Snapping Hip and Trochanteric Bursitis: Difference between revisions
No edit summary |
No edit summary |
||
| Line 8: | Line 8: | ||
There are three types of the Snapping Hip syndromes identified: the external , the internal , and the intra-articular snapping hip. | There are three types of the Snapping Hip syndromes identified: the external , the internal , and the intra-articular snapping hip. | ||
=== External Snapping Hip ( | === External Snapping Hip Syndrome (ESHS) === | ||
External (lateral) snapping hip is a painful condition also known as lateral coxa saltans. It occurs in about 10% of the general population.<ref name=":2">Randelli F, Mazzoleni MG, Fioruzzi A, Giai Via A, Calvisi V, Ayeni OR. [https://link.springer.com/article/10.1007/s00167-020-06305-w#citeas Surgical interventions for external snapping hip syndrome]. Knee Surg Sports Traumatol Arthrosc. 2021 Aug;29(8):2386-2393. </ref> The ''external'' ''extra-articular'' factor involves the posterior iliotibial band snapping over the greater trochanter. <ref name=":0">Yen YM, Lewis CL, Kim YJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961351/pdf/nihms721941.pdf Understanding and Treating the Snapping Hip]. Sports Med Arthrosc Rev. 2015 Dec;23(4):194-9. </ref> 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. <ref name=":0" />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.<ref name=":1">Idjadi J, Meislin R. Symptomatic snapping hip: targeted treatment for maximum pain relief. The Physician and Sportsmedicine 2004;32(1):25-31.</ref><ref>Byrd JT. [http://www.iortho.com.my/media/members032010_docs/sports/hip/snapping_hip.pdf Snapping hip.] Operative Techniques in Sports Medicine 2005;13(1):46-54.</ref> | External (lateral) snapping hip is a painful condition also known as lateral coxa saltans. It occurs in about 10% of the general population.<ref name=":2">Randelli F, Mazzoleni MG, Fioruzzi A, Giai Via A, Calvisi V, Ayeni OR. [https://link.springer.com/article/10.1007/s00167-020-06305-w#citeas Surgical interventions for external snapping hip syndrome]. Knee Surg Sports Traumatol Arthrosc. 2021 Aug;29(8):2386-2393. </ref> The ''external'' ''extra-articular'' factor involves the posterior iliotibial band snapping over the greater trochanter. <ref name=":0">Yen YM, Lewis CL, Kim YJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961351/pdf/nihms721941.pdf Understanding and Treating the Snapping Hip]. Sports Med Arthrosc Rev. 2015 Dec;23(4):194-9. </ref> 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. <ref name=":0" />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.<ref name=":1">Idjadi J, Meislin R. Symptomatic snapping hip: targeted treatment for maximum pain relief. The Physician and Sportsmedicine 2004;32(1):25-31.</ref><ref>Byrd JT. [http://www.iortho.com.my/media/members032010_docs/sports/hip/snapping_hip.pdf Snapping hip.] Operative Techniques in Sports Medicine 2005;13(1):46-54.</ref> | ||
=== Internal Snapping Hip ( | === Internal Snapping Hip Syndrome (ISHS) === | ||
''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: | ''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: | ||
| Line 112: | Line 112: | ||
* Ultrasound: Helps to visualise the dynamic motion of the iliopsoas tendon, but requires a skilled clinician to perform and interpret results. <ref name=":0" /><ref>Winston P, Awan R, Cassicy JD et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.</ref> | * Ultrasound: Helps to visualise the dynamic motion of the iliopsoas tendon, but requires a skilled clinician to perform and interpret results. <ref name=":0" /><ref>Winston P, Awan R, Cassicy JD et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.</ref> | ||
* Dynamic sonography: able to detect the movement of the ITB over the greater trochanter | * 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 | * Iliopsoas bursography: under fluoroscopy bursa is filled with contrast to visualised the tendon moving back and forth. This imaging is performed to confirm ISHS syndrome.<ref name=":0" /> | ||
=== Management / Interventions === | === Management / Interventions === | ||
| Line 128: | Line 128: | ||
==== Surgical intervention ==== | ==== Surgical intervention ==== | ||
''Goal'': to release the contracted ITB to resolve the snap<ref>Pierce TP, Kurowicki J, Issa K, Festa A, Scillia AJ, McInerney VK. External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review. Hip Int. 2018 Sep;28(5):468-472. </ref> | ''Goal'': to release the contracted ITB or the iliopsoas to resolve the snap<ref>Pierce TP, Kurowicki J, Issa K, Festa A, Scillia AJ, McInerney VK. External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review. Hip Int. 2018 Sep;28(5):468-472. </ref> | ||
External Snapping Hip: | External Snapping Hip: | ||
Revision as of 01:14, 14 March 2022
Top Contributors - Ewa Jaraczewska, Jess Bell, Kim Jackson, Lucinda hampton and Tarina van der Stockt
Snapping Hip Syndrome (SHS)[edit | edit source]
There are three types of the Snapping Hip syndromes identified: the external , the internal , and the intra-articular snapping hip.
External Snapping Hip Syndrome (ESHS)[edit | edit source]
External (lateral) snapping hip is a painful condition also known as lateral coxa saltans. It occurs in about 10% of the general population.[1] The external extra-articular factor involves the posterior iliotibial band snapping over the greater trochanter. [2] 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. [2]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.[3][4]
Internal Snapping Hip Syndrome (ISHS)[edit | edit source]
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.[2]
Intra-Articular Snapping Hip[edit | edit source]
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[edit | edit source]
Iliotibial Band[edit | edit source]
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.[5] 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. [1]During hip flexion, the ITB moves anterior to the greater trochanter and during hip extension it runs posterior to it. [2]
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.[6]
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[edit | edit source]
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[edit | edit source]
Iliopsoas muscle complex is made up of three muscles that include the iliacus, psoas major and psoas minor.[2] 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.[7]
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[edit | edit source]
- 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.[8]
- 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.[8]
- 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 . [8]
- 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 . [8]
Clinical Presentation[edit | edit source]
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 may report:
- pain
- muscles weakness
- activities limitation[3]
Evaluation[edit | edit source]
Physiotherapy Assessment[edit | edit source]
Physiotherapy assessment includes the patient's history, physical examination and special tests.
