Review Article

Greater Trochanteric Pain

Syndrome
Abstract
John M. Redmond, MD
Austin W. Chen, MD
Benjamin G. Domb, MD

From the Department of Orthopedic

Surgery, Mayo Clinic, Jacksonville, FL
(Dr. Redmond), the American Hip
Institute, Chicago IL (Dr. Chen and
Dr. Domb), and Hinsdale Orthopaedics,
Westmont, IL (Dr. Domb).
Dr. Domb or an immediate family
member has received royalties from
Arthrex, DJO Global, and
Orthomerica; is a member of a
speakers bureau or has made paid
presentations on behalf of Arthrex and
ATI Physical Therapy; serves as a
paid consultant to Amplitude, Arthrex,
Pacira Pharmaceuticals, and Stryker;
has received research or institutional
support from Arthrex, ATI Physical
Therapy, Breg, Pacira
Pharmaceuticals, and Stryker; and
serves as a board member, owner,
officer, or committee member of the
American Hip Institute and the
Arthroscopy Association of North
America. Neither of the following
authors nor any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Redmond and Dr. Chen.
J Am Acad Orthop Surg 2016;24:
231-240
http://dx.doi.org/10.5435/
JAAOS-D-14-00406
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.

Patients who have lateral hip pain historically have been diagnosed
with trochanteric bursitis and treated with nonsteroidal antiinflammatory medications, corticosteroid injections, and physical
therapy. Although this strategy is effective for most patients, a
substantial number of patients continue to have pain and functional
limitations. Over the past decade, our understanding of disorders
occurring in the peritrochanteric space has increased dramatically.
Greater trochanteric pain syndrome encompasses trochanteric
bursitis, external coxa saltans (ie, snapping hip), and abductor
tendinopathy. A thorough understanding of the anatomy, examination
findings, and imaging characteristics aids the clinician in treating these
patients. Open and endoscopic treatment options are available for use
when nonsurgical treatment is unsuccessful.

ateral-sided hip pain is a common problem encountered in

orthopaedic practice.1,2 Historically,
patients with lateral hip pain have
been diagnosed with trochanteric
bursitis and treated with physical
therapy, NSAIDs, and corticosteroid
injections. Although this treatment
is effective in most patients, some
patients continue to have pain
refractory to nonsurgical treatment.
One recent study showed that
lateral-sided hip pain may be as
debilitating as end-stage degenerative joint disease.3
The term greater trochanteric pain
syndrome (GTPS) encompasses trochanteric bursitis, gluteus medius and
gluteus minimus tendinopathy, and
external coxa saltans (ie, snapping
hip).1 Many patients who have previously received a diagnosis of trochanteric bursitis may actually have
hip abductor tendinopathy, which can
be refractory to nonsurgical treatment
options. To improve care and avoid
delays in diagnosis, pathology of the
gluteus medius or minimus should be

considered during evaluation of these

patients. Knowledge of the relevant
anatomy, patient profile, differential
diagnosis, and imaging options can
aid in the appropriate diagnosis of
lateral hip pain. Nonsurgical treatment should be used initially in most
patients with GTPS. In select patients,
surgical treatment via an open
approach or peritrochanteric endoscopy is appropriate.

Anatomy
The anatomy of the peritrochanteric
space has been well described2,4
(Figure 1). Most patients have three
bursae peripheral to the greater
trochanter; some have four. These
fluid-filled sacs cushion and aid in
smooth motion of the gluteus tendons, iliotibial band (ITB), and tensor
fascia lata. The largest is the subgluteus maximus bursa, which is
located between the gluteus maximus
muscle and the gluteus medius tendon, lateral to the greater trochanter.

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231

Greater Trochanteric Pain Syndrome

Figure 1

Illustrations depicting the anatomy of the greater trochanter with tendinous insertion sites and bursae insertions. A, The three
main bursae and their positions. B, Facets of the greater trochanter. C, Footprints of the gluteus medius and gluteus minimus
tendons. (Reproduced with permission from Domb BG, Nasser RM, Botser IB: Partial-thickness tears of the gluteus medius:
Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy 2010;26[12]:1697-1705.)

