Patient History
69 yo M with chronic low back pain radiating into right hip. Right hip bursitis.
Findings
SKELETAL: No fracture or dislocations. No intramedullary lesions. No osteoedema. No cortical breakthrough or periosteal reactions.
PELVIS: The right iliac blade, iliopectineal and ilioischial lines are intact.
Visualized sacrum and right sacroiliac joint are unremarkable.
JOINTS: No hip osteoarthrosis or chondromalacia.
Normal femoral head sphericity with normal tapering at the head-neck junction. No acetabular under or over coverage.
No joint effusions.
GENERAL: Normal sciatic nerves and neurovascular bundles. No space-occupying lesions or nerve compression. No secondary signs of denervation.
Unremarkable pelvic basin contents.
ACETABULUM/LABRUM: Chronic longitudinal anterosuperior labral tear.
MUSCLES/TENDONS/LIGAMENTS: Full-thickness tear of the right gluteus medius with detachment from its insertion on the lateral facet of the greater trochanter which is effaced and exposed. Proximal retraction with 1.5cm gap. Grade 2+ fatty infiltration and volumetric atrophy of the corresponding distal muscle belly.
The iliopsoas, pectineus, adductor longus, adductor brevis, adductor magnus, quadratus femoris, obturator internus and externus, superior and inferior gemellus, hamstrings, gluteus maximus and minimus, sartorius, tensor fascia lata and rectus femoris are intact.
Intact ligamentum teres, ischiofemoral, iliofemoral and transverse ligaments.
OTHER/SOFT TISSUE: Moderate fluid distention of the overlying trochanteric bursa.
Impressions
1. Right gluteus medius full-thickness tear with detachment from its insertion on the lateral facet of the greater trochanter, proximal retraction and 1.5cm gap. Grade 2+ fatty infiltration and volumetric atrophy of the distal gluteus maximus muscle belly.
2. Moderate reactive trochanteric bursitis.
3. Chronic longitudinal anterosuperior labral tear.
