Snapping Psoas / Snapping Hip
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· </span>Snapping hip
· </span>Coxa saltans
· </span>Snapping hip intra-articular
· </span>Snapping hip extra-articular
· </span>Snapping hip conservative treatment
· </span>Hip tendons
· </span>Snapping iliopsoas tendon
· </span>Snapping iliotibial band
Result: lots of case reports, some literature
reviews, no RCT of physical therapy management. More information was found by
using references of other articles and the VUB library.
Snapping hip syndrome is used for the condition in which an audible snap occurs in the area of the pelvis. It can be either painful or painless.
Another way to refer to the snapping hip syndrome is by using the term coxa saltans (coxa: hip joint, saltar: to jump) referring to the “jumping” or snapping of the iliotibial or ilipsoas tendon.
Based on the location and the tissue (e.g. the tendon) involved, three kinds of snapping hip can be described by Dr. William C. Allan and Dr. Ray Cope in their article “Coxa saltans, the snapping hip revisited” as: an internal, external and intra-articular snapping hip.
Both internal and external snapping hips are extra-articular.
The internal snapping hip occurs when the iliopsoas tendon snaps over the lower pelvic structures such as the iliopectineal eminence.
The external snapping hip occurs when the iliotibial tendon or the anterior fibers of the gluteus maximus snaps over the greater trochanter of the femur.
The intra-articular snapping hip is caused by the iliofemoral ligaments as they slide over the head of the femur, a labral tear, chondral defect or intra-articular loose bodies.
Pain symptoms are reproduced during specific movements of the hip, but most frequently when the hip moves from a position of flexion-abduction-external rotation to the neutral position” or “external rotation/abduction to internal rotation/adduction”
"Figure 1 Illustration of the iliopsoas tendon flipping back and forth
across the anterior hip and pectineal eminence. (A) With flexion of
the hip, the iliopsoas tendon lies lateral to the center of the femoral
head. (B) With extension of the hip, the iliopsoas shifts medial to the
center of the femoral head."
"Figure 8 As the iliotibial band snaps back and forth across the greater
trochanter, the tendinous portion may flip across the trochanter
with flexion and extension or the trochanter may move back and
forth underneath the stationary tendon with internal and external
Clinically Relevant Anatomy
The snapping hip injury is caused by the iliotibial or gluteus maximus tendon (external), the iliopsoas tendon (internal) or the iliofermoral ligament (intra-articular) snapping over the femur, its head or greater trochanter to be more precise.
"The syndrome most often occurs in individuals aged 15-40 years and affects females slightly more often than males."
The snapping hip injury is however mostly seen in young athletes. The internal snapping hip mostly in ballet dancers.
The cause of the snapping hip syndrome isn’t well described in literature, other than the sliding of the iliotibial tendon or gluteus maximus tendon over the greater trochtanter of the femur or the sliding of the iliopsoas tendon over the head of the femur as a cause of the extra-articular snapping hip. 
These causes contribute to the sometimes audible snap and the snapping sensation of the hip. 
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Although snapping hip is a very recognizable syndrome, it can be combined with other pathologies like bursitis trochanterica, ilopsoas tendinitis, iliopsoas tendinosis, iliopsoas bursitis, hip labral tears, hip arthritis, hip osteoarthritis, adductor tendinitis, and referred pain to the hip from the spine and pelvis. Nonetheless, in most cases the diagnosis of snapping hip and with that a tendinitis, synovitis or bursitis can be strongly suspected from the history provided by the patient. Impingement of the iliopsoas tendon is a known entity in patients after total hip replacement. 
Both sonography and MRI are useful techniques for evaluation. Therefore several other tests are suggested to locate, rule out or isolate different deficient’s. Yeoman test, Nachlas’ test, Hibb’s test, Thomas test and Gaenslen test, the straight leg raise test, Nobel’s and Ober’s test… Dynamic sonographic evaluation can often help differentiate partial thickness tears from complete-thickness tears by showing a fluid-filled gap within a complete tear as the tendon is stressed. 
Other than the obvious complaint of a clicking, snapping or popping sensation or sound in the hip, the patient is often able to deliver a lot of valuable information regarding the location and activities provoking the snapping and pain.
If during the anamnesis the subject should describe the snap as appearing on the lateral side, this could indicate the iliotibial band or gluteus maximum luxating over the major trochanter (external extra-articular snapping hip syndrome). If on the other hand the location is described as being deeper and in the groin, this could be the iliopsoas tendon snapping over the iliopectineal eminence, the hip capsule itself or in some cases the lesser trochanter (internal extra-articular snapping hip syndrome).
The pain is often described as being dull and exacerbating when extending the flexed (and eventually abducted and exorotated) hip. The duration of symptoms at presentation more commonly is several months or years rather than days or weeks. This pain usually appears to subside when resting or decreasing activity.
Inspection of the gait could display compensations or abnormalities.
A careful examination of the abdomen, pelvis, groin, and thigh could exhibit tightness and weaknesses in the musculature of the hip and lumbopelvic region.
