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. 2025 Sep 12.
doi: 10.2106/JBJS.25.00427. Online ahead of print.

The Broken Wing Sign: A New Clinical Test to Detect Gluteus Medius Pathology with and without Fatty Infiltration

Rafael J Sierra  1 , Sergio F Guarin Perez  1 , Diego J Restrepo  1 , Benjamin M Howe  2 , Ta-Wei Tai  1   3
Affiliations

The Broken Wing Sign: A New Clinical Test to Detect Gluteus Medius Pathology with and without Fatty Infiltration

Rafael J Sierra et al. J Bone Joint Surg Am. .

Abstract

Background: Gluteus medius tears and atrophy cause lateral hip pain, limp, and functional impairment. We developed the "broken wing sign," a novel physical examination test for detecting gluteus medius tendon tears and muscle degeneration. This study evaluated its diagnostic accuracy and clinical utility against magnetic resonance imaging (MRI) and intraoperative findings.

Methods: We prospectively examined 59 patients (75 hips; mean age, 69.5 ± 10.8 years; 48 women) with suspected hip abductor insufficiency. The broken wing sign was tested with patients prone, the knee flexed at 90°, and the hip actively extended. A positive sign involved ≥10° of compensatory external hip rotation, visible as an inward drift of the foot, indicating gluteus medius (and resulting internal rotation) weakness. MRI served as the reference standard for classifying gluteus medius integrity as no tear, partial, full-thickness, or massive. Fatty infiltration was graded (Goutallier grades 0 to 4), quantified, and analyzed for a correlation with the examination findings. Diagnostic accuracy metrics were calculated.

Results: The broken wing sign demonstrated high accuracy (sensitivity, 81.8%; specificity, 80.0%; positive predictive value [PPV], 91.8%; negative predictive value, 61.5%; diagnostic odds ratio, 17.8). An external rotation threshold of ≥30° yielded 100% specificity and 100% PPV for a tear. The sign detected acute tears with no or minimal fatty infiltration (100% sensitivity for massive tears). The degree of the external rotation angle was strongly correlated with muscle atrophy with fatty infiltration, showing 88.0% sensitivity for Goutallier grade ≥3 and 100% sensitivity for grade 4.

Conclusions: The broken wing sign is clinically useful for diagnosing gluteus medius tendon tears and muscle atrophy, particularly massive tears and advanced fatty degeneration. It effectively guides MRI utilization and surgical planning, serving as a valuable initial diagnostic tool in the clinical setting.

Level of evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I823).

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