Fig. 24.1
MRI scan showing an hematoma of the left thigh adductors
Treatment options include the usual conservative treatment with rest and NSAIDs. Timing of the following physical rehabilitation depends on the location of the strain. If the injury is near the bone-tendon junction, physical therapy should be delayed because these areas are less vascular, and some healing is needed before starting exercises. If the tear is close to the musculotendinous junction or in the muscle belly, which are highly vascular zones, early and aggressive rehabilitation can be instituted (Elattar et al. 2016). Return to sports after acute strains is generally recommended when athletes regain 70% of strength and a painless range of motion, usually by 4–8 weeks, while for chronic strains, the recovery period and return to sports may be as long as 6 months (Holmich et al. 1999). Acute complete adductor tears in athletes generally require surgical repair with suture anchors, but it is not a so frequent procedure (de SA et al. 2016). The role of steroid injection in adductor strains remains controversial and it is not supported by an adequate good evidence. For chronic recalcitrant adductor tears with failed conservative treatment for a minimum of 6 months, surgical treatment with tenotomy may improve the pain (Gill et al. 2014). However, even if the pain relief is reported in about 73% of patients, the athletes able to return to their previous sport after surgery are only slightly more than 50% (Atkinson et al. 2010).
24.3 Tendinopathies of the Anterior Area
24.3.1 Iliopsoas
The iliopsoas musculotendinous unit is composed of three muscles: the iliacus, psoas major and psoas minor (only present in 60–65% of individuals). Significant anatomic variability has been reported in the literature, and controversy exists regarding the number of tendons and the relative contributions of the different muscle fibres to each tendon (Anderson 2016). The iliopsoas bursa, or iliopectineal bursa, is positioned between the iliopsoas unit and the bony surfaces of the pelvis and proximal femur. It is the largest bursa in the human body, typically extending from the iliopectineal eminence to the lower portion of the femoral head, with an average length of 5–6 cm and width of 3 cm (Tatu et al. 2001). Communications of the bursa with the hip joint, through a congenital defect between the iliofemoral and pubofemoral ligaments, have been reported. The iliopsoas unit functions primarily as hip flexor. It also provides femoral external rotation, with lateral bending, flexion and balance of the trunk. The iliacus is important for stabilizing the pelvis and for early rapid hip flexion while running. The psoas major is important for sitting in an erect position and stability of the spine in the frontal plane. Variable contribution of each muscle is observed during sit-ups depending on the angle of hip flexion (Fitzgerald 1969; Andersson et al. 1995). The psoas minor distally attaches both to the iliac fascia and psoas major tendon, having also another attachment to the iliopectineal eminence. This gives a partial control of the position and mechanical stability of the underlying iliopsoas as it crosses the femoral head. Pathologic conditions of the iliopsoas have been implicated as a significant source of anterior hip pain. Iliopsoas disorders have been shown to be the primary cause of chronic groin pain in 12–36% of athletes and are observed in 25–30% of athletes presenting with an acute groin injury (Serner et al. 2015; Holmich 2007; Holmich et al. 2014; Rankin et al. 2015). Described pathologic conditions include iliopsoas bursitis, tendonitis, impingement and snapping. These conditions coexist so frequently that Johnston reported an “iliopsoas syndrome” (Johnston et al. 1998), with a common diagnostic and therapeutic process. Therefore, diagnosis and treatment of the iliopsoas disorders are reported together later in this paragraph. Less frequent are acute trauma that may result in tendon injury or avulsion fracture of the lesser trochanter.
