The guidelines established by the New York State Workers Compensation Board are crafted to assist healthcare professionals in evaluating Gluteus Medius Tendinosis and Tears. These directives aim to support physicians and healthcare practitioners in determining the appropriate treatment for these conditions.
Healthcare professionals specializing in Gluteus Medius Tendinosis and Tears can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable level of care for their patients.
It is important to stress that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding care should involve collaboration between the patient and their healthcare provider.
Gluteus Medius Tendinosis and Tears
The criteria outlined below provide a comprehensive perspective on the clinical assessment for Gluteus Medius Tendinosis and Tears (often referred to as the “Rotator Cuff of the Hip”), Greater Trochanteric Pain Syndrome, and Trochanteric Bursitis.
Diagnostic Studies
MR Arthogram
Recommended for diagnosing gluteus medius tendinosis or tears and for greater trochanteric pain syndrome in patients experiencing subacute or chronic hip pain. Indications include individuals with subacute or chronic hip pain displaying symptoms or clinical suspicion of gluteus medius tendinosis or tears, as well as those with greater trochanteric pain syndrome. It is also a consideration, especially if symptoms persist, in cases of trochanteric bursitis.
Typically, only one arthrogram is necessary. The rationale behind using MR arthrograms lies in their effectiveness in evaluating and confirming conditions like gluteus medius tendinosis or tears and greater trochanteric pain syndrome. Enhanced MR arthrogram provides superior labral evaluation compared to other imaging procedures and is recommended for diagnosing these conditions. In select cases, it is likely the most optimal imaging procedure available.
MRI
MRI is recommended for select patients experiencing subacute or chronic lateral hip pain when there is uncertainty about the underlying cause, aiming to assist in achieving an accurate diagnosis.
Ultrasound
Ultrasound is recommended for evaluating patients with gluteus medius tendinopathies, greater trochanteric bursitis, and greater trochanteric pain syndrome/lateral hip pain. It is indicated for patients with hip pain suspected to originate from these disorders. While arthrograms and MRI are generally preferred diagnostic tests, the selective use of ultrasound may be beneficial. Typically, only one ultrasound session is needed. The rationale for using ultrasound lies in its effectiveness in evaluating and confirming gluteus medius tendinopathies, making it a recommended imaging modality in these cases.
Medications
For the majority of patients, ibuprofen, naproxen, or other older generation NSAIDs are advised as the initial choice of medications. Acetaminophen (or its analog paracetamol) could be considered as a reasonable alternative for individuals who are not suitable candidates for NSAIDs, although most evidence indicates that acetaminophen is somewhat less effective. There is supporting evidence suggesting that NSAIDs provide pain relief comparable to opioids (including tramadol) but with fewer impairing effects.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs):
Recommended:
- For the treatment of gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain.
- Over-the-counter (OTC) agents are suggested and should be tried initially.
Indications:
- NSAIDs are recommended for the treatment of gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain.
- As-needed use may be reasonable for many patients.
Indications for Discontinuation:
- Discontinuation may be considered upon the resolution of gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain.
- Lack of efficacy or the development of adverse effects that necessitate discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding:
Recommended:
- Concomitant use of cytoprotective classes of drugs, including misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors, is recommended for patients at high risk of gastrointestinal bleeding.
Indications:
- For patients with a high-risk factor profile who also require NSAIDs, cytoprotective medications should be considered, especially if longer-term treatment is contemplated.
- At-risk patients include those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers.
Frequency/Dose/Duration:
- Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended. The dose and frequency should follow the manufacturer’s guidelines.
- There is generally no substantial difference in efficacy for preventing gastrointestinal bleeding among these options.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects:
Recommendations:
- Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have a discussion about the risks and benefits of NSAID therapy for pain.
- Acetaminophen or aspirin is recommended as the first-line therapy, as they appear to be the safest in terms of cardiovascular adverse effects.
Additional Recommendations:
- If necessary, non-selective NSAIDs are preferred over COX-2 specific drugs.
- For patients taking low-dose aspirin for primary or secondary cardiovascular disease prevention, to minimize the potential for the NSAID to counteract the beneficial effects of aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen:
Recommendations:
- Acetaminophen is recommended for the treatment of gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain, especially in patients with contraindications for NSAIDs.
