title: Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome.
abstract: OBJECTIVE
  This study examined patients with greater trochanteric pain syndrome (GTPS) to determine the prevalence of gluteus medius pathology by utilizing magnetic resonance imaging (MRI), and to evaluate the presence of Trendelenburg's sign, pain on resisted hip abduction, and pain on resisted hip internal rotation as predictors of a gluteus medius tear in this group of patients.
  
  
  METHODS
  Twenty-four subjects with clinical features consistent with GTPS were recruited. A standard physical assessment was performed at study entry, including assessment of the 3 specific physical signs. Following this initial assessment, MRI of the affected hip was performed. A 1.5T whole body MRI system was utilized, with T1 and T2 fast spin-echo sequences performed in the coronal and axial planes. All MR images were reviewed in random order by a single radiologist. In 12 patients, the 3 physical signs were assessed at study entry and at 2 months by the same observer and the intraobserver reliability for each of the signs was calculated.
  
  
  RESULTS
  All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg's sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg's sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).
  
  
  CONCLUSIONS
  The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg's sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg's sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.
authors.affiliation: Rheumatology Department, St George Hospital, Kogarah, New South Wales, Australia.
authors.forename: P A
authors.initials: PA
authors.lastname: Bird
authors.forename: S P
authors.initials: SP
authors.lastname: Oakley
authors.forename: R
authors.initials: R
authors.lastname: Shnier
authors.forename: B W
authors.initials: BW
authors.lastname: Kirkham
mesh_terms: D000328:Adult; D000368:Aged; D002062:Bursitis / Q000473:pathology*; D005260:Female; D005269:Femur / Q000473:pathology*; D006621:Hip Joint / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000473:pathology; D015588:Observer Variation; D010146:Pain / Q000473:pathology*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013710:Tendons / Q000473:pathology