Australasian Radiology

(2003)

47

, 85–87

Case Report

MRI in greater trochanter pain syndrome

Geraldine Walsh

1

and Colin G Archibald

2

1

Department of Radiology, Greenslopes Private Hospital and

2

Division of Medical Imaging, Princess Alexandra Hospital, Brisbane, Queensland, Australia

SUMMARY

The greater trochanter pain syndrome refers to pain on the lateral aspect of the hip joint. This is frequently attributedto trochanteric bursitis and distension of the subgluteal bursae. Associated tears of the tendons of gluteus medius andminimus have been described and may result from repetitive frictional trauma to these tendons and their associatedbursae secondary to impingement beneath the tensor fascia lata. Occasionally tendinous damage may result fromacute local direct trauma or a hyperadductive strain injury. We describe MRI in two patients with chronic lateralhip pain.

Key words:

greater trochanter pain syndrome; magnetic resonance imaging.

INTRODUCTION

The greater trochanter pain syndrome refers to pain on the

lateral aspect of the hip joint. This is frequently attributed to

trochanteric bursitis and distension of the subgluteal bursae.

Associated tears of the tendons of gluteus medius and minimus

have been described and may result from repetitive frictional

trauma to these tendons and their associated bursae second-

ary to impingement beneath the tensor fascia lata. Occasionally

tendinous damage may result from acute local direct trauma

or a hyperadductive strain injury. We describe MR imaging in

2 patients with chronic lateral hip pain.

CASE 1

A 74-year-old-female presented with a 6-month history of pain

on the lateral aspect of the left hip joint. T-weighted axial MRI

showed atrophy and partial fat replacement of the left gluteus

medius with some atrophy and fat infiltration of both gluteus

mediuus and minimus muscles (Fig. 1a) T2-weighted coronal

images showed marked distension of subgluteus maximus and

medius bursae. The gluteus medius tendon showed thickening

and increased signal intensity proximally and attenuation distally,

appearances consistent with tendinopathy/partial tear (Fig. 1b).

CASE 2

A 72-year-old woman presented with a long history of dis-

comfort on the lateral aspect of the right hip joint. T2-weighted

coronal MRI showed increased signal intensity surrounding

gluteus minimus and discontinuity of the tendon at its insertion

onto the greater trochanter. High signal intensity consistent with

fluid was also evident surrounding the gluteus medius tendon

(Fig. 2a). T1-weighted coronal images with fat suppression

post-intravenous administration of gadopentetate dimeglumine

(Magnevist; Schering, Berlin, Germany) showed a complete

tear of the gluteus minimus tendon (Fig. 2b) and a partial tear of

gluteus medius tendon with peritendinous synovial enhance-

ment (Fig. 2c).

DISCUSSION AND CONCLUSION

Pain on the lateral aspect of the hip joint is a common clinical

presentation the differential diagnosis of which includes local

trauma, hip joint osteoarthrosis, avascular necrosis of the

femoral head and degenerative spinal disease.

1

The greater

trochanteric pain syndrome refers to pain on the lateral aspect

of the hip joint and is frequently attributed to trochanteric

bursitis with fluid distension of the bursae.

G Walsh

MRCP, FRCR, FRANZCR;

CG Archibald

FFRAD, FRANZCR.

Correspondence: Dr Geraldine Walsh, Department of Radiology, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Queensland 4102,

Australia. Email: cgwalsh@ozemail.com.au

Submitted 20 September 2001; accepted 3 December 2001.

86

G WALSH AND CG ARCHIBALD

In 1961, Gordon stated that the primary lesion in ‘trochan-

teric bursitis’ was damage to the gluteal tendons at their

insertion onto the greater trochanter and that the adjacent

bursae were involved secondarily.

2

A number of reports from

the orthopaedic literature have described tears of the gluteus

medius and minimus tendons observed during hip joint sur-

gery. Bunker

et al

. described tears of the gluteus medius and

minimus tendons in 11 of 50 consecutive patients with femoral

neck fractures.

3

Kagan described partial tears of the gluteus

medius tendon at its trochanteric insertion in seven patients

with refractory symptoms undergoing iliotibial band release.

1

The greater trochanteric pain syndrome is seen most

frequently in middle-aged to elderly women but has been

described more recently in recreational runners and in those

who perform step aerobics.

