ABDUCTOR TEARS

Gluteus Medius and Minimus Tendon Injuries: Patients with abductor problems or injuries feel pain on the outside of the hip, over the greater trochanter.

ABDUCTOR PT REHAB PROGRAM

GUIDELINES FOR ABDUCTOR REPAIR

ANTI-INFLAMMATORY NUTRITION

ABDUCTOR TEARS: Gluteus Medius and Minimus Tendon Injuries

Pain felt in the side of the hip, or laterally, is often misdiagnosed as “trochanteric bursitis.” The common source of these problems involves injury, tendinitis, or tearing of the tendons of the hip’s Abductors (Gluteus Medius and Minimus) which insert on the greater trochanter of the hip.

abductor

Abductor Injuries:

Patients with abductor problems or injuries feel pain on the outside of the hip, over the greater trochanter. Common complaints include:

Pain on the side (or “lateral”) of the hip, which may radiate down the side of the hip to the knee
Difficulty stepping up onto a step or a stool with the painful side, or walking up an incline (many patients have to climb stairs leading with the other leg)
Pain laying on the affected side, often inhibiting sleep
Weakness and a limp, in which the pelvis sways to the painful side (“Trendelenburg Limp”)

Abductor tendon problems range from irritation and inflammation of the tendons (“Tendinitis”) to chronic breakdown of the tendon collagen (“Tendinosis”), to partial and then complete tearing of the tendons from the bone. Tears can occur from an acute injury, but most often occur simply with overuse and degenerative changes with age. Dr. Ferguson commonly refers to the hip abductors as the “rotator cuff of the hip.” The injury patterns and treatments are quite similar.

This figure and MRI demonstrate tendinitis of the Gluteus Medius tendon at its insertion, with inflammation demonstrated but no muscular tearing, detachment or retraction. The inflammation commonly causes fluid to accumulate in the trochanteric bursa. “Bursitis” is almost always a result of tendinitis, tendinosis, tearing or injury to the muscles that insert on the trochanter, not the primary problem. At this stage, almost all patients respond to a coordinated conservative approach (see below).

Gluteus Medius tendon ruptures can occur with too many steroid injections, thus we caution patients and providers from multiple "bursa" injections. See below for a comprehensive, coordinated approach for non-surgical management of lateral hip pain.

If a patient goes on to complete tearing and detachment of the Abductor tendons, over time they may retract and lead to chronic pain and weakness resistant to conservative/nonsurgical means. In these recalcitrant cases, surgery becomes necessary to reattach the tendons to the bone.

Conservative Non-surgical Management of Abductor Tears

Early abductor problems most commonly respond to activity modification, anti-inflammatory medications, and specific supervised physical therapy. Limited use of ultrasound guided cortisone injections may help quell the pain associated with the tendon inflammation, and allow the physical therapy to work.

*We do NOT endorse multiple, unguided steroid injections which can lead to tendon attrition and dysvascularity, resulting in complete rupture and retraction!

The physical therapy for Abductor Injuries is directed not only a gentle, progressive strengthening program, but also muscle mobilization treatments, dry needling, and collagen repair stimulating techniques which evoke a healing response in the diseased tendon tissue. The majority of patients will respond to these treatments if coordinated appropriately and when the disease process is caught early. Receiving an injection WITHOUT coordination of a physical therapy program is not advisable and commonly leads to more complicated tearing of the tendons and repeated injections.

Some patients don’t respond to the initial trials of conservative treatment. There is an evolving role of biologically active injectable therapies that may be tried, including platelet rich plasma (PRP) and stem cells. These biologically active cells are thought to accelerate tendon healing and may end up having an important role in the treatment of gluteal tendon problems.

Surgical Management of Abductor Tears

For those that fail efforts at nonsurgical treatment or have such severe damage as to include detachment of the tendon(s) from the trochanter, surgery to repair or reconstruct the tendon damage may be required.

Tears that are completely detached and/or retracted, associated with bone formation within the tendons, or have been operated previously most commonly require an open surgical approach. More than 50% of Dr. Ferguson’s patients have had (sometimes many) prior surgeries for their abductor tendon injuries that have failed. Dr. Ferguson has developed a very specific surgical technique for Abductor Tears.

Exposure of the lateral trochanter and identification of the nature of the Gluteus Medius and Minimus damage. Dr. Ferguson is prone to say “the damage found in surgery is virtually always far more extensive than identified with the MRI and sonographic evaluation.”
Identification of the muscles and tendons occurs. The muscles are then “mobilized” as they are commonly retracted and scarred down far away from where they belong on the greater trochanter.
Resection of all the scar tissue, bursal tissue, and boney fragments that tend to form in the holes left behind where the tendon is supposed to be attached to the trochanter.
The trochanteric bursa tends to get fibrotic and somewhat gooey, and worm its way into every nook and cranny left behind when the muscles detach and retract. That must all be removed to make way for the abductor tendons to return to their normal footprint on the trochanteric bone.
The sciatic nerve may be encased in this scar and bursal tissue. If it is, Dr. Ferguson removes all of the scar tissue around the nerve so that it floats freely, non-teathered or impinged on, as it courses through the back of the hip.
The bone of the trochanter needs to be cleared of sclerotic, bumpy bone to a bleeding bed so that when the tendon is brought back down to the bone, the patient’s biology will heal the interface and fully reincorporate the attachment.
The tendons are reattached to their normal footprint on the greater trochanter with several “suture anchors." Darts of suture knots are drilled into the bone, and then the suture used to weave up the tendon to then bring it back down to the bone.
Multiple points of suture anchor fixation is obtained so that if one is “lost” during the healing procedure, the repair isn’t completely threatened.
A collagen stimulating “patch” is placed over the point of greatest damage to accelerate the bone-tendon healing required for a long lasting repair.
If there is significant muscular atrophy and fatty deposition encountered, a silk augment is utilized to strengthen the muscle-tendon junction so that the suture anchors don’t pull out.
Also, in cases of severe muscular atrophy, a “stem cell” preparation is taken from bone marrow aspirate and injected into the repair/diseased muscle to optimize muscular rejuvenation.

