Trochanteric Bursitis Research Articles

Diagnostic Accuracy of Clinical Tests for Assessing Greater Trochanteric Pain Syndrome: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to evaluate the accuracy of clinical tests that are used to diagnose greater trochanteric pain syndrome (GTPS) in clinical practice. DESIGN: Diagnostic test accuracy systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CINAHL, AMED, and SPORTDiscus were searched using key words mapped to diagnostic test accuracy for GTPS. STUDY SELECTION CRITERIA: Studies with published or derivable diagnostic accuracy data were included. DATA SYNTHESIS: Risk of bias was assessed using the QUADAS-2 tool, and certainty of evidence, via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MetaDTA "R" random-effects models were used to summarize individual and pooled data including sensitivity, specificity, likelihood ratios, and pretest/posttest probabilities. RESULTS: From a database yield of 858 studies, 23 full texts were assessed. We included 6 studies for review, involving 15 tests and 272 participants (314 hips). Overall certainty of evidence ranged from very low to moderate. Meta-analysis of 6 tests revealed sequenced test clusters able to significantly shift pretest-posttest probability for or against a GTPS diagnosis. In people reporting lateral hip pain, a negative gluteal tendon (GT) palpation test followed by a negative resisted hip abduction test significantly reduced the posttest probability of GTPS from 59% to 14%. In those with a positive GT palpation test followed by a positive resisted hip abduction test, the posttest probability of GTPS significantly shifted from 59% to 96%. CONCLUSION: The value of magnetic resonance imaging for diagnosing GTPS is debated. We have identified a straightforward, clinically useful diagnostic test cluster to help confirm or refute the presence of GTPS in people reporting lateral hip pain. J Orthop Sports Phys Ther 2024;54(1):1-24. Epub 10 August 2023. doi:10.2519/jospt.2023.11890.

Relationship between the Arthroscopic Findings and Pathology of Greater Trochanteric Pain Syndrome.

In recent publications on greater trochanteric pain syndrome (GTPS), the pathology receiving the most attention has been gluteus medius muscle tendinous injury, and surgical techniques such as gluteus medius tendon repair and their outcomes for GTPS have been reported. In our department-related facilities, arthroscopic surgeries are routinely performed for the patients with recalcitrant GTPS. A total of 51 patients were diagnosed with GTPS. Surgical treatment was carried out 22 patients (24 joints; 4 males and 18 females; mean age at surgery of 52.0 years). Arthroscopic findings confirmed bursitis in all 24 joints. In all cases, debridement of the greater trochanter bursa provided rapid relief of greater trochanter pain. The Numerical Rating Scale showed significant improvement, from the preoperative mean of 7.8 (range, 6-10) to the postoperative day 7 mean of 1.6 (range, 0-3). The modified Harris Hip Score was significantly improved from the preoperative mean of 65.5 (range, 52.5-78.3) to the final follow-up (average 2.9 months) mean of 96.0 (range, 85.2-100). Fascial damage of the gluteus medius muscle was observed in 21 joints while only 2 patients had a gluteus medius tendinous injury. Greater trochanteric bursitis and fascia or muscle-fiber injury of the gluteus medius muscle are the most common pathologies in patients with lateral hip pain.

Excision of trochanteric bursa during total hip replacement: Does it reduce the incidence of post-operative trochanteric bursitis?

Trochanteric bursitis is a common complication following total hip replacement (THR), and it is associated with high level of disability and poor quality of life. Excision of the trochanteric bursa prophylactically during THR could reduce the occurrence of post-operative trochanteric bursitis. To evaluate whether synchronous trochanteric bursectomy at the time of THR affects the incidence of post-operative trochanteric bursitis. This retrospective cohort study was conducted in the secondary care setting at a large district general hospital. Between January 2010 and December 2020, 954 patients underwent elective primary THR by two contemporary arthroplasty surgeons, one excising the bursa and the other not (at the time of THR). All patients received the same post-operative rehabilitation and were followed up for 1 year. We reviewed all cases of trochanteric bursitis over this 11-year period to determine the incidence of post-THR bursitis. Two proportion Z-test was used to compare incidences of trochanteric bursitis between groups. 554 patients underwent synchronous trochanteric bursectomy at the time of THR whereas 400 patients did not. A total of 5 patients (incidence 0.5%) developed trochanteric bursitis following THR; 4 of whom had undergone bursectomy as part of their surgical approach, 1 who had not. There was no statistically significant difference between the two groups (Z value 1.00, 95%CI: -0.4% to 1.3%, P = 0.32). There were also 8 other patients who had both trochanteric bursitis and hip osteoarthritis prior to their THR; all of whom were treated with THR and synchronous trochanteric bursectomy, and 7 had resolution of their lateral buttock pains but 1 did not. Synchronous trochanteric bursectomy during THR does not materially affect the incidence of post-operative bursitis. However, it is successful at treating patients with known trochanteric bursitis and osteoarthritis requiring THR.

