Dr. Ebraheim’s educational animated video describes gluteus medius tendon tear - abductor muscle tears.
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The gluteus medius tendon tear is recognized more as a cause of hip pain and if this tear causes disability to the patient, then the treatment is repair of the tear. However, if the repair is not possible because the patient has advanced muscle atrophy or there is a big gap between the tendon and its insertion, then we will do transfer of the gluteus maximus muscle to the greater trochanter. The pathology of the hip abductor is common. It is grouped under the greater trochanter pain or bursitis and there is a spectrum between bursitis and tendonitis, tendinosis, to a partial tear, to a complete tear, to a massive chronic neglected tear. These tears happen more with hip arthritis and it is clinically silent. It is part of the greater trochanter pain syndrome, where the patient will have chronic lateral hip pain and tenderness over the greater trochanter and the pain can mimic other serious causes of hip pain, including stress fracture, AVN, arthritis, and piriformis syndrome. The lateral hip pain may not be limited to the greater trochanter. It may extend into the buttock or even to the lower back, and this may complicate the clinical picture more. The role of hip abductor tendon tear as a cause of hip pain is underestimated. Usually the condition is dismissed as trochanteric bursitis. When an elderly patient complains about trochanteric bursitis, especially if it is chronic and not getting better with treatment, careful examination is necessary and imaging may be necessary. So the patient will come with symptoms of lateral or posterior hip pain with tenderness over the greater trochanter. The patient will have a limp and will have weakness of abduction and Trendelenburg Gait. The symptoms and exam may be nonspecific or may even be confusing. The strength may be 4/5 or even 5/5. The patient may present many months or years after the onset of the symptoms. The condition may be totally occult. MRI may be necessary to diagnose the tear. MRI may show partial tear to tendonitis or tendinosis or even retraction of the tear with atrophy of the muscle, which may need soft tissue release for repairing the tendon. The MRI may show significant muscle atrophy and the patient may need gluteus maximus transfer. If an elderly patient has a hip replacement and continues to complain of symptoms of greater trochanteric pain and walks with a limp, consider in the differencial diagnsosis a gluteus medius tendon tear. An MRI can really be helpful, even in the presence of prosthesis in the hip. Before we talk about the treatment of the tear, we need to talk about what is the role of the gluteus medius and gluteus minimus muscles. The gluteus medius and minimus muscles are important in stabilizing the ipsilateral hip in the stance phase of the gait cycle. The weakened gluteus medius allows the opposite side of the pelvis to tilt downwards during stance on the weakened side. The other side of the pelvis tips down. The trunk leans towards the weakened side, which is called abductor lurch during the stance phase. This occurs because the trunk is basically trying to help the weak side of the pelvis (giving the muscle assistance). This really helps the weak side by moving the center of gravity near the fulcrum on the weak side. This shortens the moment arm from the center of gravity to the hip joint and this will reduce the force and the effort. TREATMENT OF GLUTEUS MEDIUS & MINIMUS TEARS We need to understand the area of insertion of the tendons on the greater trochanter. The greater trochanter has four facets: Gluteus Minimus - Inserts into the anterior facet. Gluteus Medius - Inserts into the lateral and superoposterior facets. Gluteus Maximus - Inserts into the posterior facet. Another important area of interest: Early Repair is Better! The tendon goes into a progressive phase of deterioration from tendinosis to partial tear, degeneration to complete tear, retraction, fatty infiltration, and atrophy. You need to think about the condition and treat it before it reaches that chronic, advanced stage. Nonoperative treatment of the hip abductor like tendinosis,tendonitis, or bursitis is successful in the majority of patients. Surgical repair for partial or complete hip abductor tendon tears is also successful in relieving the pain and improving the function of the patient. Not all tears are repairable, even with soft tissue release. A complete tear plus muscle atrophy and fatty degeneration represents a bad prognosis and a difficult, complex situation for the patient. When the tear cannot be repaired or the cause of the muscle atrophy is superior gluteal nerve injury, then a muscle transfer is necessary.