This bursa is referred to as the trochanteric bursa and is frequently

implicated in GTPS.5
The most superficial structure of the
peritrochanteric space is a fibromuscular sheath composed of the
gluteus maximus, the tensor fascia
lata, and the ITB. The gluteus maximus inserts into the posterior aspect
of the ITB, whereas the tensor fascia
lata inserts into the superior and
anterior aspects. The fascia lata that
encloses these structures extends
superiorly without muscular attachment to the tubercle of the iliac crest.
Just distal to the hip joint, the ITB has
a thick expansionthe gluteus maximus slingthat inserts on the posterolateral femur. The ITB crosses the
knee joint distally and inserts onto the
Gerdy tubercle on the anterolateral
aspect of the proximal tibia.
The gluteus medius and gluteus
minimus have been referred to as the
rotator cuff of the hip.6 Table 1
compares the shoulder rotator cuff
and the analogous structure in the

232

hip. The gluteus minimus originates

from the anterior inferior iliac spine
to the posterior inferior iliac spine,
runs parallel to the femoral neck, and
inserts into the hip capsule and lateral
facet beneath the gluteus medius7
(Figure 1). The fan-shaped gluteus
medius extends from the anterior
superior iliac spine to the outer edge
of the iliac crest and back to the
posterior superior iliac spine. It has
two or three insertion points on the
greater trochanter: a thick insertion
from the central posterior portion of
the muscle on the superoposterior
facet of the greater trochanter; the
insertion of a thin, broad lateral
portion onto the lateral facet of the
greater trochanter; and an insertion
onto the anterior facet of the greater
trochanter that is not visible macroscopically4 (Figure 1). The gluteus
minimus and posterior gluteus
medius stabilize the femoral head
within the acetabulum during
motion and gait. The anterior and
middle portions of the gluteus

medius have a vertical pull, which

helps initiate abduction. The major
abductor of the hip is the tensor
fascia lata.8

Etiology
Accurate diagnosis of the underlying
etiology is the key to successful
management of GTPS. As noted, this
condition encompasses greater trochanteric bursitis, gluteus medius and
gluteus minimus tears, and external
coxa saltans. 1 Two or more of
these diagnoses are often seen
concomitantly.
Greater trochanteric bursitis, or
inflammation of one or more of the
peritrochanteric bursae, has historically been considered the main source
of lateral hip pain. A proposed cause
is repetitive friction between the
greater trochanter and ITB associated
with overuse, trauma, and altered
gait patterns. Imaging studies have
shown that most patients who receive

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John M. Redmond, MD, et al

Table 1
Comparison of the Shoulder Rotator Cuff and the Analogous Structure in the Hip
Characteristic
Functional anatomy
Internal rotator
Stabilizers and rotators; initiation
and assistance in abduction
Abduction
Clinical presentation
Imaging
Mechanism of pathology
Arthroscopic evaluation

Shoulder

Hip

Subscapularis
Supraspinatus and infraspinatus

Iliopsoas
Gluteus medius and gluteus minimus

Deltoid
Pain with motion, tenderness, weakness
in abduction
MRI and ultrasonography
Degenerative tearing
Articular tears can be visualized as
exposed footprint or delamination

Tensor fascia lata

Tenderness over lateral aspect of hip,
weakness in abduction
MRI and ultrasonography
Degenerative tearing
Undersurface tears cannot be easily
visualized

Adapted with permission from Domb BG, Nasser RM, Botser IB: Partial-thickness tears of the gluteus medius: Rationale and technique for transtendinous endoscopic repair. Arthroscopy 2010;26(12):1697-1705.