Indications:
- All patients with gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain, including those with acute, subacute, chronic, and post-operative conditions.
Dose/Frequency:
- Follow the manufacturer’s recommendations; it may be used on an as-needed basis. Caution is advised to stay within a daily limit of four grams, as exceeding this limit may lead to hepatic toxicity.
Indications for Discontinuation:
- Discontinuation may be considered upon the resolution of pain, the occurrence of adverse effects, or signs of intolerance.
Opioids:
Not Recommended:
- Opioids are rarely used for treating patients with gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain. They are more commonly employed briefly in the immediate post-operative period.
Rationale for Recommendations:
- Opioids cause significant adverse effects, including poor tolerance, constipation, drowsiness, clouded judgment, memory loss, and potential misuse or dependence reported in up to 35% of patients.
- Patients should be informed of these potential adverse effects before opioid prescription and cautioned against operating motor vehicles or machinery.
- Opioids do not appear to be more effective than safer analgesics for managing most musculoskeletal symptoms; therefore, they should only be used if needed for severe pain or for a short time (not exceeding one week) in the post-operative period.
Recommended (Select Treatment):
- Opioids are recommended for select treatment of patients with postoperative gluteus medius tendinosis or tears, trochanteric bursitis, and greater trochanteric pain.
Indications:
- For post-operative cases, a brief course of a few days to not more than one week of opioids is recommended.
- Opioids may be helpful for brief nocturnal use after surgery, but most patients should attempt pain control with NSAIDs/acetaminophen before resorting to opioids.
Frequency/Dose/Duration:
- Generally, patients require no more than a few days to not more than one week of treatment with opioids for most epicondylar surgeries.
Indications for Discontinuation:
- Discontinuation is recommended upon the resolution of pain, sufficient control with other medications, lack of efficacy, or the development of adverse effects that necessitate discontinuation.
Treatments
Rehabilitation
Therapeutic Exercise (Physical or Occupational Therapy):
Recommended:
- For greater trochanteric pain syndrome, trochanteric bursitis, and gluteus medius tendinosis and tears.
- Particularly beneficial to address any strength deficits in the lateral hip musculature.
Frequency/Dose/Duration:
- The total number of visits may range from two to three for patients with mild functional deficits, up to 12 to 15 for those with more severe deficits, provided there is ongoing objective functional improvement.
- If ongoing deficits persist, more than 12 to 15 visits may be indicated, with documentation of functional improvement towards specific objective functional goals (e.g., range of motion, advancing ability to perform work activities).
- A home exercise program should be developed and performed in conjunction with therapy.
Indications for Discontinuation:
- Discontinuation is considered upon resolution, post-operative healing, intolerance, lack of efficacy, or non-compliance.
Injection Therapy – Glucocorticosteroid Injections:
Recommended:
- As a treatment option for acute, subacute, or chronic trochanteric bursitis, greater trochanteric pain syndrome, and gluteus medius tears with accompanying clinical bursitis.
Indications:
- Symptoms of trochanteric bursitis persisting for at least a couple of weeks, with prior treatment including NSAIDs or acetaminophen and avoidance of aggravating activities.
Frequency/Dose/Duration:
- A maximum of three injections is recommended.
- Each injection should be scheduled separately, and the effects of each evaluated before additional injections are considered.
- Targeting the most tender location is recommended.
- Fluoroscopic guidance is not necessary for an initial injection, though it may be a reasonable option for a second injection, especially if the first one is unsatisfactory.
Surgery
Surgical Repair:
Recommended:
- For gluteus medius tears that are unresponsive to medical management.
Indications/Rationale:
- Tears of the gluteus medius tendon with accompanying pain and/or functional deficits deemed amenable to surgical treatment.
- Generally, at least 3 weeks of non-operative treatment is advisable to assess whether function and pain will sufficiently recover without the need for surgery.
Post-Operative Therapeutic Exercises – Physical/Occupational Therapy:
Recommended:
- For patients with surgical repair of gluteus medius tears.
Indications:
- Programs need to be individualized, considering factors such as preoperative condition, bone quality, immediate surgical results, contraindications, and other medical conditions.
Frequency/Dose/Duration:
- Duration is primarily based on progress; two or three times weekly for four to six weeks in an outpatient setting, gradually tapered as home exercises are instituted and the patient’s recovery advances