METAL ARTIFACT REDUCTION SEQUENCE MRI ABNORMALITIES IN ASYMPTOMATIC PATIENTS WITH DUAL MOBILITY HIP PROSTHESES

Modular dual mobility (DM) articulations are increasingly utilized during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) abnormalities with serum metal ion levels in patients with DM articulations.All patients with an asymptomatic, primary THA and DM articulation with >2-year follow-up underwent MARS-MRI of the operative hip. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels.Forty-five patients (50 hips) with a modular DM articulation were included with average follow-up of 3.7±1.2 years. Two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels >3.0 μg/L. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/L. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels <1.0 μg/L, while one (2.6%) had a cobalt level of 1.4 μg/L. One patient (2.2%) had a chromium level >3.0 μg/L and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels >5.0 μg/L without associated MARS-MRI abnormalities.Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic dual mobility articulations occur infrequently (4.4%), but further assessment of these patients is necessary.Level of Evidence: Level IV

Gluteal Tendon Tear Healing on Ultrasound 10 Weeks Following a Single Platelet-Rich Plasma Injection: A Case Report

Tendinosis with or without tendon tear is a common form of tendon pathology and should be managed differently from inflammatory tendinitis although both are termed tendinopathy. The current tendinopathy management involves rest, icing, a brace, oral anti-inflammatory medicine, and physiotherapy. Should that fail a trial of Corticosteroid (CS) injection allow surgery as a last resort. This article presents a middle-aged male, a human resources manager who suffered two occasions of tendinopathy with the first one being a gradual development of symptomatic right common flexor origin calcific tendinosis (golfer’s elbow) on ultrasound (USS) secondary to competitive squash that failed conservative management and USS-guided CS injection. He had a long-term symptomatic recovery after six weeks following a single autologous platelet-rich plasma (PRP) therapy. Three years later he injured his right hip following a twisting injury to the right hip/gluteal area resulted in debilitating symptoms, USS scan revealed gluteus minimus/ medius calcific tendinosis, a partial split tear of the gluteus minimus, and trochanteric bursitis. He failed physiotherapy and anti-inflammatory medicine. He elected PRP therapy over CS injection, he became symptoms free six weeks after the injection. Teen weeks post-injection USS revealed a complete resolution of gluteus minimus tendon tear and no trochanteric bursitis, no clear tendinosis features but calcifications present. This case demonstrates the use of relatively safe affordable clinic-based PRP therapy for long-term symptomatic control of tendinopathy with/without a tear. This is superior to oral anti-inflammatory and CS injections. Additionally, the healing of the tendon tear could save people from avoiding invasive surgery with its complications and long recovery time. Thanks to the regenerative healing power of the growth factors and signaling proteins in platelets that stimulate the internal mesenchymal stem cells. We recommend a large-scale randomized control trial to confirm those findings and standardization of the PRP technique, hoping regenerative medicine to become the mainstream therapy in several musculoskeletal pathologies, particularly in resistant injuries.

Shock Waves and Therapeutic Exercise in Greater Trochanteric Pain Syndrome: A Prospective Randomized Clinical Trial with Cross-Over.

This study aimed to verify the comparative effectiveness of shock wave therapy versus therapeutic exercise, including the possibility of combining both therapies, in patients who did not respond to the first treatment. A prospective randomized clinical trial was carried out, predicting the possibility of a cross-over between the two treatment options, with patients who did not respond to either treatment. Treatments were, respectively, eccentric therapeutic exercise consisting of 30 min sessions of stretching and strengthening exercises, 5 days a week for 4 weeks (Groups A and D) and Extracorporeal Shock Waves Therapy (ESWT) according to a protocol of three sessions, one per week, each of 2000 pulses at a 4 Hz frequency and administering an energy flux density (EFD) varying between 0.03 mJ/mm2 and 0.17 mJ/mm2 (Groups B and C). Patients were evaluated at baseline (T0), 2 (T1), 4 (T2) and 6 months (T3) after the last session, using the Numeric Rating Scale (NRS), Low Extremity Functional Scale (LEFS) and Roles and Maudsley Scale (RMS). The whole study population demonstrated a progressive clinical reduction in pain according to NRS, a recovery from disability according to LEFS and a perception of recovery according to RMS within 6 months, with no significant differences between the four protocols (exercise; ESWT; exercise + ESWT; and ESWT + exercise). Both therapies are therefore valid options in patients with trochanteritis; the combination of the two therapies could be evaluated for those patients who do not respond to the single treatment.

