A 46 y.o. male presents with hip pain after a fall from standing. Plain films are normal

What injury is shown on his MRI?

Our patient had a full thickness tear of the R gluteus medius.   A gluteus medius tear presents with pain and tenderness over the lateral aspect of the hip. It is a fan shaped muscle that originates from the gluteal surface of the ilium and inserts onto the lateral surface of the greater trochanter.   This is the “rotator cuff of the hip” and a tear can make it impossible to walk without pain. 

In addition to acute tears in athletes, tears of the gluteus medius and gluteus miniuas are common causes of chronic hip pain in the middle aged patient population. Patients with chronic tears are often misdiagnosed as  trochanteric bursitis, osteoarthritis or radiculopathy. It is estimated that  gluteus medius tears affect up to 25% of late-middle-aged women and 10% of men  The gluteus medius and minimus aid in hip abduction and internal rotation. Weakness in abduction often results in a trendelenburg gait.

Trendelenburg gait video, weakness or tearing of the gluteus mediu causes  drooping of the pelvis to the  contralateral side while walking.  

https://www.youtube.com/watch?v=ka1XAT6g_nA

WHEN THE HIP XRAY IS NORMAL AND THE PATIENT CANNOT WALK BECAUSE OF HIP PAIN

In addition to the gluteus medius tear consider:

1.Labral tear- causes pain over the anterior hip or groin. It is   caused by an injury to the cartilage or labrum over the acetabulum.  A hip impingement test is often postive. This involves provoking pain with flexion, adduction and internal rotation of the symptomatic hip.  These can present after a hip dislocation or just chronic deterioration.

2. Osteonecrosis of the hip- avascular necrosis of the hip develops gradually and can be difficult to see on plain films. Chemotherapy, radiation, steroids  and trauma are the major causes.

3. Iliotibial band syndrome- the pain in this syndrome is closer to the knee than the greater trochanter. Runners frequently get the syndrome   because there is contraction of the tensor fascia lata muscle and the gluteus maxims causing compression of the iliotibial band. There is no bony attachment of the band

4. Septic hip- septic arthritis is more common in children than adults.  Risk factors in adults include age older than 80, dm, RA, joint prosthesis, immunocompromise or sexual activity in the case of GC.  Generally, a joint effusion is present and obtaining joint fluid is the best way to make the diagnosis with a WBC of 50,000 in most cases of septic joints.

MRI is the optimum test to diagnose these conditions although laparoscopy is used frequently for labral tears.  MRI can even detect an early septic joint.

 For gluteus medius injuries, if physical therapy fails, surgery can be performed endoscopically though timy incision to reattach the torn tendon back onto the greater trochanter.

 Our patient was treated with non operative management  for his injury. Physical therapy was recommended but not covered by his insurance.  He was lost to follow up.

Septic Godshaw B, Wong M, Ojard C, et al. Acute traumatic tear of the gluteus medius and gluteus minimus in a marathon runner.  The Ochsner J. 2019 Winter, 19(4): 4045-409.

 Domb BG, Gui C, Lodhia P. How much arthritis is too much for hip arthroscopy: a systematic review. Arthroscopy. 2015. Mar;31(3):520-529. doi:  10.1016/j.arthro.2014.11.008.

Su T, Chen G, Yang L. Diagnosis and treatment of labral tear. Chin Med J. 2019 Jan 20;132(2):211-219.

Earwood J, Walker T, Sue G.  Septic arthritis: diagnosis and treatment Am Fam Physician 2021;104(6):589-597.

https://news.harvard.edu/gazette/story/2015/08/understanding-the-it-band/