High-yield overview

Hip Abductor Tears | The Rotator Cuff of the Hip | Repair, Transfer, Reconstruction

F greater than MStrong female predominance (often 4:1 or more)

50-70Typical age range (years)

20-25%Peritrochanteric tendon pathology on hip MRI

less than 10%Isolated bursitis without tendon pathology

Critical Must-Knows

Rotator cuff of the hip - gluteus medius and minimus tears behave like supraspinatus tears, with footprint detachment, retraction and fatty infiltration driving outcome
A tear is not the same as tendinopathy - this topic is the structural/surgical end of the spectrum; pure tendinopathy and bursitis are covered under greater trochanteric pain syndrome
MRI is the reference standard - characterises tear thickness, retraction, and muscle fatty infiltration that determines reparability
Fatty infiltration predicts failure - high-grade atrophy makes direct repair unreliable and pushes towards transfer or reconstruction
Think abductor tear after THA - persistent limp, Trendelenburg gait or instability after hip replacement may be an iatrogenic or attritional abductor tear

Clinical Pearls

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Trendelenburg gait plus weak resisted abduction in a middle-aged woman with lateral hip pain points to a tear, not just bursitis
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A focus of T2 hyperintensity superior to the greater trochanter is the single best MRI sign of an abductor tendon tear
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Open and endoscopic repair give similar patient-reported outcomes; open techniques report higher complication rates
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Gluteus maximus transfer is a salvage option for the chronically retracted, fatty, irreparable tendon

Overview and Epidemiology

Gluteal tendon tears are tears of the gluteus medius and/or minimus tendons at their insertion on the greater trochanter. They are increasingly recognised as a discrete cause of chronic lateral hip pain and abductor weakness, distinct from simple bursitis. [1,2]

The rotator cuff of the hip. The gluteus medius and minimus stabilise the pelvis during single-leg stance in the same way the rotator cuff stabilises the glenohumeral joint. Their tears mirror supraspinatus pathology and follow a similar natural history: tendinopathy progressing to partial then full-thickness tearing, with retraction and fatty muscle change. [1,2]

Where this topic sits. A tear is the structural, surgical end of a spectrum whose milder forms, tendinopathy and bursitis, are covered under greater trochanteric pain syndrome. Telling them apart changes management. Tendinopathy and bursitis are managed non-operatively, tendinopathy with loading rehabilitation; a full-thickness tear with weakness and fatty change is a surgical problem, in which the timing of intervention and the reparability of the tendon determine the outcome.

Who. Typically a woman aged 50 to 70. Most surgical series are heavily weighted towards women, frequently around or above a 4:1 ratio, and the wider pelvis increases tendon load. Tears are usually degenerative and insidious rather than acute traumatic events.

How common. Peritrochanteric tendon pathology is common on hip MRI: in a large consecutive imaging series, peritrochanteric lesions, including partial and full-thickness gluteus medius and minimus tears, were found in roughly one in five hips. [3] Isolated trochanteric bursitis without tendon pathology is uncommon, well under 10% of patients with lateral hip pain, which reinforces that structural tendon disease drives most refractory symptoms.

Anatomy

The abductor mechanism. The gluteus medius and gluteus minimus form it, with the iliotibial band and tensor fascia lata contributing to lateral pelvic stability. Both tendons lie deep to the iliotibial band (ITB), and each has its own footprint on the greater trochanter:

Gluteus medius inserts on the lateral facet (the main, broad insertion) and the superoposterior facet. It is the principal hip abductor and the key pelvic stabiliser in single-leg stance.
Gluteus minimus inserts more anteriorly, on the anterior facet and the hip capsule. It acts as an abductor and a fine-tuner of femoral head position.

Axial T1 MR image of the hips labelling the anterior facet (insertion of gluteus minimus), the lateral facet (main insertion of gluteus medius), the ridge, tensor fascia lata, iliotibial band and gluteus maximus — Axial T1-weighted MR image through the hips, the labelled side on the image right (the patient's left). Orange marks the anterior facet, the insertion of gluteus minimus (GMIN); green marks the lateral facet, the main insertion of gluteus medius (GMED); the labelled ridge lies between them. Tensor fascia lata, the iliotibial band and gluteus maximus are also labelled.Credit: Grimaldi A et al. (PMC12179227) — CC BY 4.0

Nerve supply. The superior gluteal nerve supplies both muscles and the tensor fascia lata.

Superior gluteal nerve at risk

The superior gluteal nerve runs between gluteus medius and minimus, roughly 3 to 5 cm above the tip of the greater trochanter. Both the original lateral approach and any surgical mobilisation or transfer of the abductors can injure it. Iatrogenic superior gluteal nerve palsy produces an abductor lurch that mimics a tendon tear - assess both tendon integrity and nerve function when a patient limps after hip surgery.

Pathophysiology

Degeneration. Most tears are degenerative. Repetitive tensile load during abduction combines with the compressive load the ITB applies against the trochanter, particularly in hip adduction, producing a zone of tendinopathy near the insertion, directly analogous to the "critical zone" of the supraspinatus. Over time the degenerate tendon undergoes:

Tendinopathy - intratendinous degeneration without a discrete tear
Partial-thickness tear - undersurface (deep) or interstitial fibre failure with the footprint partly intact
Full-thickness tear - complete detachment from the facet, with progressive retraction
Muscle change - chronic tears develop fatty infiltration and atrophy of the muscle belly, which is largely irreversible and is the strongest predictor of poor repair

Tensor fascia lata hypertrophy. A recognised compensatory finding. As the gluteus medius fails, the TFL enlarges to maintain abduction, and this hypertrophy on imaging is a useful indirect clue to a significant abductor tear.

