Snapping Hip and Trochanteric Bursitis

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Snapping Hip Syndrome (SHS)

There are three types of the Snapping Hip syndromes identified: the external , the internal , and the intra-articular snapping hip.

External Snapping Hip (ESH)

External (lateral) snapping hip is a painful condition also known as lateral coxa saltans. It occurs in about 10% of the general population. The external extra-articular factor involves the posterior iliotibial band snapping over the greater trochanter. Second external extra-articular mechanism leading to this condition involves the anterior aspect of the gluteus maximus travelling over the greater trochanter during hip flexion and extension or internal and external rotation of the hip and snapping over the greater trochanter. This may lead to the inflammation of the trochanteric bursa. Individuals with external Snapping Hip syndrome may also have coxa vara, fibrotic scar tissue, a prominent greater trochanter, smaller lateral pelvic width, or a past surgery for anterolateral knee instability.

Internal Snapping Hip (ISH)

Internal extra-articular snapping is caused by the iliopsoas tendon flipping over the iliopectinal eminence or the femoral head and often requires hip flexors contraction. Other proposed extra-articular mechanisms of this condition include:

• accessory iliopsoas tendon slips
• iliopsoas snapping over a ridge at the lesser trochanter
• snapping of the iliofemoral ligament over the femoral head
• subluxation of the long head of the biceps at the ischium
• snapping at the anterior inferior iliac spine.

Intra-Articular Snapping Hip

The intra-articular factors can lead to the development of snapping hip symptoms. They include labral tears, ligamentum teres tears, loose bodies such as osteochondral fragments, or joint instability.

Clinically Relevant Anatomy

Iliotibial Band

The iliotibial band (ITB) is a thick band of fascia that runs on the lateral side of the thigh from the iliac crest and inserts at the knee. It is composed of dense fibrous connective tissue that originates from the anterior fibres of the tensor fasciae late and the posterior fibres of the gluteus maximus. After running down on the lateral thigh it ends with most of the fibres inserting onto the tibial tubercle, some inserting into the gluteus maximum tendon, the lateral femoral epicondyle and distal lateral border of the patella. During hip flexion, the ITB moves anterior to the greater trochanter and during hip extension it runs posterior to it.

On the lateral aspect of the hip joint, there are three subgluteal bursae: greater trochanter bursa, subgluteus medius bursa, and subgluteus minimus bursa. The trochanteric bursa is the largest of the three and it covers the insertion of the gluteus medius tendon and the posterior aspect of the greater trochanter. Its primary role is to reduce friction between the tendons of the gluteus medius and the ITB when they pass over the greater trochanter.

The iliotibial band role includes hip stabilisation during a single leg stance and ambulation when the band acts as a tendon of the tensor fasciae latae (TFL) and the gluteus maximus. The contraction of the gluteus maximus and the TFL muscles cause the tightening of the band.

Gluteus Maximus

Gluteus maximus originates at the outer slope of the dorsal segment of the iliac crest, the gluteal surface of the ilium, dorsal surface of the lower part of the sacrum, side of the coccyx, and the sacrotuberous ligament. It also shares its attachment to the thoracolumbar fascia with the ipsilateral multifidus and contralateral latissimus dorsi. The muscle inserts onto gluteal tuberosity and the iliotibial band.

Gluteus Maximus's primary role includes hip extension, external rotation and abduction. Its function is essential to maintain an erect posture.

Iliopsoas

Iliopsoas muscle complex is made up of three muscles that include the iliacus, psoas major and psoas minor. It can work as a unit, but each of the three muscles has separate functions. The iliopsoas originates at the fusion of the psoas major and iliacus muscles. This fusion occurs at the level of L5-S2, and the combined muscles pass from the pelvis to the thigh under the inguinal ligament. The iliopsoas muscle inserts into the lesser trochanter of the femur via the psoas tendon.

The iliopsoas bursa is the largest bursa of the hip joint and is located deep to the iliopsoas musculotendinous junction and anterior to the hip joint capsule. The bursa has been reported to communicate with the hip joint in ~15% of patients. It helps the muscle glide and slides over the front of the hip during movement.

The iliopsoas muscle is the strongest hip flexor and assists in the external rotation of the femur. It is essential for correct standing or sitting lumbar posture, and during walking and running.

