eMedicine Specialties > Sports Medicine > Hip

Snapping Hip Syndrome: Differential Diagnoses & Workup

Author: Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Department of Family Medicine, Associate Professor of Family Medicine and Exercise & Sport Science, East Carolina University Brody School of Medicine
Coauthor(s): Walter L Jenkins, MS, PT, ATC, Interim Chair, Department of Physical Therapy, Clinical Professor, East Carolina University
Contributor Information and Disclosures

Updated: Jun 15, 2006

Differential Diagnoses

Femoral Head Avascular Necrosis
Hip Overuse Syndrome
Iliopsoas Tendinitis
Iliotibial Band Syndrome

Other Problems to Be Considered

Acetabular labral tear
Bursitis
Intra-articular loose body
Synovitis

Workup

Laboratory Studies

  • Specific laboratory studies are not indicated. For an individual in whom the hip pain is of an unclear origin or with imaging study results suggestive of other pathology, specific consideration should be given for diagnostic laboratory studies at that time.

Imaging Studies

  • Plain radiographs
    • Plain films are not necessary if the diagnosis based on history and clinical examination findings is definitive. A literature review of the use of radiographs in snapping hip syndrome diagnosis demonstrated that 100% of the radiographs were within normal limits.
    • Plain films, which should consist of an anteroposterior pelvis and a frog-leg lateral view of the affected hip, may be of more benefit if the diagnosis is unclear or a bony etiology is being considered.
       
  • Ultrasound
    • Ultrasound is a useful, noninvasive diagnostic adjunct because it may demonstrate changes in anatomy and provide an assessment of function. Choi et al demonstrated that ultrasound correctly identified the abnormal motion of the iliotibial band or gluteus maximus tendon in cases of external snapping hip syndrome. Janzen et al demonstrated the usefulness of ultrasound by showing the iliopsoas tendon snapping over the iliopectineal eminence in cases of internal snapping hip syndrome. This imaging technique is highly user-dependent and may not be the best test at an institution in which the personnel are unaccustomed to performing this specific examination.
    • An additional benefit of ultrasound in the case of internal snapping hip syndrome is the ability to visualize the iliopsoas tendon to provide a directed injection of anesthetic. The possible subsequent pain relief allows the physician to further examine patients in whom pain has been a limiting factor.
       
  • Bursography
    • Bursography is an invasive technique that involves injecting the iliopsoas bursa with a contrast agent under fluoroscopic guidance and subsequent imaging of the iliopsoas tendon during aggravating motions of the hip (typically extension of a flexed, abducted, and externally rotated hip).
    • Reproduction of symptoms associated with abnormal movement of the iliopsoas tendon has been considered by some to be diagnostic of internal snapping hip syndrome due to abnormal movement of the iliopsoas tendon.
    • A potential problem with this technique is a lack of imaging in asymptomatic control subjects, which may allow for a better understanding of the normal motion of the iliopsoas tendon.
       
  • MRI

    • MRI is generally a test of anatomical structure rather than function. MRI may demonstrate a constellation of findings in a person with snapping hip syndrome.
    • For cases involving the iliotibial band, fluid may be found in the trochanteric bursa and is typically seen best on T2-weighted images.
    • In cases involving the iliopsoas tendon, the tendon may be thicker relative to the contralateral side; the iliopsoas bursa may have fluid. Additionally or independently, changes may occur that are consistent with an iliopsoas tendinitis, tendinosis, or both. Most of these findings are suggested by increased signal intensity on T2-weighted images.
       
  • Magnetic resonance arthrogram

    • The use of a magnetic resonance arthrogram (MRA) of the hip may be useful in determining other causes of internal snapping hip, particularly when a labral tear might be considered. MRA has been shown to be more sensitive in demonstrating labral tears of the hip than MRI, though MRA has little use in the diagnosis of either iliopsoas snapping hip or iliopsoas tendonitis.

Procedures

  • Lidocaine challenge test
    • This is performed under direct visualization of the iliopsoas tendon via bursography or ultrasound.
    • Generally, 7-10 mL of 2% lidocaine is injected into either the iliopsoas bursa or around the iliopsoas tendon.
    • Ablation of the patient's symptoms after injection is diagnostic.
       
  • Hip arthroscopy
    • In cases in which the diagnosis of internal snapping hip is not clearly differentiated from an acetabular labral tear, hip arthroscopy may be of benefit for diagnosis and for repair of any underlying pathology.
    • Labral tears may result from more subtle causes, such as hip subluxation or underlying acetabular dysplasia.
    • Difficulty arises in that labral tears may manifest with symptoms similar to internal snapping hip syndrome. The symptoms of a labral tear may begin at the time of injury, or onset may be more insidious. In the case of an anterior labral tear, the physical examination findings may be extraordinarily similar, thereby allowing for both definitive diagnosis and possible treatment via arthroscopy.

More on Snapping Hip Syndrome

Overview: Snapping Hip Syndrome
Differential Diagnoses & Workup: Snapping Hip Syndrome
Treatment & Medication: Snapping Hip Syndrome
Follow-up: Snapping Hip Syndrome
References
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References

  1. Beattie P. The Hip. In: Malone TR, McPoil T, Nitz AJ, eds. Orthopedic and Sports Physical Therapy. 3rd ed. St. Louis, Mo: Mosby; 1997:459-508.

  2. Brignall CG, Stainsby GD. The snapping hip. Treatment by Z-plasty. J Bone Joint Surg Br. Mar 1991;73(2):253-4. [Medline].

  3. Byrd JWT, Jones KS. Diagnositc Accuracy of Clinical Assessment, Magnetic Resonance Imaging, Magnetic Resonance Arthrography, and Intra-articular Injection in Hip Arthroscopy Patients. American Journal of Sports Medicine. 2004;32:1668-1674.

