Snapping Hip Syndrome

Definition/Description[edit | edit source]

Snapping Hip Syndrome (SHS), also known as Coxa Saltans, is a condition that is characterized by a snapping sensation, and/or audible “snap” or “click” noise, in or around the hip when it is in motion. There are various causes for SHS, which can be further classified as external, internal, or intra-articular in origin. For most people this condition is simply an annoyance; however it may result in both pain and weakness interfering with the patient’s functional mobility.[1][2]

Epidemiology/Etiology[edit | edit source]

SHS affects up to 10% of the general population. It is thought to occur more frequently in females than men, with external snapping hip syndrome being the most common origin but there is not any statistical proof to show that gender is the risk factor for SHS. The nature of this condition is typically an overuse injury, with a higher occurrence in activities that involve repetitive hip flexion and extension, such as dance, soccer, gymnastics and running.[2]

Causes[edit | edit source]

  • External (most common): Iliotibial band snapping over the greater trochanter of the femur.
  • Internal: Iliopsoas tendon snapping over a bony prominence of the pelvis.
  • Intra-articular (least common)

Characteristics/Clinical Presentation[edit | edit source]

Most cases of SHS are benign and common to the general population. Symptomatic people may experience pain or weakness during hip flexion and extension that limits participation in their activities.[3]

External SHS[edit | edit source]

People with external SHS will usually have a gradual onset of snapping or pain located laterally over the greater trochanter. The external type is not associated with a traumatic event, but mostly with a minor mechanism of injury.[3] The clinical presentation is often easily observable by observing and listening for snap as the patient actively flexes and extends the hip. These patients may describe a sense that the hip is dislocating.[4] People with external SHS 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 SHS[edit | edit source]

Internal SHS also has a gradual onset, not usually associated with a traumatic event.[3] These patients describe a painful sensation coming from deep within the anterior groin as they move their hip from flexion into extension or external rotation. The snapping movement can produce an auditory clunk or click.[4]

Intra-articular SHS[edit | edit source]

Patients with intra-articular SHS report a sudden onset of snapping or clicking from an injury or traumatic event to the hip capsule. The sources of this snapping can come from intra-capsular lesions, loose bodies settling in the acetabular fovea or synovial folds, a torn acetabular labrum, synovial chondromatosis, or a history of habitual hip dislocation in children or idiopathic recurrent subluxation.[3]

Differential Diagnosis[edit | edit source]

Outcome Measures[edit | edit source]

Examination[edit | edit source]

  • Subjective assessment of history:
    • Prevalence of snapping hip
    • Location of the snap,
    • Timing of the snap
    • Age/duration of onset
    • Pain and disability and
    • Impact on activities of daily living
  • Palpation (of painful area - most likely areas will be greater trochanter and the lateral border of the gluteus maximus)
  • Gait or biomechanical abnormalities
  • Demonstration the snap
  • Hip rang of motion
  • Muscle strength testing
  • Muscle length tests
  • Exclude differential lumbar and knee pathology

Brignal and Stainsby found that the average duration of snapping hip symptoms in patients was 2 years and 2 months, generally speaking, the patient can tell you exactly where their problem is.[6] A visual analog scale (VAS) scale can also be used to measure pain.[7] The clinical exam should consist of basic tests that include:

Special tests[edit | edit source]

External Snapping Hip[edit | edit source]

  • Ober's test: While the Ober’s test is often used to test for a tight iliotibial band, its diagnostic credibility for determining an external snapping hip is low.


  • Generally, a clinician can have the patient in side-lying and palpate the greater trochanteric region as the hip moves through flexion and extension followed by internal and external rotation.[7]
  • Brignall et al, used a specific diagnostic test in which the patient is placed on the unaffected side with a pad under the buttock so that the affected hip is held in adduction. Keeping the knee in extension, the hip is then actively flexed and extended and the iliotibial band may be felt flicking over the greater trochanter.[6]
  • Hula-Hoop test: Adduction with circumduction of the affected hip is done to test for external snapping hip syndrome and snap over greater trochanter is positive sign.
  • A version of the FABER test can be used to differentiate between internal (iliopsoas) or external (ITB) generated snapping hip. By placing the affected hip into the FABER (flexion, abduction, external rotation) and passively moving the hip into an extended, adducted and internally rotated position, a palpable or audible snap may be heard.[7]
FABER position.jpg

Internal Snapping Hip[edit | edit source]

  • The Stinchfield test: The patient lies supine with the hip flexed at 30° and ask the patient to fully flex the hip, while the examines apply a resistance force. Pain in the anterior groin indicate a positive test.