The post-arthroplasty abductor. After total hip arthroplasty, especially via a lateral (transgluteal) approach, the abductors can fail by iatrogenic detachment, suture pull-out, attritional wear, or denervation from superior gluteal nerve injury. The result is abductor deficiency, a Trendelenburg gait, and in severe cases recurrent dislocation, because the abductors also contribute to dynamic hip stability. [4] It is a recognised cause of failed THA.

Classification and Grading

There is no single universally adopted classification for gluteal tendon tears, and several descriptive schemes exist, among them a proposed endoscopic anatomical classification. [5] The useful exam framework is to describe the tear by thickness, retraction and muscle fatty infiltration, because these are what guide treatment. Always pair the structural description (thickness, retraction) with the muscle quality description (fatty change): together they determine whether you offer repair, augmentation or transfer.

Tear thickness (general)

Basis: Footprint involvement on MRI / at surgery
Categories: Partial (undersurface or interstitial) vs full-thickness
Why it matters: Partial tears may respond to loading; full-thickness usually needs repair

Endoscopic anatomical (Bitar)

Basis: Pattern of insertional involvement
Categories: Non-transfixing partial-extension, transfixing partial-extension, transfixing full-extension
Why it matters: Transfixing tears are high-grade and carry more fatty infiltration

Retraction

Basis: Distance of tendon from footprint
Categories: Minimal vs significant retraction (often around 2 to 2.5 cm threshold)
Why it matters: Greater retraction = harder, less reliable repair

Fatty infiltration (Goutallier-type)

Basis: Muscle quality on T1 MRI
Categories: Low grade vs high grade fat / atrophy
Why it matters: High grade predicts irreparability - favour transfer or graft

Frameworks for Describing Gluteal Tendon Tears
Framework	Basis	Categories	Why it matters
Tear thickness (general)	Footprint involvement on MRI / at surgery	Partial (undersurface or interstitial) vs full-thickness	Partial tears may respond to loading; full-thickness usually needs repair
Endoscopic anatomical (Bitar)	Pattern of insertional involvement	Non-transfixing partial-extension, transfixing partial-extension, transfixing full-extension	Transfixing tears are high-grade and carry more fatty infiltration
Retraction	Distance of tendon from footprint	Minimal vs significant retraction (often around 2 to 2.5 cm threshold)	Greater retraction = harder, less reliable repair
Fatty infiltration (Goutallier-type)	Muscle quality on T1 MRI	Low grade vs high grade fat / atrophy	High grade predicts irreparability - favour transfer or graft

Retraction. The threshold between minimal and significant retraction is often around 2 to 2.5 cm, and it describes the tear. It is not an agreed threshold for abandoning repair in favour of transfer, which remains a matter of controversy (see below).

Hand-drawn schematic of two abductor tears: a small defect in the abductor sheet (A) and a larger tear with the tendon end pulled away from the greater trochanter (B) — Schematic drawings of abductor tears. (A) A small defect at the edge of the abductor sheet. (B) A larger tear, the tendon end pulled away, leaving the greater trochanter and femoral head exposed.Credit: Caviglia H et al. (PMC4935799) — CC BY 4.0

Grading Muscle Fatty Infiltration: the Goutallier Scale

The Goutallier classification was originally described for the rotator-cuff muscles on CT and later adapted to MRI (the Fuchs modification). The same five grades are applied to the gluteus medius and minimus:

Grade 0 - normal muscle, no fat
Grade 1 - some fatty streaks within the muscle
Grade 2 - fatty infiltration present, but muscle bulk still exceeds fat
Grade 3 - fat and muscle in roughly equal amounts
Grade 4 - fat exceeds muscle

Why it decides the operation. Low-grade change (grades 0 to 2) behaves like a repairable tendon with viable muscle, so suture-anchor repair to the footprint is reasonable. High-grade change (grades 3 to 4) signals a muscle largely replaced by fat: the change is essentially irreversible, the tendon is functionally irreparable, and direct repair is unreliable, so graft augmentation or gluteus maximus transfer is preferred. Muscle quality, not tear size alone, is the dominant predictor of repair success.

Reading it. Fatty infiltration is best judged on T1-weighted images, where fat is bright. The scale is ordinal and shows only moderate inter-observer agreement, so it guides rather than dictates - a point worth conceding in a viva.