Tenderness over the proximal iliotibial band and lateral margin of the gluteus maximus or trochanteric bursa could be an indication of external snapping hip syndrome.
While an anterior pelvic tilt, might indicate internal snapping hip syndrome. Tenderness may be elicited in the femoral triangle, and the actual snapping may be palpable in conjunction with the audible snap.
External snapping hip syndrome symptoms can be reproduced with passive internal and external rotation of the hip with the patient in the side-lying position.
Internal snapping hip syndrome symptoms can be reproduced with extension of the flexed (30°), abducted, and externally rotated hip (frog leg position). The authors have also noted that active movement of the affected hip from a neutral position to a frog leg position may also reproduce the snapping. Additionally, if the patient has associated iliopsoas tendinitis, resisted hip flexion at 15° and palpation of the psoas muscle just below the lateral half of the inguinal ligament reproduces symptoms. Asking the patient to perform the ‘straight leg raise’ might also reproduce the same popping noise.
Direct imaging of the iliopsoas tendon is commonly performed with either MRI Scans or sonography. MRI can optimally depict the psoas tendon attachment onto the lesser trochanter of the femur, whereas most of the iliacus attaches onto the proximal femoral shaft without a tendon. Tears and hemmorages are visible on MRI and the snapping of the tendons are visible on dynamic sonography. 
add links to outcome measures here (also see Outcome Measures Database)
An accurate history of a snapping sound from the hip region is often a good indicator in diagnosing snapping hip. Often the patient complains of a snap in het hip during a certain movement sometimes accompanied with pain. This pain comes in when the snapping hip causes in time a tendinitis, synovitis or bursitis. 
To examine snapping hip we make a distinction between the three forms:
§ Iliopsoas internal snapping hip:
· </span>The patient lying supine, bringing the hip from a flexed, abducted, externally rotated position down into extension with internal rotation. Sometimes this is more of a dynamic process that the patient can actively show better than the examiner can passively produce. The snap can also be more subtle and experienced as just a sensation by the patient. 
· </span>Applying pressure over the anterior joint can block the tendon from snapping and assist in confirming the diagnosis. 
· </span>The patient in hurdle-sit, pain when palpating deep in the trigonum femorale will occur. 
§ </span>Iliotibial band external snapping hip:
· </span>This also is more of a dynamic process, better demonstrated by the patient than can be produced by passive examination. 
· </span>The patient lying on their side and then passively flexing and extending the hip. The snap can be palpated over the greater trochanter.
· </span>Origin of the snapping is confirmed by applying pressure over the greater trochanter, which can block this from occurring.
§ </span>Intra-articular snapping hip:
· </span>The patient will be complaining more about a clicking sensation rather than a snapping.
· </span>Pain is generally their primary complaint.
· </span>The history will disclose that the pain was acute in onset and was associated with significant trauma. 
§ </span>Other diagnostic procedures for all three forms are:
· </span>ROM off the hip.
· </span>Muscle strength and endurance testing, especially iliopsoas, iliotibial band, gluteus maximus, ab- and adductors. Also palpation of these muscles and their tendons.
· </span>Video analysis of both walking and jogging to see how the hip is used while moving. Can reveal the patient taking in a painless stance. 
The snapping will sound more like a pop, click or snap if it is internal or external and when the snapping is intra-articular the patient will be more reporting locking, catching or painful clicking. When the snapping is accompanied by pain, there will also be tenderness and tightness of certain muscles and tendons (iliopsoas, iliotibial band) in the hip region. Also the endurance of the muscle will be affected. 
Surgery becomes an option when conservative treatment has failed and the syndrome has come to the point where chronic inflammation of the tendon sheath and bursa occurs.
§ </span>Surgical approaches to internal snapping hip syndrome are:
· </span>A lengthening procedure can be performed on the iliopsoas tendon, typically by partial release of the tendon.
· </span>Resection of the bony prominence of the lesser trochanter.
· </span>Complete release of the iliopsoas tendon.
§ </span>Surgical approaches to external snapping hip syndrome are:
· </span>Resection of the posterior half of the iliotibial band at the insertion site of the gluteus maximus, with excision of the trochanteric bursa.
· </span>Elliptical resection of a portion of the iliotibial band overlying the greater trochanter, with removal of the trochanteric bursa.
· </span>Z-plasty of the iliotibial band, resulting in lengthening of the tendon.
· </span>A step cut procedure involving the iliotibial band over the greater trochanter.
Most of the procedures above try to release the tension on the tendon so the snapping and the irritation and pain disappears. Still the initial course of therapy should be conservative. Because surgery can bring weak hip flexion, sensory deficits, persistent hip pain or the snapping just didn’t disappeared. 
§ </span>Surgery intervention is more often the case with intra-articular snapping:
Physical Therapy Management
Snapping hip usually develops over a long period of time and finally becomes painful enough for the patient to seek medical help. The therapy chosen depends on when the snapping occurs, how long the snapping already exists, frequent or infrequent,… :
§ </span>Asymptomatic snapping on an infrequent basis, no treatment is needed. 