Upper limb and lower limb radiofrequency treatments in orthopaedics.

Radiofrequency (RF) is a minimally invasive technique for disrupting or altering nociceptive pathways to treat musculoskeletal neuropathic and nociplastic pain. RF has been employed to treat painful shoulder, lateral epicondylitis, knee and hip osteoarthritis, chronic knee pain, Perthes disease, greater trochanteric pain syndrome, plantar fasciitis, and painful stump neuromas; it has also been employed before and after painful total knee arthroplasty and after anterior cruciate ligament reconstruction. The benefits of RF include the following:it is safer than surgery; there is no need for general anaesthesia, thereby reducing adverse effects; it alleviates pain for a minimum of 3-4 months; it can be repeatable if necessary; and it improves joint function and minimizes the need for oral pain medication. RF is contraindicated for pregnant women; unstable joints (hip, knee, and shoulder); uncontrolled diabetes mellitus; presence of an implanted defibrillator; and chronic joint infection (hip, knee, and shoulder). Although adverse events from RF are unusual, potential complications can include infection, bleeding, numbness or dysesthesia, increased pain at the procedural site, deafferentation effect, and Charcot joint neuropathy. Although there is a risk of damaging non-targeted neural tissue and other structures, this can be mitigated by performing the technique under imaging guidance (fluoroscopy, ultrasonography, and computed tomography). RF appears to be a valuable technique for alleviating chronic pain syndromes; however, firm proof of the technique's efficacy is still required. RF is a promising technique for managing chronic musculoskeletal of the limbs pain, particularly when other techniques are futile or not possible.

The conservative management for improving Visual Analog Scale (VAS) pain scoring in greater trochanteric pain syndrome: a Bayesian analysis

BackgroundGreater trochanteric pain syndrome (GTPS) possesses a harmful influence on quality of life. Numerous conservative management modalities with varying success have been proposed for patients with GTPS. However, it is not clear which treatment is more effective for reducing pain. The purpose of this Bayesian analysis was to assess the current evidence for the effectiveness of conservative treatments on improving Visual Analog Scale (VAS) pain scoring of GTPS and to determine the most effective treatment protocol.MethodsA comprehensive study search was performed from inception until July 18, 2022, via the electronic databases PubMed, the Cochrane Library, and Web of Science for potential research. The risk of bias assessment for the included studies was independently performed based on the Cochrane Collaboration Risk of Bias Tool. Bayesian analysis was conducted by using ADDIS software (v1.16.5). The DerSimonian-Laird random effects model was used to perform the traditional pairwise meta-analysis.ResultsEight full-text articles with a total of 596 patients with GTPS were included in the analysis. In comparing ultrasound-guided platelet-rich plasma application (PRP-U) to ultrasound-guided corticosteroid injection (CSI-U), patients who received PRP therapy experienced reduced pain as the VAS decreased significantly (MD, -5.21; 95% CI, -6.24 to -3.64). VAS score in group of extracorporeal shockwave treatment (ESWT) was significant improved than that in exercise (EX) group (MD, -3.17; 95% CI, -4.13 to -2.15). There were no statistically significantly different VAS scores between the CSI-U group and the CSI under landmark (CSI-B) group. The treatment efficacy rankings of the different treatments on improving VAS scores showed that the most likely efficacious treatment was PRP-U (99%) followed by ESWT (81%), CIS-U (58%), usual care (48%), CIS-B (54%), and EX (84%).ConclusionBayesian analysis revealed that PRP injection and ESWT are relatively safe and effective in the treatment of GTPS. More multicenter high-quality randomized clinical trials with large sample sizes are still needed in the future to provide further evidence.

Comparison of shock wave therapy and corticosteroid injection in the treatment of greater trochanteric pain syndrome: A single-blind, randomized study.