a diagnosis of bursitis actually have

abductor tears, tendinosis, and
thickened ITBs with little to no evidence of actual bursitis.4,9,10
The use of MRI and advances in
endoscopy have resulted in increasing
diagnosis of tears of the gluteus
medius and gluteus minimus. The hip
can undergo an injury process with
subsequent tendon degeneration and
eventual tearing analogous to that of
the shoulder rotator cuff. Similar to
tears of the rotator cuff in the shoulder, tendon tears in the hip range
from interstitial to full-thickness.9
Clinical signs of a full-thickness
gluteus medius tear include weakness on examination or a Trendelenburg gait.
External coxa saltans (ie, snapping hip syndrome) is most often the
result of rubbing of the ITB over the
greater trochanter. When the hip
moves from extension to flexion,
the ITB moves from posterior to
anterior in relation to the greater
trochanter. This snapping of the ITB
over the greater trochanter can be
audible and painful; however, it can
also be asymptomatic, especially in
athletes. Repetitive snapping can
lead to a thickened ITB and trochanteric bursitis.9

History and Physical

Examination
A thorough history and physical
examination are necessary in patients
with lateral hip pain. The history
should include patient age, chief
complaint, symptom onset, duration,
course, aggravating/relieving factors,
and any previous treatment. Previous
surgical treatment of the hip may
have involved access through a portion of the abductors or a trochanteric osteotomy. Aggravating factors
can include side-bending, sleeping on
the affected side, and prolonged
sitting. Hip and back pain commonly
coexist. Symptoms of neural compression originating from the spine
include weakness, numbness, and/or
paresthesia. Painful mechanical
symptoms of snapping, catching,
clicking, locking, and popping in a
specific area may indicate a structural
problem. Patients may have already
initiated nonsurgical management,
including physical therapy, medications, the use of assistive devices,
injections, and alternative medicine
treatments. The clinician should
document any previous nonsurgical
management.

Physical examination begins with

determining the patients height,
weight, and body mass index. On
entering the room, the clinician
should note the patients standing or
sitting posture because standing with
a slightly flexed hip and ipsilateral
knee or listing to the contralateral
side while sitting can be signs of hip
pathology. Examination of gait may
demonstrate an antalgic gait, an
abductor lurch (ie, Trendelenburg
gait), or a short-leg limp. A short-leg
limp may suggest ITB pathology or a
true limb-length discrepancy. Rangeof-motion testing includes flexion,
internal/external rotation in flexion,
and abduction. The unaffected
extremity can be examined for
comparison. Strength testing of the
hip flexors, extensors, abductors,
adductors, hamstrings, and quadriceps can also be helpful. Points to
examine for tenderness are the
anterior superior iliac spine, rectus
femoris attachments, pubic symphysis, adductor musculature origin,
rectus abdominis insertion (ie, sports
hernia), sacroiliac joint, coccyx,
greater trochanter, piriformis, groin
(ie, hernia), ischial tuberosity, iliac
crest, and hamstring musculature
origin.

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233

Greater Trochanteric Pain Syndrome

Table 2
Differential Diagnosis of Hip Pain
Location of Pain

Structures
Affected

Intra-articular hip

Extra-articular hip

Muscle/tendon/
bursa

Bone
Nerve

Other
Outside the hip

Axial

Sacroiliac
Radicular

Several provocative tests can aid in

diagnosis, including log rolling and
impingement maneuvers, the FABER
(flexion, abduction, external rotation) test, internal snapping of the
iliopsoas tendon, sciatic nerve compression tests, the straight leg raise
test, and the dial test (for capsular
laxity). The Ober test can be performed with the hip in extension,
neutral, and flexion when assessing
for contractures of the ITB, gluteus
medius, and gluteus maximus,
respectively. When attempting to
elicit a mechanical symptom, such as
snapping of the ITB, the clinician
should first ask the patient to recreate
the movements that cause it. Moving

