Symptomatic Snapping Hip Targeted Treatment for Maximum Pain Relief

The Physician and Sportsmedicine: Symptomatic Snapping Hip
Symptomatic Snapping Hip
Targeted Treatment for Maximum Pain Relief
Jeremy Idjadi, MD; Robert Meislin, MD
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In Brief: A painful condition known as snapping hip may prevent athletes from attaining peak
performance, and it presents diagnostic and treatment challenges to the sports medicine
physician as well. Three types of snapping hip (external, internal, and intra-articular) are
known, and each has a distinct pathomechanic cause, specific symptoms, and classic clinical
presentation. History and physical exam are coupled with a variety of imaging modalities to
help distinguish the three types. Nonoperative approaches are the mainstay of treatment, but,
if unsuccessful, operative treatments also achieve good results. Patients may resume their
activities when pain subsides.
Benign, painless snapping in the hip is common in the general population. Symptomatic
snapping hip with debilitating pain and weakness is often seen in participants of activities such
as ballet and running hurdles. The repetitive nature of many sports may prevent athletes who
have painful symptoms from performing at their highest level or prevent them from
participating altogether. The clinician's goal is to determine the cause and treat active patients
who have symptomatic snapping hip so that they may return to peak performance in their
athletic activities.
Anatomy and Pathomechanics
The cause of symptomatic snapping hip may be external, internal, or intra-articular.
External type. The iliotibial band (ITB) is the usual culprit in the external type of snapping
hip. The ITB originates from the gluteus maximus and the tensor fasciae latae (figure 1). Most
of the ITB inserts at the proximal lateral aspect of the tibia at Gerdy's tubercle, and some fibers
insert on the lateral aspect of the distal knee, including the lateral femoral epicondyle and
lateral patella. A large bursa overlying the greater trochanter separates the trochanter and the
ITB. In general, the ITB is under tension throughout the range of hip motion. When the hip is
extended, the band lies posterior to the greater trochanter. It moves anteriorly over the
trochanter when the hip is flexed (figure 1A). If the thickened posterior aspect of the ITB or the (1 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
anterior aspect of the gluteus maximus rubs over the greater trochanter, a snapping sensation
may be felt.1-5 The greater trochanteric bursa may also become inflamed and painful.1-6
Other proposed causes of external snapping hip relate to alteration of hip mechanics.
Decreased angulation of the femoral neck (coxa vara) or fibrotic scar tissue after total hip
replacement,7,8 narrower bi-iliac width or increased distance between the greater trochanters,9
prominent greater trochanters,3,7 and surgery for anterolateral knee instability10 are all
thought to alter the normal relationship between the ITB and the greater trochanter, thereby
causing the characteristic external snapping sensation. Muscle fibrosis after intramuscular
injection may also cause snapping.11
Internal type. Pathology related to the iliopsoas tendon is most often seen as the source of
the internal snapping hip. The muscle is a confluence of the iliacus, which originates mainly
from the inner table of the ilium and the sacral ala, and the psoas, which originates from the
vertebrae and intervertebral disks of T-12 to L-5 (figure 2). Most of the iliopsoas muscle inserts
on the lesser trochanter of the femur.2,12,13 The tendinous portion of the muscle passes
through the groove on the bony pelvis that is bordered laterally by the anterior inferior iliac
spine and medially by the iliopectineal eminence. An anteromedial bony prominence lies
adjacent to the lesser trochanter, over which the tendinous portion of the iliopsoas passes
before its insertion. The iliopsoas bursa lies over the anterior hip capsule and deep to the
iliopsoas tendon.2,14 When the hip is flexed, abducted, and externally rotated, the tendinous
portion of the iliopsoas lies lateral to the anterior aspect of the femoral head and hip capsule. It
passes over the femoral head and hip capsule to a more medial position with hip extension,
adduction, and internal rotation, thereby causing snapping.1,12 (2 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
Another cause of internal snapping involves the iliopsoas tendon snapping over the iliopectineal
eminence and the bony ridge of the lesser trochanter.2,15 Iliofemoral ligaments moving over
the anterior hip capsule5 and the origin of the long head of the biceps moving over the
ischium16 have also been described as potential sites for snapping. The iliopsoas bursa may
also become inflamed and lead to painful snapping.1,2,12
Intra-articular type. A variety of intracapsular lesions may produce snapping, including loose
bodies that can occasionally settle in the acetabular fovea or synovial folds and cause
intermittent snapping symptoms.1 Torn acetabular labra, especially the posterosuperior portion
that is more prone to damage from mechanical stress, can be associated with snapping.17,18
Labral tears may also contribute to the risk of acetabular dysplasia caused by mechanical
deformation of the acetabulum.19 Other origins of snapping include idiopathic recurrent
subluxation of the hip, habitual hip dislocation in children, and synovial chondromatosis.1,20-22
Focusing the History
The cause and type of a patient's snapping hip may be found in the history. Patients who have
the intra-articular type may report a sudden onset of snapping or clicking after trauma.
