Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review

Abstract

Purpose Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space. Methods A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome. Results A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg’s test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised. Conclusion Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted. Level of evidence IV.

Satisfactory results after endoscopic gluteus medius repair combined with selective gluteus maximus reflected tendon release for the treatment of a full-thickness tear of gluteus medius

“…A full-thickness tear of the gluteus medius tendon is a common cause of pain with limping and functional limitation [ 28 ], and surgery is recommended in case of failure of non-operative management [ 12 ]. For the first time, the clinical outcomes of this novel surgical procedure combining endoscopic gluteus medius repair with the release of gluteus maximus reflected tendon and medium- and long-term follow-ups have been reported.…”

“…Although trochanteric pain is generally associated with the inflammation of the trochanteric bursa, many studies have suggested that the main cause of lateral hip pain is tearing in gluteal muscles, which is more prevalent in gluteus medius than in gluteus minimus [ 3 , 28 ]. Abductor tears are characterised more often by the onset of chronic pain generated by attritional forces than by acute traumatic pain [ 5 ].…”

A Review of Abductor Tendon Tears

“…However, this test only reached a sensitivity of 72.7% and a specificity of 76.9%. Multiple other studies have shown the utility of Trendelenburg's sign to identify gluteal tendinopathy, but the test alone cannot diagnose abductor tendon tears as it is seen in many other pathologies including superior gluteal nerve palsy, Legg-Calve-Perthes disease, osteonecrosis of the hip, and DDH 13,22,[27][28][29] . Ultimately, patients who have these symptoms as summarized in Table II and continue to have refractory pain after nonoperative management should be considered for advanced imaging.…”

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique

“…Snapping hip is an extra‐articular phenomenon involving movements of a tendon over a bony relief. External snapping hip (ESH), occurring in the lateral peri‐trochanteric area, arises due to an abrupt movement of the iliotibial band (ITB) over the great trochanter (GT) and is enhanced by a thickening of the posterior part of the ITB or the anterior margin of the gluteus maximus muscle [19, 21]. ESH usually affects young adults, mostly female, practicing sports with repetitive hip motions such as football, dance, martial arts or running [21].…”