Coronal T1 MRI of the pelvis labelling a normal gluteus medius on one side and gluteus medius tendon rupture with fatty atrophy on the other — Coronal T1-weighted MR image of the pelvis showing both hips. The labels contrast the normal appearance of the gluteus medius on the image left (the patient's right) with gluteus medius tendon rupture and fatty atrophy on the image right (the patient's left).Credit: Kaltenborn A et al. (PMC3951415) — CC BY 4.0

T1 TSE image, Dixon fat-fraction map and 3D rendering of two segmented muscles — (a) T1 TSE image. (b) Dixon fat-fraction (FF) map with two muscles segmented, one green and one red. (c) 3D rendering of the two segmented muscles, oriented by posterior, medial, lateral and anterior labels. The fat-fraction map quantifies the segmented muscle, and the rendering shows its three-dimensional distribution.Credit: Kajdi GW et al. (PMC12722596) — CC BY 4.0

Three MR images of the pelvis with a circled region at one iliac wing and arrows at the lateral hip on the same side — (a) Axial image with a circled region around one iliac wing. (b) Axial image at the level of the hip joints, with arrows at the lateral side of the same hip. (c) Fat-suppressed image with high signal between the arrows on the same side.Credit: Nieminen A et al. (PMC12174256) — CC BY 4.0

Axial and coronal MR images of the pelvis with the muscle at one iliac wing circled — (a) Axial and (b) coronal MR images of the pelvis, each with the muscle at the iliac wing on the image left (the patient's right) circled for comparison with the other side.Credit: Nieminen A et al. (PMC12174256) — CC BY 4.0

Clinical Presentation and Examination

History. Chronic lateral hip pain over the greater trochanter, often present for months to years, worse with side-lying, stairs and prolonged single-leg loading. Abductor weakness shows as difficulty climbing stairs, getting out of a car or standing on one leg, or a sense of the leg "giving way" laterally. A limp is common, and patients may describe a waddling or lurching gait.

After hip replacement. A new or persistent limp, weakness or instability after hip replacement should raise suspicion of an abductor tear, and is an abductor tear until proven otherwise. Examine gait, abductor power and stability deliberately.

Examination. The findings to look for:

Gait - Trendelenburg gait (the pelvis drops on the contralateral swing side) or a compensatory abductor lurch (the trunk shifts over the affected hip)
Trendelenburg test - single-leg stance on the affected side; the contralateral hemipelvis drops, indicating abductor failure
Resisted abduction - weak and often painful
Palpation - point tenderness over the greater trochanter
Hip lag sign (abduction lag) - inability to hold the leg in passively positioned abduction, described as a clinical predictor of significant abductor damage
Hip range of motion - typically preserved

Weakness is the discriminator. Weakness of resisted abduction, not just pain, and a frank Trendelenburg gait push you towards a structural tear. Pure tendinopathy is painful but usually retains reasonable strength.

Differential diagnosis. Beyond tendinopathy and bursitis, two conditions need separating:

Hip osteoarthritis - groin pain (C-sign) with restricted, painful internal rotation, where a gluteal tear gives lateral pain with preserved range of motion. The two can coexist.
Lumbar radiculopathy - radicular pain following a dermatome below the knee, with neurological signs, where a gluteal tear localises to the trochanter with a mechanical pattern and abductor weakness.

Investigations

Radiographs. Plain films are usually normal, and a normal radiograph does not exclude a tear, because the tendon itself is not seen. They are still worth obtaining to:

exclude hip osteoarthritis, fracture and other bony pathology as alternative causes of pain
look for calcific deposits at the trochanter (calcific tendinopathy) and for cortical irregularity or enthesophytes at the insertion
assess implant position in the post-arthroplasty patient

AP radiograph of the right hip with red arrows at the greater trochanter, and a coronal MR image labelled GMed and GT — (A) AP radiograph of the right hip (R marker), red arrows at the greater trochanter, where radiographs may show cortical irregularity or a distal spur. (B) Coronal MR image labelled GMed (gluteus medius) and GT (greater trochanter), with high signal along the lateral side of the greater trochanter.Credit: Van Quickenborne D et al. (PMC12524512) — CC BY 4.0

MRI. The reference standard for assessing gluteal tendon integrity and for surgical planning. It defines:

Tear thickness - partial (undersurface or interstitial) versus full-thickness
Retraction - the gap between torn tendon and footprint
Muscle fatty infiltration and atrophy - graded as above, and the key determinant of reparability
Associated findings - tensor fascia lata hypertrophy and peritrochanteric fluid

The MRI signs. The single best sign of an abductor tendon tear is a focus of T2 hyperintensity superior to the greater trochanter; secondary signs include tendon elongation and discontinuity. 3.0-Tesla MRI detects significantly more tears than 1.5-Tesla. [3] Around an arthroplasty, metal-artefact-reduction (MARS) MRI is generally preferred for soft-tissue assessment.

Four-panel figure of a symptomatic gluteus medius tear: AP hip radiograph, coronal MR image with an arrow at the lateral hip, and two endoscopic peritrochanteric views — Four-panel work-up of a symptomatic gluteus medius tear. (A) The AP radiograph of the hip is unremarkable. (B) Coronal MR image; the arrow marks high signal at the lateral hip. (C, D) Endoscopic peritrochanteric views: (C) sutures in place at repair; (D) the bare trochanteric footprint (star) with the retracted tendon edges (arrows).Credit: Lindner D et al. (PMC4765298) — CC BY 4.0

Axial and coronal MR images of the hip with arrows at abnormal signal at the lateral greater trochanter — Axial (left) and coronal (right) MR images, arrows marking high signal at the lateral side of the greater trochanter. Report the tendon involved, thickness, retraction and any associated bursitis rather than calling every case trochanteric bursitis.Credit: Grimaldi A et al. (PMC12179227) — CC BY 4.0

Ultrasound. A useful, dynamic, lower-cost first-line modality where MRI is limited, for example around large arthroplasty implants. It shows tendinopathy, partial and full-thickness tears and peritrochanteric fluid, and allows dynamic assessment and image-guided injection for diagnosis or therapy. It is operator-dependent and less reliable than MRI for grading muscle fatty change.

