Management of Hip Abductor Tears in Athletes

Introduction:

Hip pain is the most common orthopedic complaint and represents a wide range of etiologies. The cause of lateral hip pain is a greater trochanteric syndrome which occurs most commonly in females. This leads to significant morbidity and chronic functional limitations. The diagnosis of hip abductor insufficiency is made by a combination of physical examination and imaging with magnetic resonance imaging. Initially, conservative management is the treatment of choice. However, when conservative management does not provide relief from pain, surgical intervention has been shown to improve clinical outcomes.

What Is Hip Abductor Tear?

Tendons help in attaching the muscles to the bones, whereas abductors are the muscles that help in rotation and side movements. The abductor hip muscles (gluteus medius and gluteus minimus) are external rotator muscles that rotate outward when the leg is in the air and help in walking and running when the leg is on the ground. Unfortunately, the hip abductor tears are very painful and worsen over time which makes it difficult to stand or walk.

What Are the Types of Hip Abductor Tears?

• Chronic Degenerative: Degeneration of the hip abductor tears, also called rotator cuff tears of the hip- is seen in older adults with hip pain and weakness without arthritis.

• Traumatic Tears: Traumatic tears are usually asymptomatic.

• Iatrogenic Tears: It is due to an unknown cause.

What Is the Pathophysiology of the Hip Abductor Tears?

Tendon overuse results in micro tears in the tendon. While the body tries to heal the tear, sometimes the tears are made faster than the body can fix them. When the number of tears increases, it results in inflammation and weakens the tendon. In addition, age can also contribute to the wear and tear of the tendons.

What Are the Causes?

• Overuse while playing sports which includes jumping.

• Muscle imbalance.

• Micro tear of the tendons.

What Are the Symptoms?

• Pain around the hip bone.

• Weakness.

• Stiffness.

• Snapping sound.

• Change in gait.

• Difficult to stand and walk.

• Pain worsens on walking and jumping.

• Pain goes off after doing a warm-up.

How to Diagnose?

• X-rays: To rule out arthritis, non-displaced fractures, and any bony abnormalities.

• Ultrasound: To detect hip abductor insufficiency in persons with greater trochanteric pain syndrome and is cost-effective.

• Magnetic Resonance Imaging: It is the standard test to diagnose hip abductor insufficiency and typically provides greater visualization of soft tissue structures.

What Is the Treatment?

Conservative Management:

• Rest: Taking proper rest until completely recovered from pain is mandatory.

• Activity Modification: It emphasizes avoiding activities that cause pain, including repetitive movements and lying on the affected side of the hip.

• Physical Therapy: Exercises help to improve gait and reduce pain. Straight leg raises, wall squats, and stretching exercises help to get a compensatory gait and reduce pain.

• Nonsteroidal Anti-inflammatory Drugs: Taking nonsteroidal anti-inflammatory drugs like Ibuprofen help to control pain.

• Corticosteroid Injection: Injecting corticosteroid injection into the muscular insertion may help to reduce pain in some cases.

• Extracorporeal Shock Wave Therapy: It is a safe and effective method that uses pressure waves to deliver mechanical forces to the abductor's muscles.

Surgical Management:

• Each individual's functional goals should be taken into consideration before performing the surgical intervention.

• Surgical intervention is mandatory when there is a failure within six months of conservative treatment, and there is ongoing pain, muscle dysfunction, and compromised quality of life and daily function.

• Small hip abductor tears are amenable to arthroscopic (procedure done with the help of arthroscopy) repair.

• Larger and chronic tears are treated with open incisions and repair.

• In the open incision method, an incision is made directly on the abductor's muscle, the bursae (small fluid-filled sac) are removed, and torn tendons are identified.

• Suture anchors are placed in the greater trochanter muscle, and sutures are passed through the torn tendons to approximate each other to the normal anatomical position.

• In order to heal, weight-bearing and strengthening exercises will be limited during the first phase of rehabilitation.

Rehabilitation Phases:

Phase 1:

• Starting from the period of surgery to three weeks.

• The goal of rehabilitation is to normalize gait patterns with crutches and braces.

• The individual can start doing rehabilitation exercises after three weeks of surgery.

• During this phase, there should not be any active and passive external and internal rotation.

• After three weeks, the individual can do a continuous passive motion for two hours a day, bike for twenty minutes a day as tolerated, scar massage, hip flexion, and gait training with partial weight bearing with the assisted device.

Phase 2:

• This phase comprises four to ten weeks post-surgery.

• Rehabilitation is based on individual progress, one to two times every two weeks.

• In this phase, the rehabilitation goal is to regain and improve muscle strength and single-leg control.

• During this phase, the individual can start practicing isometric exercises, stool rotations, core strengthening exercises, scar massage, and progress with a range of motions.

• After this phase, the individual will have a normal gait, able to carry out functional movements without unloading the affected leg and with good control, and single leg balance for greater than fifteen seconds.

Phase 3:

• This phase comprises ten to twelve weeks post-surgery.

• Rehabilitation is based on individual progress, one to two times every two weeks.

• The rehabilitation goal is to improve muscle strength, discontinue crutches, single leg stand control and no pain with functional movements.

• Should avoid forced stretching during this phase.

• During this phase, the individual can ride a stationary bike, can perform gait and functional movements, standing hip abduction and extension, single leg bridging, side lying leg raises with the leg in internal rotation, and prone heel squeezes with hip extension, stretching, and core strengthening exercises.

• At the end of this phase, the individual will have a normal gait on all surfaces, be able to carry out functional movements without unloading the affected leg, and have good control and a single-leg balance for more than fifteen seconds.

Conclusion:

Hip abductor insufficiency should be suspected in persons with greater trochanteric pain syndrome when they do not respond to conservative management. Magnetic resonance imaging is the most effective in diagnosing hip abductor tears. Individuals and healthcare providers should be aware of conservative options that are clinically proven to improve results. A greater understanding and awareness will ensure individuals with appropriate treatments and clinical outcomes.