  4. Choi YS, Lee SM, Song BY, Paik SH, Yoon YK. Dynamic sonography of external snapping hip syndrome. J Ultrasound Med. 2002;21:753-758.

  5. De Paulis F, Cacchio A, Michelini O, et al. Sports injuries in the pelvis and hip: diagnostic imaging. Eur J Radiol. May 1998;27 Suppl 1:S49-59. [Medline].

  6. Dobbs MB, Gordon E, Luhmann SJ, Szymanski DA, Schoenecker PL. Surgical correction of the snapping iliopsoas tendon in adolescents. Journal of Bone and Joint Surgery. 2002;84A(3):420-424.

  7. Gruen GS, Scioscia TN, Lowenstein JE. The surgical treatment of internal snapping hip. American Journal of Sports Medicine. 2002;30(4):607-613.

  8. Hecox B, Mohrotoab TA, Weisberg J. Physical Agents: A Comprehensive Text for Physical Therapists. New York, NY: Prentice-Hall; 1994:176-177.

  9. Hoskins JS, Burd TA, Allen WC. Surgical correction of internal coxa saltans: A 20 year consecutive study. American Journal of Sports Medicine. 2004;32(4):998-1001.

  10. Howse AJ. Orthopaedists aid ballet. Clin Orthop Relat Res. 1972;89:52-63. [Medline].

  11. Hruska R. Pelvic stability: influences of lower-extremity kinematics. Biomechanics. June 1998;6:23-9.

  12. Jacobs M, Young R. Snapping hip phenomenon among dancers. Am Correct Ther J. May-Jun 1978;32(3):92-8. [Medline].

  13. Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med. Sep-Oct 1990;18(5):470-4. [Medline].

  14. Janzen DL, Partridge E, Logan PM, et al. The snapping hip: clinical and imaging findings in transient subluxation of the iliopsoas tendon. Can Assoc Radiol J. Jun 1996;47(3):202-8. [Medline].

  15. Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series. J Orthop Sports Phys Ther. Apr 1999;29(4):218-24. [Medline].

  16. Johnston CA, Wiley JP, Lindsay DM, Wiseman DA. Iliopsoas bursitis and tendinitis. A review. Sports Med. Apr 1998;25(4):271-83. [Medline].

  17. Keskula DR, Lott J, Duncan JB. Snapping iliopsoas tendon in a recreational athlete: a case report. J Nat Athl Trainer Assoc. 1999;34(4):382-85.

  18. Larsen E, Johansen J. Snapping hip. Acta Orthop Scand. Apr 1986;57(2):168-70. [Medline].

  19. Nelson RM, Currier DP. Clinical Electrotherapy. 3rd ed. Norwalk, Conn: Appleton & Lange; 1987:180-181, 205-206, 226, 239.

  20. Provencher MT, Hofmeister EP, Muldoon MP. The surgical treatment of external coxa saltans (the snapping hip) by z-plasty of the iliotibial band. American Journal of Sports Medicine. 2004;32(2):470-476.

  21. Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports Med. Nov 1988;6(5):295-307. [Medline].

  22. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma. Sep 1987;27(9):980-6. [Medline].

  23. Sanders B, Nemeth WC. Hip and thigh injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:599-622.

  24. Schaberg JE, Harper MC, Allen WC. The snapping hip syndrome. Am J Sports Med. Sep-Oct 1984;12(5):361-5. [Medline].

  25. Scott R. Snapping hip syndrome. Orthopedic Practice. 1997;9(3):6-9.

  26. Tatu L, Parratte B, Vuillier F, Diop M, Monnier G. Descriptive anatomy of the femoral portion of the iliopsoas muscle. Anatomical basis of anterior snapping of the hip. Surg Radiol Anat. 2001;23:371-374.

  27. Taylor GR, Clarke NM. Surgical release of the 'snapping iliopsoas tendon'. J Bone Joint Surg Br. Nov 1995;77(6):881-3. [Medline].

  28. Vaccaro JP, Sauser DD, Beals RK. Iliopsoas bursa imaging: efficacy in depicting abnormal iliopsoas tendon motion in patients with internal snapping hip syndrome. Radiology. Dec 1995;197(3):853-6. [Medline].

  29. White RA, Hughes MS, Burd T, Hamann J, Allen WC. A new operative approach in the correction of external coxa saltans. The snapping hip. American Journal of Sports Medicine. 2004;32(6):1504-1508.

  30. Zoltan DJ, Clancy WG Jr, Keene JS. A new operative approach to snapping hip and refractory trochanteric bursitis in athletes. Am J Sports Med. May-Jun 1986;14(3):201-4. [Medline].

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Further Reading

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Keywords

iliotibial band subluxation, iliopsoas syndrome, external snapping hip syndrome, internal snapping hip syndrome, hip disorder, hip injury, snapping hip

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Contributor Information and Disclosures

Author

Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Department of Family Medicine, Associate Professor of Family Medicine and Exercise & Sport Science, East Carolina University Brody School of Medicine
Joseph P Garry, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, North American Primary Care Research Group, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Walter L Jenkins, MS, PT, ATC, Interim Chair, Department of Physical Therapy, Clinical Professor, East Carolina University
Walter L Jenkins, MS, PT, ATC is a member of the following medical societies: American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

Andrew D Perron, MD, Residency Director, Department of Emergency Medicine, Maine Medical Center
Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose.

Chief Editor

William Jay Bryan, MD, Clinical Professor, Department of Orthopedic Surgery, Baylor University College of Medicine
William Jay Bryan, MD is a member of the following medical societies: Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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