Ultrasound of the lateral hip over the greater trochanter, an asterisk between red and blue lines — Ultrasound of the lateral hip over the labelled greater trochanter. The asterisk marks the soft tissue lying between a red outline and a blue line along the bone surface; GMx labels the gluteus maximus.Credit: Corvino A et al. (PMC13256531) — CC BY 4.0

Other tests. Three further tests have specific uses:

CT - mainly for bony detail and implant assessment
Diagnostic injection - local anaesthetic into the peritrochanteric space that abolishes pain supports a peritrochanteric source
Nerve studies - if superior gluteal nerve injury (denervation rather than tendon tear) is suspected after surgery

Management

Management is staged: structured rehabilitation first for most partial tears, surgery for refractory partial tears and full-thickness tears, and salvage transfer or reconstruction for chronic irreparable disease. Earlier is better, since chronic tears do worse than acute repairs.

Non-operative care. First-line for partial tears and tendinopathy, and overlapping heavily with greater trochanteric pain syndrome:

Education and load management - reduce compressive ITB loading by avoiding sustained adduction, such as crossing the legs and side-lying on the affected hip
Progressive abductor loading - isometric then isotonic strengthening, sparing aggressive ITB stretching that can increase trochanteric compression
Adjuncts - simple analgesia; image-guided corticosteroid injection for short-term pain relief; platelet-rich plasma in tendinopathy without a full-thickness tear, more durable than corticosteroid in tendinopathy but not for established full-thickness tears

Surgical repair. Indicated for full-thickness tears and for partial tears that fail comprehensive rehabilitation, provided muscle quality is adequate. Endoscopic repair reattaches the tendon to the trochanteric footprint with suture anchors and allows treatment of concomitant intra-articular pathology. Open repair is a direct footprint repair, often with single-row or double-row suture-anchor constructs for anatomical footprint reconstruction.

Open double-row technique. The exposed greater trochanter is mapped, the torn medius and minimus are mobilised, viable tendon is preserved, and a double-row construct compresses the repaired footprint. Traction sutures confirm mobilisation; proximal-row anchors restore the medial footprint and distal anchors complete compression across a four-anchor repair.

Endoscopic technique. Fluoroscopy confirms anterior-lateral and lateral-posterior facet anchor positions, while endoscopy verifies purchase beside the prepared bare footprint. Horizontal-mattress limbs capture the tendon for the proximal row; bites must include sound tissue without strangulating the edge.

Six intraoperative views of an open abductor reconstruction labelling Gmin, Gmed, the greater trochanter and an FLT autograft — Open abductor reconstruction in six views. (a) Gmin and Gmed exposed. (b) The greater trochanter. (c) Two sites circled in blue and green, with sutures. (d) The FLT autograft outlined, sutures passed. (e) The sutures in place. (f) The completed construct, the FLT autograft outlined.Credit: Capurro-Soler B et al. (PMC11477932) — CC BY 4.0

Three intraoperative views of an open gluteal tendon repair, one labelled proximal row — Open repair in three views. (A) The exposure, oriented by a proximal label, with sutures in the tissue. (B) The proximal row. (C) The completed repair.Credit: Rice MW et al. (PMC11272634) — CC BY 4.0

Fluoroscopic images of instruments at the greater trochanter and an endoscopic view labelling the bare area — Endoscopic repair. Two fluoroscopic images show instruments at the greater trochanter in different positions. The endoscopic view, from the labelled proximal viewing portal, shows sutures beside the labelled bare area.Credit: Kodsy MM et al. (PMC12919366) — CC BY 4.0

Endoscopic view of sutures in a double-row gluteal tendon repair, red arrows at the suture entry points — Endoscopic view labelled double row repair, the red arrows at the points where the suture limbs pass into the tissue.Credit: Kodsy MM et al. (PMC12919366) — CC BY 4.0

Open or endoscopic. Systematic review evidence shows similar patient-reported outcomes, pain scores and abduction strength, with higher reported complication rates after open surgery. [6] Read that complication difference with care. The endoscopic patients were a different group, 15 of 40 having concomitant intra-articular procedures against none of the 127 open patients; the comparison rests on a handful of level IV series rather than a pooled analysis; and complications were counted as each author reported them.

Results. Both partial and full-thickness tears improve, with low retear rates in appropriately selected patients. [2]

MR images of the hip before and after gluteal tendon repair, anchors visible in the greater trochanter — MR images of a hip before and after gluteal tendon repair. The top pair (a, b) are coronal images; anchors are visible in the greater trochanter in (b).Credit: Banke IJ et al. (PMC12566602) — CC BY 4.0

Rehabilitation after repair. Prolonged and protected, because of the high loads acting at the peritrochanteric region. A period of restricted weight-bearing and limited active abduction comes first, then graded abductor strengthening under supervision; premature loading risks repair failure.