Internal Extra-Articular Snapping Hip
This syndrome was originally attributed to snapping of the iliopsoas tendon over the iliopectineal eminence of the pelvis. Other mechanisms that have been then proposed include accessory iliopsoas tendon slips, iliopsoas snapping over a ridge at the lesser trochanter, snapping of the iliofemoral ligament over the femoral head and subluxation of the long head of the biceps at the ischium snapping at the anterior inferior iliac spine (Yen et al. 2015). However, most commonly, it is produced by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. The snapping phenomenon usually occurs when the hip is brought back to extension from a flexed position (usually flexion of more than 90°). The iliopectineal eminence and the anterior edge of the pelvis work as a pulley for the iliopsoas muscle (Lyons and Peterson 1984). The iliopsoas tendon is located lateral to the iliopectineal eminence when the hip is in full flexion, with hip extension the tendon is displaced medially until it positions medial to the iliopectineal eminence when the hip is in neutral position. The psoas tendon seems to be in contact with the iliopectineal eminence at approximately 50° of hip flexion (Yoshio et al. 2002). The snapping phenomenon can occur without pain in up to 10% of the general population (Byrd 2006). In the symptomatic internal snapping hip syndrome, patients report snapping while stair climbing or standing from a chair associated with groin pain.
Iliopsoas Bursitis and Tendonitis
Iliopsoas bursitis and tendonitis have been shown to be closely associated with the repetitive pathologic movement of the tendon observed in symptomatic internal snapping hip. This can cause irritation and inflammation of the underlying bursa (Fig. 24.2). Even so, some studies demonstrate no objective abnormality of the bursa in patients undergoing open surgery for symptomatic snapping (Anderson 2016).
Fig. 24.2
MRI scan showing a left psoas tendonitis
Iliopsoas Impingement
First described by Heyworth in 2007, iliopsoas impingement is a conflict between an excessively tight iliopsoas tendon impinges and the underlying acetabular labrum (Heyworth et al. 2007). The location of the anterior labral abnormality corresponded to the iliopsoas notch, significantly differs from the traditional location observed in FAI (Blankenbaker et al. 2007). Sometimes the labrum appears inflamed without frank tearing, which was referred to as the “iliopsoas impingement sign”. Furthermore, adjacent tendinous inflammation and scarring with adherence of the tendon to the anterior capsule were observed in some patients. Iliopsoas impingement occurs most frequently in young active women, many who participate in regular sports. Patients typically present with anterior groin pain that worsens with athletic activities and activities of daily living, such as active hip flexion, prolonged sitting and getting out of a car (Anderson 2016). Internal snapping is less commonly observed in iliopsoas impingement but has been reported in up to 17% of cases (Blankenbaker et al. 2012).
Physical examination of the internal snapping phenomenon is carried out with the patient supine by flexing the affected hip more than 90° and extending to neutral position. This may be accentuated with abduction and external rotation in flexion and adducting and internally rotating while extending. The snapping may be audible and may be palpated by placing the hand over the affected groin while performing the examination test. Commonly, weakness of the gluteus medius with a Trendelenburg sign is found and the Thomas test, which tests for psoas contracture, is often positive, as well (Yen et al. 2015). If the snapping is produced by the iliopsoas tendon over the femoral head, plain radiographs can reveal a large anterior cam deformity at the head-neck passage of the femur. Regarding iliopsoas impingement on physical examination, patients typically have a positive impingement test (flexion, adduction and internal rotation—FADIR), scour sign and tenderness with manual compression over the iliopsoas. Approximately half of them have pain with flexion, abduction and external rotation (FABER) and resisted straight leg raise testing (RSLR) (Anderson 2016). Ultrasound exam of the iliopsoas tendon is a dynamic non-invasive study that may document the snapping phenomenon as well as pathologic changes of the iliopsoas tendon and its bursa, but the ability and experience of the examiner are fundamental. MRI scan can reveal an unspecific inflammation of the iliopsoas area, but it can be useful to detect any concomitant intra-articular hip pathology, since almost half of the patients with internal snapping hip syndrome have associated intra-articular hip pathology (Ilizaliturri et al. 2005). In case of iliopsoas impingement the most pertinent radiographic finding is a labral tear at or near the 3/9 o’clock position seen on MRI (Blankenbaker et al. 2012). Diagnostic injection test with anaesthetic can be performed, but it is important to consider the possible communication between the hip joint and the iliopectineal bursa, because the drugs can expand in both compartments, confounding the results of the test (Anderson 2016).