The aim of this study was to compare the efficacy of the corticosteroid (CS) injection and shock wave therapy (SWT) in the treatment of greater trochanteric pain syndrome (GTPS). Between 2020 September and 2021 October, a total of 60 patients with GTPS (12 males, 48 females; mean age: 50.8±8.5 years; range, 34 to 65 years) were included. The patients were randomly assigned to two groups as the SWT group (n=32) receiving one session of SWT per week for a total of three weeks and CS injection group (n=28) receiving CS and local anesthetic. Both groups were evaluated using the Short Form-36 (SF-36) at baseline and three months and using the Visual Analog Scale (VAS) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) at baseline, three weeks, and three months. The mean VAS, greater trochanter tenderness, and WOMAC scores of both groups were similar at baseline, while the third-week and three-month scores were significantly lower in both groups compared to baseline (p<0.05). There was no significant difference in the treatment efficacy between the groups (p>0.05). There was a similar improvement in SF-36 physical function, physical role difficulty, and pain subscales in both groups (p<0.05). Our study results show that both CS injection and SWT are effective modalities and none of the treatments is superior to each other.

Targeting of Periprosthetic Muscles for the Ultrasonographic Screening of Hip Abnormalities in Hip Resurfacing Arthroplasty Patients.

Hip resurfacing arthroplasty (HRA) patients require subsequent annual screening for postoperative complications. Ultrasonography may be useful for this purpose but lacks a screening protocol for hips. The purpose of this study was to evaluate the accuracy of ultrasonography for detecting postoperative complications in HRA patients using a screening protocol that specifically targets periprosthetic muscles. We enrolled 45 hips from 40 HRA patients with a mean follow-up period of 8.2 years. MRI and ultrasonography scans were simultaneously conducted at follow-up. The ultrasonography assessments were conducted on the anterior part of the hip that targets iliopsoas, sartorius, rectus femoris, lateral with anterior superior and inferior iliac spine (ASIS and AIIS) as bony landmarks, and the lateral and posterior parts that target fascia tensor, short rotators, and gluteus minimus, medius, and maximus with greater trochanter and ischial tuberosity as bony landmarks. The accuracy of diagnosing postoperative abnormalities and the visibility of periprosthetic muscles were compared between these two modalities. Both MRI and ultrasonography detected an abnormal region in eight cases comprising two infections, two pseudotumors, and four patients with greater trochanteric bursitis. Among these cases, four hips required implant removal. The increase in anterior space, measured as the distance between the iliopsoas and resurfacing head, was a good indicator for the abnormal mass in these four HRA cases. In the assessment of periprosthetic muscles, MRI showed a much lower visibility than ultrasonography in the iliopsoas (6.7% vs. 100%), gluteus minimus (6.7% vs. 88.9%), and short rotators (8.8% vs. 71.4%) due to implant halation. By targeting periprosthetic muscles, ultrasonography can detect postoperative complications as effectively as MRI assessments in HRA patients. Ultrasonography has superior visibility in the periprosthetic muscles of HRA patients, indicating its utility for the screening of small legions in these cases which may not be visible by MRI.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

THE DEGREE OF GLUTEAL TENDINOPATHY CORRELATES WITH WORSENING PROMS IN TOTAL HIP ARTHROPLASTY: A PROSPECTIVE STUDY OF 797 PATIENTS

The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA.Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year.797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears.This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction.

Ultrasound-guided Musculoskeletal Interventional Procedures Around the Hip: A Practical Guide.

Several studies have shown that ultrasound guidance may contribute to improved safety, effectiveness and accuracy of musculoskeletal interventional procedures performed around the hip if compared to those performed with a landmark-guided technique. Different approaches and injectates can be used for treating hip musculoskeletal disorders. These procedures may involve injections in the hip joint, periarticular bursae, tendons, and peripheral nerves. Intra-articular hip injections are mostly used as a conservative approach for treating patients affected by hip osteoarthritis. Ultrasound-guided injection of the iliopsoas bursa is performed in patients with bursitis and/or tendinopathy, to treat those with painful prosthesis due to iliopsoas impingement, or when the lidocaine test is indicated to identify the iliopsoas as a source of pain. Ultrasound-guided interventions are routinely used in patients with greater trochanteric pain syndrome having as target the gluteus medius/minimus tendons and/or the trochanteric bursae. Ultrasound-guided fenestration and platelet-rich plasma injection are applied in patients with hamstring tendinopathy with good clinical outcomes. Last but not least, ultrasound-guided perineural injections can be used for peripheral neuropathies or blocks of the sciatic, lateral femoral cutaneous, and pudendal nerves. In this paper, we discuss the evidence and technical tips for musculoskeletal interventional procedures performed around the hip, highlighting the added value of ultrasound as an imaging guidance modality.

