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.