Treatment should be reserved for symptomatic patients and has to be initially conservative with NSAID therapy and stretching, if the tendon is too short, or lengthening, if the muscle is too active. Sometimes steroid injection in the iliopectineal bursa can give pain relief. If there is no positive response to conservative treatment surgical treatment is indicated to lengthen the iliopsoas musculotendinous unit, in order to prevent snapping and mechanical overpressure on the underlying bursa. In the past open procedures for lengthening or release of the iliopsoas tendon at different levels along its course have been proposed: results were generally good, with very high percentages (about 77%) of symptoms resolution (Khan et al. 2013). However some cases of recurrence and a significant percentage (15–45%) of post-operative subjective weakness have been reported (Yen et al. 2015). These procedures have increased morbidity and inferior results compared with recently proposed endoscopic techniques. In a recent review, there has been reported a complication rate of 21% in open procedures compared with 2.3% using arthroscopic techniques (Khan et al. 2013). Endoscopic release of the iliopsoas tendon has become more common. Three different endoscopic techniques have been described to treat this condition. First technique is a transcapsular release of the iliopsoas tendon at the level of the hip joint with an anterior hip capsulotomy during the central compartment phase of the procedure. This procedure is also used for iliopsoas impingement in association with concurrent labral abnormality debridement or repair, with generally reported favourable results (Domb et al. 2011; Cascio et al. 2013). The second technique is a release at femoral neck level trough an anterior capsulotomy in the peripheral compartment, this method is not routinely used because of the technique to find the psoas is demanding. The third option is to cut the tendon on the lesser trochanter, with this technique the iliopsoas bursa is accessed directly. Results of the endoscopic techniques are encouraging and seem to be better than those reported for open procedures, with a success rate up to 100% (Ilizaliturri et al. 2014). However, remembering the frequent intra-articular coexistent pathology in this condition, these results may be confounded by a concomitant hip arthroscopy (Yen et al. 2015; Ilizaliturri et al. 2005).
24.3.2 Rectus Femoris
Quadriceps muscle strains frequently occur in sports that require repetitive kicking and sprinting efforts, such as track and field, rugby and football. The rectus femoris is a fusiform and biarticular long muscle designed to execute movements that require significant length change or high shortening velocity. It has a high demand for eccentric muscle contraction and has a high percentage of rapid-contraction muscular fibres (approximately 65%) that can make it more prone to injury (Mendiguchia et al. 2013). Rectus femoris has two heads of origin: the direct or straight head, which arises from the anterior inferior iliac spine (AIIS), and the indirect or reflected head, which arises from the superior acetabular rim. The two heads form the conjoined tendon slightly below their origin, with the direct head contributing mostly to the superficial component of the conjoined tendon and blends anteriorly with its fascia (Hasselman et al. 1995). The rectus femoris extends the knee, flexes the hip and stabilizes the pelvis on the femur in weight bearing. Proximal rectus femoris lesions most commonly occur during hip hyperextension and knee flexion or as a result of a sharp eccentric contraction of the quadriceps. Proved risk factors include previous injury (with a recurrence rate of about 17%), short height associated with a high body weight and a low flexibility (Mendiguchia et al. 2013). According to a study evaluating 3160 hips on MRI scan, the average frequency of proximal rectus femoris origin injury was about 0.5% (Ouellette et al. 2006). Tendon avulsions are rare and account for approximately 1.5% of hip lesions that occur during sports (Dean et al. 2016). Calcification of the proximal rectus femoris tendon could follow an avulsion or a tendon rupture (partial or complete) of the rectus femoris, and a similar condition has been also described after an avulsion of the AIIS bony fragment. The healing process could lead to a protuberance, secondary to changes of ossification centres with a course following the axis of traction forces of the rectus femoris. This inferiorly prominent bony protuberance can anteriorly