Ultrasound-Guided Injection Technique for Gluteus Medius Bursitis Pain



Ultrasound-Guided Injection Technique for Gluteus Medius Bursitis Pain





CLINICAL PERSPECTIVES

Gluteus medius bursitis is a common cause of lateral hip and buttocks pain. The gluteus medius bursa lies between the distal insertional tendons of gluteus medius and gluteus minimus muscles (Fig. 125.1). The bursa serves to cushion and facilitate sliding of the musculotendinous units of the gluteus medius and minimus muscles over the bony greater trochanter. The bursa is subject to inflammation from a variety of causes with acute trauma to the hip and repetitive microtrauma being the most common. Acute injuries to the bursa can occur from direct blunt trauma to the lateral hip as well as from overuse injuries including running on uneven or soft surfaces. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur. Gout and other crystal arthropathies may also precipitate acute gluteus medius bursitis as may bacterial, tubercular, or fungal infections.

The patient suffering from gluteus medius bursitis most frequently presents with the complaint of pain in the upper outer quadrant of the buttocks that can radiate down the leg and into the sciatic notch. The patient may find walking upstairs and getting in and out of the car increasingly difficult. Physical examination of the patient suffering from gluteus medius bursitis will reveal point tenderness over the upper outer quadrant of the buttocks. If there is significant inflammation, rubor and color may be present and the entire area may feel boggy or edematous to palpation. Active resisted abduction and extension of the affected lower extremity reproduce the pain. Sudden release of resistance to abduction during the resisted abduction release test for gluteus medius bursitis markedly increases the pain. There should be no sensory deficit in the distribution of the lateral femoral cutaneous nerve, as is seen with meralgia paresthetica, which often is confused with gluteus medius bursitis. If calcification or gouty tophi of the bursa and surrounding tendons are present, the examiner may appreciate crepitus with active abduction of the hip and the patient may complain of a catching sensation when moving the affected lower extremity, especially on awaking. Often, the patient will not be able to sleep on the affected side.

Plain radiographs are indicated in all patients who present with hip pain to rule out occult bony pathology (Fig. 125.2). Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other hip bursitis, calcific tendonitis, tendinopathy, triceps tendonitis, or other hip pathology. Magnetic resonance imaging or ultrasound imaging of the affected area may also help delineate the presence of calcific tendonitis or other hip pathology (Figs. 125.3 and 125.4). Rarely, the inflamed bursa may become infected, and failure to diagnose and treat the acute infection can lead to dire consequences. Electromyography helps distinguish gluteus medius bursitis from meralgia paresthetica and sciatica.


CLINICALLY RELEVANT ANATOMY

There is significant intrapatient variability in the size, number, and location of the gluteal bursae. The gluteal medius bursa lies between the gluteal maximus and medius muscle (Fig. 125.5). The gluteus minimus bursa lies between the gluteus medius and minimus muscles (see Fig. 125.1). With the leg in anatomic position, the gluteus medius and gluteus minimus muscles work as a single functional unit to abduct the hip (Fig. 125.6). When ambulating, both muscles act principally to support the body on one leg and, in conjunction with the tensor fascia lata, prevent the pelvis from dropping to the opposite side. With the hip in flexed position, the gluteus medius and minimus muscles act to internally rotate the thigh. With the hip in extension, the gluteus medius and gluteus minimus muscles act to externally rotate the thigh.


ULTRASOUND-GUIDED TECHNIQUE

The benefits, risks, and alternative treatments are explained to the patient and informed consent is obtained. The patient is then placed in the modified Sims position (Fig. 125.7).
The skin overlying the greater trochanter of the femur is then prepped with antiseptic solution. The greater trochanter is then identified by using a grasping maneuver (Fig. 125.8). A sterile syringe containing 4.0 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 1½-inch, 22-gauge needle using strict aseptic technique. A linear high-frequency ultrasound transducer is placed over the previously identified greater trochanter with the transducer in a transverse orientation (Fig. 125.9). A survey scan is taken, which demonstrates the hyperechoic margin of the greater trochanter, the trochanteric bursa, and tendon of the gluteus maximus muscle above it (Fig. 125.10). After the greater trochanter is identified, the transversely placed ultrasound transducer is then slowly moved superiorly until the superior margin of the greater trochanter of the femur and the insertion of the gluteus medius muscle is identified (Fig. 125.11). Just medial to the gluteus medius musculotendinous unit is the gluteus minimus musculotendinous unit (see Fig. 125.1 also for orientation, Fig. 125.12). The gluteus medius bursa lies between the two. When the fascial plane between the gluteus medius and gluteus minimus musculotendinous units are identified, a 3½-inch needle is placed through the skin ˜1 cm from the anterior aspect of the transducer and is then advanced using an in-plane approach with the needle trajectory adjusted under real-time ultrasound guidance to place the needle tip into the fascial cleft between the musculotendinous
units of the gluteus medius and gluteus minimus muscles (Fig. 125.13). When the tip of the needle is thought to be in satisfactory position within the fascial cleft, a small amount of local anesthetic and steroid is injected under real-time ultrasound guidance to confirm proper placement of the needle tip by hydrodissection. After proper positioning of the needle tip placement is confirmed, the remainder of the contents of the syringe are slowly injected. There should be minimal resistance to injection. If synechiae, loculations, or calcifications are present, the needle may have to be repositioned to ensure that the entire bursa is treated. The needle is then removed, and a sterile pressure dressing and ice pack are placed at the injection site.

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Mar 1, 2020 | Posted by in ANESTHESIA | Comments Off on Ultrasound-Guided Injection Technique for Gluteus Medius Bursitis Pain
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