Epidemiology Gluteus medius pathology

Epidemiology Gluteus medius pathology

Gluteus medius pathologyGluteusMedius In biomechanical terms, the gluteus medius can be seen as a part of the abductors, or the rotator cuff of the hip “, just as the rotator cuff of the shoulder.
Incidence Etiology of the gluteus medius tendon tear remains unclear. One factor might be tendon impingement caused by undersurface trochanteric bony overgrowth. Another consideration is lateral degenerative wear from fascial friction. Only further research can complete our understanding of gluteus medius tears.4
Function Functional evaluation of the hip abductor muscles with use of MRI or EMG shows that the gluteus medius and the gluteus minimus, play an important role in hip abduction, and stabilization of the pelvis during walking and standing.1
Pain location Hip joint / greater trochanter / Pelvis and RPP into the leg
Pain sensation / Symptoms Tenderness and increased soft tissue density noted when palpating the lateral hip area over the gluteus medius muscle, located above the greater trochanter of the femur.
Pathology The abductors group are essential for walking, resulting in inclination of the pelvis on the leg where weight is taken. This component of hip biomechanics is the basis of the Trendelenburg’s sign.2When there is a gluteus medius / minimus dysfunction, the pelvis of the leg where weight is taken stands up and the side where no weight is taken stands downwards, a positive Trendelenburg sign is present.3In the diagnosis of a tear in the gluteus medius, it is important that osteoarthritis of the hip is excluded.
Prognosis With gluteus medius strain, the majority of individuals improve with conservative treatment. If surgery is performed for a gluteus medius tear, one study reported excellent outcomes at approximately 2 years after surgery, with 70% of individuals reporting a normal-feeling hip, and the remaining 30% reporting a nearly-normal hip.7The low rate of gluteus medius tendon tears recorded during primary THA, 1.6%, is considerably lower than the 22% reported by Bunker and colleagues5and the 20% reported by Howell and colleagues.6
Literature
  1. Kumagai M, Shiba N, Nishimara H, Inoue A. Functional evaluation of hip abductor muscles with use of magnetic resonance imaging. J Orthop Res 1997; 15: 888-93.
  2. Hardcastle P, Nade S. The significance of the Trendelenburg test. J Bone Joint Surg Br 1985; 67: 741-6.
  3. Trendelenburg F. Trendelenburg’s test: 1895. Clin Orthop 1998; 355: 3-7.
  4. Incidental “Rotator Cuff Tear of the Hip” at Primary Total Hip Arthroplasty Hal E. Cates, MD, Monica A. Schmidt, PhD, and Rachael M. Person
  5. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79(4):618-620.
  6. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001;16(1):121-123.
  7. Voss, James E., et al. “Endoscopic Repair of Gluteus Medius Tendon Tears of the Hip (Abatract).” American Journal of Sports Medicine 37 4 (2009): 743-747. American Journal of Sports Medicine. 24 Nov. 2009

 

EXAMINATION

Nerves of the plexus sacralis
Nerves Segments Innervated muscle Skin leaves
n.gluteus superior L4-S1
  1. gluteus medius
  2. gluteus minimus
  3. tensor fascia latae
n.gluteus inferior L5-S2 L5-S2
  1. gluteus maximus
n.cutaneus femoris posterior S1-3
  1. cutaneus femoris posterior

– nn. clunium inferiores

– rr. perineales (sensibel-innervation)

Direct leaves from the plexus
n.musculi piriformis S1-2
  1. piriformis
n.musculi obturatorii interni L5-S2
  1. obturatorii internus
  2. gernelli
n.musculi quadrati femoris L4-S1
  1. quadratus femoris

 

Motor-innervation area of the n. gluteus superior
Along with the same vessels leaving the n.gluteus superior leaves the pelvis through the foramen suprapiriforme. The nerve passes through the Spatium intergluteale and innervates the small gluteus muscles (gluteus medius and gluteus minimus) and the tensor fascia latae.