conflict with the femoral neck of a flexed hip. This condition has been referred to as iliac spine impingement or subspine impingement (Zini et al. 2014). Acute calcific tendinitis of the rectus femoris is extremely rare (IKobayashi et al. 2015). In acute injuries the patient feels a tearing sensation and stops playing any activity. In subacute conditions patients report gradual onset of pain during activities like running and kicking. At the clinical examination, pain is exacerbated by stretching, regional palpation, hip flexion and resisted knee extension. Sometimes a complete rupture is responsible for a local mass-like syndrome. Plain radiographs can reveal any bony involvement, as the AIIS avulsion in the childhood. In those cases a gap of more than 2 cm between the native bone and avulsed fragment is a factor of poor prognosis (Pesquer et al. 2016). Associated MRI scan, investigating the presence of a possible surrounding oedema, could reveal the acute or chronic character of the lesion. For other tendon disorders, US can be useful, even if MRI remains the gold standard allowing a more global assessment of the pathologic conditions. Regarding rectus femoris avulsion, in most of the cases tears are treated conservatively. However, indication for surgical repair may be considered in high-level athletes with significant demand for repetitive explosive hip flexion or in patients with failure of nonoperative treatment and continued pain or weakness for more than 3 months. Surgical procedure is carried on through a Smith-Petersen approach. Once identified both the proximal heads of the tendon, the lesion is pointed out and all of the devitalized and degenerated fibres should be removed from the tendon stump. The footprint of the direct arm of the rectus (on the AIIS) is then prepared by removing the soft tissues to expose subchondral bone, creating a bleeding bony bed to support healing. Then reattachment is performed with two suture anchors placed on the AIIS, with the right tension so that tissues are reduced and compressed against the bone. After surgery a knee brace locked in extension is recommended with no weight bearing and no active hip flexion for 6 weeks. Strength-training exercises and running typically begin after 8 weeks, while return to sport occurs between 4 and 6 months after surgery (Dean et al. 2016). In case of an AIIS avulsion in a skeletally immature patient, more often a nonoperative treatment is chosen, with a brief period of rest followed by protected weight bearing, progressive stretching and strengthening and gradual return to sports. Operative treatment with open reduction and internal fixation has been recommended for fractures with a displacement wider than 2 cm to prevent nonunion, exostosis formation and chronic pain and disability (Schuett et al. 2015). For tendon calcification the management starts with conservative treatment with injection of anaesthetic and corticosteroids. In case of symptoms persistence, surgery can be performed with open excision of the lesion through a Smith-Petersen approach, as described before for the tendon reattachment or with a less invasive endoscopic procedure. These two options are also used to treat the subspine impingement. Despite good results in treating pathology, open procedures are burdened by wound discomfort. For endoscopic treatment of either calcific tendonitis or subspine impingement, a standard fracture table is used with the patient in a supine position. The operative limb was placed with the hip in slight abduction and internal rotation. Two standard portals are used: the anterolateral that provides a complete view of the central compartment for the treatment of possible associated intra-articular pathologies and the midanterior portal. After concomitant intra-articular lesions are evaluated and eventually treated, the traction is removed and a shaver is used to clear all soft tissue to better delimit the plane between the acetabular rim and the calcification. After complete exposure of the calcification is achieved, using the image intensifier as a guide in addition to the direct view, the calcification is removed using a bur. After surgery, weight bearing is permitted as tolerated, but extension of the hip was forbidden for 3 weeks to avoid excessive elongation of the tendon, and prophylaxis versus heterotopic ossification is given to avoid recurrence. Outcome data reported are satisfactory with a significant improvement in terms of pain, hip flexion ROM and function, without any complication (Zini et al. 2014; Hetsroni et al. 2012).
