation, with minimal metabolic cost.
Based on the known characteristics of local muscles and the limited research available on hip muscles, it is proposed that the local hip muscles; quadratus femoris, gluteus minimus, gemelli, obturator internus and externus, iliocapsularis and the deep fibres of iliopsoas, may be primary stabilisers of the hip joint. Interventions aimed at restoring isolated neuromuscular function of the primary hip stabilisers may be considered when treating people with passive hip instability prior to commencing global muscle rehabilitation. Finally, further research is needed to investigate the potential association between function of the hip muscles (including muscles likely to have a role in stabilising the hip) and hip pathology affecting hip stability such as acetabular labral lesions.
The Association Between Degenerative Hip Joint Pathology and Size of the Gluteus Maximus and Tensor Fascia Lata Muscles
The aim of this study was to obtain, using Magnetic Resonance Imaging (MRI), muscle volume measurements for the gluteus maximus (upper:UGM and lower:LGM portions) and tensor fascia lata (TFL) muscles in both healthy subjects (n=12) and those with unilateral osteoarthritis of the hip ( mild: n=6, and advanced: n =6). While control group subjects were symmetrical between sides for the muscles measured, subjects with hip joint pathology showed asymmetry in GM muscle volume dependent on stage of pathology. The LGM demonstrated atrophy around the affected hip in subjects with advanced pathology (p< 0.05), however asymmetry of the UGM (p<0.01) could be attributed largely to hypertrophy on the unaffected side, based on between group comparisons of muscle volume.
TFL showed no significant asymmetry, or difference compared to the normal control group. This study highlights the functional separation of UGM and LGM, and the similarities of the UGM and TFL, both superficial abductors appearing to maintain their size around the affected hip. Further research is required to determine the specific changes occurring in the deeper abductor muscles. This information may assist in the development of more targeted and effective exercise programmes in the management of OA of the hip.
The Association Between Degenerative Hip Joint Pathology and Size of the Gluteus Medius, Gluteus Minimus, and Piriformis Muscles
This study aimed to investigate changes in the deep abductor muscles, gluteus medius(GMED), piriformis (PIRI), and gluteus minimus (GMIN), occurring in association with differing stages of unilateral degenerative hip joint pathology (mild: n=6, and advanced: n =6). Muscle volume assessed via magnetic resonance imaging was compared for each muscle between sides, and between groups (mild, advanced, control (n=12)). GMED and PIRI muscle volume was smaller around the affected hip in subjects with advanced pathology (p<0.01, p<0.05) while no significant asymmetry was present in the mild and control groups. GMIN showed a trend towards asymmetry in the advanced group (p=0.1) and the control group (p=0.076) which appears to have been associated with leg dominance.
Between group differences revealed a significant difference for the GMED muscle reflecting larger muscle volumes on the affected side in subjects with mild pathology, compared to matched control hips. This information suggests that while GMED appears to atrophy in subjects with advanced hip joint pathology, it may be predisposed to hypertrophy in early stages of pathology. Assessment and exercise prescription methods should consider that the response of muscles of the abductor synergy to joint pathology is not homogenous between muscles or across stages of pathology.
Lateral Hip Pain Mechanisms And Management
Lateral hip pain (LHP) has traditionally been referred to as trochanteric bursitis. More recent evidence has demonstrated that bursal distension is an inconsistent feature of lateral hip pain (Connell et al. 2003—15%; Bird et al. 2001—8%). Furthermore, histological studies of the bursa in such cases have found no signs of acute or chronic inflammation (silva et al. 2008). radiological and surgical studies have now shown that bursal distension is almost always a secondary finding associated with a primary pathology of gluteus medius or minimus tendinopathy (Bird et al. 2001, Cvitanic et al. 2002, Connell et al. 2003, dwek et al. 2005, Kingzett-taylor 1999, Kong et al. 2007, Pfirrmann et al. 2005, Woodley et al. 2008).
Prevalence studies suggest that degenerative tears of the gluteus medius or minimus tendons occur in 20% of patients with osteoarthritis of the hip (Howell et al. 2001). Prevalence of tendinopathy that has not yet progressed to a tear is therefore likely to be much higher. Gluteus medius tendinopathy (GMt) also occurs in 20–35% of patients with low back pain (Collee et al. 1991, tortolani et al. 2002). due to the pseudoradicular referral pattern from the greater trochanter down the lateral thigh, it is often misdiagnosed as lumbar pathology. this may lead to years of inappropriate and ineffective treatment, including laminectomy (tortolani et al. 2002). GMt is much more common in females than males, with a ratio of 3–4:1, peaking in the perimenopausal period. However, this condition may also occur in young athletes, particularly runners or those involved in step training.
Assessing Lateral Stability of the Hip and Pelvis
Adequate function of the hip abductor mechanism has been shown to be integral to ideal lower limb function and musculoskeletal health. Clinical assessment of hip abductor muscle function may include observational assessment of postural habits, muscle bulk, and of the ability to control optimal frontal plane femoropelvic alignment during a variety of single leg tasks. Strength testing using a hand held dynamometer is perhaps our most robust clinical assessment tool but should not be considered a ‘gold standard’ in the assessment of abductor muscle function. Evidence from magnetic resonance imaging (MRI), and electromyography (EMG) studies provides a deeper understanding of specific deficits that occur within the abductor synergy. The assessment of abductor function should not be based on a single test, but a battery of tests. The findings should be interpreted together rather than independently, and in the context of a thorough understanding of function of the lateral stability mechanism. Manner and comprehensiveness of abductor assessment will have important implications for management and particularly therapeutic exercise.