Although trauma may eventually incite the internal or external types of snapping hip, the onset
is usually more gradual and the trauma tends to be more minor.
For the external type, the location described by patients tends to be lateral to the greater
trochanter; for the internal type, the location is anterior to the hip or in the groin.1 Patients
may also report movements that reproduce snapping, especially dancers and hurdlers who tend
to repeat particular motions. Dancers often have a painful internal type snapping hip and report (3 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
an exacerbation of symptoms during passè developpè (repetitive active hip flexion, external
rotation, and abduction) while their hips are turned out.23 These repetitive movements place
stress and torque on the iliopsoas tendon as it passes over the iliopectineal eminence and/or
the femoral head and capsule. The history may also reveal other potential mechanical or
anatomic causes of snapping hip, such as hip or knee surgery.
Telltale Physical Exam
External or internal snapping hip is usually a clinical diagnosis. The causes of snapping hip are
directly related to pathomechanics seen on physical exam. External snapping may be elicited
by placing the patient in a lateral position (side lying) on the examining table with the
unaffected side down. The affected hip is then passively flexed from extension (0° to 90°) and
then returned to extension. The leg should be maintained in neutral position for both abduction/
adduction and internal/external rotation while this test is performed. A palpable and audible
snapping will be recreated as the ITB passes from the posterior to the anterior plane of the
greater trochanter. Snapping may be prevented if the examiner's hand places enough force on
the greater trochanter or if the patient walks with the limb externally rotated.1,8,24 Pain
associated with the provocative testing is often a symptom of trochanteric bursitis.6
The physical exam for internal snapping is done by placing the patient supine on the examining
table and passively extending, internally rotating, and adducting a flexed, externally rotated,
and abducted hip. Snapping will be recreated as the iliopsoas tendon passes from lateral to
medial over the femoral head and joint capsule or other anatomic structures. As with external
snapping, the examiner will note a palpable and audible snapping over the anterior femoral
head. Snapping may be prevented by placing significant pressure on the iliopsoas tendon and
anterior hip.1,8
Iliopsoas syndrome, characterized by internal snapping hip, iliopsoas tendinitis, and bursitis,
may be evaluated with the iliopsoas test. The test is positive if the patient has pain or
weakness when the hip is flexed against resistance in abduction and external rotation.23 In
some patients who have both the external and internal types, using other movements or
examining the standing patient may be required to elicit snapping.25 Intra-articular loose
bodies may become more symptomatic if the patient loads the hip while standing.
Details From Diagnostic Imaging
Plain radiographs are part of the routine evaluation for hip complaints. If the diagnosis remains
unclear, or if intra-articular pathology is suspected, other techniques, such as magnetic
resonance imaging (MRI), computed tomography (CT), or dynamic ultrasound, may augment
the studies. Bursography and tenography, although invasive, may be indicated if the diagnosis
remains unclear despite clinical findings and other diagnostic tests.
