A 44-year-old woman comes to the office due to increasing right hip pain for the past several days. The pain is exacerbated by walking and by sitting with the right leg crossed over the left leg. The patient has a history of plantar fasciitis. Vital signs are within normal limits. BMI is 30 kg/m2. On examination, right hip abduction and internal rotation against resistance when the hip is flexed reproduce the pain. The cause of this patient's symptoms is suspected to be pathology at a tendon insertion site. The tendon of which of the following muscles is most likely involved?
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This patient has greater trochanteric pain syndrome (GTPS) characterized by lateral hip pain. GTPS is an overuse tendinopathy of the gluteus medius and gluteus minimus at their insertion on the greater trochanter of the femur. It is often referred to as trochanteric bursitis, although bursal involvement varies and is not likely the primary pathology. Risk factors include obesity, plantar fasciitis, and altered gait mechanics (eg, osteoarthritis).
The gluteus medius and gluteus minimus originate from the upper and lower gluteal surfaces of the ilium, respectively, and insert onto the greater trochanter. Their primary functions include:
Examination typically is notable for point tenderness over the greater trochanter. The pain is reproduced by hip abduction and internal rotation (when the hip is flexed) against resistance because muscle contraction stresses the tendons. Sitting with the affected leg crossed over the other can also produce pain. Muscular weakness or tendon rupture is suggested by the Trendelenburg sign: with the patient standing on the affected leg, the pelvis falls to the contralateral side due to impaired abduction.
(Choice A) The adductor brevis originates from the inferior pubic ramus and inserts onto the linea aspera of the femur. Strain typically produces groin and medial thigh pain that can be reproduced by resisted hip adduction (not abduction).
(Choices C and D) The obturator externus originates from the obturator membrane and obturator foramen and inserts onto the trochanteric fossa of the femur. The quadratus femoris originates from the ischial tuberosity and inserts onto the intertrochanteric crest of the femur. These muscles externally rotate the hip (regardless of whether the hip is flexed, unlike gluteus medius), and muscle strain would cause pain on resisted external (not internal) rotation.
(Choice E) Vastus lateralis is part of the quadriceps femoris complex. It originates from the intertrochanteric line, greater trochanter, gluteal tuberosity, and linea aspera of the femur and inserts onto the tibial tubercle via the quadriceps tendon/patellar ligament. Strain presents with thigh pain that is reproduced by resisted knee extension.
Educational objective:
Greater trochanteric pain syndrome is an overuse tendinopathy of the gluteus medius and gluteus minimus at their insertion on the greater trochanter of the femur. Examination shows tenderness over the greater trochanter; pain is reproduced by resisted hip abduction and internal rotation (when the hip is flexed).