 

Signs for weakness of the small gluteus muscles: Trendelenburg sign and Duchenne gait
  1. In healthy person, the pelviscan stabilize inthefrontalplaneinstanding position on one leg with the aid ofthegluteus musclesofthelegside.
  2. Paralysisorweaknessof the smallgluteusmuscles,for example,as a result ofdamage to then.gluteussuperiorbyan improperlyadministeredinjection, is expressed in aclearabduction weaknessof the effected hip joint; in addition, thepelvisin the frontal plane can no longerbe stabilized. When standing on one leg, the pelvisdropsonthe healthyside(leg swing side)down (positive Trendelenburgsign).
  3. By inclination of the upper body to the affected side and thus displacement of the center of gravity to the supporting leg side, the pelvis on the swing leg side can be raised (Duchenne gait). Failure of the small gluteus muscles on both sides leads to the typical waddling.
  1. Anatomische atlas, prometheus. Algemene anatomie en bewegingsapparaaat. Michael Schunke, Erik schulte, Udo Schumacher, Markus Voll, Karl Wesker. p: 476

 

The implementation and scientific evidence of the two main tests, are described in the EBP header which can be found below.
For testing inspection visual imagery has been collected.

Trendelenburg

Trendelenburg sign + gait/ambulation/walking (visual information)

 

Evidence Based Practice

Quadas: Quality Assessment of Diagnostic Accuracy StudiesThe Quadas helps the reader to get clarity about what BIAS in a study had influence.WhentheQuadasscore is low, there shouldbecriticallylooked atthevalueofthestudy.The Quadas consists of a scoring system of 14 points that being tested.
Utility scores:

  1. Evidence strongly supports the use of this test.
  2. Evidence moderately supports the use of this test
  3. Evidence minimally supports or does not support the use of this test
  4. ? The Test has not been researched sufficiently so we are unsure of its value

 

Trendelenburg’s Sign Utility 2
Study Sensitivity Specificity QUADAS Score 0-14
Bird et al.4 73 77 11
Comments: The test is performed while standing and confirmed during the gait analysis.
  1. The patient stands withhis back to thetherapist.
    2. The therapist instructs the patient to stand on one leg.
    3. The therapist observes the number of degrees that the leg drop to the contralateral pelvis while standing on one leg
    4. Confirmation of an abnormal pelvic drop is needed during gait analysis
    5. The test is positive in a single asymmetric reduction of the hip in relation to the other while standing on one leg.

 

Resisted Hip Abduction Utility 3
Study Sensitivity Specificity QUADAS Score 0-14
Bird et al.4 73 46 11
Comments: Weakness is not a positive result in this test. The low specificity is due to the testing of multiple disorders by this test, such as bursitis and tendinitis abductor.
1.The patient lies on his or her side.
2. The therapist will instruct the patient to make 45 degrees of abduction of the leg.
3. The therapist provides resistance to the abducted hip.
4. a positive test is a reproduction of the symptoms during the test.

 

Literature
  1. Bird PA, Oakley SP, Shnier R, Kirham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheumatism. 2001;44:2138

Physical examination results. The sensitivity and specificity of the clinical signs in predicting a gluteus medius tear (partial or complete) were assessed using MRI as the surrogate gold standard. A positive Trendelenburg’s sign provided the highest sensitivity and specificity overall. The results were as follows: Trendelenburg’s sign sensitivity 72.7%, specificity 76.9%; pain on resisted hip abduction sensitivity 72.7%, specificity 46.2%; pain on resisted hip internal rotation sensitivity 54.5%, specificity 69.2%.

The intraobserver reliability (kappa score) for each of the 3 physical signs was calculated. Trendelenburg’s sign demonstrated the highest intraobserver reliability. Kappa scores were as follows: Trendelenburg’s sign 0.676 (95% confidence interval [95% CI] 0.270, 1.08), resisted hip abduction 0.625 (95% CI 0.155, 1.09), and resisted hip internal rotation 0.027 (95% CI −0.016, 1.10).

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