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Symptomatic Snapping Hip

Targeted Treatment for Maximum Pain Relief

Jeremy Idjadi, MD; Robert Meislin, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 1 - JANUARY 2004


In Brief: A painful condition known as snapping hip may prevent athletes from attaining peak performance, and it presents diagnostic and treatment challenges to the sports medicine physician as well. Three types of snapping hip (external, internal, and intra-articular) are known, and each has a distinct pathomechanic cause, specific symptoms, and classic clinical presentation. History and physical exam are coupled with a variety of imaging modalities to help distinguish the three types. Nonoperative approaches are the mainstay of treatment, but, if unsuccessful, operative treatments also achieve good results. Patients may resume their activities when pain subsides.

Benign, painless snapping in the hip is common in the general population. Symptomatic snapping hip with debilitating pain and weakness is often seen in participants of activities such as ballet and running hurdles. The repetitive nature of many sports may prevent athletes who have painful symptoms from performing at their highest level or prevent them from participating altogether. The clinician's goal is to determine the cause and treat active patients who have symptomatic snapping hip so that they may return to peak performance in their athletic activities.

Anatomy and Pathomechanics

The cause of symptomatic snapping hip may be external, internal, or intra-articular.

External type. The iliotibial band (ITB) is the usual culprit in the external type of snapping hip. The ITB originates from the gluteus maximus and the tensor fasciae latae (figure 1). Most of the ITB inserts at the proximal lateral aspect of the tibia at Gerdy's tubercle, and some fibers insert on the lateral aspect of the distal knee, including the lateral femoral epicondyle and lateral patella. A large bursa overlying the greater trochanter separates the trochanter and the ITB. In general, the ITB is under tension throughout the range of hip motion. When the hip is extended, the band lies posterior to the greater trochanter. It moves anteriorly over the trochanter when the hip is flexed (figure 1A). If the thickened posterior aspect of the ITB or the anterior aspect of the gluteus maximus rubs over the greater trochanter, a snapping sensation may be felt.1-5 The greater trochanteric bursa may also become inflamed and painful.1-6

Other proposed causes of external snapping hip relate to alteration of hip mechanics. Decreased angulation of the femoral neck (coxa vara) or fibrotic scar tissue after total hip replacement,7,8 narrower bi-iliac width or increased distance between the greater trochanters,9 prominent greater trochanters,3,7 and surgery for anterolateral knee instability10 are all thought to alter the normal relationship between the ITB and the greater trochanter, thereby causing the characteristic external snapping sensation. Muscle fibrosis after intramuscular injection may also cause snapping.11

Internal type. Pathology related to the iliopsoas tendon is most often seen as the source of the internal snapping hip. The muscle is a confluence of the iliacus, which originates mainly from the inner table of the ilium and the sacral ala, and the psoas, which originates from the vertebrae and intervertebral disks of T-12 to L-5 (figure 2). Most of the iliopsoas muscle inserts on the lesser trochanter of the femur.2,12,13 The tendinous portion of the muscle passes through the groove on the bony pelvis that is bordered laterally by the anterior inferior iliac spine and medially by the iliopectineal eminence. An anteromedial bony prominence lies adjacent to the lesser trochanter, over which the tendinous portion of the iliopsoas passes before its insertion. The iliopsoas bursa lies over the anterior hip capsule and deep to the iliopsoas tendon.2,14 When the hip is flexed, abducted, and externally rotated, the tendinous portion of the iliopsoas lies lateral to the anterior aspect of the femoral head and hip capsule. It passes over the femoral head and hip capsule to a more medial position with hip extension, adduction, and internal rotation, thereby causing snapping.1,12

Another cause of internal snapping involves the iliopsoas tendon snapping over the iliopectineal eminence and the bony ridge of the lesser trochanter.2,15 Iliofemoral ligaments moving over the anterior hip capsule5 and the origin of the long head of the biceps moving over the ischium16 have also been described as potential sites for snapping. The iliopsoas bursa may also become inflamed and lead to painful snapping.1,2,12