24.4 Tendinopathies of the Lateral Area
The term greater trochanteric pain syndrome (GTPS) references a variety of diagnoses with a localized lateral hip pain and focal point tenderness over the greater trochanter. These conditions typically include external snapping hip, trochanteric bursitis and gluteus medius and minimus tendinopathies (Strauss et al. 2010), often with a coexistence of both bursitis and tendinopathy. Prevalence is about 10–25% in population between 40 and 60 years. Female are 2–5 times more frequently affected: this seemed to be related to the greater prominence of the trochanters and the associated increased tension of the iliotibial band (ITB) over them. Other predisposing factors could be an increased acetabular anteversion and a low femoral neck shaft angle. However, about 22% of the elderly individuals present some form of gluteus tear (Kagan 1999). A concurrent or past history of low back pain have been reported in 20–62% of patients with GTPS diagnosis perhaps because of the functional connection between the hip and lumbopelvic complex (Segal et al. 2007). Up to 20 bursae have been described in the trochanteric area, but only three are consistently present in the majority of individuals. These include the gluteus minimus bursa, located anterosuperiorly to the greater trochanter; the subgluteus medius bursa, which lies deep to the gluteus medius tendon; and the subgluteus maximus bursa, which lies lateral to the greater trochanter between the gluteus medius and maximus and is often described as the “trochanteric bursa”. Regarding muscles anatomy, the most superficial gluteal muscle, the gluteus maximus, has a broad origin including fibres from the ilium and sacrum and inserts onto the gluteal tuberosity of the femur and the ITB. The gluteus medius lies deep within this muscle, and the gluteus minimus is deeper; they both originate from the ilium and insert onto the greater trochanter of the femur. The tensor fascia lata originates from the iliac crest and inserts onto the ITB. This fibrous band of tissue inserts distally onto the lateral condyle of the tibia. The gluteus medius and minimus, both innervated by the superior gluteal nerve, are part of the abductors of the hip. The abduction, particularly its initiation, is attributable to the anterior and middle fibres of gluteus medius. Usually, tears of the gluteus medius start from medial fibres to the lateral ones (Fig. 24.3) (Reid 2016). Soft tissue structures in the trochanteric area are similar to those in the area of the greater tuberosity of the shoulder. Gluteus medius and minimus tendons are prone degeneration or failure, and the trochanteric bursa have potential for inflammation (Ho and Howard 2012). Even if historically this syndrome has been referred to as a “bursitis”, the presentation is rarely accompanied by the characteristic symptoms of inflammation including erythema, oedema and rubor. Therefore, it is now thought, also as a result of dissection, clinical and radiological studies, that bursa may be acquired as a result of friction between the greater trochanter and gluteus maximus. Bursal tissue from patients with GTPS undergoing total hip arthroplasty showed no signs of acute or chronic inflammation. This finding supports the understanding that inflammation plays a limited role in GTPS (Bird et al. 2001; Dunn et al. 2003; Silva et al. 2008). The aetiology of gluteal tendinopathy is proposed to be multifactorial with both intrinsic and extrinsic components, but the exact mechanism is unknown: repetitive activity, abnormal mechanical loads and altered cellular responses are the major suspects, but tendinopathy can occur in patients without overuse. Otherwise chronic tendinopathies seen on imaging can be asymptomatic (Kaux et al. 2011). As it regards external snapping, this phenomenon can occur as a result of a thickening of the posterior ITB, the tensor fascia lata or the gluteus maximus as they slide over the greater trochanter, during hip flexion. In more severe cases the snap may be also reproduced with hip rotations. This phenomenon is always voluntary and is the most common form of coxa saltans (Ilizaliturri and Camacho-Galindo 2010).
Fig. 24.3
MRI scan showing a right medius gluteus tendonitis
In GTPS pain is referred by the patient as lateral, with an insidious onset. It is persistent and often exacerbated by lying on the affected side, sitting with the legs crossed or by prolonged weight bearing in unilateral stance. Symptoms may also extend laterally down the thigh, rarely below the knee or posteriorly into the gluteal region. In case of an external snapping, patient can complain a snap while flexing or rotating the hip, often in absence of pain. At the physical examination, neurological and screening examination for the lumbosacral region is mandatory. The consistent feature of the syndrome is increased tenderness to palpation, but it has been seen that the intertester error in palpating the greater trochanter bony landmark is greater than 15 mm which is significantly larger than the dimensions of the normal bursae or footprint of the tendon insertions (Moriguchi et al. 2009). A positive FABER test and pain with resisted hip