Trochanteric Pain Syndrome and Disclosures: Hamstring Pathology • Consultant: Bioclinica • Advisory Board: Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier Professor of Radiology • Not relevant to this talk Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.
Trochanteric Bursal Fluid + Glut Min Tear Trochanteric Pain Syndrome: • Most commonly caused by gluteus minimus and medius tendon AF abnormalities1 • Trochanteric bursitis: uncommon LF 2 AF – 20% of symptomatic patients Glut – Not actually inflamed3 Max PF – Not associated with pain4 1Kong A et al. Eur Rad 2007; 17:1772 2Long SS et al. AJR 2013; 201:1083 3Sylva F et al. Clin Rheumatol 2008; 14:82 Axial 4Blankenbaker DG et al. Skeletal Radiol 2008; 37:903
Trochanteric Bursitis: Septic Trochanteric Bursa: infection + gas
Gmax
Note posterior location of bursa PF
Gmax
1 Tendinosis: Gluteus Medius Gluteal Tendon Pathology: • Tendinosis: hypoechoic, no defects • Partial tear: anechoic clefts • Complete tear: discontinuous tendon • >2 mm cortical irregularity (depth) AF LF SPF LF – Associated with tendon tear – Positive predictive value = 90% (xray)*
*Steinert et al. Radiology 2010; 257:754
Tendinosis: Gluteus Minimus Tear: Gluteus Minimus
AF LF AF LF AF AF
>2 mm cortical irregularity depth (x-ray) = 90% positive predictive value for gluteus tendon tear
Steinert et al. Radiology 2010; 257:754
Tear: Gluteus Medius after THA Tear: Gluteus Medius
LF SPF LF LF AF LF LF AF AF
>2 mm cortical irregularity depth (x-ray) = 90% positive predictive value for gluteus tendon tear
Steinert et al. Radiology 2010; 257:754
2 Calcific Tendinosis: Gluteus Medius Gluteus Medius Fenestration
LF LF Greater AF Trochanter Needle
Normal
Gluteus Maximus and Minimus Fenestration: pelvis • Randomized controlled: 30 patients • 22 tendons in 21 patients • PRP versus fenestration alone • Gluteus medius (11), hamstring (8), • Significant improvement at weeks 1 and 2 gluteus minimus (2), tensor fascia lata (1) • Approximately 80% had long term • Marked or some improvement: 82% improvement: up to 1 year follow-up • No difference between treatment groups1 • Two injections: more sustained response2
Jacobson JA et al. J Ultrasound Med 2015; 34:2029 1Jacobson JA et al. J Ultrasound Med 2016; 35:2413 2Fitzpatrick J et al. Am J Sports Med 2019; 47:1130
Semimembranosus Tear Potential Treatment Algorithm: Conjoint Conjoint Tendon Tendon • If bursa: aspirate, inject steroids ST • If tendinosis: ST – Tenotomy or fenestration BF
– Inject steroids superficial to tendon SM • 72% of patients significantly improved1 Sciatic • If tendon tear: platelet-rich plasma injection? Nerve Tear Normal 1Labrosse, et al. 2010 AJR 2010; 194:202
3 Semimembranosus: tendinosis Tendinosis: proximal hamstring
Conjoint Conjoint Tendon Tendon
Ischium
SM
Long Axis Short Axis Long Axis Short Axis
Conjoined Biceps Femoris- Conjoined BF-ST Tendon: tendinosis Semitendinosus: tendinosis
Conjoined BF-ST tendon
Ischium
Ischium Conjoined BF-ST Tendon Semimembranosus
Short Axis Long Axis Semimembranosus
Conjoined BF-ST Tendon: partial tear Snapping Conjoined Long Head Biceps Femoris, Semitendinosus Sacrotuberous Ligament + Sacrotuberous Ligament Conjoined BF-ST Tendon Sacrotuberous Ligament BF-ST
Ischial Tuberosity
Ischium SM Semimembranosus
Long Axis From: Bierry et al. Radiology 2014; 271:162 From Bierry G et al. Radiology Spencer-Gardner LS et al. PMR 2015; 7:1102 2014;271:162
4 Hamstring: complete tear with retraction Hamstring Tear: FTT: Conjoint PTT: semimembranosus
Conjoint Tendon Ischium
ST BF Long Axis SM Sciatic Nerve Normal
Biceps Femoris: remote tear Semimembranosus: remote tear
With muscle contraction Long Axis
Short Axis
Semimembranosus: remote tear Seroma
Long Axis Sagittal
5 Take-home points
• Greater trochanteric pain syndrome: – It is not bursitis – Gluteal tendon pathology • Hamstring pathology – Proximal: often limited utility – Massive tears: often need MRI
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