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Snapping Hip Syndrome

From WikiSM

Other Names

  • Snapping Hip Syndrome
  • Coxa Saltans
  • Dancer’s Hip
  • Coxa saltans interna

Background

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  • This page refers to snapping hip syndrome (SHS), a pathology with multiple etiologies characterized by an audible or palpable snapping sensation during movement of the Hip Joint

History

  • The term was originally coined Nunziata and Blumenfeld to describe the audible snapping sound that occurs around the hip during motion [1]

Epidemiology

  • Roughly 5% to 10% of the population is affected by coxa saltans, the majority of patients experiencing painless snapping[2]
  • Among ballet dancers, almost 90% reported symptoms of snapping hip syndrome and 80% had bilateral involvement[3]
  • External SHS has roughly the same incidence between men and women, however more females are diagosed with internal SHS[4]

Introduction

Internal snapping hip. When the hip is flexed (A), the iliopsoas tendon (in grey) is lateral to the iliopectineal eminence (blue star). When the hip is extended (B), the iliopsoas tendon translates medial to the iliopectineal eminence.[5]
External snapping hip occurs lateral to the hip joint and is attributed to the abrupt movement of the iliotibial band across the greater trochanter.[6]
Coxa Saltans[7]

General

  • Snapping hip syndrome is a clinical diagnosis characterized by the presence of snapping, clicking or poping at the hip
  • It can be acute/chronic, bilateral/unilateral, painful/painless with a wide variety of etiologies
  • Generally considered to be an overuse syndrome, less commonly can be precipitated by trauma, surgery
  • Most cases respond well to non-surgical management

Etiology

  • Can be brokwn down into
    • Intra-articular
    • Extra-articular- medial/ internal
    • Extra-articular- lateral/external
    • Posterior

Etiology: Intra-articular

Etiology: Extra-articular - Internal

  • General
    • Also referred to as Coxa saltans interna
    • Most common overall cause
  • Iliopsoas Tendon snapping over Iliopectineal Eminence or anterior aspect of the Femoral Head
    • Most commonly implicated[8]
    • snapping has been visualized via arthroscopy to occur when the medial fascicle of the iliacus muscle interposes itself with the iliopsoas tendon and pelvic bone during abduction and external rotation[9]
    • May also snap over femoral head
  • Other less commonly implicated causes:
    • Iliofemoral ligament over femoral head, anterior aspect of joint capsule
    • Iliopsoas tendon over the anterior inferior iliac spine
    • Iliopsoas tendon over the bony ridge on the lesser trochanter
    • Tenosynovitis of the iliopsoas tendon
    • Iliopsoas bursitis
    • Rectus Femoris tendinitis
    • Accessory iliopsoas tendon slips

Etiology: Extra-articular - External

Etiology: Posterior

  • Tendinous origin of the long head of the Biceps Femoris muscle over the ischial tuberosity

Associated Conditions

Pathoanatomy

Risk Factors

Sports that require large large range of hip motions

Other Risk Factors

  • Hypertrophied Psoas Muscle
    • Individuals who exercise frequently
    • Overweight/obese individuals
  • Hypertrophy of gluteus maximus or posterior iliotibial band tendon

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Groin Pain

Clinical Features

Illustration of FABER Test[11]
Physical exam maneuvers useful for SHS[12]

History

  • "External snapping one can see from across the room, while internal one may hear from across the room"[13]
  • Patients may have the snapping sensation without any pain
  • Patients can often pin point the area of painful snapping
  • Ballet dancers may report symptoms worst with external hip rotation, abduction at or over 90°
  • Patients often state that there is an audible component to the snapping
  • External: May describe a sensation like the hip is going to dislocate or snapping
  • Internal: Describes sensation as snapping or “getting stuck” or locking
  • Internal: snapping while climbing stairs, getting out of a car, or standing from a chair[14]
  • Intra-articular: intermittent clicking, catching, locking, giving way

Physical Exam: Physical Exam Hip

  • Snapping hip, palpation around the entire joint can often isolate the area of interest
  • External snapping is commonly more obvious than internal snapping
  • External: may be able to visualize or palpate the snapping under the patients skin
  • External: May have tenderness over the greater trochanter
  • External: Lay in lateral decubitus position, palpate greater trochanter and bring hip into flexion-extension motions
  • Internal: Often weakness of gluteus medius is found

Special Tests

34 year old female affected by external snapping hip. MRI images (Signa, GE Medical System, 1.5 T) of the pelvis. T1-weighted spin echo sequence, axial (a) and coronal (b) planes showing a sickle-shaped myotendinous junction of the gluteus maximus muscle (arrows) (a) and the atrophy and fatty muscle degeneration (arrows) (b), respectively. T2 weighted fat saturated sequence, axial (c) and sagittal (d) planes, showing a small area of high signal intensity (arrows) corresponding to a small edematous area adjacent to the left posterior greater trochanter.[15]
34 year old female affected by external snapping hip. Transverse sonograms (linear 5-12 MHz probe) were performed at the level of the left greater trochanter. When the hip is adducted and extended, the miotendineous junction of the gluteus maximus muscle (GM) (arrows) is located in the posterior side of the greater trochanter (GT) (a). During flexion with abduction and external rotation of the hip, dynamic sonography shows abnormal movement of the miotendineous junction of the gluteus maximus muscle (GM) (arrows) that suddenly snaps anteriorly to the greater trochanter (GT) (b)[15]

