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Snapping Hip Syndrome

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Other Names

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

Background

  • This page refers to snapping hip syndrome, a disease 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]
  • More common in women than men

Pathophysiology

  • Generally considered to be an overuse syndrome
    • May also be precipitated by trauma, surgery

Etiology

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

Intra-articular

Extra-articular - Internal

  • General
    • Also referred to as Coxa saltans interna
    • Most common overall cause
  • Iliopsoas Tendon snapping over Iliopectinal Eminence or anterior aspect of the Femoral Head
    • Most commonly implicated[4]
    • 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[5]
    • 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

Extra-articular - External

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
    • Ballet dancers
    • Weight lifters
    • Soccer players
    • Runners[6]

Differential Diagnosis

Clinical Features

  • History
    • "External snapping one can see from across the room, while internal one may hear from across the room"[7]
    • 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[8]
    • 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

Evaluation

  • 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)[9]
    • Localize area for diagnostic/ therapeutic injection
    • Limited by body habitus, doesnt visualize intra-articular pathology well
  • Place transducer over iliopectineal eminence[10]
    • 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

Prognosis

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[11]

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

  • Inability to return to sport
  • Chronic pain

See Also

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. ↑ Howse AJ. Orthopaedists and ballet. Clin Orthop Relat Res. 1972; 89:52–63.
  5. ↑ 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
  6. ↑ 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
  7. ↑ https://www.orthobullets.com/knee-and-sports/3096/snapping-hip-coxa-saltans
  8. ↑ Ilizaliturri VM Jr, Camacho-Galindo J. Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon. Sports Med Arthrosc 2010;18(2):120–127
  9. ↑ 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.
  10. ↑ 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
  11. ↑ 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:
5 October 2022 13:09:44
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