Sports Medicine Disorders of the Hip: Posterolateral

Author(s): Gerardo E. Miranda Comas, MD

Originally published:04/04/2016

Last updated:04/04/2016

1. DISEASE/DISORDER

Definition

Sports related injuries to the posterolateral hip typically affect the greater trochanter (GT) and peritrochanteric soft tissue structures.

Etiology

Historically, lateral hip pain was believe to only involve bursal inflammation, but now it is better understood that bursitis comprises only a part of a complex pathological process. 1 The gluteus medius, gluteus minimus tendon, piriformis tendon and the iliotibial band (ITB) may be affected. 2,3

Epidemiology (risk factors and primary prevention)

In individuals between 50-79 years of age, posterolateral hip pain has a reported prevalence of 15% in women and 6.6% in men with unilateral presentation, and 8.5% in women and 1.9% in men with bilateral presentation. 4 In active military individuals, the prevalence was similar, but 5 times more common in women. 3 Disorder-specific risk factors include age older than 40 years, female gender, obesity, knee or hip osteoarthritis (OA), Rheumatoid Arthritis, low back pain, gluteal weakness, pelvic morphology, ITB tightness, leg-length discrepancy, and foot hyperpronation. 4,5

Pathoanatomy/physiology

The Greater Trochanter (GT) anatomy is similar to that of the greater tuberosity of the shoulder. The gluteus medius and minimus are referred to as the “rotator cuff” of the hip, functioning as the main hip abductors, stabilizing the pelvis during the stance phase of gait.6ITB originates from the tensor fascia lata muscle and inserts on Gerdy’s tubercle. It moves anteriorly over the GT with hip flexion and posteriorly during hip extension.  The subgluteus maximus or trochanteric bursa may be painful, as seen with repetitive compression or friction from the surrounding bony structures.

Disease progression including natural history. Phases or stages, trajectory, clinical features and presentation overtime

New onset/acute: Acute focal lateral hip pain is worse when lying on the involved side, ambulating, running, lateral movements, single leg activities, standing on the affected leg, and descending stairs. This could be related to direct macrotrauma or repetitive microtrauma resulting in bursal inflammation and myotendinous injury.

Sub-acute: Gluteal tendinopathy with or without calcifications and a reactive bursitis may be present. Sub-acute pain may lead to biomechanical maladaptations, such as asymmetric pelvic stabilization affecting the contralateral hip and/or other joints along the kinetic chain.5

Chronic/stable: The most common finding is gluteus medius or minimus tendinosis without active inflammation in the bursa. Tendon degeneration similar to that of the shoulder’s rotator cuff with chronic subacromial impingement is observed. 5

Pre-terminal: Pain is usually present at rest, limiting function. Furthermore, the presence of gluteal tendon degenerative tears is common even unrelated to acute trauma. 5,7

Specific secondary or associated conditions and complications

GTPS is associated with obesity, low back pain, ipsilateral and contralateral knee pain and degenerative disease. 4 Moreover, untreated symptoms of lateral hip pain may lead to persistent biomechanical changes along the kinetic chain from the trunk to the lower extremities, ultimately leading to decrease functional activity. 4

2. ESSENTIALS OF ASSESSMENT

History

Pain about the GT and the peri-trochanteric area of acute or insidious onset, associated with physical activity. It is exacerbated when lying on the involved side, or with repetitive hip flexion-extension movements, prolonged standing, and single leg activities. A snapping sensation when ascending stairs, performing sit to stand, or exercising may be noticed.

Physical examination

Initial evaluation includes observation for anatomic asymmetries or tissue deformities, and direct palpation to the affected area to elicit pain and/or symptoms. Passive adduction and active internal rotation may reproduce symptoms, while passive internal rotation usually does not. Active external rotation and abduction with pain or symptom reproduction may be present in gluteal muscle-tendon injury. 5 The FABER test can help differentiate intra-articular pain from lateral hip pain. 8 Ober’s test evaluates for ITB contracture. 5 A snapping sensation with hip motion from extension to flexion and vice-versa suggests ITB friction; a positive finding can be confirmed by manually compressing proximal to the GT with symptom relief. 9

Clinical functional assessment: mobility, self care cognition/behavior/affective state

Poor tolerance to single leg stance, although not specific for lateral hip pain, is useful in identifying symptomatic hip pathology. 8 Gait analysis can evaluate for a Trendelenburg sign, muscle tear, or neurologic injury, as well as dynamic leg-length discrepancy. Walking duration can help differentiate lateral hip pain from hip OA. 8

Laboratory studies

If an infectious process is suspected, then a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein can be evaluated in the setting of an active inflammatory process.

Imaging

Radiographs (pelvic AP, and hip AP/lateral-cross table and frog leg) help screen for avulsion fractures, or intra-tendinous calcifications. In the setting of acute trauma, CT scanning may be useful to assess acute fractures or for those who cannot undergo MRI. 10 MRI may reveal a combination of peritrochanteric edema, gluteus minimus or medius tendinosis, and fluid in the local bursae. 11 Ultrasound (US) may reveal similar findings to MRI and provide a dynamic assessment in real time.