Salvage. For chronic, retracted, fatty, irreparable tears, direct repair is unreliable and salvage is required:

Graft augmentation / superior gluteal reconstruction - graft or synthetic mesh reinforces a thin, poor-quality tendon. Human dermal allograft incorporated into a double-row construct has shown promising short-term outcomes for massive irreparable tears, including in revision cases. [7]
Gluteus maximus tendon transfer - the workhorse salvage when the gluteus medius and minimus are severely atrophied or retracted but the gluteus maximus is functioning, alone or combined with the tensor fascia lata in revision arthroplasty (below)

Abductor deficiency after THA. A distinct management track. The goals are pain relief, restoration of abductor function and prevention of recurrent dislocation.

Direct repair to the greater trochanter is reasonable when instability presents relatively early after primary THA and tissue is adequate. [4]
Soft-tissue augmentation (acellular dermal allograft) and tendon transfers (gluteus maximus, vastus lateralis, latissimus dorsi in tumour resection) are options for avulsion or chronic deficiency. [4]

Literature quality is limited, but outcomes are generally favourable for pain and stability even when limp persists.

Gluteus Maximus Tendon Transfer: How the Salvage Works

Principle. When the gluteus medius and minimus are functionally lost (high-grade fatty infiltration and retraction) but the gluteus maximus is intact and innervated by the inferior gluteal nerve, part of gluteus maximus is transferred to reconstruct an active abductor pull across the greater trochanter. It is a dynamic, muscle-based reconstruction rather than a repair of the native tendon.

Technique in outline.

Through a lateral approach, debride the diseased abductor tendon and prepare the greater trochanter to a bleeding bony bed.
Mobilise the anterior portion (flap) of gluteus maximus on its neurovascular pedicle, preserving the inferior gluteal nerve supply, and advance it anterolaterally over the trochanter.
Place anchors in the anterior and lateral greater-trochanter facets to reproduce an abductor line of pull, then secure the flap to the trochanter or to the vastus lateralis / residual abductor stump under appropriate tension, with the hip held in abduction so that resting tone helps hold the pelvis level.
Protect it as for an abductor repair: restricted weight-bearing with the limb supported in slight abduction and limited active abduction, then graded strengthening, because early loading pulls the transfer out.

Variations. The classic Whiteside description uses a gluteus maximus flap alone. Combined constructs add the posterior part of the tensor fascia lata, and the two flaps are wrapped to recreate an abductor sleeve; this has been described to augment abductor reconstruction for severe, irreparable abductor deficiency in revision THA. [8]

Intraoperative photograph of a muscle flap held up in two clamps — Elevation of the transfer flap: a strip of muscle held up in two clamps through the wound.Credit: Lemme NJ et al. (PMC10757414) — CC BY 4.0

Operative field with orientation labels and two marked suture points, A and B — Operative field oriented by printed labels (anterior, posterior, proximal, distal), with sutures emerging from two marked points, A and B.Credit: Lemme NJ et al. (PMC10757414) — CC BY 4.0

What to warn the patient. Transfer reliably improves pain and stability, but it does not restore normal power. Residual abductor weakness, a persistent Trendelenburg gait or lurch, and continued reliance on a walking aid are common, and the reconstruction can still fail. A more comfortable, more stable hip, but not a normal gait: that honest counselling is exactly what examiners want to hear, and it matches the outcomes reported for salvage transfer.

Complications and Outcomes

Retear and failure of repair. The main concern, especially in chronic tears with high-grade fatty infiltration, large retraction, obesity, and non-compliance with protected rehabilitation.

Other complications. The remaining risks are these:

Persistent abductor weakness - residual weakness and a degree of Trendelenburg gait can persist even after successful repair or transfer, especially after salvage transfer for irreparable tears
Superior gluteal nerve injury - meticulous technique and respecting the safe zone above the trochanter reduce the risk of iatrogenic denervation
Wound and general surgical risks - infection, haematoma and prominent or irritating hardware, with the higher overall complication rate reported for open repair

Prognosis. Appropriately selected partial and full-thickness tears with reasonable muscle quality do well with repair, achieving meaningful pain relief and strength gains by open or endoscopic technique. Chronic, retracted, fatty, irreparable tears do less well and rely on salvage transfer or reconstruction, where pain relief is more reliable than full restoration of strength.

Guidelines, Registries & Global Practice

Global Epidemiology

Peritrochanteric tendon pathology, including partial and full-thickness gluteus medius/minimus tears, is found in roughly one in five hips on MRI in unselected imaging populations, and is detected more reliably on 3.0-Tesla scanners. [3]
A strong female predominance and a peak in the sixth and seventh decades are consistent across surgical series worldwide; most tears are degenerative rather than acute.
Abductor deficiency is a recognised cause of pain, limp and instability after total hip arthroplasty, particularly following lateral (transgluteal) approaches. [4]

Society Guidance Compared

BOA / UK practice

Diagnosis: Clinical plus US/MRI for surgical planning
Repairable tears: Endoscopic or open suture-anchor repair
Irreparable / revision: Graft augmentation or tendon transfer

AAOS / US sports medicine

Diagnosis: MRI to grade thickness, retraction, fatty infiltration
Repairable tears: Open or endoscopic repair (single/double row)
Irreparable / revision: Gluteus maximus transfer, dermal allograft reconstruction

