Retro-trochanteric sciatica-like pain: current concept

Abstract

The aim of this manuscript is to review the current knowledge in terms of retro-trochanteric pain syndrome, make recommendations for diagnosis and differential diagnosis and offer suggestions for treatment options. The terminology in the literature is confusing and these symptoms can be referred to as 'greater trochanteric pain syndrome', 'trochanteric bursitis' and 'trochanteritis', among other denominations. The authors focus on a special type of sciatica, i.e. retro-trochanteric pain radiating down to the lower extremity. The impact of different radiographic assessments is discussed. The authors recommend excluding pathology in the spine and pelvic area before following their suggested treatment algorithm for sciatica-like retro-trochanteric pain.

Figures

Fig. 1

The normal anatomy of the sciatic nerve in relationship to the piriformis muscle. Copyright Catarina Kartus

Fig. 2

The bipartite piriformis muscle. Copyright Catarina Kartus

Fig. 3

The piriformis muscle lying anterior to the sciatic nerve. Copyright Catarina Kartus

Fig. 4

The sciatic nerve splits and encircles the piriformis muscle. Copyright Catarina Kartus

Fig. 5

The patient localises the pain by gripping the affected hip, just above the greater trochanter, between the thumb and index finger, thus forming the C-sign

Fig. 6

a Normal tendon from a patient with a fracture of the collum femoris. H&E staining, original magnification ×100. b Scar tissue from a patient with OA indicating a ruptured tendon. H&E staining, original magnification ×400. c Calcium deposits (black stain at arrows) in the scar of a previously ruptured tendon in a patient with OA. Van Kossa staining, original magnification ×400. d Moderately increased amount of mucin, indicating GAGs between collagen structures, in a patient with OA (blue stain at arrows). Alcian Blue/Periodic Acid Schiff staining. Original magnification ×400 (republished with the kind permission of John Wiley and Sons)

Fig. 7

a TEM micrograph showing fewer small and medium-sized fibrils in a patient with OA. Original magnification X50,000. b Relative distribution of the fibril diameter size in the internal obturator tendon in a group of patients with OA. c TEM micrograph showing more small and medium-sized fibrils in a patient with a fracture of the collum femoris d Relative distribution of the fibril diameter size in the internal obturator tendon in a group of patients with a fracture of the collum femoris. Original magnification X50,000 (republished with the kind permission of John Wiley and Sons)

Fig. 8

a TEM micrograph from a patient with a fracture of the collum femoris, showing a homogeneous ECM, where collagen fibrils are running in the same direction. Original magnification X3,000. b TEM micrograph from a patient with OA, showing collagen fibrils oriented in different directions representing a scar. Furthermore, between the fibrils, empty spaces can be seen, representing non-collagenous ECM. Original magnification X3,000 (republished with the kind permission of John Wiley and Sons)

Fig. 9

The sciatic nerve and the internal obturator tendon as found during an operation for retro-trochanteric pain syndrome. The internal obturator tendon is tense and hypertrophic, lying in close contact with the sciatic nerve, which turns sharply over the tendon [53]. Copyright Catarina Kartus

Fig. 10

After sectioning the internal obturator tendon, the sciatic nerve is released from the tendon. Copyright Catarina Kartus

Fig. 11

The lateral portal is located 1–2 cm distal to the anterior superior iliac spine, in line with the tip of the greater trochanter. The posterolateral portal is located 3–5 cm proximal to the posterior tip of the greater trochanter, in line with the posterior edge of the trochanter, directed towards the piriformis fossa. Copyright Khaled Meknas

Fig. 12

The gemellus-internal obturator complex is identified and shows hyperaemia in this case. Copyright Khaled Meknas

Fig. 13

In this case, the microtenotomy is performed using an electronic microdebrider. Copyright Khaled Meknas

Fig. 14

The treatment algorithm for retro-trochanteric pain syndrome