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 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. The external extra-articular factor causing the ESHS 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 the ESHS 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 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:

• 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 the 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 may 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 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 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 ISHS syndrome.

Management / Interventions

Conservative Management

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 months 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
3. Movements that provoke the snap should be avoided
4. Sports activities must be reduced
5. Active Release Techniques
6. Use of modalities: Laser therapy or Extracorporeal shockwave therapy ESWT

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.

Clinically Relevant Anatomy

A bursa or bursae (plural form) it is a double - membrane sac filled with 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 you can find here.

In 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 development of the GTPS. The etiology of this syndrome is multifactorial and the following pathologies are believed to contribute to its presence:

Femoral neck shaft angle, activity levels, and hormone physiology are believed to affect prevalence, though the exact etiology is multifactorial in origin.1,3,5-8 Converging evidence, however, suggests that GTPS results primarily from degeneration or tendinopathy in the gluteus medius and minimus musculature.9-14 This can be caused by aberrant lower extremity biomechanics and imbalances that result from trauma to the lower extremity, instability, overuse, and/or compression of the gluteal nerve branches.6,8,10,15,16 Other theories posit that GTPS is the result of repetitive microtrauma to the interposed bursa caused by friction between the greater trochanter and iliotibial band, as in the case of external coxa saltans or “snapping hip.”5,17-21 Bursal-derived pain in GTPS has also been supported by intraoperative findings.2,5,18,19,22

Clinical Presentation

lateral side of the hip. They will also mention that it's difficult side-lying on the affected side. They're going to have problems and pain while walking as a result of which you will be seeing gait abnormalities as well. Patients will complain that they're not able to walk a further distance due to pain on the lateral side of the hip. The pain is also referred down, like it's a radiating pain on the lateral side of the leg and the thigh, and this is usually seen in patients, as we said before females between 40 to 60 years, but also in the clientele that has just started working out, like they threw themselves in the deep end with their exercises or on weight-bearing or with hip abductor weakness, we're looking at long-distance runners, where we're seeing a lot of ITB friction going on

Differential Diagnosis:

• Iliotibial Band Syndrome
• Snapping Hip Syndrome
• Gluteus Medius Tendon Dysfunction and Tears
• Meralgia Paresthetica
• Referred Pain
• Osteoarthritis
• Lower Back Pain
• Pelvic Pathology

Evaluation

Physiotherapy Assessment

watching a patient walk, when we do gait analysis, so we're looking at the pelvic obliquity, we're looking at the pelvic drop as well. No matter how minimal it is. And we want to see if the hip has the tendency to go into adduction while ambulating. So watching someone's gait pattern goes ahead and gives us that confirmation that we could be possibly looking at a greater trochanteric pain syndrome. So, what this also means for us is to go ahead and palpate the ITB and see if we can identify any tightnesses, irritation, pain, trigger points, so on and so forth.

So some of the special tests that we can do in terms of palpation is literally to put the patient in side-lying, so the affected side is going to be on top and go ahead and put pressure around the lateral hip or the greater trochanteric region. This is called the Jump Sign where the patient's going to be so tender that he's literally going to get startled or jump with that pain. And this has a positive predictive value of about 83% for confirmation for the MRI. If the patient does not experience pain, then we can almost definitely say that he's not suffering from GTPS. Another test that we can run if we don't want to put your patients in pain is to do a single-leg stance. Have them stand for 30 seconds as a single-leg stance and this has almost got a hundred percent positive predictive value that confirms the MRI findings later on if your patient is not able to hold balance. So this will show, you know, the weakness of the hip abductors, the pelvic drop and so on and so forth. So if your patient is not able to say, for example, if you have a patient of size, somebody who's not able to lay down and you want to run a quick check, just have them stand unsupported, 30 seconds on the affected side. Other tests that can be performed is obviously the FADIR, the FABER, the Ober's Test, then we have the Step Down and Step Up test, and obviously the Trendelenburg test.

Management/Interventions

Conservative Management

Goal:

activity modification, ice, oral NSAIDs (non-steroidal anti-inflammatory drugs), and corticosteroid and platelet-rich plasma (PRP) injections.While prior investigations reported that 90% of patients with GTPS experienced pain relief with two years of non-operative management, more recent literature reports that only about 64% of patients find relief after one year and 71% after five years in the primary care setting. Additionally, GTPS symptoms often recur and require several rounds of conservative therapy.

So our acute phase management is obviously rest, ice, some soft tissue therapy. Don't go too deep into it. Just superficial release, if we can. Taping, medications such as NSAIDs, paracetamol, painkillers, and your advice for the runner would be first of all to reduce the intensity and frequency of running as much as possible and not to run on uneven surfaces or banked track.

Shockwave therapy may be used under special circumstances, and there's not enough evidence as far as ultrasound therapy is concerned. As mentioned before we have exercise and load management obviously, strengthening of the abductors of the hip. And we talked about. Target the adductors, stretch them out, strengthen the abductors on the other side, not forgetting the lumbopelvic control as well. So we are bringing everything back into balance, back into the right biomechanical performance. Now, as much as we want, we know that the hip goes into adduction, which is the reason why this happens. So the best thing is to tell the patient not to adduct the hips or not to sit cross-legged or, you know, do any excessive ITB stretching exercises at this point. At night, the patient may be advised to sleep on the contralateral side with pillow in between the knees or by the side, if they just need to go in and roll their hip. We do not want the affected hip to dip down and thus creating that adduction at the hip, even when they're sleeping.

Surgical Intervention

Goal: Pain reduction

Recalcitrant cases with imaging concerning for abductor tears or intraarticular pathology that have not responded to extensive conservative management are often referred for surgical intervention.

• Open or Arthroscopic Surgical Management for Recalcitrant Trochanteric Bursitis (trochanteric bursectomy).

Resources

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