0:00

The next area we're gonna go look at is at the abductors.

0:04

And here you're at the lateral hip, right at the level

0:08

of the greater trocanter.

0:10

So at the level of the greater trocanter,

0:12

we have our gluteus minimus inserting anteriorly

0:16

and our gluteus medias inserting posteriorly.

0:21

Now this has a very broad insertion.

0:24

I'm only showing you a portion of it on this sagittal image.

0:28

Fibers also extend along the outer surface of the bone,

0:31

so you wanna work your way back

0:33

and forth on your sagittal images

0:36

to make sure you include all of it.

0:38

And again, the axial images are really,

0:41

really important when you're trying to evaluate the area

0:45

of the abductor tendons.

0:47

Now they can tear in trauma, but that's unusual.

0:51

Most of the tearing that we see is degenerative, uh,

0:54

occurring in older

0:56

and middle-aged women with a background of tendinosis.

1:00

I'm showing you here a traumatic tear of the gluteus medias.

1:04

It's not visible. Don't confuse the slips

1:07

of the external rotators with gluteal tendons.

1:11

They're also inserting on the greater trocanter,

1:14

but they insert along the inner wall of it

1:16

and have a more horizontal course.

1:19

Uh, they're well outlined here

1:20

by the hemorrhage and are intact.

1:23

You can see the fracture fragments slightly displaced,

1:26

but the gluteus minimus looks normal.

1:29

But the gluteus medias was torn in this, uh,

1:32

particular, uh, example.

1:34

So this is relatively uncommon.

1:37

So let's look at that anatomy,

1:38

'cause I always found this quite, uh, challenging.

1:41

Uh, so the things that I have learned are

1:44

to start on my axial

1:46

and look at where the hip capsule is inserting.

1:48

There's often a little bump where the capsule inserts

1:51

that is different than the FAI bump,

1:54

which is gonna be located at the head neck junction.

1:57

Once you sign the capsular insertion, immediately lateral

2:01

to it along this anterior flat facet is

2:05

the gluteus minimus.

2:07

So that's the gluteus minimus here.

2:09

The gluteus medias inserts higher up,

2:12

so you may not see it on the same slice,

2:15

and the gluteus minimus goes down a long way.

2:18

So when I'm down low, I'm only looking at gluteus minimus.

2:21

On this particular example,

2:23

the gluteus medias has a dominant tendon

2:26

that inserts very high along the

2:30

supra posterior facet,

2:32

but then it also sends slips

2:34

that insert along the lateral facet,

2:37

a little bit more cranial than this image.

2:39

And then you get this rounded facet.

2:42

This is where the trocanter bura lives,

2:44

and nothing inserts on that rounded portion.

2:47

So if you keep that anatomy in mind, then you'll be able

2:51

to follow these tendons a little bit better.

2:54

So again, on our axial images, we look for the bump where

2:58

The capsule inserts the flat area next to it is

3:03

where the gluteus minimus is living,

3:05

and it's going to go down further distally than

3:08

the gluteus medias.

3:10

As soon as we make the bend is

3:12

where the gluteus medias is living,

3:14

it's gonna go up cranial all the way to

3:17

that postal superior facet where the big tendon inserts.

3:21

And then we have the round area

3:23

where there's nothing inserting,

3:25

but that's where you have your trocanter bursa.

3:28

So let's take a look at some abnormalities

3:32

involving these structures.

3:33

This is a patient who has degenerative tearing

3:37

of the gluteus medias tendon.

3:39

Notice that there's fluid overlying it.

3:42

This is the more posterior fibrous of the gluteus medias,

3:47

and this is the more anterior fibers.

3:49

I like this image. This is taken from, uh, an article

3:53

by flock showing you how these tendons between the minimus

3:58

and medias are basically continuous.

4:00

You have a, a sheath of tendon inserting

4:04

around the greater trocanter akin to what we see

4:07

with the rotator cuff at the shoulder.

4:09

And that's why this particular structure is often referred

4:13

to as the rotator cuff of the hip.