abduction can be found. The gluteal tendon pathology can be represented by pain, weakness or a lag during resisted hip abduction testing. The presence of a Trendelenburg sign is both reliable and accurate with a sensitivity of 73% and specificity of 77% in patients with MRI evidence of a torn tendon (Bird et al. 2001). Reproduction of the lateral hip pain during resisted hip internal rotation back to neutral, with hip flexed to 90°, also had a high correlation with the presence of tendon change on MRI with a sensitivity of 88% and specificity of 97% (Lequesne et al. 2008). The Ober test is described as a mechanism to evaluate for ITB (tensor fascia lata/gluteus maximus) tightness and may cause compressive pain over the trochanter but has not been studied for its accuracy as a specific predictor of GTPS (Mulligan et al. 2015). The hip lag sign, in which the ability to hold an antigravity position of hip abduction is used to detect a gluteus medius tear, is considered positive if the foot drops more than 10 cm or the patient cannot hold the internally rotated position. It seems to be 89% sensitive and 97% specific (Kaltenborn et al. 2014). For the external snapping hip, the patient could be asked to voluntarily reproduce the sign. Otherwise in a side lying position with the ITB on stretch, it can be evaluated if the snapping complaint is present as the patient actively flexes and extends the hip (Mulligan et al. 2015). Radiological investigations start as usual with a plain radiograph of the pelvis that can depict greater trochanteric enthesopathy. Ultrasound can be useful to get a dynamic imaging investigation. MRI showed good accuracy for the diagnosis of tears of the gluteus medius and gluteus minimus tendons. However, Blankenbaker found a high prevalence (50%) of peritrochanteric imaging abnormalities in patients without trochanteric pain (Blankenbaker et al. 2008). In difficult cases, injection test with local anaesthetic in the trochanteric area may be performed.
Most patients have resolution of their symptoms with conservative treatments, with surgical interventions usually appointed for refractory cases, nonrespondent to conservative treatments. Also regenerative injection therapy is also a potential treatment option for GTPS (Reid 2016). Conservative treatments start with NSAID therapy and physiotherapy with eccentric exercises. Patient treated with corticosteroid local injection showed significant early improvement up to 3 months, but often recurrence in the longer term (Mani-Babu et al. 2015). A concern for use of corticosteroid injections is the possibility for weakening the tendon structure in the long term. There is a low rate of serious adverse effects after multiple injections, while minor side effects such as skin depigmentation and post injection pain are common (Reid 2016). Shock wave therapy (SWT) has been shown to be effective in particular for GTPS, even if the mechanism of how SWT has an effect on GTPS is unclear (Mani-Babu et al. 2015). It is considered to stimulate healing, possibly by stimulating cellular activity and increasing blood flow (Kaux et al. 2011). Low-energy SWT is an effective treatment for chronic GTPS with improvement being maintained at 12 months. There is a significant improvement with repetitive low-energy SWT compared to CS injection at 4 months (Rompe et al. 2009). However, the available evidence for SWT for GTPS is still limited. Then also platelets reach plasma (PRP) or whole blood injections have been used for the treatment of tendinopathies to promote natural healing by providing/manipulating cellular mediators and growth factors. However, no studies directly relating to GTPS are present. Present in literature, but with limited evidence for efficacy and safety of use in clinical practice, are some advances in non-surgical treatments that include topical glycerol trinitrate therapy, matrix metalloproteinase-inhibitor injection, gene or stem-cell therapy, autologous tenocyte injection and sclerosant injections (Reid 2016). In case of conservative options failure surgical treatment could be taken in account for different GTPS entities. Surgery, open or by endoscopic procedure, can include bursectomy, gluteal tendon repair, ITB release or trochanteric reduction osteotomy, often with a combination of these interventions. Surgery can provide also a grading of the gluteal tears. Using open procedures, two classifications can be obtained. The first one is the Milwaukee classification, in which the trochanter is represented by a clock face and grade 1, 2, 3 and 4 tears correspond to 1 h, 2 h, 3 h and a bald trochanter (Davies et al. 2013). The other one is the Walsh classification, in which type 1 tears had a normal bursa, normal appearance of the gluteus medius tendon, deep surface detachment anteriorly only and a normal gluteus minimus; type 2 tears had a normal bursa, thickening of the tendon, greyish discoloration, loss of normal striations, detachment that may extend posteriorly and a stretched gluteus minimus; type 3 tears had a scarred bursa and may have free fluid and tendon changes as in type 2 but a small disruption exposing the underlying trochanter with a partial tear or detachment of