Snapping Hip Syndrome

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Lead Editors - John Fite, Tre Hinojosa, Jacqueline Keller, Elizabeth Record, John Winkelhaus,

Search Strategy

Search Timeline: June 10-

Databases Searched: Cinahl, Cochrane Library, Medline, PubMed, JOSPT,

Keywords: snapping hip syndrome, conservative management, physical therapy, physiotherapy, coxa saltans, tendinosis management, iliotibial band syndrome, iliopsoas tendon, diagnosis, examination, identification, ultrasound

Definition/Description

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 snapping hip syndrome, which can be further classified as external, internal, or intra-articular in origin (See Below). 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.

External (most common)

• Iliotibial band (or “IT band”) snapping over the greater trochanter of the femur.

Internal

• Iliopsoas tendon snapping over a bony prominence of the pelvis.

Intra-articular (least common)

• Usually due to a tear of the cartilage and/or loose body within the hip joint that may also cause the hip to “lock up”.

  

Epidemiology/Etiology

Snapping Hip Syndrome is thought to effect up to 5% of the population, with a higher prevalence in individuals between the ages of 15 and 40. It is thought to occur more frequently in females than men, with external snapping hip syndrome being the most common origin. 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.

Characteristics/Clinical Presentation

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.

• External 
  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 there can be a minor MOI. The clinical presentation is often easily observable by watching and listening for snap as the patient actively flexes and extends the hip. These patients may describe a sense that the hip is dislocating. 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.

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

• Intra-articular 
  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 intracapsular 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.

Differential Diagnosis

• Intra-articular Hip Disorders
• Trochanteric Bursitis
  
• Iliopsoas Bursitis
• Iliotibial Band Syndrome
• Iliopsoas Syndrome: a hip pathology characterized by internal snapping hip, iliopsoas tendonitis, and iliopsoas bursitis

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Visual Analog Scale (VAS)

Self-report forms

Examination

An examination for SHS should consist of the patient’s history that includes (but not limited to) prevalence of snapping hip, location of the snap, age of onset, pain and disability and impact on activities. A visual analog scale (VAS) scale can also be used to measure pain. The clinical exam should consist of basic tests that include:

~ Palpation (of painful area- most likely areas will be greater trochanter and the lateral border of the glut max)

~ Oberserve any gait or biomechanical abnormalities

~ Having the patient demonstrate the snap

~ Hip ROM

~ MMT

~ Muscle length tests

~ A screen to the lumbar spine and knee to differentiate between any other diagnoses.

Special tests:

External Snapping Hip: While the Ober’s test is often used to test for a tight IT Band, its diagnostic credibility for determining an external snapping hip is low. Currently, the most efficient way to diagnose an external snapping hip is by having the patient in side-lying and palpating the greater trochanteric region as the patient moves through flexion and extension of the hip followed by internal and external rotation.

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.

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.

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.

Medical Management

As previously discussed, a majority of Snapping Hip Syndrome 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: 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 Physical Therapy. ^{, , , ,}

Surgical Intervention: Recommended as a last resort only when conservative treatment has not improved symptoms. Main purpose is to lengthen or relax the tight tendon/ligament to eliminate the snapping and also to correct any associated/contributing pathologies which are very common in SHS.       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.    

Types of Surgical Procedures per Category:
External     : 
     • 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    :
     • Lengthening of the iliopsoas tendon 
     • Resection of the bony prominence of the lesser trochanter
     • Complete release of the iliopsoas tendon

Intra-articular   :
     • Cause not as clear due to possible involvement of many different intra-articular lesions that can cause symptoms
     • Correction of intra-articular pathologies

Complications.jpg

Pilot Study :
2010 Pilot Study by Contreras et al. tracked 7 patients for 2 years following arthroscopic surgery related to snapping of the iliopsoas tendon. Patients were referred for surgery between December 2005 and June 2006 after having received no benefit from conservative treatment. Visual Analog Scale (VAS) and Harris Hip scores were recorded pre-op and at 3, 6, 12 and 24 months post-op (clinical significance = 30% reduction in symptoms). 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.

Physical Therapy Management

Compared to the body of literature for surgical management, there is a lack of evidence for specific interventions in the conservative management of snapping hip syndrome and/or tendonitis of the involved structures. Given that this condition is classified as a syndrome, the physical therapist can expect to find multiple abnormalites, 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.

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 physical therapy interventions.

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 latae, gluteus medius, and gluteus maximus, and adductor musculature was performed, and the patient was prescribed a general stabilization and strengthening program focusing on the abductor musculature.

A systematic review by the Cochrane Library showed no increased benefit of transverse friction massage, when compared to other interventions, for iliotibial band friction syndrome.
 

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed) 

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References

8. Konczak CR, Ames R. Relief of Internal Snapping Hip Syndrome In A Marathon Runner After Chiropractic Treatment. Journal of Manipulative and Physiologic Therapeutics. January 2005; 28(1):67.e1-67.e7