4:16

It has a very similar, uh, type of, uh, of anatomy.

4:24

So if you remember, the gluteus medias has two pieces

4:28

I think that'll help you look at this minimus in the front.

4:31

And then the medias having the dominant big tendon coming to

4:36

that posterior superior facet.

4:39

And then a large lateral tendon

4:41

that inserts along the lateral facet,

4:43

which is a often looks like it's two pieces.

4:46

You need to really look at all of that when you are looking

4:49

to see if there is tearing.

4:52

Here's a patient, uh, sorry.

4:54

This is a cadet cric specimen from an article

4:57

by Christian Fearman

4:58

and our partner, uh, Christine Chung,

5:00

who you will be hearing from, uh,

5:02

showing you the fluid notice that it's going around,

5:05

that rounded, uh, posterior, uh, facet deep

5:09

to the ileal tibial tract.

5:11

And in this article, uh, they outlined

5:14

that there are other additional smaller bura.

5:16

I am not gonna show you examples that are intimate

5:18

and deep to the gluteus minimus and, uh, medias bursa.

5:22

But when we talk about tro enteric bursitis,

5:24

it is this greater tro enteric bursa that we are usually,

5:28

uh, focusing on the large one over here, covering

5:32

that posterior facet.

5:34

People who have pain in this area can have pathology, uh,

5:39

that encompasses a number of different, um,

5:43

uh, abnormalities.

5:44

They may have tendinopathy or tendinosis.

5:47

They may have a frank tear.

5:49

You can have active calcific tendonitis in this area,

5:52

or they may get pain from tro enteric bursitis.

5:55

And these can all

5:56

Sort of coexist.

5:58

Again, you wanna remember the demographic generally in your

6:01

middle aged and elderly women.

6:03

They complain of focal pain.

6:05

This is easily palpable, uh, by the clinician.

6:08

They have pain now with the, with direct, uh, pressure.

6:11

And in this example we see, uh,

6:13

a tear involving the dominant, uh, tendon

6:17

of the gluteus medias with quite a bit of inflammation

6:20

and edema, as well as overlying, uh, soft tissue fluid.

6:25

But consider the other entities that you want to look at.

6:28

You also want to look to see if there's any

6:31

calcifications in that area.

6:33

The, it's easier often on an x-ray.

6:36

This is an example again, of calcific tendonitis.

6:39

You can see that there are multiple low signal foci,

6:43

intimate with the gluteus mids tendon.

6:47

Lot of swelling in the soft tissues, little bit

6:49

of streaky edema overlying, uh, the tendon.

6:53

And, uh, this particular patient, the tendon is intact,

6:57

but she has active, uh, calcific tendonitis.

7:00

So same thing as I showed you with the rectus.

7:04

Remember this, that history is different.

7:05

The patients, uh, are of more variable age.

7:08

It's usually an acute onset.

7:10

And if you're at an institution

7:12

where you have an opportunity to look at the radiographs,

7:16

those are very helpful for making this, uh,

7:19

this particular diagnosis.

7:21

Another, uh, thing that you wanna look at in your patients

7:24

that come in with this greater tro enteric pain syndrome is

7:28

the overlying tibial band.

7:31

Uh, notice how thickened and irregular it is.

7:33

In this particular example,

7:35

she had had an injury several months earlier.

7:38

We did not have acute imaging at that time,

7:41

and I'm presuming this is post-traumatic.

7:44

Um, uh,

7:45

and, uh, this thickened sort

7:48

of structure really can impinge on the underlying tendons

7:52

and on the bursa.

7:53

So we take a quick eye on that area.

7:56

The iliotibial band has complex anatomy

7:59

with origins from multiple gluteal muscles as well

8:03

as the tensor fascia.

8:04

Lata wraps around the area of the hip, superficial

8:09

to the greater trocanter and can cause impingement.

8:13

And again, as we talked about this term

8:15

of the rotator cuff tear of the hip,

8:18

that iliotibial band has been likened

8:21

to the acromion being a rigid structure that leads

8:24

to impingement of the underlying bone and soft tissues.