Post-Operative Protocols

Post-operatively we think about 4 phases of healing:

1. Acute post-surgical phase: (week 0-8): Restrictions focused on PROTECTING THE REPAIR. The patient’s biology takes 3-4 months to start to form the bond between the tendon and the bone. Until this process has started, it is critical that the patient’s motion be restricted to ensure the repair is not pulled away from the bone. During the first 8 weeks the following precautions are followed:

Limited weightbearing: 30 lbs only with the foot flat. Walker or crutches required for 10 weeks postoperatively.
No active abduction to strain the muscle.
No passive adduction to stretch the muscles at the point of repair.
A hip abduction brace is required when out of bed and moving around.
When in bed, or sitting in a chair, a pillow is placed between the patient’s legs to avoid passively adducting the leg.
High protein diet recommended.

2. Phase 2 (Week 8-12): Activities are still limited, as is weight bearing, but the brace is discontinued. The biological repair is still immature and not sufficient to maintain the tendon-bone interface without the suture anchors. Patients start formal PT at this point (click here for Abductor PT Rehab Program).

Continue limited weight-bearing until week 10 postoperatively. Then at the 10th week, under the direction of the therapists, patients are allowed to slowly put more weight on their operative side until they are able to walk LIMP-FREE without assistive devices. This starts at week 10 and generally takes 2-4 weeks before patients are able to ambulate safely without a crutch or the walker.
Patients may be allowed to start walking in a pool and may be advanced to a stationary bike without resistance during phase 2.
Therapists start some gentle deep tissue mobilization, dry needling and scar mobilization. Joint mobilization by the physical therapist is started.

3. Phase 3 (Week 12-16): At week 12 we assume that the biology has started to incorporate the repair enough to start gently strengthening the muscles. Motion restrictions and weight-bearing restrictions are dialed back under the direction of the physical therapist. Week 12-16 is when we start to progressively strengthen the muscles with the goal of a normal, unassisted gain and pain-free hip motion. Resistance training is added under the therapist's direction.

4. Phase 4: (Week 16+): The goal is directed toward a 100% return to normal activity and function. Any residual weakness is addressed with advanced therapy modalities including dry needling, Neuromuscular Electrical Stimulation Treatments (NMES), and laser therapy (LLLT) as well as guided muscular strengthening activites with the physical therapy team.

Outcomes after Abductor Tear Surgery

Abductor tears are qualitatively the most painful condition of the hip, and when chronic often have lead a patient to years of sleepless misery. Dr. Ferguson’s practice sees these patients as the happiest surgical patients we encounter. Patients often have almost no pain early after surgery. We talk about the “period of negotiation,” when at 4-8 weeks, patients have no pain but are still required to adhere to strict restrictions on their activity and weightbearing. The “negotiations” start with, “Do I REALLY have to use the walker?” “Can’t I get rid of the brace now?” Most recently “It doesn’t hurt, so can’t I ride my motorcycle?” We find the biggest challenge is getting patients to continue with the rehab program, which is critical for LONG TERM SUCCESS.

Recurrence can happen, particularly in previously operated hips and hips with severe muscular atrophy. The carefully sculpted rehab program is ESSENTIAL to the patient’s biological incorporation of the repair which is required for long term success.

Nuts and Bolts of Dr. Ferguson's Abductor Surgery

The surgery that is performed commonly takes 3 or more hours depending on how much damage and scar tissue is encountered. Patients generally spend one night in the hospital after the operation.
General anesthesia is required to allow complete relaxation of the muscles for reattachment surgery,
The surgical incision is ultimately closed with a suture under the skin, with no sutures or staples to be removed after the operation. A waterproof dressing is applied which stays on for 7 days after surgery. Once the waterproof dressing is removed, patients change their own dressings every other day for 2 more weeks.
After the operation, patients use aspirin every day for 3 weeks as well as compression hose for blood clot prevention (see below for exceptions).
We endorse the use of the GameReady cold compression device for cryotherapy and to decrease swelling after surgery (you will receive information about this device in the office before surgery).
After surgery, patients use a walker/crutches to limit the weight placed across the operative hip for 10 weeks after surgery. This is demonstrated during physical therapy in the hospital.
Patients are fit for a hip abduction brace at their preoperative appointment and use the brace while out of bed for 8 weeks after surgery. When just sitting on the couch or in a recliner, a pillow can be placed between the legs and the brace can be removed.
A foam pillow is used after surgery while in bed to prevent patients from accidentally moving their operated leg inward, past midline, which can threaten the repair.
When severe damage and muscular atrophy is encountered in surgery, bone marrow aspirate may be taken from the pelvis as a source of PRP which is then applied to the repair to enhance the healing process. If this is required, patients are not treated with aspirin or NSAIDS (Celebrex/Mobic) after surgery, as these anti-inflammatory medications work against the PRP actions. In these cases (10% of Dr. F’s abductor patients), a medication called “Xeralto” is utilized for blood clot prevention, and different pain medications are used.
Physical therapy is not formally started for the first 8 weeks after surgery in most cases, saving your PT visits for the second phase in which supervised and “hands on” manual therapies become critical.
Follow-up appointments and therapy protocols are well delineated on the “Physical Therapy” forms as well as the “Abductor Care Pathway” documents on this web site. These will also be given to surgical patients in the preoperative counseling appointments.