European (ESSKA / EFORT) consensus

Diagnosis: Tendinopathy-to-tear spectrum framing
Repairable tears: Repair for full-thickness and refractory partial tears
Irreparable / revision: Transfer / reconstruction for chronic retracted tears

Arthroplasty (AAHKS / revision THA practice)

Diagnosis: MARS MRI / US around implants; exclude nerve injury
Repairable tears: Direct abductor repair if early and good tissue
Irreparable / revision: Soft-tissue augmentation and tendon transfers

Gluteal Tendon Tears - How Major Bodies Approach Surgery
Body / Source	Diagnosis	Repairable tears	Irreparable / revision
BOA / UK practice	Clinical plus US/MRI for surgical planning	Endoscopic or open suture-anchor repair	Graft augmentation or tendon transfer
AAOS / US sports medicine	MRI to grade thickness, retraction, fatty infiltration	Open or endoscopic repair (single/double row)	Gluteus maximus transfer, dermal allograft reconstruction
European (ESSKA / EFORT) consensus	Tendinopathy-to-tear spectrum framing	Repair for full-thickness and refractory partial tears	Transfer / reconstruction for chronic retracted tears
Arthroplasty (AAHKS / revision THA practice)	MARS MRI / US around implants; exclude nerve injury	Direct abductor repair if early and good tissue	Soft-tissue augmentation and tendon transfers

There is broad international agreement that MRI guides surgical decision-making, that repairable tears are treated by open or endoscopic suture-anchor repair with comparable outcomes, and that chronic retracted irreparable tears require salvage transfer or reconstruction. No body endorses a single proven fixation construct.

Registry & Outcome Notes

There is no dedicated gluteal tendon tear registry. Surgical-outcome evidence comes from systematic reviews and case series: open and endoscopic abductor repair give comparable patient-reported outcomes with more complications reported after open surgery [6], and salvage reconstruction with dermal allograft shows promising early results in massive irreparable tears [7]. In the arthroplasty setting, abductor deficiency is an important but under-captured cause of an unhappy hip in registry follow-up, often presenting as persistent limp or instability rather than a discrete revision diagnosis. [4]

High- vs Limited-Resource Practice Variation

Well-resourced settings: 3.0-T MRI, ultrasound-guided injection, endoscopic and open repair, dermal allograft reconstruction, and tendon-transfer salvage are all available.
Limited-resource settings: diagnosis leans on clinical assessment (Trendelenburg gait, weak resisted abduction, abduction lag sign) and ultrasound; management emphasises structured abductor loading rehabilitation, with open repair where surgery is available and endoscopic equipment or graft is not. The global priority remains accurate identification of a structural tear so that rehabilitation and surgery are directed appropriately.

Controversies and Areas of Uncertainty

Open vs endoscopic repair

Both achieve similar outcomes, with open surgery carrying higher reported complications - though the compared groups differ (concomitant intra-articular work in the endoscopic series, none in the open) and complications were never adjudicated to a common definition. There is no randomised comparison, so technique selection remains surgeon- and tear-dependent.

Single- vs double-row, augmentation

The optimal fixation construct and the role of graft augmentation (dermal allograft, synthetic mesh) are not defined by high-quality evidence; practice is extrapolated from rotator cuff surgery.

When is a tear irreparable?

There is no agreed threshold of fatty infiltration or retraction at which to abandon repair for transfer. Decision-making is individualised on muscle quality and patient demand.

Best salvage in revision THA

Multiple transfer and reconstruction techniques exist for post-arthroplasty abductor deficiency, but comparative evidence is sparse and persistent limp is common whichever is chosen.

Further uncertainty surrounds the prevalence of asymptomatic abductor tears, the prognostic value of MRI grading for predicting repair success, and the place of biologics in established full-thickness tears.

MCQ Practice Points

Best MRI sign of an abductor tear

Q: What is the single best MRI sign of a hip abductor tendon tear?

A: A focus of T2 hyperintensity superior to the greater trochanter. Secondary signs include tendon elongation and discontinuity. 3.0-Tesla MRI detects more tears than 1.5-Tesla.

Predictor of poor repair outcome

Q: Which factor most strongly predicts an irreparable tear or failed repair?

A: High-grade muscle fatty infiltration / atrophy (graded in a Goutallier-type fashion). With high-grade fat, direct repair is unreliable and salvage with transfer or graft is preferred.

Open versus endoscopic repair

Q: How do open and endoscopic gluteal repairs compare?

A: Similar patient-reported outcomes, pain and strength, but open repair has a higher reported complication rate. There is no randomised comparison proving one superior (Chandrasekaran systematic review).

Salvage for irreparable tears

Q: What is the workhorse salvage procedure for a chronic, retracted, fatty, irreparable abductor tear with a functioning gluteus maximus?

A: Gluteus maximus tendon transfer. It improves pain but residual abduction weakness and gait abnormality are common. Dermal allograft superior gluteal reconstruction is an alternative.

Abductor deficiency after THA

Q: What should a persistent limp with recurrent dislocation after a lateral-approach THA make you consider?

A: Abductor deficiency from an iatrogenic or attritional abductor tendon tear (or superior gluteal nerve injury). Options include direct repair, dermal allograft augmentation, and tendon transfers.

