Anatomy
- Glut med originates on the iliac crest
- Minimus originates on the centre of the iliac surface
- Both attach to the greater trochanter
- Both act as hip abductors and internal rotators, posterior fibres act as external rotators
- When torn, ischemia, failed healing, matric degradation, diminished load-bearing capacitiy
Risk Factors
- Excessive tension and compression |
- Repetitive, ballistic, high-force , eccentric gluteal contractions |
- Inequal leg length |
- Alteration in femoral neck |
- Obesity |
- Usually presents in 2nd half of life |
- Females |
- Lower extremity/lx dysfunction |
Presentation
- >40 year old |
- Insidious, persistent lateral hip pain |
- Radiates into buttock and lateral thigh |
- Walking, climbing stairs, hills, standing on one leg and prolonged sitting |
- Night time pain common |
- Usually no leg numbess/pain beyond knee |
- TTP over greater trochanter (posterior aspect = glut med involvement, anterior = glut minimus) |
- Hypertonicitiy of hip adductors, psoas, TFL, gluteal and lumbar muscles |
- Glut max and ITB should be palpated (compresses gluteal tendons) |
- Limited hip ROM - pain upon passive adduction or external rotation |
- RROM painful in abduction |
- +ve Obers |
- +ve Treledenberg, single leg squat |
- Lateral trunk flexion over stance leg |
- Knee adduction, hyperpronation, contralateral arm abduction |
DDx
- OA |
- RA |
- FAI |
- Lx radiculopathy |
- Mechanical LBP |
- SI Dysfunction |
- Meralgia paresthetica |
- Piriformis syndrome |
- iliopsoas tendinitis/tendinopathy |
- Labral tear/injury |
- Fibromyalgia |
- AVN |
- Stress f# |
- Primary/secondary bone tumour |
- Soft tissue neoplasm |
- Visceral somatic referral - GI/GU |
- Children: SCFE, LCP, infection, primary neoplasms |
Imaging
- Usually not indicated, unless: |
- Unreponsive to treatment |
- Severe pain |
- Inability to bear weight |
- Limited passive mobility |
- MRI for labral tears, soft tissue abnormalities |
- US gold standard |
Management
- Avoid "hanging on one hip" and sitting/standing with legs crossed |
- Avoid prolonged sitting, spread knees out when getting up of a chair |
- Avoid side lying postures |
- Place pillow between knees |
- Athletes should temporarily avoid long distance/fast paced running, hill climbing and plyometrics, consider cycling and water based exercise |
- Avoid running on banked, wet, icy surfaces |
- Pts with Narrow based gait should widen their legs |
- Weight reduction if overweight |
- TFL/ITB in hip adduction |
- Clam exercises |
- Change in nighttime pain as a guide for advancing/retreating exercise intensitiy |
- High tensile load exercises should not be performed >3 x a week |
- Single leg stance, single leg squats, glut squeezes, bridging, side planks, lunges, band walk, side steps, clam exercises |
- Start with frontal plane exercises - sitting to standing |
- Hip hinging, squatting to limit hip internal rotation |
- Orthotics |
- SMT/Mobilisation of LS + lower mechanical chain |
- Myofascial release of Glut med/min |
- Consider surgery if no improvement |
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