What is the recommended treatment for a high-grade partial tear of the gluteus medius tendon of the lateral band?

Treatment of High-Grade Partial Tear of the Gluteus Medius Tendon

For high-grade partial tears of the gluteus medius tendon that have failed conservative management for more than 6 months, endoscopic surgical repair is recommended to improve outcomes and prevent progression to more severe injury.

Initial Conservative Management (First-Line Treatment)

Conservative management should be attempted for at least 3-6 months before considering surgical options:

1. Relative Rest and Activity Modification

   • Reduce activities that aggravate symptoms 1
   • Avoid positions that compress the greater trochanter (like sleeping on the affected side)

2. Physical Therapy

   • Eccentric strengthening exercises of the gluteal muscles 1
   • Progressive loading program to improve tendon healing
   • Hip abductor strengthening

3. Pain Management

   • Cryotherapy (ice) for acute pain relief - 10-minute applications through a wet towel 1
   • Short-term NSAIDs (oral or topical) for pain relief, though they don't affect long-term outcomes 1

4. Injections

   • Corticosteroid injections may provide short-term pain relief but should be used with caution 1
   • Multiple steroid injections may compromise tendon integrity 1
   • Platelet-rich plasma (PRP) injections may be beneficial for grade 1-2 tendinopathy 2

Imaging Assessment

MRI is the preferred imaging modality for gluteus medius tears:

• Can assess peritrochanteric structures including the gluteus medius muscle and tendon 1
• Helps differentiate between tendinopathy, partial tears, and complete tears
• Identifies tendon defects and fatty atrophy that may influence treatment decisions 1

Ultrasound is an alternative that can:

• Identify tendinopathy, partial tears, and complete tears/avulsions 1
• Be used for guided injections
• Help differentiate between bursitis and tendinosis, though these may coexist 1

Surgical Management

If conservative treatment fails after 6 months, surgical intervention should be considered:

1. Indications for Surgery

   • Persistent pain despite 6+ months of conservative treatment 3
   • MRI evidence of high-grade partial tear 4
   • Functional limitations and weakness in abduction

2. Surgical Options

   • Endoscopic repair is preferred for high-grade partial tears with less severe fatty infiltration 4

     • Lower complication rates than open repair
     • Faster recovery time
     • Double-row repair technique maximizes tendon-to-bone contact area 4

   • Open repair may be more appropriate for cases with severe fatty infiltration 4

Post-Surgical Rehabilitation

Rehabilitation after surgical repair is crucial for optimal outcomes:

• Protected weight-bearing initially
• Progressive strengthening exercises
• Return to full activities typically at 4-6 months post-surgery 5
• Close supervision of rehabilitation protocol is mandatory 5

Important Considerations and Pitfalls

1. Misdiagnosis Risk: Gluteus medius tears are often misdiagnosed as trochanteric bursitis due to non-specific clinical signs 3, 6

2. Prognostic Factors: Tendon retraction and fatty degeneration are poor prognostic factors for functional results and tendon healing 3

3. Timing of Intervention: It's preferable not to wait for the onset of Trendelenburg gait (indicating severe dysfunction) before considering surgical repair 3

4. Surgical Technique Selection: The choice between endoscopic and open repair should consider the degree of fatty infiltration and tear characteristics 4

5. Recovery Expectations: Most patients with tendinopathies (about 80%) fully recover within 3-6 months with appropriate treatment 1