Clinical Decision Scenarios

Practise clinical reasoning and management decisions out loud

Viva scenarioStandard

Clinical prompt

“Classic chronic gluteal tendon tear presentation. The examiner wants a structured work-up that distinguishes a structural tear from tendinopathy and uses imaging to drive management.”

Viva scenarioStandard

Clinical prompt

“The examiner is testing conceptual understanding linking shoulder and hip tendon pathology.”

Viva scenarioChallenging

Clinical prompt

“High-yield post-arthroplasty scenario testing recognition and management of abductor deficiency, including transfer and reconstruction options.”

Viva scenarioChallenging

Clinical prompt

“Tests knowledge of the comparative evidence and how to apply it.”

Exam day cheat sheet

GLUTEAL TENDON TEARS (HIP ABDUCTOR TEARS)

KEY CONCEPT

Rotator cuff of the hip - gluteus medius/minimus tendon tears
Structural/surgical end of the spectrum (vs tendinopathy/bursitis in GTPS)
Female predominance, age 50-70, usually degenerative
Fatty infiltration is the key predictor of reparability

ANATOMY

Gluteus medius to lateral and superoposterior facets of GT
Gluteus minimus to anterior facet
Tendons lie deep to the ITB (compressive load)
Superior gluteal nerve runs between medius and minimus - at risk

CLINICAL FEATURES

Chronic lateral hip pain plus abductor WEAKNESS
Trendelenburg gait and positive Trendelenburg test
Weak resisted abduction; abduction lag sign
Preserved hip ROM (helps exclude hip OA)
Suspect after lateral-approach THA with limp/instability

INVESTIGATIONS

Radiographs usually normal - exclude OA, calcific deposits, check implant
MRI is reference standard - grade thickness, retraction, fatty infiltration
Best MRI sign: T2 hyperintensity superior to greater trochanter
3.0-T MRI detects more tears than 1.5-T
Ultrasound for dynamic assessment and around implants

MANAGEMENT

Partial tears: load management + progressive abductor rehab first
Full-thickness / refractory partial: suture-anchor repair
Open and endoscopic repair give SIMILAR outcomes
Open repair has higher reported complication rate
Protected, prolonged rehabilitation after repair

SALVAGE / IRREPARABLE

Irreparable = high-grade fatty infiltration + retraction
Dermal allograft superior gluteal reconstruction
Gluteus maximus tendon transfer (functioning maximus)
Combined Gmax + TFL transfer in revision THA
Counsel about residual weakness / limp

Evidence Base

Evidence

Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: a systematic review. Arthroscopy. 2015;31(10):2057-2067

Level IV (systematic review of Level IV studies)

Key Findings:

Open and endoscopic repair give similar patient-reported outcomes and strength
Open repair carries a higher reported complication rate
No randomised comparison exists to declare one technique superior

Finding: Systematic review of 7 studies (127 open, 40 endoscopic abductor repairs). Modified Harris Hip Scores, visual analogue pain scores and improvement in abduction strength were similar between open and endoscopic groups at 1- and 2-year follow-up. The only clear difference was a higher reported complication rate in the open group. Endoscopic series more often addressed concomitant intra-articular pathology.

Clinical implication: Both open and endoscopic abductor repair are reasonable for appropriately selected tears; technique choice can be guided by surgeon experience, tear pattern and the need to address intra-articular pathology, while counselling that open surgery has more reported complications.

Limitation: THE COMPARISON RESTS ON ONE OPEN STUDY AGAINST THREE ENDOSCOPIC ONES, AND THE GROUPS ARE NOT COMPARABLE - the modified Harris Hip Score, on which the 'similar outcomes' conclusion mainly rests, was reported by only 1 of the 3 open studies and 3 of the 4 endoscopic studies; the visual analogue pain comparison is 1 study against 1 study. That is not a pooled analysis, it is a handful of series read side by side, and the review's own level of evidence is IV - a systematic review of level IV studies, with no randomisation, no meta-analysis and no risk-of-bias appraisal. The complication finding needs the most care because it is the one clinicians repeat: 15 of the 40 endoscopic patients had concomitant intra-articular procedures against 0 of the 127 open patients, so the populations differ systematically; the open series are larger and drawn from older literature with different reporting conventions; and complications were counted as reported rather than adjudicated to a common definition. Note finally that all six authors come from a single endoscopy-focused hip centre, so a conclusion favouring the endoscopic technique on complications is not independent of the technique its authors practise.

Verify on PubMed (PMID 26033462)

Evidence

Morgan A, Moore M, Derry K, et al. Surgical treatment and outcomes for gluteal tendon tears. Curr Rev Musculoskelet Med. 2024;17(6):157-170

Level V (narrative review)

Key Findings:

Repair (open or endoscopic) is first-line surgery for repairable tears
Gluteus maximus transfer is a salvage option for irreparable tears
Evidence is still insufficient to mandate a specific fixation construct or graft

Finding: Contemporary review of surgical management of gluteus medius/minimus tears. Open and endoscopic repair show similar outcomes with improvements in patient-reported scores and low complication and retear rates for both partial and full-thickness tears. Gluteus maximus transfer is positioned as a salvage option for the severely atrophied, retracted or revision tendon, with persistent abduction weakness and gait abnormality common. Optimal fixation construct and the role of graft augmentation remain undefined.