Thomas Test video provided by Clinically Relevant

  • Iliopsoas stress test[2]
Hip ext add ir.jpg

To more accurately diagnose internal and intra-articular snapping of the hip, real-time ultrasonography can be used. This method has replaced fluoroscopy for its direct and noninvasive identification of the psoas and iliopsoas tendons and other hip capsule movements.[10][11] Overall, it was shown that self-reported snapping hip is likely to be considered a clinical snapping hip. External SHS caused by the ITB can be clinically evaluated, while internal SHS of the iliopsoas tendon should be evaluated via ultrasound.[7]

Medical Management[edit | edit source]

As previously discussed, a majority of SHS cases are asymptomatic and usually don’t require intervention. However, in more persistent cases which cause pain and/or activity limitations, some form of intervention may be necessary.

Conservative Management[edit | edit source]

Referred to as the first and most preferred treatment approach and often involves methods used to treat common forms of tendinitis. Commonly consists of rest, ice, non-steroidal anti-inflammatory medication (NSAIDs), corticosteroid or lidocaine injections and physiotherapy.[3][4][12][13][14]

Surgical Intervention[edit | edit source]

Recommended as a last resort only when conservative treatment has not improved symptoms. The main purpose is to lengthen or relax the tight tendon or ligament to eliminate the snapping as well as to correct any associated/contributing pathologies which are very common in SHS.[3][4][6][15][16][17] There continues to be some controversy over which type of surgical procedure is best for each of the classifications of SHS. However, researchers do agree that if surgical intervention is necessary, arthroscopic surgery allows for better results and less complications when compared to traditional open surgery.[14][16][18]  

The type of surgery are determined by the cause of the SHS:

  • External[3][4][6][12][17]:
    • Z-plasty of the iliotibial tract
    • Resection of the posterior half of the iliotibial tract
    • Elliptical resection of a portion of the iliotibial band
  • Internal[4][12][16][17]:
    • Lengthening of the iliopsoas tendon 
    • Resection of the bony prominence of the lesser trochanter
    • Complete release of the iliopsoas tendon
  • Intra-articular[3][4][17]:
    • Cause not as clear due to possible involvement of many different intra-articular lesions that can cause symptoms
    • Correction of intra-articular pathologies

A study by Contreras et al. tracked 7 patients for 2 years following arthroscopic surgery related to snapping of the iliopsoas tendon. All reported resolution of snapping post-op and at 2 year follow-up. VAS scores for pain decreased from 7.7 pre-op to 4.3 by 3 months, 3.6 by 6 months and 2.4 at one and two years. Harris Hip Scores increased from 56.1 pre-op to 88.4 at one year and 87.9 at two years. None reported post-op complications and all returned to their previous level of function or better.[16]

Physiotherapy Management[edit | edit source]

Compared to the body of literature for surgical management, there is a lack of evidence for specific interventions in the conservative management of SHS and/or tendonitis of the involved structures. Given that this condition is classified as a syndrome, the physiotherapist can expect to find multiple abnormalities, each of which should be individually addressed. Examination findings of each individual patient should guide the impairment-based approach to treatment.

Since the mechanism of injury and focus of surgical intervention has been identified as excessive shortening and tightness of the iliopsoas tendon and iliotibial band, patients may benefit from stretching of anterior hip structures or the iliotibial band and its associated structures.[4][19][20]

Andres et al. conducted a systematic review of interventions for tendonitis, and determined that eccentric strengthening exercises showed the greatest value in decreasing pain and increasing function, when compared to other physiotherapy interventions.[21]

A case study has been published which documents the complete resolution of pain in a case of lateral coxa saltans. Myofascial release of the tensor fascia lata, gluteus medius and gluteus maximus, and adductors was performed, and the patient was prescribed a general stabilization and strengthening program focusing on the abductors.[22]

A Cochrane review showed no increased benefit of transverse friction massage, when compared to other interventions, for iliotibial band friction syndrome.[23]

It is important that the patient is educated to avoid motions that cause pain and/or the snapping sensation. Once the pain and discomfort have been addressed, and a more complete global hip range of motion can be achieved, education to avoid excessive repetition of the offending pattern may help prevent a relapse into acute aggravation.

