Snapping Hip and Trochanteric Bursitis

Original Editor - Ewa Jaraczewska based on course by Rina Pandya
Top Contributors - Ewa Jaraczewska, Jess Bell, Kim Jackson, Lucinda hampton and Tarina van der Stockt

Snapping Hip Syndrome (SHS)

Three types of snapping hip syndrome have been identified: external, internal, and intra-articular types, with the external type being the most common.

External Snapping Hip Syndrome (ESHS)

External (lateral) snapping hip is a painful condition (also known as lateral coxa saltans), occurring in about 10% of the general population.

• External extra-articular snapping is caused either by the posterior iliotibial band or the anterior aspect of the gluteus maximus as they move over the greater trochanter during hip flexion / extension or hip internal / external rotation. This may lead to the inflammation of the trochanteric bursa.
• Individuals with the ESHS may also have coxa vara, fibrotic scar tissue, a prominent greater trochanter, smaller lateral pelvic width, or have had surgery in the past for anterolateral knee instability.

Internal Snapping Hip Syndrome (ISHS)

Internal extra-articular snapping is caused by the iliopsoas tendon snapping over the iliopectinal eminence or the femoral head and is more likely to occur while the hip flexors are contracting. 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

Intra-articular factors can also lead to the development of snapping hip symptoms, including labral tears, ligamentum teres (ligament of the head of the femur) 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 most of its fibres insert onto the tibial tubercle, some insert 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 is involved in hip stabilisation during 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 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 the gluteal tuberosity and the iliotibial band.

Gluteus maximus is primarily involved in hip extension, external rotation and abduction. Its function is essential to maintain an erect posture.

Iliopsoas

The iliopsoas muscle complex is made up of three muscles: iliacus, psoas major and psoas minor. It can work as a unit, but the three muscles all have 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 is believed to communicate with the hip joint in ~15% of patients. It helps the muscle glide and slide over the front of the hip during movement.

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

Pathophysiology

• External snapping hip
  • Visual component to 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 the anterior portion of the gluteus maximus.

• Internal snapping hip
  • Audible component to the snap when the movement of the iliopsoas tendon 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 labral tears, or osteochondral fractures can interfere with the articulation of the femoral head into the acetabulum.
    

Clinical Presentation

Individuals with external snapping hip syndrome typically describe a sensation that feels like hip dislocation. With internal snapping hip, patients describe a 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 intra-articular pathology.

Additionally patients may report:

• Pain
• Muscle weakness
• Activity limitations

Evaluation

Physiotherapy Assessment

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

Patient's History

• Description of symptoms (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's 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
• 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 examiner applies 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 iliopsoas involvement. May assist with the diagnosis of iliopsoas bursa or iliopsoas muscle inflammation. This modality helps to visualise a thickened ITB and focal thickening of the gluteus maximus when ESHS 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 visualise the tendon moving back and forth. This imaging is performed to confirm ISHS syndrome.

Management / Interventions

Iliotibial Band stretch

Conservative Management

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

A conservative approach should be continued for at least 6 months and the following strategies are recommended:

Iliopsoas stretch

1. Rest, icing and anti-inflammatories should be advocated to reduce inflammation
2. Muscle tightness causing the snapping must be identified: passive and active stretching programme specific to the ITB and the iliopsoas muscles to be initiated
3. Single leg stance exercises (ESHS)
4. Lateral walking with theraband (ESHS)
5. Hip hiking exercises (ESHS)
6. Movements that provoke the snap should be avoided
7. Sports activities must be reduced
8. Active release techniques
9. Use of modalities: laser therapy or extracorporeal shockwave therapy ESWT

Ilizaliturri’s ITB release technique. Adapted from: Randelli F, Mazzoleni MG, Fioruzzi A, Giai Via A, Calvisi V, Ayeni OR. Surgical interventions for external snapping hip syndrome.

Surgical Intervention

Goal: to release the contracted ITB or the iliopsoas to resolve the snap

External snapping hip:

1. Fractional lengthening of the tendon
2. Complete release of the tendinous portion

The lengthening procedures include: Z-shaped release, formal Z-lengthening, cross-shaped release and release of the gluteus maximus tendon insertion to the femur.

Internal snapping hip:

1. Anterior approach to release the posteromedial tendinous portion of the iliopsoas
2. Endoscopic release of the iliopsoas tendon

Trochanteric Bursitis

Lateral hip pain due to the inflammation of the bursa, usually as a consequence of microtraumas, produces a condition called trochanteric bursitis or greater trochanteric pain syndrome (GTPS). It affects females between the age of 40 to 60 most commonly. The abnormal hip biomechanics is the leading cause of development of the symptoms where the gluteus medius and minimus tendinopathy along with or without bursitis can lead to this painful lateral hip syndrome.

Trochanteric bursitis

Clinically Relevant Anatomy

A bursa or bursae (plural form) is a membrane sac lined by a synovial membrane or synovium containing the synovial fluid. It is located between bone and surrounding soft tissue and near a joint. Its role is to lubricate and reduce tension and friction between the soft tissue/bone interface. It also acts as a shock absorber during the movement of muscles and joints. Detailed information on the mechanism of injury or the pathological process of bursitis is available here.