234

Disorders
Femoroacetabular impingement
Dysplasia
Labral tear
Ligamentum teres tear
Synovitis
Capsulitis
Loose body
Degenerative joint disease
Osteonecrosis
Adductor strain
Iliotibial band syndrome
Iliopsoas complex disorders
Piriformis/hip external rotator
disorders
Greater trochanteric pain syndrome
Hamstring complex disorders
Stress fracture
Epiphysitis
Transient osteoporosis
Meralgia paresthetica
Genitofemoral nerve disorders
Ilioinguinal nerve disorders
Sciatic nerve disorders
Sports hernia
Pelvic visceral pain
Disk disorders
Facet disorders
Lumbar strain
Vertebral fracture
Sacroiliac disorders
Spinal stenosis
Radiculopathy
Spondylolisthesis

the affected extremity from flexion,

abduction, and external rotation to
extension, adduction, and internal
rotation is the classic sequence used
to test for external snapping of the
ITB. During a positive Trendelenburg
test, the patients torso will lean to
the affected side while the contralateral side of the pelvis will sag,
demonstrating abductor weakness or
insufficiency.11

Differential Diagnosis
The diagnosis of GTPS can be complicated given the multiple possible
sources of pain surrounding the hip

girdle. The differential diagnosis

includes intra-articular hip pathology,
extra-articular hip pathology, and
pain resulting from sources outside the
hip (Table 2). Intra-articular sources
of pain include labral tears, loose
bodies, femoroacetabular impingement, capsular laxity, ligamentum
teres rupture, and chondral damage.
Extra-articular sources include stress
fractures, piriformis syndrome, and
neoplasms.12 Sources of hip pain that
are outside the hip include pathology
of the superior gluteal nerve, meralgia
paresthetica, lumbar spondylosis, and
lumbar radiculopathy. In patients
with lumbar spondylosis or lumbar
radiculopathy, as in patients with
GTPS, a limp and hip abductor
weakness may be present along with
radiating pain. Patients with a history
of total hip arthroplasty, especially
through an anterolateral approach,
may have iatrogenic injury to the
abductor mechanism or its innervation. A detailed history, physical
examination, and appropriate imaging will help narrow the differential
diagnosis.

Imaging
The most common imaging modalities used in the evaluation of GTPS
are plain radiography, ultrasonography, and MRI. A better understanding of the role of the gluteus medius
and/or gluteus minimus in GTPS has
led to an increased interest in defining
the normal and pathologic appearance of these structures via ultrasonography and MRI.
Standard radiography may be useful when evaluating patients with
lateral hip pain. Many patients with
intra-articular pathology have pain
referred to the lateral hip. Routine
radiography can assist in ruling out
hip degenerative joint disease, femoroacetabular impingement, and dysplasia. These conditions should be
ruled out before treatment of GTPS is

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John M. Redmond, MD, et al

Figure 2

Coronal T2-weighted magnetic

resonance image demonstrating a
normal left hip. The arrowhead
indicates the gluteus medius
tendon, the long arrow indicates
the greater trochanter, and the
short arrow indicates the iliotibial
band.

initiated. Diagnostic injections can

assist in further differentiating intraarticular pain from lateral hip pain. In
one study, a trochanter protruding
farther lateral than the lateral border
of the iliac crest was shown to be a
predisposing risk factor for GTPS.13
Peritrochanteric calcifications are
often seen but typically are nonspecific findings. Intrabursal calcification, calcific abductor tendinosis,
and enthesophytes are frequently
encountered. In one study comparing 150 hip radiographs to 150 hip
MRIs, surface irregularities of the
trochanter .2 mm had a 90% correlation with abductor tendon
abnormalities.14
Ultrasonography has been shown
to be an effective tool in the evaluation of GTPS. In one systematic
review, the use of ultrasonography
for diagnosis of abductor tendon
pathology was shown to have a sensitivity of 79% to 100% and a positive predictive value of 95% to
100%.15 Ultrasonography has the
benefit of allowing dynamic evaluation, which can be beneficial for
confirming external snapping of the

