Revista de Medicina Desportiva (English) September 2018 | Page 14

superior nerve pathology (middle
gluteus atrophy and signs of their
insufficiency) and pathology of the
lumbar spine (radiculopathy or neu-
rogenic lameness). 10,11,13,14,17,24,27,36
Treatment
The initial treatment is always
conservative and only if this is
ineffective the surgical repair of the
rupture will be indicated. The prin-
ciples of the conservative treatment
are, in this context, similar to those
for treatment of the insertional
tendinopathies of the gluteus: first
to treat the pain and then the intro-
duction of a progressive strengthen-
ing program for the muscle-tendon
complex with the aim to increase
the tolerance to load and to correct
abnormal motion patterns. 4,16,27,37
The approach to pain is essentially
to remove or minimize the abu-
sive and deleterious loads for the
abductor apparatus, in particular
the repeated activities of hip adduc-
tion, which cause high compression
and tension forces over the gluteus.
It includes changes on postural
habits, but above all to suspend or to
modify some physical activities. On
lateral decubitus, both the abductor
apparatus are compressed, one by
direct compression against the bed
and the other by hip adduction and
compression caused by the iliotibial
band, and avoiding this position or
placing a cushion between the lower
limbs will decrease the abduction
of the hip. For the same reason, the
orthostatic position with unipodal
support should also avoid, as well as
the seated position with crossed legs
or with the knees in contact. 4,16,27,37,38
In turn, the long-distance race, at
high speed or on uneven surfaces,
are examples of activities known to
cause worsening of the pain. The
athletes must to run on flat sur-
faces and on line, avoiding irregular
surfaces and to run around the
track, or even to altering the racing
technique, reducing the abduction of
the hips during it. 4,16,37-39 The initial
pharmacological treatment of pain
includes oral anti-inflammatory
medications. The next step will be
one or two local injections with cor-
ticosteroids and anesthetic, which
gives satisfactory results in the short
12 september 2018 www.revdesportiva.pt
and medium term. However, there
is some evidence that steroids can
adversely affect the regenerative
capacity of the tendon by reducing
the production of collagen, affecting
its adequate response to loads and
favoring ruptures. 1,4,27,37,40-44
The program of progressive
strengthening must start with the
isometric abduction exercises, on
neutral or with slight abduction,
being the main objective at this
stage the relief of pain. 38 Beyond
this stage, the program should
include exercises directed to the
hip abductor muscles, focusing on
strict adduction control. The exer-
cises should progressively be more
functional and specific to the sports
of the practitioner (bridge, Isometric
abduction, squats). Some authors
still suggest good results with local
extracorporeal shock waves, espe-
cially on the gluteal tendinopa-
thy. 4,27,37,38,40,45
When the conservative treatment
fails after a period of about 3 to 6
months and if the gluteal rupture
imaging agrees with the clinic signs,
it is indicated the surgical repair.
The traditional surgical treatment
is the open procedure repair (via
posterolateral-lateral approach)
after tendon insertion cruentation
on the large trochanter and mobili-
zation of the tendon, and transosse-
ous anchors or sutures can be used
through holes created in the great
trochanter. 1-3,5,19-23,26,30,46,47 In theory,
the earliest tendon repair prevents
the evolution of the retraction and
the adipose degeneration, favoring
adequate healing and improving
the prognosis for the pain relief and
muscle strength recovery. Hence,
we should be aware of this diag-
nosis, especially on the sportsman
population, where an early return
to the sports practice with high
functional levels is desired. 1,19,20
More recently, the development
of minimally invasive approaches
allows the repair to be carried out
through endoscopic access, which,
in theory, decreases the recovery
time in the postoperative period
and allows for the earliest return to
sports practice. 4,19,21,23,26,31,48-50 In the
case of simple total ruptures, the
suture is usually performed with
non-absorbable wire anchored on
the large trochanter, which allows to
create the tension appropriate to the
function of the abductor apparatus
for the stabilization of the pelvis. On
the increasingly number of diagno-
sis of partial ruptures of the inner
face of the gluteus medium and of
the intrasubstance ruptures, it is
indicated its endoscopic repair with
transtendon techniques. 11,19 With
extensive ruptures, sharp fat degen-
eration and osteolysis of the tendon
insertion on the large trochanter,
it may be necessary to perform a
flap of the large gluteus, the vastus
lateralis, the fascia lata or halogenic
Achilles tendon with bone insert to
adequate closure and without exces-
sive tension of the rupture. 1,5,19,51-54
About surgical recovery, after about
six weeks of unloading of the limb
and the ware of an anti-abduction
hip splint to allow adequate healing
of the repair, the load over the limb
and the program of rehabilitation
of the apparatus are progressive to
recover levels of muscular strength.
The return to competition must be
monitored closely to ensure the time
needed for tissue adaptation. 1,5,15,19
Conclusion
The pathology of the medium and
small gluteus has been increas-
ingly recognized as an important
cause and probably underdiagnosed
the frequent persistent pain in the
trochanteric area. In the case of a
trochanteric pain refractory to the
systemic and local anti-inflamma-
tory treatment and physiotherapy,
and especially in the presence of the
hip abductors insufficiency, an MRI
should be ordered for diagnosis of a
tendon gluteal rupture. If it is con-
firmed, especially on athletes, early
repair is indicated to allow adequate
rehabilitation and to provide rapid
return to sports with similar abduc-
tive muscular strength levels a
before the injury.
Bibliography
1. Lachiewicz PF. Abductor tendon tears of the
hip: evaluation and management. J Am Acad
Orthop Surg. 2011; 19(7):385-91.
2. Bunker TD, Esler CN, Leach WJ: Rotator-cuff
tear of the hip. J Bone Joint Surg Br 1997;
79(4):618-620.