Intra-articular type. A variety of intracapsular lesions may produce snapping, including loose bodies that can occasionally settle in the acetabular fovea or synovial folds and cause intermittent snapping symptoms.1 Torn acetabular labra, especially the posterosuperior portion that is more prone to damage from mechanical stress, can be associated with snapping.17,18 Labral tears may also contribute to the risk of acetabular dysplasia caused by mechanical deformation of the acetabulum.19 Other origins of snapping include idiopathic recurrent subluxation of the hip, habitual hip dislocation in children, and synovial chondromatosis.1,20-22

Focusing the History

The cause and type of a patient's snapping hip may be found in the history. Patients who have the intra-articular type may report a sudden onset of snapping or clicking after trauma. Although trauma may eventually incite the internal or external types of snapping hip, the onset is usually more gradual and the trauma tends to be more minor.

For the external type, the location described by patients tends to be lateral to the greater trochanter; for the internal type, the location is anterior to the hip or in the groin.1 Patients may also report movements that reproduce snapping, especially dancers and hurdlers who tend to repeat particular motions. Dancers often have a painful internal type snapping hip and report an exacerbation of symptoms during passè developpè (repetitive active hip flexion, external rotation, and abduction) while their hips are turned out.23 These repetitive movements place stress and torque on the iliopsoas tendon as it passes over the iliopectineal eminence and/or the femoral head and capsule. The history may also reveal other potential mechanical or anatomic causes of snapping hip, such as hip or knee surgery.

Telltale Physical Exam

External or internal snapping hip is usually a clinical diagnosis. The causes of snapping hip are directly related to pathomechanics seen on physical exam. External snapping may be elicited by placing the patient in a lateral position (side lying) on the examining table with the unaffected side down. The affected hip is then passively flexed from extension (0° to 90°) and then returned to extension. The leg should be maintained in neutral position for both abduction/adduction and internal/external rotation while this test is performed. A palpable and audible snapping will be recreated as the ITB passes from the posterior to the anterior plane of the greater trochanter. Snapping may be prevented if the examiner's hand places enough force on the greater trochanter or if the patient walks with the limb externally rotated.1,8,24 Pain associated with the provocative testing is often a symptom of trochanteric bursitis.6

The physical exam for internal snapping is done by placing the patient supine on the examining table and passively extending, internally rotating, and adducting a flexed, externally rotated, and abducted hip. Snapping will be recreated as the iliopsoas tendon passes from lateral to medial over the femoral head and joint capsule or other anatomic structures. As with external snapping, the examiner will note a palpable and audible snapping over the anterior femoral head. Snapping may be prevented by placing significant pressure on the iliopsoas tendon and anterior hip.1,8

Iliopsoas syndrome, characterized by internal snapping hip, iliopsoas tendinitis, and bursitis, may be evaluated with the iliopsoas test. The test is positive if the patient has pain or weakness when the hip is flexed against resistance in abduction and external rotation.23 In some patients who have both the external and internal types, using other movements or examining the standing patient may be required to elicit snapping.25 Intra-articular loose bodies may become more symptomatic if the patient loads the hip while standing.

Details From Diagnostic Imaging

Plain radiographs are part of the routine evaluation for hip complaints. If the diagnosis remains unclear, or if intra-articular pathology is suspected, other techniques, such as magnetic resonance imaging (MRI), computed tomography (CT), or dynamic ultrasound, may augment the studies. Bursography and tenography, although invasive, may be indicated if the diagnosis remains unclear despite clinical findings and other diagnostic tests.

