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Poster 167: Gluteus Medius Tendon Tear—An Underdiagnosed Entity: A Case Report
PM&R
Program Description: The patient presented with 6 months of nontraumatic left hip pain starting in the gluteal region and radiating to the groin and down the anterolateral thigh. The pain is worse with walking and sleeping on the left side and better with sitting. She failed extensive physical therapy, and 2 greater trochanteric bursa injections resulted in moderate improvement temporarily. On examination, she was tender to palpation of the left greater trochanter and along the deep external rotators of the hip. Strength in bilateral legs was 5/5 including hip abductors, and single leg stance was normal. Setting: Outpatient clinic of an academic medical center. Results: Musculoskeletal (MSK) ultrasound of the left hip revealed a high-grade gluteus medius partial tear and gluteus minimus tendinosis and partial thickness tear. Discussion: Gluteal tendon tears are commonly underdiagnosed. Greater trochanteric pain syndrome is commonly due to gluteus minimus or medius injury rather than trochanteric bursitis. Gluteal tendinopathy most frequently occurs in latemiddle-aged women and reportedly occurs in 10% of individuals over 60 years. Magnetic resonance imaging of the hip is considered the best test for gluteal tears, but the patient had metal in her arm. MSK ultrasound is an excellent alternative, if available, and is significantly cheaper. When conservative therapy fails, open or endoscopic surgical intervention can provide significant relief of pain. Conclusions: Gluteal tendinopathy is commonly misdiagnosed as greater trochanteric bursitis. Practitioners should consider MSK ultrasound to evaluate persistent greater trochanteric pain.
Poster 167 Gluteus Medius Tendon Tear—An Underdiagnosed Entity: A Case Report. Ramya Nagarajan, MD (William Beaumont Hospital, Royal Oak, MI); Nancy M. DeSantis, DO. Disclosures: R. Nagarajan, None. Patients or Programs: A 57-year-old African American woman with hip pain. Program Description: A 57-year-old woman presented to the office with a 3-week history of left groin, lower back and knee pain after noticing a pop while dancing. She reported sudden buckling of the left leg while walking. On examination, there was tenderness to palpation over the left sciatic notch. She experienced groin pain with stretch of the hip flexors and with internal and external rotation of the abducted hip. She had some weakness in the left hip abductors and external rotators. She was started on anti-inflammatory medication. Physical therapy treatment consisting of deep-tissue mobilization, stretching and strengthening was initiated. The patient returned after 1 month reporting increased pain, now along the posterior trochanteric area and the left buttock. An MRI was ordered, which revealed edema in the left gluteus medius and minimus insertion with mini-
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mal associated bone marrow edema in the left greater trochanter. We then prescribed land-based and pool therapy, cold packs to the gluteus muscles and use of a cane for protective ambulation. She progressed to a home exercise program. Setting: Outpatient office. Results: She returned for evaluation after 3 months. She reported less pain. Strength had significantly improved and she no longer experienced buckling of the leg. She continued to use proper body mechanics, avoided aggravating activities and used NSAIDS when needed. Discussion: Tears of the abductor mechanism of the hip are compared with rotator cuff tears of the shoulder. Tears usually begin in the anterior part of the tendon. A complete tear will lead to loss of hip abduction. In cases of intractable pain with examination findings of trochanteric bursitis and weakness in the hip abductors, imaging studies calling attention to a possible tendon rupture may be diagnostic. Endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Conclusions: Hip abductor tendinopathy is an uncommonly diagnosed and reported clinical condition. The recent use of MRI has increased the diagnosis of this condition when it presents as intractable buttock or trochanteric pain.
Poster 168 Hamstring Shortening and Pain as an Initial Presentation of Lumbosacral Radiculopathy: A Case Report. Farid Kia, MD (Thomas Jefferson University, Philadelphia, PA); Adam L. Schreiber, DO. Disclosures: F. Kia, None. Patients or Programs: A 36-year-old woman with right posterior thigh tightness. Program Description: The patient reported a history of localized right hamstring tightness and aching pain causing difficulty flexing her hip. After 3 months of physical therapy without significant resolution of tightness or pain, she presented for physiatric consultation. She denied back pain or radiating symptoms down the leg. On examination, passive range of motion at the right hip with knee extension was limited to 20°, which improved to 70° with knee flexion. There was significant tightness and tenderness of the entire hamstring complex. With the exception of hamstring myofascial trigger points and lumbosacral somatic dysfunction, her neuromusculoskeletal examination was otherwise negative. Additional treatment with osteopathic manipulation and motor point blocks produced no relief. Further workup included EMG/NCS, which was negative for radiculopathy and lumbar MRI revealing broad central L4-L5 and L5-S1 disk protrusions, affecting the right greater than the left. Setting: Outpatient physical medicine and rehabilitation clinic.
