Revista de Medicina Desportiva (English) September 2018 - Page 12

Rev. Med. Desp. informa, 2018; 9(5):10–13. Hip Abductor Apparatus Ruptures Dr. Diogo Lino Moura 1 , Dr. José Pedro Marques 2 , Dr. António Figueiredo 3 , Prof. Doutor António Bernardes 4 , Prof. Doutor Fernando Fonseca 5 1 Resident of orthopedics at the hospital and University Center of Coimbra (CHUC); Invited Assistant of Anatomy at the Faculty of Medicine of the University of Coimbra (FMUC); 2 Hospital Assistant of Sports Medicine at the CHUC; 3 Hospital assistant graduate of orthopedics – hip department of the CHUC; 4 Regent of Anatomy at the FMUC; 5 Director of the orthopedics department at CHUC. Coimbra, Portugal ABSTRACT Gluteus medius and minimus muscle disease has beed increasingly recognized as an important cause and probably underdiagnosed of the common persistent trochanteric pain. Also known as hip rotator cuff, the abductor apparatus of the hip can be affected by more frequent chronic degenera- tive tears and also by acute traumatic tears. Besides the trochanteric pain, it is also present the typical abductor weakness gait. When these symptoms are unresponsive to anti-inflammatory and rehabilitation conservative treatment, the magnetic resonance is indicated. If a gluteus tear is confirmed and is consistent with the symptoms, its surgical repair is indicated. In this paper we present a review of the current scientific literature about anatomy and biomechanics of the abductor apparatus of the hip, and the symptoms, diagnosis and treatment of gluteus tears. KEYWORDS Abdutor apparatus, hip, medius gluteus, rotator cuff, tear, tendon, great trochanteric pain Anatomy and biomechanics of the hip abductor apparatus The hip abductor apparatus is com- posed by the trochanteric abductor muscles (responsible for 70% of the abduction force are the medium and the small gluteus) and by tension- ers muscles of the iliotibial band, which are the upper portion of the large gluteus, the fascia lata tensor and the vastus lateralis (figure 1). The hip abductor complex involves the hip joint in a manner similar to the rotator cuff of the glenohumeral joint, being fundamental for the dynamic stability of the hips and the pelvis and, consequently, it is essential for the gait. 1-4 The muscle gluteus medium It is the iliofemoral muscle (because it is directed from the ilium to the femur) most impor- tant of this complex and this is the one we are looking at in this text. It is the primary abductor muscle and the main controller of the hip rotation, being still responsible for supporting and stabilizing the pelvis, in order to maintain both hips at the same height during the gait and the unipodal support, and its nor- mal function is fundamental for a normal gait. The muscle is mostly in the sagittal plane and its amplitude 10 september 2018 allows the various groups of mus- cle bundles to function as a cuff involved on hip rotation (hip rotator cuff). 1-3,5-9 Ruptures of the abductor apparatus of the hip The gluteal pathology has been increasingly recognized as an impor- tant, and probably underdiagnosed, cause of the frequent persistent pain in the trochanteric area or lateral side of the hip, the so-called trochanteric pain syndrome. The tendinopathy and the total or partial ruptures of hip abductors are cur- rently considered primary injuries Figure 1 – Hip abductor apparatus 1,4 and secondary lesions, consequent to the primary, are trochanteric bur- sitis, retraction and gluteal adipose degeneration and the development of sclerosis and osteophytes at the level of the great trochanter, par- ticularly with the chronic tendon ruptures. 1-5,10-21 The ruptures of the hip abductor muscles may be: 1,3-5,13-16,22-26 Chronic degenerative ruptu- res, coming from a sequence of the continuous process of gluteal tendinosis (by imbalance between anabolism-catabolism in the tendon, due to repeated friction and micro- trauma, tension and compressive forces exerted by the iliotibial band, that favors the catabolism), without known acute traumatic cause; Traumatic acute ruptures, result- ing from the strong contraction of the hip abductors (after falls or vigorous exercises on hip abduction), and also due to acute aggravation of pre-existing chronic ruptures; Ruptures associated with hip arthroplasty, particularly with incomplete or dehiscence of the inci- sion made in the gluteus medium after hip arthroplasty on the lat- eral (transgluteus) or anterolateral approach. Throughout this text we only will focus on tendon ruptures not associated with hip arthroplasty. The ruptures are more frequent in the gluteus medium and in a third of these ruptures there are also concomitant ruptures in the small gluteus. They usually occur on the tendon, at the insertion on the large trochanter, because this section is more subject to tension forces, is less vascularized and is subjected to a mechanical conflict where a large prominent trochanter or osteophytes