Pathophysiology

• External Snapping Hip
  • visual component of the snap observed by the patient when the ITB slides from the anterior to posterior aspect of the greater trochanter during hip movement from extension to flexion. This is usually caused by the thickening of the posterior ITB and/or anterior portion of the gluteus maximus.

• Internal Snapping Hip
  • audible component of the snap when the iliopsoas tendon movement from the lateral to the medial position is restricted during hip extension and internal rotation. This restriction can be caused by the femoral head or pectineal eminence of the pelvis.

• Intra-articular Snapping Hip
  • pathological process of the hip joint when loose bodies, acetabular labrum tears, or osteochondral fractures can interfere with articulation of the femoral head into the acetabulum .
    

Clinical Presentation

The External Snapping Hip syndrome presents with the sensation described as a feeling of hip dislocation. With the Internal Snapping Hip patients describe the feeling of the hip joint being "stuck" or locked and they report hearing the sound of snapping. The intermittent sound of clicking or catching characterises the Intra-articular pathology.

Additionally patients report:

• pain
• muscles weakness
• activities limitation

Evaluation

Physiotherapy Assessment

Physiotherapy assessment includes the patient's history, physical examination and special tests.

Patient's History

• symptoms description (location, sensation, timing and duration)
• impact on activities of daily living

Physical Examination

• Joint palpation: snapping palpated over the anterior hip indicates coxa saltans interna
• Range of motion assessment
• Strength assessment
• Pain assessment (Visual Analogue Scale)
• Functional assessment including gait assessment.

Special Tests

External Snapping Hip Syndrome:

• FADIR test including flexion, adduction and internal rotation or impingement
• Ober test: assessment of the ITB tightness
• Hip active flexion followed by passive extension and abduction: positive test reproduces the snapping over the greater trochanter.
• Hula hoop test is an alternative test when the hip is adducted and circumducted in a standing position. Positive test: snapping is reproduced over the greater trochanter
• Hip active flexion followed by passive extension and abduction: positive test reproduces the snapping over the greater trochanter.
• Biomechanical abnormalities (Trendelenburg sign)

Internal Snapping Hip Syndrome:

• Dynamic testing (loop-the-loop): starting at FABER (flexion, abduction and external rotation) position and moving into EADIR (extension, adduction and internal rotation) position. Positive test: snapping of the iliopsoas tendon

• Thomas test: positive test indicates psoas contracture
• Stinchfield Test: The patient lies supine with the hip flexed at 30°. The patient is asked to fully flex the hip, while the examines apply a resistance force. Pain in the anterior groin indicates a positive test.

Imaging

• X-Ray: no typical findings indicative of coxa saltans interna on X-Ray. Evidence of femoroacetabular impingement can be found on a plain X-ray.
• MRI: not specific for the iliopsoas involvement. May assists with the diagnosis of iliopsoas bursa or iliopsoas muscle inflammation. Help to visualise a thickened ITB and focal thickening of the gluteus maximus when ESH is suspected.
• Ultrasound: Helps to visualise the dynamic motion of the iliopsoas tendon, but requires a skilled clinician to perform and interpret results.
• Dynamic sonography: able to detect the movement of the ITB over the greater trochanter
• Iliopsoas bursography: under fluoroscopy bursa is filled with contrast to visualised the tendon moving back and forth. This imaging is performed to confirm ISH syndrome.

Management / Interventions

Conservative Management

Goal: to improve pain, to increase flexibility and to equalise the limb length discrepancy if needed.

1. Identify the cause of snapping: look for the muscle tightness and stretching program specific to the ITB and the iliopsoas muscles is indicated
2. Rest
3. avoiding movements that provoke the snap
4. reduction of the sport activities
5. laser therapy
6. extracorporeal shockwave therapy ESWT

avoiding movements that provoke the snap, and reduction of the sport activities. A stretching program specific to the ITB and the iliopsoas muscles is indicated, and local corticosteroids injections and physical therapies, as laser therapy and extracorporeal shockwave therapy ESWT, can be useful to manage the pain [3]. The conservative treatment should be continued for at least 6 months

Surgical intervention

Goal: to release the contracted ITB to resolve the snap

Differential Diagnosis

add text here relating to the differential diagnosis of this condition

Resources

Walker P, Ellis E, Scofield J, Kongchum T, Sherman WF, Kaye AD. Snapping Hip Syndrome: A Comprehensive Update. Orthopedic Reviews. 2021;13(2).