Radiographs. Although plain x-rays are often normal in patients who have snapping hip, radiographs, including anteroposterior and frog-lateral views, are imperative to rule out fractures, loose bodies, dysplasia, and synovial chondromatosis. Reports conflict on the usefulness of plain-film parameters (eg, smaller-than-normal bi-iliac width and femoral neck angle) to establish a diagnosis.1,7-9

MRI. The evaluation of intra-articular causes of hip snapping, such as acetabular labral tears, osteochondral fractures, and loose bodies, may be accomplished with MRI.26 Because of its high level of soft-tissue contrast, MRI may also be useful in visualizing bursitis, as well as bone and soft-tissue tumors27 that may contribute to hip snapping.

CT. For determining the cause of snapping hip, CT has limited diagnostic usefulness.27 Although CT is used to evaluate bony architecture (eg, the iliopectineal eminence) that may be responsible for internal- type snapping,28 bone is rarely the cause of snapping hip. Loose bodies, fractures, and soft-tissue structures, such as tendons, may be visualized, and CT helps define soft-tissue masses, such as lipomas and hematomas.1,27 CT of the hip and knee may, however, identify anteversion or retroversion of the patient's femoral neck. Increased retroversion may allow greater ease in turnout at the hip for a dancer. CT with contrast media has also been used to demonstrate an abnormal course of the iliopsoas tendon.15

Ultrasonography. Static and dynamic ultrasound play an important role in the diagnosis of snapping hip. With internal snapping hip, static ultrasound demonstrates iliopsoas tendon thickening, enlarged bursae, and peritendinous fluid collections. Dynamic ultrasound reveals abnormal jerking motion of the tendon corresponding temporally to the patient's painful sensation and to palpable and audible snapping.25-27,29 Similarly, dynamic ultrasound has been used to visualize the ITB or gluteus maximus muscle snapping over the greater trochanter in the external type.25,30 Advantages of ultrasound include that it is widely available, less costly, and noninvasive, and that it provides a dynamic study of a reclining or standing patient, depending on which provocative movements elicit snapping.

Bursography. Used to evaluate internal snapping hip, bursography involves injecting contrast material into the iliopsoas bursa under fluoroscopic guidance. The iliopsoas tendon is visualized by a longitudinal absence of contrast material surrounded by the filled bursa. Extending the flexed, abducted, externally rotated hip elicits a lateral-to-medial jerking of the tendon over the hip capsule or bony structures. Bursography may be augmented with anesthetic or corticosteroid injection if bursitis is a suspected cause of pain.14,31 We are unaware of any reports of greater trochanteric bursography being used to diagnose external snapping hip.

Tenography. Similar to bursography, tenography involves injecting contrast media into the iliopsoas tendon sheath. Snapping is then visualized with fluoroscopic imaging.1,15,32

Ultrasonography, bursography, and tenography all require an experienced operator; therefore, the diagnostic capabilities of some imaging centers will be better than others. When the cause of snapping has been determined, treatment can begin.

Conservative and Surgical Treatments

Most hip snapping is benign and painless and does not require treatment. Patients who have symptomatic snapping that is troublesome tend to seek medical help. Nonoperative management should be attempted first, including rest, avoiding movements that provoke snapping, oral nonsteroidal anti-inflammatory medication, and physical therapy (table 1).

TABLE 1. Variations in Diagnosis and Treatment for 3 Types of Symptomatic Snapping Hip

TypeCauseDiagnostic TestImagingTreatment

ExternalThickened posterior aspect
of the ITB or anterior gluteus
maximus rubs over greater
trochanter as hip is extended
Passive flexion of an extended
hip may elicit a palpable and
audible snap with pain over
the greater trochanter
Dynamic
ultrasonography
Activity modification,
ITB stretching, pain
medication (eg,
NSAIDs), steroid
injection, surgery
InternalIliopsoas tendon rubs over
anterior hip capsule or
iliopectineal eminence
Passive extension, internal
rotation, and adduction of a
flexed, externally rotated,
and abducted hip may elicit
a palpable and audible snap
with pain in the anterior
hip or groin
Static and
dynamic
ultrasonography,
tenography, CT,
bursography,
Activity modification,
hip flexor stretching
and strengthening,
pelvic mobilization,
alignment exercises,
pain medication (eg,
NSAIDs), steroid
injection, surgery
Intra-
articular
Loose bodies, torn acetabular
labrum, recurrent subluxation,
habitual hip dislocation in
children, or synovial
chondromatosis
Depends on causePlain x-rays,
ultrasonography,
MRI or CT
Depends on cause

