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)
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