Patient's History[edit | edit source]
- symptoms description (location, sensation, timing and duration)
- impact on activities of daily living
Physical Examination[edit | edit source]
- 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[edit | edit source]
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[edit | edit source]
- 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.[2]
- Ultrasound: Helps to visualise the dynamic motion of the iliopsoas tendon, but requires a skilled clinician to perform and interpret results. [2][12]
- 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 ISHS syndrome.[2]
Management / Interventions[edit | edit source]
Conservative Management[edit | edit source]
Goal: to improve pain, to increase flexibility and to equalise the limb length discrepancy if needed.
Conservative approach should be continued for at least 6 month and the following approaches are recommended:[1]
- Muscle tightness causing the snapping must be identified: passive and active stretching program specific to the ITB and the iliopsoas muscles to be initiated [2]
- Rest, icing and anti-inflammatories should be advocated to reduce inflammation[2]
- Movements that provoke the snap should be avoided
- Sport activities must be reduced
- Active Release Techniques[13]
- Use of modalities: Laser therapy or Extracorporeal shockwave therapy ESWT[14]
Surgical intervention[edit | edit source]
Goal: to release the contracted ITB or the iliopsoas to resolve the snap[15]
External Snapping Hip:
- Fractional lengthening of the tendon
- Complete release of the tendinous portion[16]
The lengthening procedures include: Z-shaped release, formal Z-lengthening, cross-shaped release and release of the gluteus maximus tendon insertion to the femur.[2][1]
Internal Snapping Hip:
- Anterior approach to release the posteromedial tendinous portion of the iliopsoas
- Endoscopic release of the iliopsoas tendon[2][17]
Resources
[edit | edit source]
Walker P, Ellis E, Scofield J, Kongchum T, Sherman WF, Kaye AD. Snapping Hip Syndrome: A Comprehensive Update. Orthopedic Reviews. 2021;13(2).
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 Randelli F, Mazzoleni MG, Fioruzzi A, Giai Via A, Calvisi V, Ayeni OR. Surgical interventions for external snapping hip syndrome. Knee Surg Sports Traumatol Arthrosc. 2021 Aug;29(8):2386-2393.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Yen YM, Lewis CL, Kim YJ. Understanding and Treating the Snapping Hip. Sports Med Arthrosc Rev. 2015 Dec;23(4):194-9.
- ↑ 3.0 3.1 Idjadi J, Meislin R. Symptomatic snapping hip: targeted treatment for maximum pain relief. The Physician and Sportsmedicine 2004;32(1):25-31.
- ↑ Byrd JT. Snapping hip. Operative Techniques in Sports Medicine 2005;13(1):46-54.
- ↑ Baker RL, Fredericson M. Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Physical médicine and réhabilitation clinics of North America, 2016; 27(1):53-77
- ↑ Weerakkody, Y., Bell, D. Hip bursae. Reference article, Radiopaedia.org. (accessed on 13 Mar 2022) https://doi.org/10.53347/rID-64260
- ↑ Bordoni B, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Iliopsoas Muscle. [Updated 2021 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531508/
- ↑ 8.0 8.1 8.2 Walker P, Ellis E, Scofield J, Kongchum T, Sherman WF, Kaye AD. Snapping Hip Syndrome: A Comprehensive Update. Orthopedic Reviews. 2021;13(2).
- ↑ The Physio Channel. How to test for a Snapping Clicking Hip. 2018.Available from: https://www.youtube.com/watch?v=xkEq7nGUA1o [last accessed 13/03/2022]
- ↑ Sports Injuries And Rehabilitation. Ober`s Test - Hip Special Test. 2017.Available from: https://www.youtube.com/watch?v=6FEvmhjMVNs[last accessed 13/03/2022]
- ↑ John Gibbons. THE PSOAS Muscle - Simple test for tight HIP FLEXORS (Modified Thomas test). 2018. Available from: https://www.youtube.com/watch?v=qsgrMVuataI [last accessed 13/03/2022]
- ↑ Winston P, Awan R, Cassicy JD et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.
- ↑ Spina AA. External coxa saltans (snapping hip) treated with Active Release Techniques: a case report. J Can Chiropr Assoc. 2007 Mar;51(1):23-9.
- ↑ Frizziero A, Vittadini F, Pignataro A, Gasparre G, Biz C, Ruggieri P, Masiero S. Conservative management of tendinopathies around hip. Muscles Ligaments Tendons J. 2016 Dec 21;6(3):281-292.
- ↑ Pierce TP, Kurowicki J, Issa K, Festa A, Scillia AJ, McInerney VK. External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review. Hip Int. 2018 Sep;28(5):468-472.
- ↑ Malinowski K, Kalinowski Ł, Góralczyk A, Ribas M, Lund B, Hermanowicz K. External Snapping Hip Syndrome Endoscopic Treatment: “Fan-like” Technique as a Stepwise, Tailor-made Solution.Arthroscopy Techniques, 2020; 9(10): e1553-e1557.
- ↑ Maldonado DR, Lall AC, Battaglia MR, Laseter JR, Chen JW, Domb BG. Arthroscopic Iliopsoas Fractional Lengthening. JBJS Essent Surg Tech. 2018 Nov 28;8(4):e30.
