What is the diagnosis and treatment approach for a patient presenting with a right-sided Trendelenburg gait?

Right-Sided Trendelenburg Gait: Diagnosis and Treatment

A right-sided Trendelenburg gait indicates right hip abductor weakness (gluteus medius and minimus), requiring immediate evaluation with MRI or ultrasound to identify the underlying pathology—most commonly abductor tendon tears, particularly after total hip arthroplasty, or neurogenic causes affecting the superior gluteal nerve.

Diagnostic Approach

Clinical Examination Findings

• Positive Trendelenburg sign: The left (contralateral) hip drops during stance phase on the right leg, indicating right hip abductor weakness 1
• Compensatory lateral trunk lean: The patient shifts their trunk over the affected right hip during stance to reduce abductor muscle demand 2
• Assess abductor muscle strength: Grade the hip abduction strength, with weakness ≤M4 being significant 3
• Evaluate for post-surgical history: Anterolateral or transgluteal approaches to total hip arthroplasty are high-risk for abductor injury 1, 4

Imaging Strategy

First-line imaging depends on surgical history:

• For post-THA patients with Trendelenburg gait: MRI hip without IV contrast or ultrasound hip are equally appropriate initial studies 1

  • MRI identifies tendon defects, fatty atrophy of gluteus medius and posterior gluteus minimus, and fluid undermining the abductors 1
  • Ultrasound can identify tendinopathy, partial tears, and complete tears/avulsions in both native and post-surgical hips 1
  • Critical finding: Goutallier grade ≥3 fatty degeneration indicates poor prognosis for primary repair 3

• For native hip patients: Start with radiography hip, then proceed to MRI or ultrasound if abductor pathology is suspected 1

• Arthrography consideration: If abductor avulsion is suspected post-THA, arthrography has 100% specificity but only 60.1% sensitivity—a positive study confirms avulsion, but negative study does not exclude it 1, 4

  • Communication between joint and trochanteric bursa on arthrography indicates abductor avulsion 4
  • False negatives occur when fibrous capsule blocks contrast flow 4

Differential Diagnosis to Exclude

• Superior gluteal nerve injury: Neurogenic cause of abductor weakness, may occur with pelvic trauma or iatrogenic injury 2
• Sacroiliac joint dysfunction: Can produce compensated Trendelenburg gait pattern through somatic dysfunction 2
• L5 radiculopathy: Can weaken hip abductors through nerve root compression 1
• Trochanteric bursitis: May coexist but does not cause true Trendelenburg gait 1

Treatment Algorithm

For Acute/Subacute Abductor Tears (Repairable Tissue)

Surgical repair is indicated when:

• Tendon continuity is disrupted on imaging 1
• Fatty degeneration is <Goutallier grade 3 3
• Patient has functional limitations from positive Trendelenburg sign 3

Approach selection:

• Direct tendon repair with reattachment to greater trochanter for acute tears 1
• Verify tendon continuity postoperatively with ultrasound 1

For Chronic Abductor Insufficiency (Irreparable Tissue)

When fatty degeneration ≥Goutallier grade 3 and muscle strength ≤M4:

• Gluteus maximus tendon transfer is the salvage procedure of choice 3
  • Transfer anterior third of gluteus maximus to greater trochanter 3
  • Suture under mobilized vastus lateralis 3
  • Expected outcomes at 12 months: 80% improvement rate, pain reduction from 7/10 to 3.2/10, Harris Hip Score improvement from 41.6 to 80.2,68% achieve negative Trendelenburg sign 3

For Non-Surgical Candidates or Conservative Management

Gait retraining with biofeedback:

• Microprocessor-based EMG biofeedback comparing affected versus unaffected gluteus medius activity 5
• Expected outcomes: Average 29-degree reduction in Trendelenburg angle, stride length increase from 0.32m to 0.45m, gait speed improvement from 1.6 km/h to 3.1 km/h 5

Osteopathic manipulative treatment:

• May improve compensated Trendelenburg gait when caused by sacroiliac somatic dysfunction 2
• Consider trial before surgical intervention in select cases 2

Critical Pitfalls to Avoid

• Do not rely on negative arthrography to exclude abductor avulsion post-THA—fibrous capsule can block contrast flow, creating false negatives in 47% of cases 4
• Do not assume all post-THA Trendelenburg gait is mechanical—evaluate for infection, adverse reaction to metal debris, and trochanteric bursitis as alternative diagnoses 1
• Do not delay imaging in progressive cases—chronic denervation and fatty infiltration become irreversible, limiting surgical options to salvage procedures 3
• Do not confuse compensated versus uncompensated Trendelenburg—compensated gait shows lateral trunk lean without contralateral hip drop, indicating different biomechanical adaptation 2