What is the recommended management for a non-athlete with a partial gluteus medius tear?

Management of Partial Gluteus Medius Tear in Non-Athletes

The recommended initial management for a non-athlete with a partial gluteus medius tear is conservative treatment consisting of physical rehabilitation, activity modification, oral analgesics, anti-inflammatories, and peri-trochanteric injections for at least 6 months before considering surgical intervention.

Diagnosis and Assessment

• Imaging:

  • MRI is the preferred method for assessing gluteus medius tears, with high sensitivity for detecting tendon defects and fatty atrophy 1
  • Ultrasound can also identify tendinopathy, partial tears, and complete tears/avulsion of the gluteus medius tendon 1
  • Differentiation between trochanteric bursitis and gluteus medius tendinosis may be difficult, and the two conditions may coexist 1

• Clinical Presentation:

  • Lateral hip pain aggravated by weight-bearing and sleeping on the affected side
  • Weakness in hip abduction
  • Possible Trendelenburg sign on examination in more severe cases 2

Conservative Management

First-Line Treatment

1. Physical Rehabilitation:

   • Eccentric strengthening exercises targeting the hip abductors
   • Gentle passive and active-assisted range of motion exercises
   • Progressive loading of the tendon
   • Focus on external rotation and abduction exercises 3, 4

2. Activity Modification:

   • Reduce activities that exacerbate symptoms
   • Avoid excessive tensile and compression stresses on the hip abductor tendons 4

3. Pain Management:

   • Acetaminophen (up to 4g/day) as first-line analgesic
   • NSAIDs at the lowest effective dose for the shortest duration if acetaminophen is inadequate 5
   • Topical NSAIDs may provide pain relief with fewer systemic side effects 5

4. Injections:

   • Corticosteroid injections for short-term pain relief
   • Platelet-rich plasma (PRP) injections may be considered 3, 4

Duration of Conservative Treatment

• Conservative treatment should be pursued for at least 6 months before considering surgical intervention 3
• Exercise interventions typically show improvement in symptoms after 4 months to a year of therapy 4

Surgical Management

Surgical intervention should be considered in the following circumstances:

1. Failure of conservative management for at least 6 months
2. Persistent pain with MRI-confirmed tear
3. Significant functional limitation with abductor weakness 3, 6

Surgical Options

• Endoscopic Repair:

  • Lower rate of complications than open techniques
  • Allows for correction of intra-articular pathology
  • Significant improvement in functional scores and pain in short and medium term 3, 6
  • Options include:
    • Isolated bursectomy with microperforation for minor tears
    • Single or double row tendon repair (double-row repair maximizes contact area between tendon and bone) 7

• Open Repair:

  • May be more appropriate for severe tears with significant retraction
  • Better for cases with more severe fatty infiltration 7

Prognostic Factors

• Poor Prognostic Factors:

  • Tendon retraction
  • Fatty degeneration of the gluteus medius muscle 3
  • Delayed diagnosis and treatment

• Outcomes:

  • Endoscopic repair studies show significant improvement in pain scores and function at minimum two-year follow-up 6
  • Of patients with preoperative gait deviation, 58% regained completely normal gait after endoscopic repair 6

Follow-up and Monitoring

• Close supervision of rehabilitation protocol is mandatory 4
• Progressive loading of the tendon should be implemented
• Monitor for improvement in pain, strength, and gait pattern

Conclusion

For non-athletes with partial gluteus medius tears, a structured conservative approach should be pursued for at least 6 months. If symptoms persist despite adequate conservative treatment, endoscopic repair offers good outcomes with lower complication rates than open surgery. Early intervention before the onset of significant functional limitation (Trendelenburg gait) is preferable for optimal outcomes.