Courtesy: Eurico Monteiro MD, Porto, Portugal
Peritrochanteric Space Disorders
Introduction
Peritrochanteric space disorders refer to pathology occurring in the region between the iliotibial band (ITB) and the greater trochanter of the femur.
These conditions commonly present as:
- Greater Trochanteric Pain Syndrome (GTPS)
GTPS is a broad clinical entity that includes:
- Gluteus medius tears
- Gluteus minimus tears
- Trochanteric bursitis
- External snapping hip
- Iliotibial band pathology
Surgical Anatomy
Key Anatomical Structures
The major structures in the peritrochanteric space include:
Gluteus Medius and Minimus Tendons
- Primary hip abductors and stabilizers
- Functionally analogous to the rotator cuff of the shoulder
Iliotibial Band (ITB)
- Forms the superficial boundary of the peritrochanteric space
- Commonly involved in external snapping hip
Gluteus Maximus Insertion
- Contributes to hip stability and dynamic movement
Bursae Around the Greater Trochanter
Important bursae include:
- Trochanteric bursa
- Subgluteus medius bursa
- Subgluteus minimus bursa
Facets of the Greater Trochanter
The greater trochanter consists of several distinct facets:
- Anterior facet
- Lateral facet
- Posterior facet
- Superoposterior facet
These facets serve as tendon attachment sites and are important during endoscopic repair.
The “Bald Spot”
The “bald spot” refers to:
- An area on the greater trochanter without tendon insertion
This region is clinically important because it is:
- A safe portal entry zone
- A preferred site for anchor placement during repair
Functional Concept
The peritrochanteric region is often described as the:
- “Rotator cuff of the hip”
Stabilizers
- Gluteus medius
- Gluteus minimus
Movers
- Tensor fascia lata (TFL)
- Iliopsoas
Risk Factors
Several factors increase the risk of peritrochanteric pathology:
- Older age
- Obesity
- Hip osteoarthritis
- Knee osteoarthritis
- Lumbar spine pathology
- Coxa vara
- Pelvic imbalance
- Hypermobility syndromes
Hypermobility, particularly increased Beighton scores in females, is strongly associated with these disorders.
Clinical Features
Patients commonly present with:
- Lateral hip pain
- Tenderness over the greater trochanter
- Weakness of hip abduction
- Difficulty lying on the affected side
- Limping
Trendelenburg Sign
In severe gluteus medius tears:
- Trendelenburg sign may be positive
This reflects abductor insufficiency and pelvic instability during gait.
External Snapping Hip
Some patients experience:
- Audible or palpable snapping over the greater trochanter
This is usually caused by:
- Iliotibial band movement over the greater trochanter
Imaging
MRI
MRI is considered the:
- Gold standard for tendon pathology
MRI helps evaluate:
- Partial tendon tears
- Full-thickness tears
- Tendon degeneration
- Fatty atrophy
- Retraction
Ultrasound
Ultrasound is particularly useful for:
- Dynamic assessment of snapping hip
- Guided injections
- Evaluation of bursitis
Dynamic ultrasound is considered the best imaging modality for:
- External snapping hip
Differential Diagnosis
Peritrochanteric pain may mimic several other conditions.
Intra-Articular Hip Pathology
Must exclude:
- Femoroacetabular impingement (FAI)
- Labral tears
- Avascular necrosis (AVN)
Extra-Articular Causes
Important differentials include:
- Lumbar radiculopathy
- Stress fractures
- Nerve entrapment syndromes
Spine pathology should always be assessed in patients with lateral hip pain.
Classification of Gluteus Medius Tears
Grade 1
- Less than 25% tendon involvement
Grade 2
- 25–50% tendon involvement
Grade 3
- 50–75% tendon involvement
Grade 4
- Full-thickness tear
GTPS Classification
Type 1
- Isolated bursitis
Type 2
- Bursitis with tendon fraying
Type 3
- Partial tendon tear
Type 4
- Full-thickness tear
Type 5
- Full-thickness tear with retraction
Treatment Principles
Treatment depends on:
- Severity of tendon involvement
- Functional limitation
- Degree of tendon retraction
- Patient factors
Conservative Management
Usually indicated for low-grade pathology.
Treatment options include:
- Physiotherapy
- Activity modification
- PRP injections
- NSAIDs
- Image-guided injections
Management by Tear Grade
Grade 1 Tears
Management includes:
- Conservative treatment
- PRP injections
- Physiotherapy
Endoscopic options may include:
- Bursectomy
- Trans-tendinous microfracture
Grade 2 Tears
Treatment usually involves:
- Trans-tendinous repair
- Suture anchor fixation
Grade 3 Tears
High-grade partial tears are often:
- Converted into full-thickness tears
Repair techniques include:
- Side-to-side repair
- Anchor fixation at the bald spot
Grade 4 Tears
Full-thickness tears are repaired similarly to:
- Rotator cuff tears of the shoulder
Techniques include:
- Single-row repair
- Double-row repair
- Roman bridge technique
Grade 5 Tears
Massive tears with retraction may require:
- Open reconstruction
Common reconstructive options include:
- Gluteus maximus transfer
- Tensor fascia lata transfer
Endoscopic Surgical Technique
Common Portals
Frequently used portals include:
- Modified mid-anterior portal
- Proximal accessory lateral (PALA) portal
- Distal accessory lateral (DALA) portal
- Posterolateral portal
Key Surgical Steps
Step 1: Identify the Bald Spot
Serves as the reference point for repair.
Step 2: Bursectomy
Inflamed bursae are excised.
Step 3: Debridement
Degenerated tendon tissue is cleaned.
Step 4: Anchor Placement
Anchors are inserted into the greater trochanter.
Step 5: Tendon Repair
Tendon is repaired using suture fixation techniques.
Post-Operative Rehabilitation
Rehabilitation protocols aim to protect the repair while maintaining mobility.
Weight Bearing
- Two crutches for approximately 6 weeks
Movement Restrictions
Avoid:
- Active abduction for 6 weeks
- Passive abduction for 2 weeks
Early Rehabilitation
Encouraged activities include:
- Stationary cycling
- Hydrotherapy
Immobilizers are generally not required.
Outcomes
Endoscopic treatment offers several advantages:
- Smaller incisions
- Reduced soft tissue damage
- Lower complication rates
Studies show:
- Similar functional outcomes between open and arthroscopic techniques
Poor Prognostic Factors
Factors associated with worse outcomes include:
- Older age
- Obesity
- Smoking
- Large tears
- Fatty degeneration of muscles
External Snapping Hip
Cause
Usually caused by:
- Iliotibial band snapping over the greater trochanter
Diagnosis
Best diagnosed using:
- Dynamic ultrasound
Treatment
Surgical treatment may involve:
- Diamond-shaped IT band release
- Partial gluteus maximus release
Key Clinical Pearls
- Greater Trochanteric Pain Syndrome is often considered the “rotator cuff disease of the hip.”
- MRI is the best investigation for gluteal tendon pathology.
- Dynamic ultrasound is best for evaluating external snapping hip.
- The “bald spot” is the safest area for anchor placement.
- Lumbar spine pathology should always be excluded in lateral hip pain patients.
Final Take-Home Message
Peritrochanteric space disorders are an important and increasingly recognized cause of lateral hip pain.
Successful management requires:
- Accurate diagnosis
- Recognition of associated tendon pathology
- Appropriate imaging
- Individualized treatment planning
Endoscopic management has become an effective minimally invasive option with excellent outcomes when performed in appropriately selected patients.
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