The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement.

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Joint Mobility among Patients with Trochanteric Bursitis in Erbil-Iraq

Background: Trochanteric bursitis is the inflammation of greater trochanter bursa, which is located lateral to the greater trochanter of the femur. The underlying causes of trochanteric bursitis are multifactorial. Joint mobility considered as one of the possible causes; Joint laxity is a condition in which the range of motion in the joints are greater than normal, which are more in women than men with higher prevalence in young ages. Aim of the study: to assess joint mobility among people with trochanteric bursitis.Patients and Methods: A cross sectional study was conducted in Rheumatology Outpatient clinic in Rizgary Teaching Hospital in Iraqi Kurdistan region between February and December 2021. A sample of 100 Iraqi patients with trochanteric bursitis, and another 100 healthy controls matched in age and sex were studied. Beighton score were performed on patients and controls to assess joint mobility. Results: Joint hypermobility was reported in 24(12%) patients with trochanteric bursitis compared to 29(14.5%) in healthy controls (p= 0.423, OR 0.773; 95%CI 0.412-1.452), no significant differences were detected between the two groups. Joint hypermobility was more in females using cutoff score ≥4 of Beighton score; forty-six among fiftythree hypermobile participants were female, the p-value was 0.001 which was statistically significant.Conclusion: There is no positive correlation between joint hypermobility and the presence of trochanteric bursitis.

Spontaneous tensor fascia lata abscess caused by Parvimonas micra presenting as lateral hip pain.

Dear Editor, Parvimonas micra is a gram-positive obligate anaerobic bacterial species and known flora of the human oral cavity, respiratory system, gastrointestinal tract, and the female genitourinary tract.[1,2] It was originally identified in 1933 as Peptostreptococcus micros, underwent a reclassification in 1999 to Micromonas micros and ultimately was reclassified as P. micra in 2006.[1,3]Parvimonas micra has been implemented as an infectious organism in case reports of spondylodiscitis, vertebral osteomyelitis, iliopsoas abscess, hepatic abscess, endocarditis, empyema, meningitis, brain abscess and septic arthritis.[1–3] Although multiple areas of infection by P. micra have been described, tensor fascia lata infection has not been described.[4] A patient with no significant past medical history presented to our outpatient multidisciplinary pain center complaining of left hip pain. He was seen in the emergency department the day prior. X-ray of the hip was performed which did not reveal any acute pathology. His pain had been present for one week and had been worsening in intensity. He did not describe any radiation of the pain to the lower legs and denied any recent trauma to the area. He described swelling and fullness of the hip worsened with movement and relieved by rest. His physical examination was only positive for tenderness of palpation over the left greater trochanter. Due to a presumed diagnosis of greater trochanteric bursitis, conservative measures were pursued. He was prescribed naproxen 500 mg twice a day as needed, tizanidine 2 mg three times per day as needed, topical EMLA to the painful area. He was also instructed to start physical therapy and was provided a referral for the same. He was discharged from the emergency department after this visit. Nearly two weeks later, the patient presented to the emergency department with left thigh erythema and swelling. His laboratory work was significant for ESR of 115 and CRP of 16, white counts were 8.2. On exam, in the ED, he was afebrile and physical exam was positive for erythema, tenderness to palpation over the left thigh. Several pustules overlying the area along with areas of induration and fluctuance were noted. A CT with contrast of the left hip was performed which demonstrated a 20 × 10 × 6.5 cm rim enhancing fluid collection in the proximal lateral left thigh/gluteal region abutting and extending along the fascia lata of the thigh, dissecting into the substance of the tensor fasciae lata muscle and extending into the deep subcutaneous tissues [Figure 1]. The patient was started on broad-spectrum IV antibiotics and scheduled for incision and drainage in the operating room by general surgery. Drains were placed and the wound closed by secondary intention. Cultures from the operating room (anaerobic- tissue and abscess) yielded P. micra. Repeat blood cultures were negative at 5 days. The patient was kept on vancomycin and piperacillin/tazobactam for 3 days and transitioned to oral trimethoprim and sulfamethoxazole at discharge.Figure 1: Coronal view of left thigh CT demonstrating abscessThis case represents an unusual occurrence of P. micra abscess requiring prompt recognition of the abscess and prudent microbial identification. Financial support and sponsorship Nil. Conflicts of interest Dr. Shaparin reports the following disclosures outside the submitted manuscript; he was a consultant for Averitas Pharma and AcelRx Pharmaceuticals and has received research grant funding from Grunenthal and Heron Therapeutics. Dr. Koushik has served as a consultant for AcelRx Pharmaceuticals.