Figure 3

Coronal T2-weighted magnetic

resonance image demonstrating
the left hip of a patient with
trochanteric bursitis. The arrow
indicates inflammation of
the trochanteric bursa. The
arrowhead indicates the greater
trochanter.

hip because snapping of the trochanter against the ITB can be visualized and correlated with patient
symptoms. In the evaluation of gluteus medius pathology, the probe can
be used to palpate different areas of
the tendon for a pain response, and a
diagnostic injection can be performed
to test for pain resolution. In a recent
study, Long et al9 retrospectively
evaluated 877 trochanteric sonograms in patients with greater trochanteric pain and found that most
patients did not have trochanteric
bursitis. The ultrasonographic characteristics identified included gluteal
tendinosis in 50% of patients, a
thickened ITB in 28.5% of patients, a
gluteal tendon tear in 0.5% of
patients, and trochanteric bursitis in
20% of patients.
The primary means of evaluating a
patient for GTPS is MRI (Figure 2).
MRI or magnetic resonance arthrography allows visualization of
the hip joint and extra-articular
structures, which can help rule out
other hip disorders. Trochanteric
bursitis can result in inflammation
visible within the area surrounding

Figure 4

Coronal T2-weighted magnetic

resonance image demonstrating the
right hip of a patient with a gluteus
medius tendon tear. The arrow
indicates the gluteus medius muscle.
The arrowhead indicates disruption
of the gluteus medius insertion on
the greater trochanter.

the greater trochanter (Figure 3). In

one study, MRI was used to evaluate
gluteus medius pathology in 250
patients with lateral hip, groin, or
buttock pain.16 A thickened tendon
and increased signal intensity on T2weighted images were characteristic
of tendinosis. Partial-thickness tears
were indicated by focal discontinuity
of the gluteus medius fibers, and
complete tears were defined as those
involving retraction of the tendon. In
this study, 35 patients (14%) demonstrated hip abductor pathology. In
a different study, Cvitanic et al17
compared MRI findings with intraoperative findings in 15 patients with
hip abductor tears and 59 control
subjects. The accuracy of MRI in this
cohort was 91%. The authors identified an area of T2 hyperintensity
superior to the greater trochanter
that had 73% sensitivity and 95%
specificity in the diagnosis of
abductor tears17 (Figure 4). A recent
study demonstrated that patients
who have gluteus medius tendon
tears also have tensor fasciae latae
that are hypertrophied compared
with the contralateral side as a result

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235

Greater Trochanteric Pain Syndrome

Figure 5

Arthroscopic images viewed 70 cephalad through a distal lateral portal,

demonstrating management of an inflamed trochanteric bursa during
peritrochanteric endoscopy in a left hip. A, The thickened bursal tissue can be
seen upon entering the peritrochanteric space. B, The same hip after
bursectomy with a suction shaver. GM = gluteus medius, VL = vastus lateralis

of compensation for decreased

abductor strength. In this study, the
ratio of the area of the tensor fascia
lata to the sartorius on the side of the
gluteus medius tear was considerably
larger than the ratio on the contralateral side.18

Management
Nonsurgical
As noted, GTPS has typically been
classified as trochanteric bursitis
and treated with anti-inflammatory
medications, physical therapy, and
corticosteroid
injections.
Nonsurgical management of GTPS has
been successful in most patients.19
Furia et al20 analyzed a group of
patients treated nonsurgically with
rest, physical therapy, ultrasonography, injections, ice, and heat. The
authors noted that 10 of 15 patients
(66%) were able to return to sports
and 5 of 6 patients (83%) were able
to return to labor occupations 3
months after initiation of nonsurgical management.
The use of corticosteroid injection
in the treatment of GTPS has been