In the case of trochanteric bursitis, two bursae are commonly involved:

1. Subgluteus medius bursa - located above the greater trochanter and underneath the insertion of the gluteus medius.
2. Subgluteus maximus bursa - located between the greater trochanter and the insertion of the gluteus medius and gluteus maximus muscles.

Pathophysiology

Altered lower extremity biomechanics and imbalances lead to the development of the GTPS. The aetiology of this syndrome is multifactorial and the following issues are believed to contribute to its presence:

• A lower femoral neck-shaft angle
• Recently increased activities levels
• Improper footwear
• Hormonal changes after menopause
• Degeneration or tendinopathy in the gluteus medius and minimus musculature
• Repetitive microtrauma to the bursa caused by friction between the greater trochanter and iliotibial band

Clinical Presentation

The following clinical presentation may occur:

• Pain at the lateral side of the hip radiating down
• Difficulties with side-lying on the affected side
• Pain while walking
• Gait abnormalities
• Tenderness over the greater trochanter
• Pain interfering with sleep and physical function

Differential diagnosis:

• Iliotibial band syndrome
• Snapping hip syndrome
• Gluteus medius tendon dysfunction and tears
• Meralgia paresthetica
• Referred rain
• Osteoarthritis
• Lower back pain
• Pelvic pathology

Evaluation

Physiotherapy Assessment

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

Patient's History

• Description of symptoms (pain)
• Impact on activities of daily living

Physical Examination

• Observation
  • Observe patient's posture in sitting and standing: watch for slightly flexed posture, slouch position, leaning to uninvolved side.
  • Watch a patient walk: look at pelvic obliquity, the hip tendency to move into adduction while ambulating.

• Palpation:
  • Palpate the iliotibial band and watch for tightness, irritation, pain, trigger points.
  • Check the lumbar spine, sacroiliac joints, ischium, iliac crest, lateral aspect of the greater trochanteric bursa, muscle bellies and the pubic symphysis to determine a potential source of hip symptoms or pain.

• Range of motion assessment: check active hip flexion, internal and external rotation, abduction and adduction. Movement can reproduce pain in the injured area.
• Muscle strength assessment: assess major muscle groups acting on the hip joint. Hip abductor weakness is a common finding and testing the abductors can provoke lateral hip pain during the examination.
• Functional assessment: mobility, gait. Look for any limb length discrepancy, weakness and heel strike which contributes to the function of the gluteus maximus. Inability to perform a putting on socks test, which requires the patient to sit with one leg crossed over in the figure 4 position, may indicate that changes are occurring in the hip joint. These changes can lead to osteoarthritis or trochanteric bursitis.

Special Tests

• Jump sign: patient in side-lying, so the affected side is on top, apply pressure around the lateral hip or the greater trochanteric region. This test a positive predictive value of about 83% for confirmation for the MRI.
• Single leg stance test: patient to stand for 30 seconds on one leg. The test is positive when the patient is not able to hold the balance. This test has almost a hundred per cent positive predictive value that confirms the MRI findings.
• FADIR test
• FABER test
• Ober's test
• Step down and step pp test
• Trendelenburg test

Imaging

• Ultrasound: shows distension of the greater trochanteric bursa by anechoic or hypoechoic fluid
• MRI: not necessary to diagnose trochanteric bursitis. It can assist with confirming or ruling out possible diagnoses.

Management/Interventions

Adapted from: Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B., 2018. Education plus exercise versus cortico- steroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: a prospective, single-blinded, randomised clinical trial.

Conservative Management

Reports from the literature indicate that about 64% of patients find relief after one year of conservative therapy for trochanteric bursitis and 71% after five years. There is a high rate of recurrence of GTPS symptoms requiring repeated conservative therapy.

Goal: pain reduction, improvement in functional activities.

Acute phase:

• Activity modification: reduction in the intensity and frequency of running, avoid running on uneven surfaces or banked tracks
• Position modification: sleeping on the uninvolved side with a pillow in between the knees or by the side
• Ice
• Oral NSAIDs (non-steroidal anti-inflammatory drugs), and corticosteroid and platelet-rich plasma (PRP) injections
• Superficial release with soft tissue therapy
• Taping
• Shockwave therapy: may be used under special circumstances
• Ultrasound therapy: not enough evidence

Hip abductors strengthening exercises

Subacute phase:

• Strengthening of the abductors of the hip
• 

  Adductors stretch
  Stretching of adductors
• Activity modification: avoid hip adduction (legs crossing)
• Exercise modification: avoid excessive ITB stretching exercises

Surgical Intervention

Cases with abductor tears or intra articular pathology confirmed by imaging do not respond well to conservative management and often require surgical intervention.

Goal: pain reduction

• Trochanteric bursectomy with or without iliotibial band release: good treatment option in grades 1 and 2 tendinopathy
• Lengthening or release of the ITB and fascia late (Z-plasty)
• Trochanteric reduction osteotomy
• Surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy: low-level evidence

Resources

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

Olufade O, Yoo A, Negron G, McDermott H, Jayanthi N. Greater Trochanteric Pain Syndrome (GTPS): A clinical prospective study of treatment options. J Orthop Pract. 2021;1(1).

Pianka MA, Serino J, DeFroda SF, Bodendorfer BM. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE open medicine. 2021 Jun;9:20503121211022582.