Treatment of Ruptured Gluteus Tendon at 4 Months Post-Injury
At 4 months post-injury, a ruptured gluteus medius tendon should be evaluated for surgical repair if conservative treatment has failed, particularly if you have persistent lateral hip pain, weakness, positive Trendelenburg sign, or gait disturbance. 1
Clinical Assessment at 4 Months
Your evaluation should focus on:
- Pain severity and location: Persistent lateral hip/trochanteric pain despite conservative measures indicates surgical consideration 1
- Functional deficits: Assess for hip abduction weakness, positive Trendelenburg sign (pelvis drops on opposite side during single-leg stance), and presence of limp 1
- Muscle quality: Obtain MRI to evaluate for muscle atrophy and fatty degeneration using Goutallier grading—Grade 4 fatty degeneration is a contraindication to repair 2
- Tear characteristics: Confirm tear size, location (typically anterior and lateral portions of tendon), and whether tissue is reconstructable 2, 3
Treatment Algorithm
Conservative Management Failure = Surgical Candidate
If you have completed 4 months of conservative treatment (activity modification, physiotherapy, injections) without adequate improvement, surgical repair should be performed. 1
Surgical Indications at This Timeframe:
- Persistent pain after failed conservative treatment 1
- Significant functional impairment (weakness, gait disturbance) 1
- Reconstructable tendon tear with Goutallier grade 0-3 muscle quality 2
- Patient desire to return to higher activity levels 1
Surgical Technique Options:
Open or arthroscopic double-row anchor fixation techniques provide 80-90% success rates when muscle atrophy is minimal. 2
- Mini-open double-row technique: Uses knotless anchor fixation with suture tape in a fan-shaped pattern, providing large-area anatomic footprint contact 2
- Endoscopic approach: Comparable outcomes to open surgery with potential for reduced soft tissue trauma 4
- Both techniques show good results with improved pain, strength, gait, and low re-rupture rates 1
Surgical Contraindications:
- Goutallier grade 4 fatty degeneration (severe muscle atrophy) 2
- Non-reconstructable massive rupture with irreparable tissue 2
- Local infection 2
Post-Surgical Rehabilitation Protocol
Following repair, expect a 6-month structured rehabilitation with strict early restrictions:
- Weeks 0-6: Partial weight-bearing (20 kg maximum), no active abduction, no adduction, no external rotation in flexion 2
- Week 7 onward: Free range of motion begins, active-assisted abduction initiated, progressive weight-bearing increase by 15 kg/week 2
- Months 4-6: Gradual return to full activities, avoiding peak loads until 4 months 2
- Thromboembolic prophylaxis until full weight-bearing achieved 2
Salvage Option for Irreparable Tears
If the tear is deemed irreparable (Type 5 rupture with severe atrophy), Whiteside transfer of gluteus maximus and tensor fascia lata provides palliative improvement in pain and function, though abduction strength gains are modest. 4
This tendon transfer procedure shows significant improvement in pain scores (VAS 8→3), functional scores (mHHS 22→55), and gait, with both open and endoscopic approaches yielding comparable results 4
Critical Timing Consideration
At 4 months, you are past the acute injury window but still within a reasonable timeframe for primary repair if tissue quality is adequate. The key determinant is muscle quality on MRI—proceed with repair if Goutallier grade ≤3, consider transfer if grade 4 with persistent symptoms. 2, 4
Common Pitfalls to Avoid
- Delaying imaging: MRI or ultrasound confirmation is essential to assess tear size and muscle quality before deciding on treatment 1
- Operating on severely atrophic muscle: Grade 4 fatty degeneration predicts poor repair outcomes 2
- Inadequate post-operative protection: Early aggressive abduction or weight-bearing increases re-rupture risk 2
- Missing associated pathology: Check for valgus proximal femur deformity, which is associated with gluteus medius tears 3