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain. Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis. Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis. Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p&lt; 0.001). Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region. Keywords: Trochanteric Bursitis, evaluation, clinical tests, ultrasound

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain.&#x0D; Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis.&#x0D; Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis.&#x0D; Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p&lt; 0.001).&#x0D; Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region.

"I feel I have been taken seriously" Women's experience of greater trochanteric pain syndrome treatment-A nested qualitative study.

Women experiencing greater trochanteric pain syndrome (GTPS) report high levels of pain and reduced quality of life. Exploring how they manage GTPS in a daily life context can provide important knowledge about individual coping strategies. Education, extracorporeal shockwave therapy (ESWT) and exercise have good group level evidence for efficacy in clinical trials and are increasingly used in routine care for patients with GTPS. Exploring women's experiences of such treatment may help understand the mechanisms underpinning these positive results and inform treatment strategies. We therefore aimed to explore how women with GTPS experience and manage their daily life, and their experience of the combined treatment of education, ESWT and exercises. This qualitative study was nested within a cohort study based in a hospital outpatient clinic and a physiotherapy clinic in Denmark assessing the combined treatment of education, ESWT and exercises. Data was collected from eleven women using in-person, individual, semi-structured interviews which were audio recorded. Transcripts were coded and analysed using an inductive thematic analysis approach. Five themes were identified: (1) Daily life was controlled and structured by pain; (2) The condition was acknowledged and taken seriously by treating professionals; (3) The participants´ experiences of the intervention-information is key; (4) Improved capability and autonomy in pain management and (5) The women´s perspectives on improving and expanding the intervention. Learning how to manage pain was experienced as the most important element of the program to the women to be able to minimize pain and manage daily life. Exploration of how women with greater trochanteric pain syndrome experienced and managed daily hip pain, and how they experienced and adapted to treatment are important novel findings that will inform clinical practice. This new knowledge may be used to inform an individualized patient education, treatment and evaluation strategy for women with the painful and debilitating condition of GTPS.

Natural History of Degenerative Hip Abductor Tendon Lesions

Background: The best treatment of degenerative hip abductor tendon lesions remains largely unknown, as the natural course of the disease has not yet been reported. The aim of the present study was to investigate the natural history of symptomatic degenerative hip abductor lesions. Hypothesis: Nonoperatively treated hip abductor lesions progress over time, resulting in refractory hip pain and low functional outcomes. Study Design: Case series (prognosis); Level of evidence, 4. Methods: Consecutive patients with greater trochanteric pain syndrome and degenerative changes on magnetic resonance imaging (MRI) of the symptomatic hip were included. Bilateral hip MRI scans and a clinical examination were performed at a minimum follow-up of 36 months to study the type and location of hip abductor lesion. Progression of a lesion was defined as a more severe lesion as compared with the initial MRI results or if the lesion extended to another, initially not involved, trochanteric facet. The muscle’s fatty infiltration (FI) was also described. Results: From 106 patients identified, 58 patients (64 hips) aged 66 ± 14 years (mean ± SD) agreed to return to the clinic for follow-up MRI and met the inclusion criteria. At a mean 71-month follow-up, an overall 34% (22/64) of lesions had progressed over time: from trochanteric bursitis to tendinopathy (9/64, 14%) or partial tear (5/64, 8%), from tendinopathy to partial tear (4/64, 6%), from a partial to complete tear (3/64, 4.5%), and with 1 complete tear (1/64, 1.5%) extending to another trochanteric facet. Interestingly, 90% of partial tears remained stable or transformed into a scar. Although patients with a progressive lesion experienced more trochanteric pain (visual analog scale, 4.6 vs 2.8; P = .001), the functional outcomes were comparable with patients with a stable lesion. The majority of hips with a partial tear (64%) demonstrated a progression of gluteus minimus FI from a median grade of 1 to 2, whereas only 1 hip (3%) progressed from grade 2 to 3. Only 3 hips (9%) with a partial tear had a progression of gluteus medius FI, which did not differ significantly from the contralateral unaffected side. Conclusion: Nonoperative treatment might be a valid long-term option for degenerative hip abductor lesions, especially for partial tears, which demonstrated a low risk of clinically relevant progression or muscle FI and similar clinical outcomes to those reported in the literature for operatively treated hip abductor tendon lesions.