Revista de Medicina Desportiva (English) September 2018 - Page 13

exist. They are more prevalent on women and at the middle age, both on the sedentary and involved on sports, in particular runners. They can be partial thickness (more frequently), total thickness or intra- substance ruptures. Its extension is variable, from simple U-shaping to massive oval or circular ruptures (Figure 2). 1,2,4,5,11,15,21,23,27 The presence of varus hip, high femoral offsets, prominent trochanters, decreased bi-iliac distance and shorter con- tralateral leg increase the tension of the iliotibial band against the large trochanter, favoring compres- sive damaging forces on the gluteus medium, which are therefore ana- tomical risk factors for the develop- ment of gluteal pathology. 4,16 The typical symptomatology of the hip abductors muscles ruptures includes mixed pain at the trochan- teric region and, depending on the size of the rupture, changes of the gait due to the inability of pelvic stabilization during the monomodal support because of the insufficient abductors muscles. The pain is mixed, of mechanical predomi- nance, and worsens with the local palpation, during the activities that involve monopodal support, such as walking and climbing stairs, and also during the lateral decubitus support on the symptomatic side and after long periods of sitting. 1,2,4 In turn, the insufficiency of the abductors is the most sensitive and specific sig- nal for the gluteal rupture. The posi- tive Trendelenburg sign and march, when there is insufficiency of the abductors, during the unipodal sup- port on the side of the dysfunctional middle gluteus, there is a fall of the contralateral hemipelvis due to the inability for contraction of that gluteus medium (its contraction maintains the distance between iliac bone and the large trochanter) and keep the pelvis balanced (Figure 3). As a compensate attempt to elevate the contralateral hemipelvis, there is tilting of the torso to the side of the dysfunctional gluteus. Usually the passive hip mobility is main- tained, but there is often decreased hip abduction force, tested on lateral decubitus when the patient elevates the lower limb, without and against resistance. 4,14,19,23,28,29 Diagnosis In addition to the symptoms and clinical tests described before, the gold-standard examination to diag- nose ruptures of the muscle-tendon hip abductor apparatus is the MRI, which can also identify several degrees of retraction, muscular atrophy and adipose degeneration, which will influence the effective- ness of the repair and healing. On the total thickness ruptures of the tendon there is total discontinuity of the fibers, while on the partial thickness usually there is a focal discontinuity, associated with a thickening Inflammation of the tendon, with hypersignal on T2. Usually associated with the rup- ture, there are signs of trochanteric bursitis. 1,4,5,21,23,25,30-32 The ultrasound exam can also identify ruptures and bursitis, however it is less reliable and more dependent on the radiolo- gist compared to the MRI. 4,33 The X-ray of the pelvis and hip might be useful to exclude hip arthrosis and to identify sclerosis and osteophytes at the large trochanter, particularly on chronic tendon ruptures. 1,2,13,23 Figure 2 – Rupture of the gluteus medium at the level of its tendon portion 1 The differential diagnosis most frequent for the gluteal rupture is the tendinopathy of the gluteus, in which the symptoms may be similar, but there is no rupture on the MRI. The intratendon calcifications can be seen in the radiography, corre- sponding to calcified tendinopathy, similar to the one that occurs in supraspinatus in the shoulder. As previously mentioned, the degenera- tive ruptures are part of a continu- ous process of gluteal tendinosis and it is, therefore, the same condition. Often the inflammation triggered by the gluteal rupture, also implies inflammation of the adjacent tro- chanteric synovial bursa, and both diagnostics are often present simul- taneously. The suspicion for gluteal rupture, and if there isn’t only a trochanteric bursitis, occurs when the pain is persistent after the anti- inflammatory treatment and physi- otherapy and when there is clearly present a typical gait of insufficiency of the abductors muscles, that will lead to a MRI for confirmation of the clinical suspicion. 1,5,13,34,35 In this way, the ruptures of the middle gluteus have been increasingly diagnosed in situations that were previously understood as trochanteric bursitis refractory to the treatment. In fact, trochanteric bursitis rarely occurs isolated, being almost always a sec- ondary inflammation consequence of a gluteal pathology. Other differ- ential diagnoses are lateral snapping hip syndrome (trochanteric pain and lateral snapping), hip joint pathol- ogy (deep inguinal pain), gluteus Figure 3 – Normal gait and insufficiency of the right gluteus middle muscle (sign and march of Trendelenburg) Revista de Medicina Desportiva informa september 2018 · 11