Evaluation

General

  • Snapping hip syndrome is primarily a clinical diagnosis, however imaging is critical in identifying the etiology and planning management

Radiographs

  • Standard Radiographs Hip
    • Initial imaging modality of choice
    • Often normal
  • May show
    • Cam/ pincer deformity (FAI)
    • Small femoral neck angle (coxa vara)
    • Developmental dysplasia
    • Degenerative joint disease
  • Iliopsoas bursography followed by fluroscopy is a somewhat outdated modality
    • Can be used to help confirm etiology

MRI

  • Useful to evaluate for intra-articular etiology or pathology
    • Even more valuable with arthrography is included
  • Can show
    • Inflammation of the iliopsoas bursa/ muscle
    • Inflammation of the trochanteric bursa
    • Can demonstrate abnormal soft tissue pathology of the involved tendon, muscle, or bursa

Ultrasound

  • General
    • Advantage is that it works well dynamically on affected muscle group(s)[16]
    • Localize area for diagnostic/ therapeutic injection
    • Limited by body habitus, doesnt visualize intra-articular pathology well
  • Place transducer over iliopectineal eminence[17]
    • During hip flexion, external rotation, and abduction with return to neutral position
    • Abnormal iliopsoas tendon snapping against the bony pelvis can be visualized

Computed Tomography

  • Best modality for assessing osseous structures of the hip

Classification

  • Intra-articular
  • Extra-articular - Internal
  • Extra-articular - External
  • Posterior

Management

Nonoperative

  • General
    • Nonop treatment is generally considered initial treatment of choice
    • Relative rest from offending activities
  • Medications
  • Physical Therapy
    • Identify affected muscles groups
    • Lengthen/strengthen antagonist/protagonist muscle groups
    • Correct posture or abnormal biomechanics
    • Important to maintain after resolution of symptoms to prevent recurrence
  • Corticosteroid Injection
    • External: Can try injection of CSI directly beneath the IT band
    • Internal: Can guide needle into iliopsoas bursa, which was shown to be beneficial by Wahl et al[18]

Operative

  • Indications
    • Refractory to conservative therapy
  • Technique depends on etiology
    • Internal: Open vs endoscopic lengthening or release of iliopsoas tendon (multiple approaches reported in the literature)
    • External: Lengthening of the IT band including Z-plasty
    • External: Excision of trochanteric bursa
    • External: Release of gluteus maximus tendon
    • Arthroscopic approach for loose bodies, labral repair

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

Prognosis

  • Needs to be updated

Complications

  • Inability to return to sport
  • Chronic pain

See Also

Internal

External

References

  1. ↑ Nunziata A, Blumenfeld I. Snapping hip; note on a variety [article in undetermined language]. Prensa Med Argent 1951;38(32): 1997–2001
  2. ↑ Byrd JW. Evaluation and management of the snapping iliopsoas tendon. Instr Course Lect 2006;55:347–355
  3. ↑ Winston P, Awan R, Cassidy JD, Bleakney RK. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med 2007;35(1):118–126
  4. ↑ Via, A. Giai, Alberto Fioruzzi, and Filippo Randelli. "Diagnosis and management of snapping hip syndrome: a comprehensive review of literature." Rheumatology (Sunnyvale) 7.4 (2017): 228.
  5. ↑ Petchprapa, Catherine N., and Jenny T. Bencardino. "Tendon injuries of the hip." Magnetic Resonance Imaging Clinics 21.1 (2013): 75-96.
  6. ↑ Mohamed, Elalfy M., and Ahmed Zaghloul. "External Snapping Hip Diagnosis; Making complex simple."
  7. ↑ Image courtesy of eclipsewellnessnova.com<
  8. ↑ Howse AJ. Orthopaedists and ballet. Clin Orthop Relat Res. 1972; 89:52–63.
  9. ↑ Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol 2008;190(3):576–581
  10. ↑ Konczak CR, Ames R. Relief of internal snapping hip syndrome in a marathon runner after chiropractic treatment. J Manipulative Physiol Ther 2005;28(1):e1–e7 Anderson SA, Keene JS. Results
  11. ↑ Bernstein, Robert M., and Harold Cozen. "Evaluation of back pain in children and adolescents." American family physician 76.11 (2007): 1669-1676.
  12. ↑ Walker, Paul, et al. "Snapping hip syndrome: a comprehensive update." Orthopedic reviews 13.2 (2021): 25088.
  13. ↑ https://www.orthobullets.com/knee-and-sports/3096/snapping-hip-coxa-saltans
  14. ↑ Ilizaliturri VM Jr, Camacho-Galindo J. Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon. Sports Med Arthrosc 2010;18(2):120–127
  15. ↑ 15.0 15.1 Battaglia, Milva, et al. "An unusual cause of external snapping hip." Journal of radiology case reports 5.10 (2011): 1.
  16. ↑ Deslandes M, Guillin R, Cardinal E, et al. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. Mar; 2008 190(3):576–581.
  17. ↑ Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol 2008;190(3):576–581
  18. ↑ Wahl CJ,Warren RF, Adler RS, Hannafin JA, Hansen B. Internal coxa saltans (snapping hip) as a result of overtraining: a report of 3 cases in professional athletes with a review of causes and the role of ultrasound in early diagnosis and management. Am J Sports Med 2004;32(5):1302–1309
Created by:
John Kiel on 5 July 2019 08:50:50
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Last edited:
26 June 2025 00:31:04
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