§ </span>Active rest'* a'nd avoidance of those activities that produce the snapping if:
· </span>the snapping is of recent onset (within the previous 6 months).
· </span>Intermittently present.
§ </span>Active rest* and corticosteroïd injections into the tendon sheath and associated bursa, followed by stretching and strengthening exercises*:
NSAID’s can be used to reduce the symptoms. The vast majority of patients with a symptomatic snapping hip improve with conservative therapy.  The period of recovery can range from weeks to months. The patient or athlete must be pain free with simple activities before attempting to return to the activities that had precipitated the symptoms.  Even after this, the patient must be careful to avoid repetitive snapping by modification of his or her exercise program or sport. 
However this figure is based on the treatment of iliopsoas bursitis, which is not necessary a part of the treatment of snapping hip, only if the snapping is causing abursitis this is. Nonetheless it can be seen as a schematic build up of the therapy in general for snapping hip, how long a specific therapy should be tried and what options there are in the different stages of the therapy.
§ </span>Also tried during the therapy in case reports and reported positive results:
release = applying moderate digital pressure to the involved tissue in a
direction proximal to distal while actively moving the muscle through its range
of motion in both eccentric and concentric contraction phases. 
If all that doesn’t work, surgery is the last treatment to try.
* Active rest = Resting the hip from activities that cause pain, while allowing the individual to continue with an alternative exercise program, staying below the threshold of symptoms. Stretching and flexibility to reduce the tension within the iliopsoas or iliotibial band is emphasized in addition to gentle conditioning and incorporating a core stabilization program. 
* Stretching and strengthening program = Anti-lordotic exercises, stretching and strengthening exercises for the iliopsoas, iliotibial band or an other muscle in the hip region that causes the snapping. With biofeedback, so the exercises are well done. Neuromuscular re-education: hold-relax PNF exercises and contract-relax PNF-exercises.  (see  chapter 6 for exercises)
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
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Clinical Bottom Line
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Recent Related Research (from Pubmed)
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- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Deslandes M., Guillin R., Cardinal E., Hobden R., Bureau N.J., The snapping iliopsoas tendon: New mechanisms using dynamic sonography, Am. J. Roentgenol, 190(3), 567 http://www.ajronline.org/cgi/reprint/190/3/576
- ↑ 2.0 2.1 2.2 2.3 2.4 Morelli V., Smith V., Groin injuries in athletes, Am Fam Physician 2001; 64: 1405-14 http://www.aafp.org/afp/2001/1015/p1405.pdf
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Allan W.C. and Cope R., Coxa Saltans, the snapping hip revisited, Journal of American Academy of Orthopaedic Surgeons, 1995, vol. 3, no. 5: 303-308 http://scottsevinsky.com/pt/reference/hip/aaos_hip_coxa_saltans.pdf
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Spina A.A., External coxa saltans (snapping hip) treated with active release techniques: a case report, JCCA 2007; 51(1): 23-29 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924651/pdf/jcca51_1p023.pdf
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Byrd T., Snapping hip, Oper Tech Sports Med 13: 46-54, 2005 http://nsmoc.com/files/pdfs/Op%20Tech%20Snapping%20Hip.pdf
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 eMedicine on Medscape, Garry J.P., Jenkins W.L. et al., Snapping hip syndrome, updated 19 January 2010 http://emedicine.medscape.com/article/87659-overview
- ↑ 7.0 7.1 Solomon R, Solomon J, and Cerny Minton S, editors. Preventing dance injuries. 2nd ed. United States of America: The American Alliance of Health, Physical Education, Recreation &amp;amp;amp;amp;amp;amp;amp;amp; Dance, 1990.
- ↑ Gupta, Amitabh; Brad Fernihough, Glen Bailey, Petra Bombeck (13 May 2004). "The functional anatomy of the iliopsoas muscle and its implications for hip and back injury in dancers"(PDF). Curtin University of Technology
- ↑ 9.0 9.1 Snapping Iliopsoas Tendon in a Recreational Athlete: A Case Report from National Center for Biotechnology Information (pdf)
- ↑ Laura W. Bancroft1,2 and Donna G. Blankenbaker . Imaging of the Tendons About the PelvisfckLRhttp://www.ajronline.org.ezproxy.vub.ac.be:2048/cgi/content/full/195/3/605
- ↑ 11.0 11.1 11.2 11.3 Clark R, Konczak, Ames R. Relief of internal snapping hip syndrome in a marathon runner after chiropractic treatment. J Manipulative Physiol Ther. Jan;28(1):e1-7, 2005. (level 3)
- ↑ 12.0 12.1 12.2 Meeusen R, editor. Sportrevalidatie – heup- en liesletsels. Diegem: Kluwer, 1999. (level 3)
- ↑ 13.0 13.1 13.2 Johnston et al. Iliopsoas bursitis and tendinitis, a review. Sports Med 25 (4): 271-283, 1998. (level 3)
- ↑ 14.0 14.1 Cara L. Lewis. Extra-Articular Snapping Hip: A Literature Review. Sports Health; May/June 2010; Vol. 2. No. 3. Pp. 186-190.(level 3)
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