Radiographs. Although plain x-rays are often normal in patients who have snapping hip,
radiographs, including anteroposterior and frog-lateral views, are imperative to rule out
fractures, loose bodies, dysplasia, and synovial chondromatosis. Reports conflict on the
usefulness of plain-film parameters (eg, smaller-than-normal bi-iliac width and femoral neck
angle) to establish a diagnosis.1,7-9
MRI. The evaluation of intra-articular causes of hip snapping, such as acetabular labral tears,
osteochondral fractures, and loose bodies, may be accomplished with MRI.26 Because of its (4 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
high level of soft-tissue contrast, MRI may also be useful in visualizing bursitis, as well as bone
and soft-tissue tumors27 that may contribute to hip snapping.
CT. For determining the cause of snapping hip, CT has limited diagnostic usefulness.27
Although CT is used to evaluate bony architecture (eg, the iliopectineal eminence) that may be
responsible for internal- type snapping,28 bone is rarely the cause of snapping hip. Loose
bodies, fractures, and soft-tissue structures, such as tendons, may be visualized, and CT helps
define soft-tissue masses, such as lipomas and hematomas.1,27 CT of the hip and knee may,
however, identify anteversion or retroversion of the patient's femoral neck. Increased
retroversion may allow greater ease in turnout at the hip for a dancer. CT with contrast media
has also been used to demonstrate an abnormal course of the iliopsoas tendon.15
Ultrasonography. Static and dynamic ultrasound play an important role in the diagnosis of
snapping hip. With internal snapping hip, static ultrasound demonstrates iliopsoas tendon
thickening, enlarged bursae, and peritendinous fluid collections. Dynamic ultrasound reveals
abnormal jerking motion of the tendon corresponding temporally to the patient's painful
sensation and to palpable and audible snapping.25-27,29 Similarly, dynamic ultrasound has been
used to visualize the ITB or gluteus maximus muscle snapping over the greater trochanter in
the external type.25,30 Advantages of ultrasound include that it is widely available, less costly,
and noninvasive, and that it provides a dynamic study of a reclining or standing patient,
depending on which provocative movements elicit snapping.
Bursography. Used to evaluate internal snapping hip, bursography involves injecting contrast
material into the iliopsoas bursa under fluoroscopic guidance. The iliopsoas tendon is visualized
by a longitudinal absence of contrast material surrounded by the filled bursa. Extending the
flexed, abducted, externally rotated hip elicits a lateral-to-medial jerking of the tendon over the
hip capsule or bony structures. Bursography may be augmented with anesthetic or
corticosteroid injection if bursitis is a suspected cause of pain.14,31 We are unaware of any
reports of greater trochanteric bursography being used to diagnose external snapping hip.
Tenography. Similar to bursography, tenography involves injecting contrast media into the
iliopsoas tendon sheath. Snapping is then visualized with fluoroscopic imaging.1,15,32
Ultrasonography, bursography, and tenography all require an experienced operator; therefore,
the diagnostic capabilities of some imaging centers will be better than others. When the cause
of snapping has been determined, treatment can begin.
Conservative and Surgical Treatments
Most hip snapping is benign and painless and does not require treatment. Patients who have
symptomatic snapping that is troublesome tend to seek medical help. Nonoperative
management should be attempted first, including rest, avoiding movements that provoke
snapping, oral nonsteroidal anti-inflammatory medication, and physical therapy (table 1). (5 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
TABLE 1. Variations in Diagnosis and Treatment for 3 Types of Symptomatic Snapping Hip
Diagnostic Test
External Thickened posterior aspect
of the ITB or anterior gluteus
maximus rubs over greater
trochanter as hip is extended
Passive flexion of an extended Dynamic
hip may elicit a palpable and ultrasonography
audible snap with pain over
the greater trochanter
Activity modification,
ITB stretching, pain
medication (eg,
NSAIDs), steroid
injection, surgery
Internal Iliopsoas tendon rubs over
anterior hip capsule or
iliopectineal eminence
Passive extension, internal
rotation, and adduction of a
flexed, externally rotated,
and abducted hip may elicit
a palpable and audible snap
with pain in the anterior
hip or groin
Activity modification,
hip flexor stretching
and strengthening,
pelvic mobilization,
alignment exercises,
pain medication (eg,
NSAIDs), steroid
injection, surgery
IntraLoose bodies, torn acetabular Depends on cause
articular labrum, recurrent subluxation,
habitual hip dislocation in
children, or synovial
Static and
tenography, CT,
Plain x-rays,
Depends on cause
ITB = iliotibial band; NSAIDs = nonsteroidal anti-inflammatory drugs; CT = computed
tomography; MRI = magnetic resonance imaging
Stretching exercises. For patients who have external snapping, physical therapy should
include stretching of the ITB.6 In one exercise, the involved leg is crossed over the unaffected
leg in a standing position. The patient then leans to the uninvolved side until a stretch is felt on
the outside of the affected hip. Another exercise stretches the ITB by having the patient lie or
sit on the floor and bend and raise the affected leg (flexed knee) over the opposite leg (figure
3). For patients who have internal snapping, hip flexor stretching and strengthening, pelvic and
peripelvic mobilization, and alignment exercises are used to help ease pain.23 (6 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
Pelvic tilt should be addressed, because an increased anterior tilt may cause subtle tightening
of the hip flexor tendons. A pelvic tilt exercise can be performed by lying supine with the knees
flexed and the feet flat on the floor. The patient tightens the abdominal muscles and squeezes
the buttock muscles together, allowing the lower back to push into the floor. These exercises
should be done with care to avoid repetitive snapping.
