|ECR 2019 / C-0716|
|Greater trochanteric pain syndrome: clinical and radiological semiology|
GTPS is a regional pain syndrome that is characterized by chronic pain of the lateral hip area, involving the greater trochanter, buttock and lateral thigh. Clinically it presents with tenderness on palpation of the greater trochanter area with the patient in the side-lying position.
Absence of generalized myofascial tenderness to palpation is needed.
Stegemann (1923) Trochanteric bursitis
Leonard (1958) Trochanteric syndrome
Gordon 1961). Gluteal tendinopathy
GTPS affects between 10% and 25% of people living in industrialized countries,
with a lifetime incidence of more than 20%.
Hip pain is prevalent in all age groups, but more so in the fourth and sixth decades of life.
There is controversy in the literature over the trend towards greater incidence of GTPS in females: the majority of studies suggest a ratio of 3 to 4:1, whereas other studies failed to show any gender predominance.
CONDITIONS ASSOCIATED WITH GREATER TROCHANTERIC PAIN SYNDROME.
It is essential to understand the pathophysiology of the disease, its radiological expression and the arthroscopic approach to it, a prior anatomical knowledge of the greater trochanter, the bursas and the insertions of the abductor musculature in the greater trochanter.
The bony surface of the greater trochanter consists of four facets: anterior, lateral, posterior, and superoposterior. The gluteus medius muscle attaches to the superoposterior and lateral facets. The gluteus minimus muscle attaches to the anterior facet. The trochanteric bursa covered the posterior facet and the lateral insertion of the gluteus medius muscle. Fig. 3
Pfirrmann et al (Radiology 2001) and Gottschalk (J.
described the abductor attachments in the greater trochanter.
The gluteus medius attachment could be divided into three parts.
The main tendon arose from the central posterior portion of the muscle and had a strong insertion covering the superoposterior facet.
This tendon was thicker medially than laterally.
The lateral part of the gluteus medius tendon insertion was obliquely orientated in the lateral facet from posterior to anterior,
and this tendon continued anteriorly covering the insertion of the gluteus minimus tendon.
The lateral part of the gluteus medius tendon arose from the undersurface of the muscle and was usually thin or almost purely muscular in nature.
The anterior tendon was surrounded by and attached to the gluteus minimus tendon but was not visible macroscopically.
The gluteus minimus attachment could be divided into two distinct components. The main tendon demonstrated a consistent insertion in the anterior facet of the trochanter on its lateral and inferior aspect.
In contrast with the gluteus medius muscle, the main tendon arose from the superficial part of the muscle fascia. The second part of the gluteus minimus minimus insertion was a muscular insertion in the ventral and superior capsule of the hip joint.
Dunn et al (Clinical Anatomy 2003 ) described the “trocanteric bursae” in sixteen embalmed hip specimens and Woodley et al (JBJS 2008) described the detailed morphology of the bursae adjacent to the greater trochanter of the femur in eighteen specimens ( fig 4-7)
Four bursae have been consistently described outside the GT, with three being present in most individuals. The gluteus minimus bursa is a minor bursa located cephalad and ventral to the GT. The two major bursae
are the subgluteus maximus and subgluteus medius bursae. The subgluteus maximus bursa is located lateral to the GT, juxtaposed between the gluteus medius tendon and the gluteus maximus muscle.
This largest of the greater trochanteric bursae is most frequently incriminated in GTPS.
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