Clinical implication: Frame surgical decision-making around reparability: repair when tissue and muscle quality allow, and reserve tendon transfer for the chronically retracted, fatty, irreparable tendon while counselling about residual weakness.

Limitation: A NARRATIVE REVIEW - NO SEARCH STRATEGY, NO INCLUSION CRITERIA, NO POOLED DATA, SO NO FIGURE ON THIS PAGE SHOULD CITE IT - it is a good synthesis and a sensible framing of the reparability decision, but it is expert summary rather than evidence, and the authors are explicit that clinical evidence remains limited for the questions that actually matter: which fixation construct, whether graft augmentation helps, and which patient factors predict outcome. Its statement that open and endoscopic repair 'demonstrate similar outcomes' inherits the weakness of the comparative review above rather than adding to it. The one claim worth carrying with confidence is the negative one about salvage: after gluteus maximus transfer, persistent abduction weakness and gait abnormality are COMMON, so a patient consenting to transfer should be told the operation aims at pain and stability rather than at a normal gait.

Verify on PubMed (PMID 38619805)

Evidence

Oehler N, Ruby JK, Strahl A, et al. Hip abductor tendon pathology visualized by 1.5 versus 3.0 Tesla MRIs. Arch Orthop Trauma Surg. 2020;140(2):145-153

Level III

Key Findings:

About one in five hips show peritrochanteric tendon pathology on MRI
3.0-T MRI detects significantly more tears than 1.5-T
Abductor pathology associates with muscle atrophy and osteoarthritis

Finding: Analysis of 1000 hips (500 consecutive patients) imaged on 1.5-T or 3.0-T MRI. Peritrochanteric lesions (including partial and full-thickness gluteus medius/minimus tears) were present in 31.4% of patients and 22.3% of hips. Lesions clustered ipsilateral to muscle atrophy and to osteoarthritis. Significantly more tendon lesions, particularly partial/full-thickness tears, were detected on 3.0-T than 1.5-T MRI.

Clinical implication: Use 3.0-T MRI where available when an abductor tear is suspected, and actively look for peritrochanteric tendon pathology - it is common and easily missed, particularly on lower-field scanners.

Limitation: MORE LESIONS DETECTED IS NOT THE SAME AS MORE LESIONS PRESENT - there was no surgical, histological or clinical reference standard, so the finding that 3.0-T identified significantly more partial and full-thickness tears than 1.5-T (p = 0.019) is equally consistent with better sensitivity or with more false positives, and the study cannot distinguish them. Nor was field strength allocated: 341 hips went to 3.0-T and 159 to 1.5-T by scanner availability rather than at random, so indication and referral pattern may differ between the groups. The prevalence figure needs the same caution - 31.4% of patients had peritrochanteric lesions, but these are 500 consecutive patients undergoing PELVIC MRI, a group already selected for having a reason to be imaged, so it is not a population prevalence and must not be quoted as one. What is robust, because it does not depend on a reference standard, is the association pattern: trochanteric bursitis occurred almost exclusively alongside gluteal tendinopathy, and lesions clustered ipsilateral to muscle atrophy (76.8% vs 23.2%) and to osteoarthritis - so bursitis in isolation should prompt a deliberate search for the tendon.

Verify on PubMed (PMID 31243547)

Evidence

Browning RB, Clapp IM, Alter TD, et al. Superior gluteal reconstruction results in promising outcomes for massive abductor tendon tears. Arthrosc Sports Med Rehabil. 2021;3(5):e1321-e1327

Level IV (therapeutic case series)

Key Findings:

Dermal allograft reconstruction is an option for massive irreparable tears
Promising short-term outcomes including in revision cases
Small series and short follow-up limit strength of conclusions

Finding: Eight patients with massive, irreparable full-thickness gluteus medius/minimus tears (severe tendon loss and atrophy) underwent open superior gluteal reconstruction using human dermal allograft in a double-row construct; three were revisions of prior endoscopic repair. At a mean of 11.5 months, patient-reported outcomes were good (mean mHHS 83.6, HOS-ADL 82.9, high satisfaction) with no retears on examination or MRI.

Clinical implication: For massive irreparable abductor tears with severe tendon loss, dermal allograft superior gluteal reconstruction is a reasonable salvage that can improve pain and function, including after a failed prior repair - but evidence is early and small.

Limitation: EIGHT PATIENTS, ONE SURGEON, ONE YEAR, NO COMPARISON GROUP - this is a technique feasibility series and the paper says so, reporting level IV. With n = 8 a single poor result moves every mean, and the scatter shows it: the Hip Outcome Score sports subscale is 73.2 with a standard deviation of 37.3 on a 0-100 scale, and the iHOT-12 is 63.9 plus or minus 27.4, so the spread covers most of the available range and the group plainly contains patients who did badly. Quote the technique as promising; never quote the scores as expected results. 'No retears' also needs reading carefully - retear was assessed by physical examination AND/OR MRI, so not every patient was imaged, and clinical assessment cannot exclude structural failure of a construct with allograft interposed. Three of the eight were revisions of a previous endoscopic repair, which is the population where this operation is genuinely useful but also where the threshold for calling it a success is lowest. Twelve months is short for a graft-augmented construct working under abductor load.

Verify on PubMed (PMID 34712970)