Editorial Commentary: It Is Imperative to Fix Symptomatic Hip Gluteus Medius Tears at Time of Femoroacetabular Impingement: Why Ignore This Pain in the Butt?

Greater trochanteric pain syndrome (GTPS) describes the patient with recalcitrant lateral hip pain and although historically it has been thought to be attributed to greater trochanteric bursitis, more recently it has been connected with gluteus medius and minimus tendon tears.^{,  ,  ,}  GTPS, although not caused by femoroacetabular impingement (FAI), the symptoms and limp may be exaggerated due to the intra-articular pathology. This well-designed study performed by Sun, Huang, Mamtimin, Yang, Duan, Zhang, and Wang, entitled “Hip Gluteus Medius Tears Are Associated With Lower Femoral Neck-Shaft Angles and Higher Acetabular Center-Edge Angles,” discusses short-term outcomes with the relative improvement of symptoms of GTPS with isolated FAI correction.

We commend the authors for isolating a treatment group in their retrospective study of patients with FAI and determining what they define as a symptomatic gluteus medius tear. Their study showed a mean follow-up of 13 months isolating 41 patients with FAI with a partial-thickness gluteus medius tear on magnetic resonance imaging (MRI) and 10 patients with FAI with a complete gluteus medius tear on MRI. Their quest in today’s day and age to avoid unnecessary procedures and the subsequent recovery is to be applauded, but what is lost in the data of short-term outcomes study is the importance of physical examination and correlation with the MRI results. In the United States, the prevalence of gluteus medius pathology in patients with FAI was found to be as high as 30.6% on MRI. This is important when examining how the study was designed. With the fact that the article is a retrospective study, the natural progression for including patients is finding patients who underwent FAI correction and then correlate if they were found to have a gluteus medius tear on MRI. Although the authors explain key factors and criteria they looked for during chart review, including greater trochanter tenderness, abductor weakness, positive Trendelenburg sign, and the failure of 3 months of conservative management, they cannot truly determine, retrospectively, the reason for the patient’s presentation to the office and the root of all of their pain.

In our experience, the most important diagnostic predictor in the world of hip arthroscopy is not an MRI but a well-executed history and physical examination to determine the patient’s complaints and the root of their pain. To accurately determine which patients should undergo gluteus medius repair at the time of FAI correction, we must determine the root of the patient’s symptoms. In our office, we use the quadrant approach to accurately do this. We divide the hip in to 4 quadrants; a medial, anterior, posterior, and lateral. The medial quadrant accounts for adductor bursitis, adductor tears, pudendal neuralgia, or sports hernias. The posterior quadrant may account for a hamstring tear, lumbar radiculopathy, ischiofemoral impingement, or in rare cases piriformis syndrome. The anterior quadrant, often described as a “C” around their hip/groin, accounts for more intra-articular pathologies including FAI, labral tears, osteoarthritis, avascular necrosis, or iliopsoas bursitis. Finally, the lateral quadrant would include GTPS, gluteus medius and minimus tears, external snapping hip syndrome, and iliotibial band syndrome. By using this systematic approach to our history and physical examination and then using the MRI to confirm our already thought-out diagnosis, we believe we are more accurately determining patient’s hip pathologies.

Sun et al. have simply stated that patients with FAI with gluteus medius tears may not display symptoms, which may be true, which is why we argue not to repair gluteus tears in the general population, but to repair them in the symptomatic population. The authors also stated that no surgical procedure for gluteus medius was performed, because they felt it was hard to determine whether these symptoms could be attributed to gluteus medius pathology or other conditions. They also felt that the cause of the patient’s lateral hip pain may be functional in nature. This could have further been investigated preoperatively. In our practice, besides using this quadrant approach to the hip, we find that in a patient with multiple complaints across multiple quadrants, a simple intra-articular diagnostic hip injection with local anesthetic is extremely helpful. After performing the hip injection and interviewing the patient while the local is still in effect, we can determine whether the patient’s hip pain is 25%, 50%, 75%, or 100% better, proving that their pain is either FAI or a combination of FAI and GTPS.

Sun et al. state that they retrospectively report that, preoperatively, 25 hips isolated the pain to be in the groin, 31 hips reported pain at greater trochanter, and 7 hips to have pain isolated to the buttocks. They report that, postoperatively, 2 hips continued to have pain at greater trochanter and 3 hips continued to have pain in buttock. They found that limps decreased from 8 patients to 1 and Trendelenburg sign decreased from 8 patients to 3. Personally, we feel that this is difficult to quantify retrospectively when one is looking at patients postoperatively for FAI correction. It is also important to note that in their results they found that abductor strength improved from 3.4 to 3.9 in complete tears, which was not statistically significant. Strength will not improve from pain control if the cause of the weakness is not addressed. From our point of view, the outcomes reported are due to the fact it is a relatively short-term, retrospective study and do not fully appreciate the long-term outcomes. The authors acknowledge that they only described patients with gluteus medius tears and do not include patients with gluteus minimus tears. It is important to note that isolated gluteus minimus tears do occur in the spectrum of GTPS and their prevalence may be as high as 80%. The authors feel that excluding minimus tears is a weakness in the study.

This study by Sun et al. reveals an interesting theory that correcting a patient’s FAI without addressing their gluteus medius tendon tear may improve their GTPS. Although we agree that in asymptomatic patients a gluteus medius repair is unnecessary, we feel strongly about gluteus medius repairs in the symptomatic patient at the time of the FAI correction. An extremely thorough history and physical examination determining the patient’s primary complaints and location of their pain should then be correlated with the patient’s MRI. Keep in mind, we treat patient’s symptoms and not strictly their MRI findings. By addressing the root of the patient’s true pain, which can be bimodal, we can combine postoperative therapy and return the patient to a greater postoperative state with improved outcomes. The gluteus medius and minimus have been compared with the supraspinatus and infraspinatus of the shoulder and are classically referred to as the “rotator cuff of the hip” by Bunker et al. Like the rotator cuff, if abductor tears are left untreated, these tears can progressively worsen, cause chronic hip pain and weakness, and affect the gait of the patient. While it may be a “pain in the butt” to repair a gluteal tendon tear after a labral repair with FAI correction, the senior author would recommend addressing any significant gluteal tendon tear that correlates with the patient’s history and physical examination. In our opinion, by only addressing the patient’s FAI, we would only be treating half of the symptomatic patient’s pain and lead to further hip and functional problems in the future.