4,5

An acute syndrome might result

from severe local trauma or from a hyperadductive strain

injury.

6

When conservative treatment fails, surgery to release

the iliotibial band has been advocated.

5

Surgical options range

from transverse fascial release to fascial windowing with or

without reattachment of the gluteal tendons to the greater

trochanter.

1

Fig. 1.

(a) T1 weighted axial sequence showed atrophy with partial

fat replacement of the left gluteus medius muscle (arrow) with some fat

infiltration of the gluteus minimus muscle bilaterally. (b) T2-weighted

coronal image showing marked distension of the subgluteus maximus

and subgluteus medius bursae with thickening and increased signal

intensity of the gluteus medius tendon proximally and attenuation

distally (arrows), with appearances consistent with tendinopathy/

partial tear.

Fig. 2.

(a) T2-weighted coronal image showing increased signal

intensity surrounding the gluteus minimus and medius tendons. (b,c) T1-

weighted coronal image with fat suppression post-intravenous adminis-

tration of gadopentetate dimeglumine showing a complete tear of the

gluteus minimus tendon (arrow; b) and a high grade tear of the gluteus

medius tendon (arrowhead; c) together with peritendinous synovial

enhancement.

GREATER TROCHANTER PAIN SYNDROME

87

Imaging has traditionally played a limited role in the diag-

nosis of the greater trochanteric pain syndrome.

7

Plain

radiographs might show calcification at the trochanteric inser-

tion of the gluteal tendons or irregularity and sclerosis of the

greater trochanter.

8,9

A characteristic scintigraphic appearance

has been described as a linear band of increased tracer uptake

on the superior and lateral aspect of the greater trochanter

on blood pool and delayed images.

10

More recently, Kingzett-

Taylor

et al

. described gluteal tendon tears in 22 cases and

appearances consistent with tendinopathy in 13 of 250 patients

undergoing MRI evaluation for buttock, lateral hip and groin

pain.

6

We found appearances consistent with tendinopathy

and partial tear of gluteus medius and muscle atrophy together

with associated distension of the subgluteus maximus bursa in

one patient while our other case showed gluteus medius and

minimus tendon tears with surrounding synovial enhancement.

In conclusion, we suggest that MRI evaluation for greater

trochanteric pain syndrome should include assessment for both

bursal distension, evidence of tendinopathy and tears involving

gluteus medius and minimus. Recognition of atrophy and fatty

replacement of the gluteus medius and minimus muscles

should prompt a review of the tendon insertions for signs of

tendinopathy and tears. This syndrome has not received much

attention in the radiological literature to date and increased

familiarity with the imaging signs will probably result in diag-

nosis of a greater number of cases.

REFERENCES

1. Kagan A. Rotator cuff tears of the hip.

Clin Orthop Rel Res

1999;

368

: 135–40.

2. Gordon EJ. Trochanteric bursitis and tendinitis.

Clin Orthop

1961;

20

: 193–202.

3. Bunker TD, Esler CNA, Leach WJ. Rotator cuff tear of the hip.

J Bone Joint Surg

1997:

79

: 618–20.

4. Clancy WG. Runner’s injuries. 2. Evaluation and treatment of

specific injuries.

Am J Sports Med

1980;

8

: 287–9.

5. Slawski DP, Howard RF. Surgical management of refractory

trochanteric bursitis.

Am J Sports Med

1997;

25

: 86–9.

6. Kingzett-Taylor A, Tirman PFJ, Feller J. Tendinosis and tears of

gluteus medius and minimus muscles as a cause of hip pain.

AJR

1999;

173

: 1123–6.

7. Ege Rasmussen KJ, Fano N. Trochanteric bursitis: treatment by

corticosteroid injection.

Scand J Rheumatol

1985;

14

: 417–20.

8. Leonard MH. Trochanteric syndrome.

J Am Med Assoc

1958;

168

:

175–7.

9. Anderson TP. Trochanteric bursitis: diagnostic criteria and clinical

significance.

Arch Phys Med Rehab

1958;

39

: 617–22.

10. Allwright SJ, Cooper RA, Nash P. Trochanteric bursitis: bone scan

appearance.

Clin Nucl Med

1994;

13

: 561–4.