Gluteussehnensyndrom

Zusammenfassung

Tendinosen (= degenerative Sehnenveränderungen) sowie Teil- und Komplettrupturen der Gluteussehnen (Gluteus-medius- und/oder Gluteus-minimus-Sehne) wurden in der Vergangenheit als Ursache chronischer Schmerzen unterschätzt, und die Behandlung erfolgte meist unter der Diagnose Bursitis trochanterica. Ansatznahe Veränderungen dieser Sehnen können auch ohne Koxarthrose Schmerzen und Funktionsstörungen auslösen, sie können jedoch auch asymptomatisch bleiben [1]. Seit der Terminus „Rotatorenmanschettenriss der Hüfte“ 1997 publiziert wurde [2], sind ätiopathogenetische Überlegungen stimuliert sowie Diagnose und Therapie verbessert worden. Die Bedeutung dieser Sehnenpathologien ist jedoch verzögert in das Fachwissen eingedrungen [3]. Durch Ultraschall-, MRT- und histopathologische Untersuchungen wurde die Bedeutung der akuten Bursitis als Ursache von Trochanterschmerzen infrage gestellt [4], [5], [6] und die Rolle degenerativer Sehnenveränderungen als Ursache von Beschwerden hervorgehoben [6], [7], [8]. Unter dem Terminus Greater-trochanteric-Pain-Syndrom (= GTPS) werden auch andere, lokale Ursachen wie z. B. Tendinosis calcarea subsumiert [1], [5]. Die Inzidenz des GTPS wird mit 10–25 % der Erwachsenenbevölkerung beziffert [5]. Sonografie und MRT liefern nichtinvasiv den Beweis von Sehnen- und Bursenveränderungen unterschiedlicher Inzidenz [7], [8], [9]. Bei einem hohen Prozentsatz der Patienten mit Trochanterschmerzen findet man pathologische MRT-Befunde (88 %) [10], allerdings ist der Prozentsatz symptomfreier Menschen (50 %) mit abnormalen pertrochantären Befunden nicht unerheblich [1], [10]. Die Inzidenz von Sehnenrissen, die anlässlich der Implantation von Hüftendoprothesen wegen Schenkelhalsfraktur bzw. Koxarthrose festgestellt wurden, reicht bis 22 % [2], [11], [12], [13]. Sehneneinrisse lösen meist Schmerzen und eine eingeschränkte Muskelfunktion aus. Traumatische Rupturen ohne Vorschädigung sind selten. Tendinosen und Teilrupturen werden in erster Linie konservativ behandelt. Das therapeutische Spektrum ist dem der Schulterbehandlung sehr ähnlich. Häufig angewendete Verfahren sind lokale Kortikosteroidinfiltrationen, physikalische Behandlung und Physiotherapie. Die Wirksamkeit der ESWT (= extrakorporale Stoßwellentherapie) wurde in den letzten Jahren nachgewiesen [14]. Die Operationsindikation ergibt sich aus therapieresistenten Beschwerden und/oder Funktionsausfall der Glutealmuskulatur. Die offene Sehnenreinsertion ist die Methode der Wahl. Anwender endoskopischer Verfahren berichten über ähnliche oder sogar bessere Erfolge [15], [16], [17], [18], [19], [20], [21].

Abstract

Gluteal tendinopathy as well as partial and full-thickness tears of gluteal tendons (gluteus minimus and/or medius tendon) were underestimated as a cause of chronic pain in the past, and treatment was most commonly based on the diagnosis of trochanteric bursitis. Tendinous pathologies can either stay asymptomatic or cause pain and muscular dysfunction, not necessarily being associated with osteoarthritis of the hip [1]. As the terminus “rotator cuff tear of the hip” was published in 1997 [2], its aetiopathogenesis was reconsidered, resulting in improvements in diagnosis and treatment. Nevertheless the adoption of those findings into clinical daily routine took time [3]. Ultrasound and magnetic resonance imaging (MRI) as well as histopathologic examination questioned the relevance of acute bursitis being the only cause of greater trochanteric pain [4], [5], [6], while emphasizing degenerative tendinopathy causing those symptoms [6], [7], [8]. The terminus “greater trochanteric pain syndrome” (GTPS) should hereby also include further pathologies, e.g. calcific tendinitis [1], [5]. GTPS affects about 10–25 % of the adult population [5]. Ultrasound and MRI are reliable, non-invasive methods for detecting tendinous and bursal pathologies [7], [8], [9]; in 88 % of all patients with trochanteric pain, MRI gives pathological findings [10]. Nevertheless, in 50 % of suspicious pertrochanteric pathologies, patients are free of symptoms [1], [10]. In patients undergoing total hip arthroplasty, the incidence of intraoperative macroscopically identified gluteal tendon tears reaches up to 22 % [2], [11], [12], [13]. Tendinous tears cause pain and constrained muscular function. Sole traumatic tears are rare, most commonly they are based on pre-existing defects. Tendinosis and partial tears are primarily treated conservatively. Hereby, therapeutic options are similar to those for rotator cuff pathologies of the shoulder. Topical infiltration of corticosteroids and physical therapy offer good results especially in early stages. The effectiveness of extracorporeal shock wave therapy has also been proven [14]. Surgical intervention is necessary in case of non-responsiveness to treatment or loss of gluteal muscular function. Hereby, the open gluteal repair always represented the method of choice, whereas recently, users of endoscopic systems reported similar or even better outcomes [15], [16], [17], [18], [19], [20], [21].

Key words

Hüftschmerz - Bursitis trochanterica - Gluteustendinopathie - Rotatorenmanschette der Hüfte - Gluteussehnenriss - Gluteussehnenreinsertion - Hüftendoprothese - Trochanter-major-Enthesopathie

Key words

hip pain - greater trochanteric pain syndrome - trochanteric bursitis - gluteus tendon tear - rotator cuff tear of the hip - gluteus tendon repair - total hip arthroplasty

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