236

examined in a systematic review.19

Patients had symptoms for 7.1 weeks
to 4.4 years before the injection.
Follow-up ranged from 3 months to 4
years. The results of these studies are
difficult to summarize because of the
variety of outcome measures used;
however, improvement ranged from
49% to 100% compared with the
patients baseline activities. The mean
improvement in the visual analog
score (VAS) was 2.8 in the three
studies that used this pain score. A
comparison of the efficacy of standard injection and ultrasonographyguided injection demonstrated no
difference. However, ultrasonographyguided injection may be helpful in
patients with extremely large body
habitus.
The use of extracorporeal shock
wave therapy (ESWT) for GTPS has
been evaluated in several studies.21
Furia et al20 compared 33 patients
treated with ESWT and a control
group treated with rest, physical
therapy, anti-inflammatory medications, and corticosteroid injections.
The authors found improved pain
and function following ESWT at 1,
3, and 12 months compared with the

use of other nonsurgical treatment

modalities. At 12-month follow-up,
the VAS decreased from 8.5 to 2.7 in
the ESWT group, compared with a
decrease from 8.5 to 6.3 in the
control group. The modified Harris
hip score increased from 49.6 to 79.9
in the ESWT group at 12 months,
compared with an increase from 50.4
to 57.6 in the control group. Rompe
et al22 compared three methods of
treatment of GTPS in a randomized
trial. In that study, 78 patients
underwent ESWT, 75 patients
received a corticosteroid injection,
and 76 patients underwent physical
therapy. Pain scores were evaluated at
1 month, 4 months, and 15 months.
Although the corticosteroid injection
was more successful than physical
therapy or ESWT at 1 month, the
results of ESWT and physical therapy
were more successful at 15 months.
Pain scores in the ESWT and physical
therapy groups decreased from 6.3 to
2.4 and from 6.2 to 2.7, respectively.22 On the basis of limited data,
ESWT appears to be effective for the
treatment of GTPS.
Data on the use of platelet-rich
plasma (PRP) for the treatment of
GTPS are limited. In one study,
researchers evaluated the use of PRP
in the management of chronic tendinopathy and documented patients
perceived improvement in symptoms.23 Sixteen patients had gluteus
medius tendon injections, and 81%
reported moderate improvement or
better at a mean 15-month followup. Further study of the use of PRP
for GTPS is needed.

Surgical
Surgical management of GTPS should
be reserved for patients with symptoms
that have been present for a minimum
of 6 to 12 months and in whom nonsurgical treatment has been unsuccessful. Multiple techniques have been
used to treat GTPS depending on the
etiology of the pain. Open or endoscopic approaches can be used.

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John M. Redmond, MD, et al

Figure 6

Arthroscopic image of a left hip

viewed 70 cephalad from a distal
lateral portal demonstrating the
release of the iliotibial band (ITB)
with electrocautery during
peritrochanteric endoscopy.

Trochanteric Bursitis
Open treatment of refractory trochanteric bursitis has been performed
for decades. Brooker24 described
bursectomy with release of the ITB in
1979. In most case series, whether
the approach was open or endoscopic, the treatment of trochanteric
bursitis has involved both release of
the ITB and dbridement of the trochanteric bursa.
In several small case series, open
ITB release and bursectomy have
been performed with satisfactory
results. In one study, 12 patients
underwent trochanteric reduction
osteotomy for refractory bursitis and
had good results at 23.5 months. In
that study, 11 of 12 patients reported
their improvement as great or very
great. Five of these patients had previously undergone a failed open ITB
release with bursectomy.25
Isolated trochanteric bursectomy
can be performed arthroscopically
(Figure 5). Published results consist
primarily of small case series. Fox26
reported the results of isolated
arthroscopic trochanteric bursectomy without ITB release for
refractory trochanteric bursitis in
2002. In that study, 23 of 27 patients

Figure 7

Arthroscopic images viewed 70 cephalad through a distal lateral portal,

demonstrating gluteus medius repair during peritrochanteric endoscopy of a
left hip. A, A high-grade partial-thickness tear of the gluteus medius (GM)
with the exposed trochanter (T). B, The GM has been repaired with suture
anchors.

