Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Snapping Hip

Basics
Description
  • Snapping of the hip is a sensation that is normally felt on an infrequent basis by many people.
    • If it becomes frequent or painful, patients may seek attention and treatment.
    • The causes may include structures outside or inside the joint.
  • Synonyms: Popping hip; Tendinitis; Coxa saltans
General Prevention
  • Perform adequate stretching before and after sports.
  • Avoid frequent intramuscular injections into the gluteal muscles.
Epidemiology
  • Snapping of the hip may occur at any age, including in the elderly.
  • It is slightly more common in females than in males.
Incidence
  • Uncommon clinical problem
  • No statistics on frequency or prevalence
Risk Factors
  • Coxa vara, or decreased angle of the femoral neck, renders the greater trochanter more prominent and increases the risk of snapping.
  • Another risk factor is a history of multiple intramuscular injections into the buttock, which may cause fibrosis of the gluteus and, in turn, may predispose to snapping.
  • Athletes who increase their training to an extreme degree may also develop this condition.
Genetics
No known genetic predisposition exists.
Etiology
  • Internal:
    • A structure in front of the joint, such as the psoas tendon, causes the snapping by riding over the front of the femoral head or the pubic ramus.
  • External:
    • May be from snapping of the iliotibial band or the anterior fibers of the gluteus maximus riding over the greater trochanter.
    • May follow multiple intramuscular injections into the buttock, which render the gluteus and iliotibial band fibrotic and contracted.
  • Intra-articular:
    • Includes loose bodies or a tear in the acetabular labrum, which may cause sensation of snapping or clicking.
    • Rarely, may occur after total hip arthroplasty secondary to malposition or loosening of the femoral component.
Associated Conditions
Snapping hip usually occurs in isolation and is not related to any systemic conditions or other skeletal problems.
Diagnosis
Signs and Symptoms
  • The patient has a sensation of muscle jumping over the front or the side of the hip.
    • The patient may be able to point to the location of snapping, thus aiding in the diagnosis.
  • The patient may have difficulty getting into or arising from a squat.
  • The diagnosis may be confirmed by blocking the movement of the psoas or the iliotibial band during flexion and extension of the hip.
History
  • Patients note the spontaneous onset of snapping or popping of the hip, usually in the absence of trauma.
  • It is more common in athletes than in the general population, and typically begins in the juvenile or adolescent period.
  • Ask the patient about what activity or position produces the snapping, and its frequency.
Physical Exam
  • Ask the patient to point to the area where the snapping is felt.
    • This procedure is helpful in distinguishing snapping of the iliotibial band (lateral) from the psoas (anteriorly).
  • Ask the patient if, he/she can reproduce the snapping.
  • For psoas tendon snapping over the pectineal eminence, the figure 4 test is helpful.
    • This test consists of the patient actively moving the affected hip from extension to a figure 4 or flexed and abducted position while keeping the foot in the midline.
  • To test for the snapping iliotibial band, the patient is placed in the lateral position on the opposite hip, and the hip in question is flexed and extended in progressively greater adduction.
    • Note the presence of abduction contracture, reproduction of symptoms, and actual snapping.
Tests
Imaging
  • Plain radiography of the pelvis is indicated to rule out any bony abnormality of the pelvis or joint.
  • CT scan may be helpful if a structural abnormality is found.
  • Ultrasound has been reported to document dynamically the snapping and possibly to guide injection, but it requires experience.
  • Iliopsoas bursography is done under fluoroscopy, with contrast medium injected anteriorly into the bursa.
    • If the psoas tendon is the cause, it may be seen to flip over the front of the hip corresponding with the symptoms.
    • Psoas tendon and bursa can be injected with steroid and lidocaine at this time.
    • If the injection relieves symptoms, it is additional confirmation of the diagnosis.
  • Injection of the greater trochanteric bursa does not require imaging but is a helpful confirmatory test.
  • A hip arthrogram, combined with CT scan may be helpful in diagnosing a torn acetabular labrum.
  • MRI may be helpful to rule out other conditions or diagnose acetabular labral tears .
Diagnostic Procedures/Surgery
Hip arthroscopy may be useful in confirming an intra-articular cause and treating a torn labrum or loose body.

Pathological Findings
  • Internal type of snapping hip:
    • The psoas and iliacus tendons ride in a shallow groove between the iliopectineal eminence and the anterior inferior iliac spine.
    • They may cause snapping by riding over each other, over the psoas bursa, or over the bone during flexion and extension.
  • The iliotibial band attaches to the tensor fasciae latae and the gluteus maximus and minimus.
    • It remains taut during flexion and extension, and it rides over the trochanteric bursa.
    • Any thickening of this bursa, or increasing tension of the tendon, may contribute to the snapping.
Differential Diagnosis
  • Snapping of the meniscus may masquerade as snapping hip because the hip and knee usually flex together.
  • Exostosis around the hip may contribute to snapping.
  • Habitual hip subluxation in children and adolescents is an uncommon phenomenon, which may be confused with a snapping hip.
Treatment
General Measures
  • Injection into the appropriate region is an intermittent step between physical therapy and surgery.
    • It may be done using a mixture of local anesthetics (e.g., lidocaine) to confirm the diagnosis and steroids to interrupt the inflammatory cycle and perhaps provide permanent relief.
  • Make the diagnosis by physical examination and imaging.
  • The extent of treatment depends on how much snapping bothers the patient.
    • If the snapping is severe, the following are advised:
      • Avoidance of provocative activities
      • Stretching exercises
      • Anti-inflammatory medications
      • Injection with steroids may be repeated every 6 months.
      • Surgery
  • The patient should refrain from activities involving flexion and extension, or adduction (such as running on the side of an incline), which may predispose to snapping.
Special Therapy
Physical Therapy
Stretching the iliotibial band or psoas tendon may alleviate the problem.

Medication
First Line
  • NSAIDs:
    • Dosing schedules vary from quick-onset, short duration, to once-a-day agents, which are less effective for acute pain.
    • Gastrointestinal upset is a possible side effect, and these drugs are to be used cautiously in patients with a history of gastric ulcer disease.
  • Narcotics should be avoided.
Surgery
  • If other measures do not help, surgery may be offered, depending on the underlying cause.
    • If the cause is the iliotibial band, it can be incised over the greater trochanter to relieve the pressure.
    • If the cause is the psoas tendon, it may be lengthened at the pelvic brim.
  • Surgery is reserved for the most recalcitrant cases because the results are unpredictable when no structural abnormalities have been identified.
  • Intra-articular factors, such as a loose body or a torn acetabular labrum, may be dealt with appropriately.
Follow-up
Prognosis
  • Usually not a long-standing problem
  • Does not lead to arthritis
Complications
  • Failure to improve is the most common complication .
  • Femoral neuropathy is another possible risk of psoas lengthening.
Patient Monitoring
Because this condition is benign, patients may be allowed to self-monitor and return for follow-up if symptoms warrant.
Miscellaneous
Codes
ICD9-CM
  • 719.65 Snapping hip
  • 726.0 Bursitis
Patient Teaching
The phenomenon of a snapping tendon or other structure, including the rationale for rest and stretching, should be explained to the patient.
FAQ
Q: Is snapping hip likely to lead to arthritis?
A: No. It does not normally lead to arthritis because most causes are outside the joint.

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