Working Diagnosis:
Gluteus medius tendonitis of left hip

Treatment:
A musculoskeletal ultrasound examination revealed a high grade tear versus complete rupture of insertional gluteus medius tendon at the left greater trochanter, with dynamic evaluation limited due to extremely limited ability to engage hip abduction against gravity. Case Photo #2 Case Photo #3 She consented to undergo an ultrasound guided greater trochanteric corticosteroid injection, which resulted in pain relief for one month following the injection. The pain recurred at 4 months after the initial steroid injection and she continued to use a walker for ambulation.

Regenerative medicine interventions were considered to help with tendon healing and decrease pain. A platelet rich plasma injection was cost prohibitive. An ultrasound guided percutaneous tenotomy (TENEX) was performed, with finding of diffuse gluteus medius tendinopathy with vast amount of interstitial tissue tearing and partial thickness tearing at the superior aspect of tendon during the procedure.

Outcome:
Two weeks after the procedure, the patient endorsed a 9 percent improvement of overall pain, with increased complaint of moderate anterior groin pain. Within 3 months of the procedure, the patient had improvement, was able to ambulate without her walker, with improved stability of gait, and was beginning physical therapy.

Author's Comments:
Unilateral Gluteus medius tendinopathy occurs in 15 percent of women and 6 percent of men.1

Platelet rich plasma injections could play a significant role in cases such as this; in a randomized double blinded study platelet rich plasma improved pain and function scores compared to steroid injection after 12 weeks.2

If patients are not improving after 12 months, and continue to have refractory symptoms, surgical repair of a torn tendon is often warranted.3

The Tenex procedure offers a minimally invasive alternative to arthroscopic or open repair.4

Editor's Comments:
The gluteus medius and minimus muscles provide pelvic stabilization during single leg stance of the gait cycle. When these muscles are dysfunctional, patients develop a waddling gait with contralateral hip drop due to muscle weakness, and pain at the ipsilateral greater trochanter due to tendon pathology. This occurs particularly with movements that require activation of the muscle for pelvic stabilization in single leg stance, such as climbing stairs, walking, getting out of a chair. As the gluteus medius and minimus are innervated by the superior gluteal nerve supplied by the L4, L5 and S1 nerve roots, gluteus medius and minimus pathology is particularly common in patients with radiculopathy or spinal stenosis affecting those nerve roots. Although short term relief can be obtained with greater trochanteric corticosteroid injections5, this is relief is typically short term, and may further worsen underlying tendon degeneration. Approaches targeting tendon remodeling such as graduated tendon-loading therapeutic exercise programs, needle tenotomy, PRP6, prolotherapy have been attempted in order to heal the tendons.7,8 In refractory cases, surgical tendon fixation is sometimes used, however evidence regarding best surgical approach is limited.9 Conservative treatment includes offloading the painful tendon with use of a cane or walker in order to limit tendon loading force, and use of a pillow between the legs during sleep to avoid compressive forces that result during the night with ipsilateral leg adduction. This compressive force has been implicated as a source of delayed tendon healing in other tendinopathic processes.

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