Resources[edit | edit source]

Clinical Bottom Line[edit | edit source]

Snapping Hip Syndrome (whether internal, external or intra-articular) presents with a multitude of symptoms and a variety of impairments. The cause has not been definitively identified, so specific prescriptions of interventions will need to be based on individual patient presentations. The predominant etiological theory suggests that there is an overuse component that leads to an excessive shortening of the involved structures. Logic dictates that effective conservative management will involve stretching and lengthening of shortened structures, and patient education with respect to avoiding motions that cause discomfort. Once treatment has addressed the patient's primary complaints, a more global evaluation may be performed in an attempt to identify imbalances and limitations that may have led to the condition in the first place.

References[edit | edit source]

  1. Konczak CR, Ames R. Relief of internal snapping hip syndrome in a marathon runner after chiropractic treatment. Journal of Manipulative and Physiological Therapeutics 2005;28(1):e1-7.
  2. 2.0 2.1 2.2 Via AG, Fioruzzi A, Randelli F. Diagnosis and Management of Snapping Hip Syndrome: A Comprehensive Review of Literature. Rheumatology (Sunnyvale) 2017;7(228):2161-1149.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Idjadi J, Meislin R. Symptomatic snapping hip: targeted treatment for maximum pain relief. The Physician and Sportsmedicine 2004;32(1):25-31.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Byrd JT. Snapping hip. Operative Techniques in Sports Medicine 2005;13(1):46-54.
  5. Hinojosa T. EBP - Snapping Hip. Available from (accessed 15/11/2020).
  6. 6.0 6.1 6.2 6.3 Brignall CG, Stainsby GD. The snapping hip. Treatment by Z-plasty. The Journal of Bone and Joint Surgery. British volume 1991;73(2):253-4.
  7. 7.0 7.1 7.2 7.3 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.
  8. Bigesor. Ober's Test. Available from: (accessed 15/11/2020).
  9. MSK Medicine. Stinchfield's Test. Available from: (accessed 28/11/2020).
  10. Deslandes M, Guillin R, Cardinal É, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. American journal of Roentgenology 2008;190(3):576-81.
  11. Schaberg JE, Harper MC, Allen WC. The snapping hip syndrome. The American Journal of Sports Medicine 1984;12(5):361-5.
  12. 12.0 12.1 12.2 Medscape. Garry J, Jenkins W. Snapping hip syndrome. Available from: (accessed 28/11/2020).
  13. Wahl CJ, Warren RF, Adler RS, Hannafin JA, Hansen B. Internal coxa saltans (snapping hip) as a result of overtraining: a report of 3 cases in professional athletes with a review of causes and the role of ultrasound in early diagnosis and management. The American Journal of Sports Medicine 2004;32(5):1302-9.
  14. 14.0 14.1 Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. The American journal of sports medicine 2008;36(12):2363-71.
  15. Lin CL, Huang MT, Lin CJ. Snapping hip caused by a venous hemangioma of the gluteus maximus muscle: a case report. Journal of Medical Case Reports. 2008;2(1):386.
  16. 16.0 16.1 16.2 16.3 Contreras ME, Dani WS, Endges WK, De Araujo LC, Berral FJ. Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study. The Journal of Bone and Joint Surgery (British volume) 2010;92(6):777-80.
  17. 17.0 17.1 17.2 17.3 Bond RP, Snyckers CH. Management of sports overuse injuries of the lower limb: an evidence-based review of the literature. SA Orthopaedic Journal 2010;9(2):48-58.
  18. Byrd J. Evaluation and management of the snapping iliopsoas tendon. Techniques in Orthopaedics 2005;20(1):45-51
  19. Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. The American journal of sports medicine 1990;18(5):470-4.
  20. Gose JC, Schweizer P. Iliotibial band tightness. Journal of Orthopaedic & Sports Physical Therapy 1989;10(10):399-407.
  21. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research. 2008;466(7):1539-54.
  22. Spina AA. External coxa saltans (snapping hip) treated with active release techniques: a case report. The Journal of the Canadian Chiropractic Association. 2007;51(1):23.
  23. Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002(4).