had good to excellent results at

a minimum 1-year follow-up. Two
recurrences occurred in the 5 years
after surgical treatment. Baker et al27
described their experience with
arthroscopic trochanteric bursectomy in 25 patients. Their technique
included making a longitudinal
incision in the ITB with an ablator.
At a mean 26.1-month follow-up,
the authors noted significant
improvements in the mean Harris
hip score (from 51 to 77), VAS score
(from 7.2 to 3.1), and Medical
Outcomes Study 36-Item Short Form
scores. The development of a seroma
in one patient required repeat surgery, and one patient underwent
revision to open bursectomy.
External Snapping of the Hip
Multiple case series have documented
successful treatment of external
snapping of the hip. The techniques
involve open or arthroscopic release
of the ITB.28 External snapping of
the hip is thought to be the result of a
thickened area of the posterior
ITB snapping across the trochanter
as it moves from posterior in hip

extension to anterior in hip flexion.

Release of the ITB decreases the
tension on this thickened area.
Open techniques have involved
Z-plasty and ITB release, usually in
combination with trochanteric bursectomy. To date, no comparative
studies have been performed. Proponents of Z-plasty have argued that
leaving a defect in the ITB following
release may affect hip abduction
strength; however, this theory
remains to be proven.29 In general,
the available case series document a
high success rate in eliminating
snapping and pain, with few failures
requiring revision surgery.
Arthroscopic ITB release has been
reported for the treatment of external
snapping of the hip (Figure 6).
Ilizaliturri et al28 reported the results
of arthroscopic ITB release in 11
patients. The technique involved
making a diamond-shaped window
over the trochanter. Snapping was
relieved in 10 of 11 patients at
a minimum 2-year follow-up. One
patient continued to have snapping
but was pain free and did not require
revision surgery. The authors of the

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237

Greater Trochanteric Pain Syndrome

Figure 8

Illustrations depicting surgical repair of a gluteus medius tendon tear in a right hip.
Proximal is left, and distal is right. A, Superficial view of an intact gluteus tendon.
B, Cross-sectional view of an intact gluteus tendon. C, Superficial view of the
undersurface of a gluteus tendon tear (gray shaded area). D, Cross-sectional view of
the undersurface of a gluteus tendon tear (arrow). E, Superficial view of a longitudinal
incision along the gluteus tendon fibers. F, Cross-sectional view of a longitudinal
incision along the gluteus tendon fibers (arrow). G, Superficial view demonstrating
anchor placement and suture passage through tendon edges, after dbridement of
the tear and decortication of the bony bed. H, Cross-sectional view demonstrating
anchor placement and suture passage. I, Superficial view of the final repair of the
gluteus tendon. J, Cross-sectional view of the final repair of the gluteus tendon.

study noted that the arthroscopic

procedure is typically more time
consuming and costly but is less
invasive than open surgical treatment.

238

Hip Abductor Tears

The analogy of the hip abductors to
the shoulder rotator cuff has led to a
similar progression in treatment.

Open and arthroscopic treatment

options exist for partial-thickness
and full-thickness tears. For the
treatment of irreparable tears, muscle
transfers and allograft augmentation
have been described. The literature
on surgical treatment of hip abductor
tears largely consists of case series
and lags substantially behind that of
rotator cuff disorders.
Full-thickness tears of the gluteus
medius have been recognized and
treated in several case series. In three
studies documenting the prevalence of
abductor tendon tears identified during arthroplasty, rates of 20% to 25%
were noted.6,30,31 Open treatment
techniques that use drill holes
through the trochanter and suture
anchors have been described. Walsh
et al32 reported on a series of 72
patients undergoing open repair with
1-year follow-up. They noted
improvement in pain and function in
95% of patients. Davies et al33
recently reported their experience
with open repair and described a
grading system for tears based on tear
size. The improvement in Harris hip
scores in their patient population was
similar to that of patients undergoing
total hip arthroplasty. The mean
Harris hip score improved from 53 to
88 at a minimum 5-year follow-up.
Strength testing on a 5-point scale
improved from 3.1 preoperatively to
4.7 at 1-year follow-up. The authors
documented improvement in 16 of 19
patients and poor results in 3
patients. The poor results tended to
be in patients with the largest tears.33
Arthroscopic treatment of abductor
tendon tears of the hip has also been
described in several case series (Figure
7). McCormick et al34 reported on 10
patients undergoing isolated endoscopic gluteus medius repair and
noted improved outcomes, improved
strength, and decreased pain at an
average follow-up of 23 months. The
mean modified Harris hip score was
84.7 postoperatively. The authors
also reported on arthroscopic repair

