Greater Trochanter: Disclosures:

Anatomy and Pathology • Consultant: Bioclinica

• Book Royalties: Elsevier
Jon A. Jacobson, M.D. • Advisory Panel: GE, Philips
Professor of Radiology
Director, Division of Musculoskeletal Radiology
University of Michigan
Note: all images from the textbook
Fundamentals of Musculoskeletal Ultrasound are copyrighted
by Elsevier Inc.

Greater Trochanter: gluteal tendons

Anterior Lateral Posterior
Outline
• Anatomy and Scanning Technique
• Bursal Pathology
• Tendon Injury
• Miscellaneous

Gluteus medius (red) Gluteus minimus (blue)

Greater Trochanter
Greater
Trochanter

Yellow arrow =
gluteus medius
White arrow = Inferior 1 2
gluteus minimus

Axial MRI
FACETS: AF = anterior; LF = lateral; SPF = superoposterior; PF = posterior
3 Superior 4
Pfirrmann et al. Radiology 2001; 221:469

1
 Greater Trochanter Greater Trochanter
Subgluteus
Medius
Gluteus Medius Gluteus
Bursa Minimus
TFL
Trochanteric
Bursa

Glut
Subgluteus Max
Minimus
Bursa
LF AF

PF

AF: anterior facet

Anterior Posterior LF: lateral facet
PF: posterior facet
Yellow arrow = gluteus medius
White arrow = gluteus minimus

Gluteus Minimus and Medius: Long Axis Gluteus Minimus: Long Axis
Gluteus Gluteus
Medius Minimus

Gmed
Gmed Gmed

AF

Anterior Anterior
Facet Facet

From: Philippon et al. Orth J Sports Med 2014

Gluteus Medius: Long Axis

Iliotibial Outline
Tract
• Anatomy and Scanning Technique
LF
• Bursal Pathology
• Tendon Injury
Lateral
Facet • Miscellaneous

2
 Trochanteric Bursitis
Trochanteric Pain Syndrome:
• Most commonly caused by gluteus
minimus and medius tendon
Gmax
abnormalities1
• Trochanteric bursitis: uncommon Gmed
LF Gmed
– 20% of symptomatic patients2 PF
– Not actually inflamed3
– Not associated with pain4 Transverse
1Kong A et al. Eur Rad 2007; 17:1772
2Long SS et al. AJR 2013; 201:1083
3Sylva F et al. Clin Rheumatol 2008; 14:82
4Blankenbaker DG et al. Skeletal Radiol 2008; 37:903

Trochanteric Bursal Fluid + Glut Min Tear Trochanteric Bursitis

Posterior Anterior
LF AF
Glut
Max PF

Axial

Trochanteric Bursitis: Septic

Trochanteric Bursa: infection + gas
Gmax

Note
posterior
location
of bursa PF

T1w
Greater
Trochanter

Gmax

3
Trochanteric Trochanteric Bursitis
Region Bursae
• Trochanteric: deep to
gluteus maximus
• Subgluteus medius
• Subgluteus minimus
LF
• Axial or coronal plane
PF

Transverse Arthrogram

Muscle and Tendon Injury

Outline
• Tear:
• Anatomy and Scanning Technique – Anechoic or hypoechoic defect
• Bursal Pathology – Partial-thickness tear
• Tendon Injury – Full-thickness tear: retraction

• Miscellaneous • Tendinosis:
– Hypoechoic, enlarged
– No inflammation (not tendinitis)

Tendinosis: Gluteus Medius

Gluteal Tendon Pathology:
• Tendinosis: hypoechoic, no defects
• Partial tear: anechoic clefts
• Complete tear: discontinuous tendon
AF LF SPF LF
• >2 mm cortical irregularity (depth)
– Associated with tendon tear
– Positive predictive value = 90% (xray)*

*Steinert et al. Radiology 2010; 257:754

4
 Gluteus Medius: tendinosis Tear: Gluteus Minimus

LF AF LF
AF
Short Axis Long Axis

Tear: Gluteus Medius Tear: Gluteus Medius after THA

LF
LF LF SPF
AF LF LF
AF AF

>2 mm cortical irregularity depth (x-ray) =

90% positive predictive value for gluteus
tendon tear
Steinert et al. Radiology 2010; 257:754

Post-operative: Gluteus Medius Calcific Tendinosis: Gluteus Medius

LF LF
AF
AF LF SPF LF

Long Axis Short Axis

5
 Gluteus Medius Fenestration
Potential Treatment Algorithm:
• If bursa: aspirate, inject steroids
• If tendinosis:
Greater
Trochanter
– Tenotomy or fenestration
Needle – Inject steroids superficial to tendon
• 72% of patients significantly improved1
• If tendon tear: platelet-rich plasma injection?

1Labrosse, et al. 2010 AJR 2010; 194:202

Normal

Outline Snapping Hip Syndrome

• Anatomy and Scanning Technique • Painful snap with hip motion

• Bursal Pathology • Intraarticular
• Tendon Injury • Extraarticular:
– Anterior: iliopsoas tendon
• Miscellaneous
– Lateral: iliotibial tract or gluteus maximus

Snapping Gluteus Maximus / Iliotibial Band

Gluteus
Iliotibial Band
Snapping Hip: lateral Medius

TFL Gluteus Maximus

Gluteus
Maximus
• Transverse over Gmin
greater trochanter
• Hip external rotation /
flexion
• Abrupt motion of
iliotibial tract or
gluteus maximus over
greater trochanter

6
Snapping Hip Syndrome: iliotibial tract
Take-home points:
Iliotibial Band • Trochanteric anatomy
• Bursitis: rare
Gmax • Gluteal tendons abnormalities: frequent
Gmin
Gmed
• Snapping hip: dynamic

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