the gluteus minimus; and type 4 tears had total disruption of the gluteus medius and minimus tendons exposing the entire trochanter front and back with ulceration of the fascia lata (Walsh et al. 2011). Using an endoscopic procedure, Domb and Carreira intraoperatively graded gluteal tears based on the percentage of the tendon involved. Grade 2 tears were repaired using a transtendinous technique and grade 4 tears with a full-thickness repair technique. Grade 3 tears were repaired with either technique depending on how near the tear was to full thickness (Walsh et al. 2011). Regarding gluteal tendon tears, surgical repair has shown good long-term improvement. A study about 72 cases reported 95% improvement, maintained at 12 months (Walsh et al. 2011). In the open procedure, patients are positioned in the lateral decubitus position, and a direct approach to the greater trochanter is performed. Then a bursectomy can be carried out or neither. The gluteus medius and minimus tendons are identified, and the ends are debrided. The trochanter is decorticated and then the tendons are sutured to bone with transosseous tunnels, or by anchors or with a combination of both these two techniques. Sutures are used in a vertical mattress configuration in the tendon or in a double-row configuration with anchor sutures securing the avulsed edge and heavy absorbable sutures to oversew the free edge to create a watertight seal. If the posterior fibres of the gluteus medius are involved, these are secured to the trochanter through a set of medial and lateral transosseous tunnels, with simple vertical stitches over the free flap to simulate a double-row repair. In addition, for retracted tears with an exposed trochanter, repair can be supplemented with a fascial allograft (Chandrasekaran et al. 2015). In the endoscopic procedure, the patient can be placed in a supine position or in a lateral position with the leg slightly abducted. A combination of direct distal-lateral and proximal portals (plus other accessory portals) are used to view the peritrochanteric space and facilitate instrumentation. A trochanteric bursectomy is performed every time to aid visualization. For partial tears, a longitudinal split is made in the gluteal tendon to create a trochanteric window for bone preparation. The gluteal tendons are mobilized by removing scar tissue and adhesions. Then anchors are placed in the greater trochanter, and horizontal mattress sutures are placed in the tendons. A double-row technique for full-thickness tears is used to provide added compression of tendon to bone. After surgery, the patient has a period of restricted weight bearing for about 6 weeks, before starting with rehabilitation protocols. Some surgeons recommend an abduction brace for the first post-operative period. Outcome results are very good for both the procedures. However, open technique has retears and wound problems in some cases (7.8% and 3.1% respectively) as disadvantages, while no complications are reported for endoscopic procedures (Chandrasekaran et al. 2015). Also bursectomy can be performed with open or endoscopic procedures. For the open surgery, a direct lateral approach is used. For the endoscopic bursectomy, the patient can be placed either in the supine or lateral position. If a supine position is preferred an anterolatral (AL) portal, slightly more superior than the standard one is created initially. Then a 30° scope is used to visualize the peritrochanteric space, which is often found to be occupied by copious amounts of thickened bursa. Then a distal AL (DAL) portal in line with the initial AL portal is created to be used as a working portal. In case of a lateral decubitus position, an anterior portal and a distal posterior portal are used to allow for visualization and adequate access to the peritrochanteric space. Bursectomy is then performed using a shaver. An ITB release either preceding or subsequent to the bursectomy has been described, with favourable results (Reich et al. 2013). Painful external snapping that is refractory to conservative treatment is rare. The goal of the surgery is to relax the tendon to eliminate the snapping. This can be obtained by a fractional lengthening or a complete release of the tendon. Various types of lengthening procedures have been described including Z-shaped release, formal Z lengthening, cross-shaped release and release of the gluteus maximus tendon insertion to the femur. All techniques can be performed both open, with a direct lateral approach, and endoscopically (Yen et al. 2015). In the endoscopic procedure the patient could be placed as usual in both supine and lateral positions. In the lateral position, working from the outside surface of the ITB, it is exposed and released with a diamond-shaped resection (Ilizaliturri et al. 2006). In another technique performed with the patient placed in a supine position, a gluteus maximus tenotomy is performed through the ITB with an inside-out technique to decrease tension on the iliotibial band (Polesello et al. 2013). All the procedures show good results at the long-term follow-up without significant complications (Reid 2016).
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