Program Description: The patient presented with 6 months of nontraumatic left hip pain starting in the gluteal region and radiating to the groin and down the anterolateral thigh. The pain is worse with walking and sleeping on the left side and better with sitting. She failed extensive physical therapy, and 2 greater trochanteric bursa injections resulted in moderate improvement temporarily. On examination, she was tender to palpation of the left greater trochanter and along the deep external rotators of the hip. Strength in bilateral legs was 5/5 including hip abductors, and single leg stance was normal. Setting: Outpatient clinic of an academic medical center. Results: Musculoskeletal (MSK) ultrasound of the left hip revealed a high-grade gluteus medius partial tear and gluteus minimus tendinosis and partial thickness tear. Discussion: Gluteal tendon tears are commonly underdiagnosed. Greater trochanteric pain syndrome is commonly due to gluteus minimus or medius injury rather than trochanteric bursitis. Gluteal tendinopathy most frequently occurs in latemiddle-aged women and reportedly occurs in 10% of individuals over 60 years. Magnetic resonance imaging of the hip is considered the best test for gluteal tears, but the patient had metal in her arm. MSK ultrasound is an excellent alternative, if available, and is significantly cheaper. When conservative therapy fails, open or endoscopic surgical intervention can provide significant relief of pain. Conclusions: Gluteal tendinopathy is commonly misdiagnosed as greater trochanteric bursitis. Practitioners should consider MSK ultrasound to evaluate persistent greater trochanteric pain.
Poster 167 Gluteus Medius Tendon Tear—An Underdiagnosed Entity: A Case Report. Ramya Nagarajan, MD (William Beaumont Hospital, Royal Oak, MI); Nancy M. DeSantis, DO. Disclosures: R. Nagarajan, None. Patients or Programs: A 57-year-old African American woman with hip pain. Program Description: A 57-year-old woman presented to the office with a 3-week history of left groin, lower back and knee pain after noticing a pop while dancing. She reported sudden buckling of the left leg while walking. On examination, there was tenderness to palpation over the left sciatic notch. She experienced groin pain with stretch of the hip flexors and with internal and external rotation of the abducted hip. She had some weakness in the left hip abductors and external rotators. She was started on anti-inflammatory medication. Physical therapy treatment consisting of deep-tissue mobilization, stretching and strengthening was initiated. The patient returned after 1 month reporting increased pain, now along the posterior trochanteric area and the left buttock. An MRI was ordered, which revealed edema in the left gluteus medius and minimus insertion with mini-
Vol. 2, Iss. 9S, 2010
S77
mal associated bone marrow edema in the left greater trochanter. We then prescribed land-based and pool therapy, cold packs to the gluteus muscles and use of a cane for protective ambulation. She progressed to a home exercise program. Setting: Outpatient office. Results: She returned for evaluation after 3 months. She reported less pain. Strength had significantly improved and she no longer experienced buckling of the leg. She continued to use proper body mechanics, avoided aggravating activities and used NSAIDS when needed. Discussion: Tears of the abductor mechanism of the hip are compared with rotator cuff tears of the shoulder. Tears usually begin in the anterior part of the tendon. A complete tear will lead to loss of hip abduction. In cases of intractable pain with examination findings of trochanteric bursitis and weakness in the hip abductors, imaging studies calling attention to a possible tendon rupture may be diagnostic. Endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Conclusions: Hip abductor tendinopathy is an uncommonly diagnosed and reported clinical condition. The recent use of MRI has increased the diagnosis of this condition when it presents as intractable buttock or trochanteric pain.
Poster 168 Hamstring Shortening and Pain as an Initial Presentation of Lumbosacral Radiculopathy: A Case Report. Farid Kia, MD (Thomas Jefferson University, Philadelphia, PA); Adam L. Schreiber, DO. Disclosures: F. Kia, None. Patients or Programs: A 36-year-old woman with right posterior thigh tightness. Program Description: The patient reported a history of localized right hamstring tightness and aching pain causing difficulty flexing her hip. After 3 months of physical therapy without significant resolution of tightness or pain, she presented for physiatric consultation. She denied back pain or radiating symptoms down the leg. On examination, passive range of motion at the right hip with knee extension was limited to 20°, which improved to 70° with knee flexion. There was significant tightness and tenderness of the entire hamstring complex. With the exception of hamstring myofascial trigger points and lumbosacral somatic dysfunction, her neuromusculoskeletal examination was otherwise negative. Additional treatment with osteopathic manipulation and motor point blocks produced no relief. Further workup included EMG/NCS, which was negative for radiculopathy and lumbar MRI revealing broad central L4-L5 and L5-S1 disk protrusions, affecting the right greater than the left. Setting: Outpatient physical medicine and rehabilitation clinic.