What is the appropriate assessment of a symptomatic, partial‑thickness tear of the left gluteus minimus identified incidentally on a right‑hip MRI performed for trochanteric bursitis?

Assessment of Incidentally Discovered Symptomatic Partial Gluteus Minimus Tear

Order a dedicated MRI of the left hip without contrast to fully characterize the partial gluteus minimus tear, assess for associated pathology, and guide treatment decisions. 1, 2

Rationale for Dedicated Left Hip MRI

The incompletely visualized finding on the right hip MRI is insufficient for proper clinical decision-making. A complete MRI assessment is essential because it will determine critical prognostic factors including tear size, degree of retraction, and fatty degeneration—all of which directly impact treatment selection and surgical timing. 2

Key Imaging Considerations

• MRI of the hip has sensitivity ranging from 33-100% and specificity of 92-100% for detecting gluteal tendon tears, making it the definitive diagnostic study. 2

• The dedicated left hip MRI must evaluate:

  • Full extent and thickness of the gluteus minimus tear 2
  • Presence of gluteus medius involvement (frequently coexists) 1, 3
  • Degree of tendon retraction 2
  • Fatty infiltration/degeneration of the muscle 2
  • Associated trochanteric bursitis 1
  • Bone marrow edema or greater trochanter pathology 1

Clinical Assessment During Workup

While awaiting or scheduling the MRI, perform a focused physical examination:

• Palpate for point tenderness over the left greater trochanter 4
• Assess hip abductor strength with resisted abduction testing 3
• Observe gait for Trendelenburg sign (hip drop on contralateral side during stance phase) 3, 5
• Document pain-free range of motion 3

Treatment Algorithm Based on MRI Findings

If Full-Thickness Tear Confirmed

Refer urgently to orthopedic surgery for repair within 3 weeks of symptom onset if acute, as early surgical intervention prevents worse outcomes from tendon retraction and fatty degeneration. 2

• Delaying surgical repair beyond 6 months or waiting for Trendelenburg gait to develop results in poor prognostic factors for functional outcomes and tendon healing. 2

If Partial-Thickness Tear Confirmed

The treatment decision depends on functional deficit:

• For patients with minimal functional deficit, no Trendelenburg gait, and strong preference for non-operative care: Attempt conservative treatment for less than 6 months including activity modification, physical therapy with eccentric strengthening of hip abductors, NSAIDs, and cryotherapy 2

• For patients with significant weakness, Trendelenburg gait, or failed conservative treatment: Consider endoscopic trans-tendinous repair, which has shown good patient satisfaction and improved strength 6, 7, 5

Critical Pitfalls to Avoid

• Do not rely on the incomplete visualization from the right hip MRI to make treatment decisions—this is inadequate for assessing tear characteristics. 2

• Do not perform corticosteroid injections into the tendon substance itself, as this has deleterious effects; peritendinous injections only if needed for symptom control. 2

• Do not dismiss this as simple "trochanteric bursitis"—gluteus medius and minimus tears are frequently misdiagnosed as bursitis, leading to delayed appropriate treatment. 3, 7

• Avoid repeated corticosteroid injections, which have long-term deleterious effects on tendon integrity. 2

Additional Diagnostic Considerations

• Obtain plain radiographs of the left hip first to exclude bony pathology, fracture, or arthritis as alternative pain sources. 1, 2

• If the patient is under 45 years old and reports morning stiffness lasting more than 30 minutes, obtain MRI of the sacroiliac joints and refer to rheumatology to evaluate for axial spondyloarthropathy. 1

• Ultrasound-guided diagnostic injection with local anesthetic can provide both diagnostic confirmation and temporary therapeutic benefit if the diagnosis remains unclear after imaging. 1, 8