Supplemental assessment tools

Proposed diagnostic criteria for GTPS includes at least 2 of the following: lateral hip pain, tenderness about the GT, or one of the following: pain at extremes of rotation, abduction, adduction, pain on strong contraction of hip abductors, or pain radiating to the lateral aspect of the thigh. 8,11

Early prediction of outcomes

No studies have reported early predictors of outcome. Age and pre-injury activity level may positively influence recovery. Additionally GTPS is associated with low back pain and knee osteoarthritis that could affect clinical improvement. 5 Moreover, no association has been found with body mass index. 11

Environmental

Active or relative rest is the mainstay of activity modification. Severe injuries may limit ADLs, as well as athletic activity, therefore avoidance of prolonged walking, standing, stairs, and repetitive sit to stand movements is important. Modifiable sport-related extrinsic risk factors include decrease sport-specific demands, correcting training errors, evaluating equipment, and modifying the environment. 12

Social role and social support system

The patient, family, coaches, or caregiver need education about risk factors, activity modification, and injury recovery process.  An adequate support system is often helpful to maintain compliance with treatment, especially rest in active individuals.

Professional issues

A multi-disciplinary treatment approach may be needed to some patients affected by this disorder. The treatment team may include a non-surgical musculoskeletal specialist, a physical therapist, an athletic trainer, coaching staff, and in refractory cases an orthopedic surgeon.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

A multimodal approach to treatment is needed. Initial treatment focuses in pain management with oral, topical, or infiltrated medications (acetaminophen, non-steroidal anti-inflammatory medications) Physical therapy is often recommended as the first-line of treatment for the acute presentation. This consists of physical modalities, stretching, and soft tissue massage. Bursal infiltration (corticosteroids) may be performed as part of the treatment. Most patients respond to conservative management. However, patients presenting with muscle-tendon tears or chronic pain may undergo surgical interventions sooner. 7 Open surgical techniques have been standard of care in past, but newer endoscopic techniques are increasingly utilized for bursectomies, ITB release, and trochanteric reduction osteotomy. 7

At different stages

New onset/acute: Pain control modalities such as relative rest including partial weight bearing, avoidance of the lateral decubitus position, and limiting repetitive hip movements, ice, and anti-inflammatory medications (for analgesia rather than anti-inflammatory effect) or oral analgesics.5 Modalities such as electrical stimulation, ultrasound, and low-level laser therapy (studied in other tendinopathies13) can be used for symptom relief.

Sub-acute: Continue with activity modification by avoiding potentially painful hip movements, especially repetitive hip flexion-extension, active rotation (internal/external), and resisted abduction. If hip abductor weakness is present then a strengthening program with focus on the hip abductors, progressing from isometric contractions to eccentric exercises should be implemented. Stretching or manual decompression of the ITB needs to be started and continued through the rehabilitation course in patients with tight iliotibial bands, or asymptomatic snapping, avoiding foam rolling over the painful area because it will increase the compression. 9 At this point, lumbo-pelvic deficits (core) need to be addressed as well.

Chronic/stable: Activity specific exercises should be started. Exercise should progress to multi-planar controlled eccentric exercises and postural re-education. 9 Orthotics, bracing, or taping may be used to correct any biomechanical deficits. 9

Pre-terminal: Finally, correction of kinetic chain biomechanical deficits, training techniques, equipment, and other extrinsic risk factors need to be addressed in order to prevent re-injury.14

Coordination of care

Referral to the physical therapist is common to implement a supervised office based 1-3 times/week or unsupervised home based exercise program. The main focus is core and hip girdle strengthening, but training errors must be assessed as well.  Other patients may benefit from referral to the orthopedic surgeon due to the severity of the injury and failed conservative care.

Patient and family education

A home exercise/stretching program may be an effective long-term solution to symptoms related to GTPS. 15 In addition, education regarding risk factors can be helpful for early identification of injury and future prevention.

Measurement of treatment outcomes

The main outcome measure use is pain reduction. Most studies use the visual analog scale (VAS) to measure pain reduction after an intervention. Due to the variability on study methodology no specific percentage of improvement has been established for this disorder. Although a disease specific functional outcome measure for GTPS is not available, 9 the number of missed sport-related activities (practices/games) and timing of return to previous activity level could be a useful tool to measure treatment success.

Translation into Practice: Pearls/Performance improvement in practice/ change in clinical practice behaviors and skills

Early recognition is essential in order to establish an adequate treatment plan. Identifying modifiable risk factors such as muscle imbalances in the pelvic/hip girdle muscles, fatigue secondary to muscle weakness, and training errors (equipment, surface, and overtraining) may help in establishing an early injury specific rehabilitation program. The use of diagnostic ultrasound in the office setting represents a point of care diagnostic tool with possible therapeutic application. 16 Recognition of bursal inflammation may suggest that an ultrasound guided infiltration could be beneficial early in the rehabilitation process to promote better tolerance and adherence to the treatment.11

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

The increase use of ultrasound for diagnosis and procedural guidance has led to more non-surgical treatment options for MSK injuries. Regenerative medicine procedures involving ultrasound-guided dry-needling or tenotomy, platelet rich plasma, show early promise in treatment of chronic tendinopathies. 17,18 Low energy shock wave therapy (SWT) appears to be another non-surgical option with results of 64% and 76% return to normal activity. 15,19Surgical procedures such as GT bursectomy alone or combined with ITB release or partial resection can now be done with an endoscopic techniques. 20

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Controversies and gaps in the evidence based-knowledge

The multi factorial etiology of lateral hip pain makes an isolated diagnosis unlikely, thus study uniformity is lacking. The efficacy of multiple treatment options is unclear; including ultrasound-guided bursal infiltration, platelet-rich plasma or whole blood, prolotherapy, percutaneous needle tenotomy, focused scar tissue aspiration (FAST) procedure, and open versus endoscopic surgical technique. 17,18,20

REFERENCES

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Author Disclosure

Gerardo E. Miranda Comas, MD
Nothing to Disclose

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