ITB = iliotibial band; NSAIDs = nonsteroidal anti-inflammatory drugs; CT = computed tomography; MRI = magnetic resonance imaging

Stretching exercises. For patients who have external snapping, physical therapy should include stretching of the ITB.6 In one exercise, the involved leg is crossed over the unaffected leg in a standing position. The patient then leans to the uninvolved side until a stretch is felt on the outside of the affected hip. Another exercise stretches the ITB by having the patient lie or sit on the floor and bend and raise the affected leg (flexed knee) over the opposite leg (figure 3). For patients who have internal snapping, hip flexor stretching and strengthening, pelvic and peripelvic mobilization, and alignment exercises are used to help ease pain.23

Pelvic tilt should be addressed, because an increased anterior tilt may cause subtle tightening of the hip flexor tendons. A pelvic tilt exercise can be performed by lying supine with the knees flexed and the feet flat on the floor. The patient tightens the abdominal muscles and squeezes the buttock muscles together, allowing the lower back to push into the floor. These exercises should be done with care to avoid repetitive snapping.

Other modalities. Biofeedback may also help to teach the patient how to avoid repetitive hip snapping. Local corticosteroid injection of the bursa may relieve pain and may help if other nonoperative management fails.6 With these measures, most patients find relief and are able to return to activities, with the caveat that they must continue to avoid repetitive snapping of the hip.1,6,12 Nonoperative management of internal snapping hip is usually successful,23 but if it is not, surgery may be needed.

Operative treatment. Surgery is sometimes indicated for an external snapping hip. Multiple techniques have been suggested, from resection of a portion of the ITB and the trochanteric bursa,6,8 to lengthening the band and transposing it anterior to the greater trochanter.11 The goal of surgery is either to alter the anatomy and mechanics of the ITB so that it remains anterior to the greater trochanter or to lessen the tension of the ITB so that it does not snap over the greater trochanter. Surgery has decreased pain and snapping in a number of studies.6,8,11 Despite these outcomes, surgery is not without risk. The most commonly reported complications have been recurrence of pain and snapping.6,8,11

Although several approaches to operative treatment are used for internal snapping, the general goal is to lengthen or release the iliopsoas tendon to decrease snapping and pain.2,12,33-36 Despite relief from pain and snapping, some surgical complications can be serious. Recurrence of snapping, weakness, and numbness were the most common complications of surgery for internal snapping hip, and some patients required further surgery.2,12,33-36

Intra-articular snapping hip can result from a variety of lesions. Thus, whether treatment is nonoperative or operative depends largely on the pathology. Hip arthroscopy may be both diagnostic and therapeutic and can be used to debride a torn acetabular labrum or to remove small loose bodies. An arthrotomy or other open procedures may be warranted for patients who have synovial chondromatosis, large loose bodies, or instability.1,17,24,37

Snapping Reprise

The three basic types of snapping hip (external, internal, and intra-articular) can be painful and limiting to active patients. A detailed history and physical exam are paramount to determine the proper diagnosis. Various imaging modalities can further distinguish most causes of snapping hip. Once the cause is determined, nonoperative care is often successful, but operative treatments may be instituted if necessary. Both approaches achieve good results and return patients to their activities.

References

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Dr Idjadi is an orthopedic resident and Dr Meislin is an assistant professor of orthopedic surgery at New York University-Hospital for Joint Diseases in New York City. Address correspondence to Robert Meislin, MD, NYU-Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003; address e-mail to [email protected].

Disclosure information: Drs Idjadi and Meislin disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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