Other modalities. Biofeedback may also help to teach the patient how to avoid repetitive hip
snapping. Local corticosteroid injection of the bursa may relieve pain and may help if other
nonoperative management fails.6 With these measures, most patients find relief and are able
to return to activities, with the caveat that they must continue to avoid repetitive snapping of
the hip.1,6,12 Nonoperative management of internal snapping hip is usually successful,23 but if
it is not, surgery may be needed.
Operative treatment. Surgery is sometimes indicated for an external snapping hip. Multiple
techniques have been suggested, from resection of a portion of the ITB and the trochanteric
bursa,6,8 to lengthening the band and transposing it anterior to the greater trochanter.11 The
goal of surgery is either to alter the anatomy and mechanics of the ITB so that it remains
anterior to the greater trochanter or to lessen the tension of the ITB so that it does not snap
over the greater trochanter. Surgery has decreased pain and snapping in a number of
studies.6,8,11 Despite these outcomes, surgery is not without risk. The most commonly
reported complications have been recurrence of pain and snapping.6,8,11
Although several approaches to operative treatment are used for internal snapping, the general
goal is to lengthen or release the iliopsoas tendon to decrease snapping and pain.2,12,33-36 (7 of 10)2/17/2005 9:51:59 AM
The Physician and Sportsmedicine: Symptomatic Snapping Hip
Despite relief from pain and snapping, some surgical complications can be serious. Recurrence
of snapping, weakness, and numbness were the most common complications of surgery for
internal snapping hip, and some patients required further surgery.2,12,33-36
Intra-articular snapping hip can result from a variety of lesions. Thus, whether treatment is
nonoperative or operative depends largely on the pathology. Hip arthroscopy may be both
diagnostic and therapeutic and can be used to debride a torn acetabular labrum or to remove
small loose bodies. An arthrotomy or other open procedures may be warranted for patients
who have synovial chondromatosis, large loose bodies, or instability.1,17,24,37
Snapping Reprise
The three basic types of snapping hip (external, internal, and intra-articular) can be painful and
limiting to active patients. A detailed history and physical exam are paramount to determine
the proper diagnosis. Various imaging modalities can further distinguish most causes of
snapping hip. Once the cause is determined, nonoperative care is often successful, but
operative treatments may be instituted if necessary. Both approaches achieve good results and
return patients to their activities.
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Dr Idjadi is an orthopedic resident and Dr Meislin is an assistant professor of orthopedic
surgery at New York University-Hospital for Joint Diseases in New York City. Address
correspondence to Robert Meislin, MD, NYU-Hospital for Joint Diseases, 301 E 17th St, New
York, NY 10003; address e-mail to [email protected].
Disclosure information: Drs Idjadi and Meislin disclose no significant relationship with any
manufacturer of any commercial product mentioned in this article. No drug is mentioned in this
article for an unlabeled use.
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The Physician and Sportsmedicine: Symptomatic Snapping Hip
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