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John M. Redmond, MD, et al

of the gluteus minimus in five

patients. Domb et al35 and Voos
et al36 described their experience
with concomitant hip arthroscopy
and peritrochanteric endoscopy and
noted a high prevalence of intraarticular pathology in patients
undergoing endoscopic gluteus medius repair. They reported satisfactory hip outcome scores and pain
improvement at 2-year follow-up. In
the series by Domb et al,35 nine
patients had full-thickness tears and
six had partial-thickness tears. At a
mean follow-up of 27.9 months, the
VAS score decreased from 6.8 to 1.4,
and the modified Harris hip score
increased from 50 to 84. Voos et al36
reported on 10 patients with a mean
follow-up of 25 months. Five patients
had full-thickness tears, and five had
partial-thickness tears. All of the
patients had complete resolution of
lateral hip pain and full strength at
final follow-up. The mean modified
Harris hip score was 94 at 1-year
follow-up. To date, all case reports of
endoscopic hip abductor repairs have
demonstrated satisfactory results
without notable complications. No
comparative studies of open and
arthroscopic techniques exist; however, Voos et al36 described the
potential need for conversion to open
surgical repair in patients with larger
chronic tears, and our experience has
been similar.
Partial-thickness tears of the gluteus
medius tendon are thought to develop
on the undersurface of the tendon,
which makes identification of the
lesion difficult. In the shoulder, the
rotator cuff can be evaluated from
the articular side and the bursal
side, but in the hip, evaluation of the
undersurface of the gluteus medius
is difficult. An arthroscopic probe
can be placed behind the tendon and
the quality of the tendon can be assessed. Often the surgeon will note
near-complete tears and delamination from the trochanter. Repair of
partial-thickness tears has been re-

ported in two case series (Figure 8). The

study by Domb et al35 included six
patients with partial-thickness tears,
and Thaunat et al37 reported on four
patients with a 6-month follow-up. In
both series, satisfactory results were
obtained without complications.
In patients with chronic, complete
avulsions of the gluteus medius,
mobilizing the tendon back to its
trochanteric attachment may be
impossible. In these patients, several
reconstructive options are available. If
the gluteus medius muscle has not
atrophied, an allograft tendon or graft
can be used for interposition to augment the gluteus medius.33,38 Another
option is to advance the vastus lateralis muscle to bridge the defect.39 For
patients with an atrophied gluteus
medius muscle, Whiteside40 described
a transfer of the gluteus maximus and
tensor fascia lata to the trochanter.
Follow-up was an average of 28
months after the transfer, and Whiteside40 noted that four of five patients
were able to walk without a cane. The
fifth patient sustained a fall 10 months
postoperatively and fractured his
trochanter.

Summary
The anatomy and characteristic
pathology of the peritrochanteric
space has recently begun to be better
understood. The diagnosis of GTPS,
which encompasses greater trochanteric bursitis, gluteus medius and
gluteus minimus tears, and external
coxa saltans (ie, snapping hip), can be
complicated. Nonsurgical methods
are the mainstay of treatment of
GTPS. In patients who do not
respond well to nonsurgical treatment, open or endoscopic surgical
treatment has shown promise.

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