Snapping Hip Syndrome Treatment & Management
- Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Craig C Young, MD more...
Treatment for a patient with snapping hip syndrome begins with a thorough examination. During the subjective evaluation, the clinician must question the patient to determine which actions exacerbate symptoms during daily activities and athletics. The objective examination is designed to determine the severity of pathology and to perform a biomechanical assessment. Included in the objective portion of the examination are the standard muscle-tendon unit and joint assessments. The information gathered in this portion of the examination can be used to guide specific elements of the treatment program. Muscle-tendon length and strength, joint mobility testing, and palpation of the injured area are key to a proper examination.
Biomechanical assessment of the patient includes both static (posture) and dynamic (gait/functional movement) elements. Inspect the entire lower extremity while it is static. Particular areas of attention during this portion of the examination include observation of genu recurvatum, knee flexion contracture, overpronation of the foot, hip flexion contracture, and the amount of internal or external rotation present in the lower extremity during static stance. Also take note of leg length. Gait analysis allows the clinician to confirm the findings of static examination and to observe if a movement dysfunction is present. Functional movements (eg, squatting, stair ascent/descent) may further demonstrate to the clinician the severity of the movement dysfunction. During examination, the clinician must be aware that even minor deviations in posture, gait, or functional movement can contribute to pathology.
External snapping hip syndrome
External snapping hip syndrome (iliotibial band, bursitis, or both) is commonly associated with physical therapy examination findings that include leg length difference (usually the long side is symptomatic), tightness in the iliotibial band on the involved side, weakness in hip abductors and external rotators, and poor lumbopelvic stability. Abnormal foot mechanics (eg, overpronation) leading to increased femoral internal rotation may also be a part of the clinical picture.
Muscle weakness, tightness, or both in the thigh or pelvis are addressed with a strengthening and stretching program. Overpronation may require a foot orthotic to assist with foot stabilization. Leg length deformities commonly require a lift in the shoe to assist with balancing the entire lower extremity (including the pelvis).
Internal snapping hip syndrome
Internal snapping hip syndrome (iliopsoas tendinitis, iliopsoas tendinosis, iliopsoas bursitis, or a combination) has a similar clinical picture. Commonly, the patient has an underlying mechanical problem in the lower extremity that eventually manifests in this region. The basis of physical therapy management is to treat the pathology with mechanical measures. Tightness, weakness, or both in the musculature of the hip and lumbopelvic region, leg length differences, and overpronation of the foot are common findings during the physical examination of patients with iliopsoas bursitis. Therapy consists of treating abnormalities identified during the physical examination.
Because the findings from the physical therapy examination are similar in iliopsoas and trochanteric bursitis, treatment of these pathologies is also similar. As described for trochanteric bursitis, every effort should be made to balance length and strength in musculature and to balance the biomechanics of the involved extremity to the uninvolved extremity. Lumbopelvic stability is particularly important in this patient population. Once treatment goals have been accomplished, restoration of normal movement patterns should decrease the mechanical stresses placed on the affected muscle, tendon, or bursa.
Treatment during the acute phase consists of standard anti-inflammatory care and elimination of activities that exacerbate symptoms. Physical therapy modalities (eg, ice, ultrasound, phonophoresis, electrical stimulation, iontophoresis) may be used during this time. Activity modification depends on the severity of the pathology. Crutches may be used in severe cases, while decreasing the time and intensity of the aggravating activity is commonly used in less severe cases.
In most cases, an acute event related to the onset of symptoms is not identified. During the acute phase of treatment for patients with pain associated with snapping hip syndrome, the initiation of relative rest, the application of ice, and a short course (eg. 10-21 d) of nonsteroidal anti-inflammatory drugs (NSAIDs), along with a physical therapy rehabilitation program, is the treatment of choice.
Perform this examination in a similar fashion to that described for the acute-phase examination (see Acute Phase, Physical Therapy). Again, the clinician emphasizes examination of the muscle-tendon units, joints of the lower extremity, and biomechanics of the lower extremity. Treatment programs are linked directly to examination findings. Patients are cautioned to eliminate repetitive motion activities (eg, running, cycling) until they are relatively asymptomatic. Premature return to repetitive motion activities may result in a resumption of symptoms.
During the rehabilitation treatment phase, the emphasis of treatment is physical therapy. Occasionally, patients may require intermittent NSAID therapy or simple analgesics as they progress in activities.
Several surgical interventions have been described for patients with persistent pain associated with a snapping hip that has failed to respond to an adequate trial of nonsurgical therapy. However, surgical intervention is rarely necessary in the management of this condition.
EXTERNAL SNAPPING HIP
One of several common surgical approaches to external snapping hip syndrome can be used:[15, 16, 17, 18, 19, 20]
The first is resection of the posterior half of the iliotibial tract at the insertion site of the gluteus maximus, with excision of the trochanteric bursa.
Alternatively, an elliptical resection of a portion of the iliotibial band overlying the greater trochanter, with removal of the trochanteric bursa, can be performed.[15, 20] This procedure, described by Zoltan et al., was performed in 5 patients and repeated at 11 months on a single patient with a recurrence of symptoms. All patients had resolution of their snapping, were involved in sports, and self-reported significant improvement.
Another approach involving a Z-plasty of the iliotibial band, resulting in lengthening of the tendon has been described.[16, 17] Brignall and Stainsby described this technique in 6 patients. A single patient required a second, more extensive Z-plasty to obtain symptom resolution. In all patients, snapping was absent and pain relief was excellent.
Provencher et al. reported that in 8 patients treated by Z-plasty, all but one had complete resolution of pain and 5 patients returned to activities such as daily running, hiking, or cycling. Finally, a step cut procedure involving the iliotibial tract over the greater trochanter was described by White et al. in which 14 of 16 patients had resolution of pain and symptoms, although it was unclear at what level of activity they were able to return.
Polesello et al. reported success with endoscopic release of the gluteus maximus tendon for management of external snapping hip due to snapping of the gluteus maximus tendon.
INTERNAL SNAPPING HIP
Several options are also available for surgical treatment of internal snapping hip syndrome.[21, 22, 23, 24, 25, 26] A lengthening procedure can be performed on the iliopsoas tendon, typically by partial release of the tendon. Jacobson and Allen described the results of this procedure after it was performed in 20 hips of 18 patients. At an average of 25 months of follow-up, 85% reported they were "much better." One patient reported no change in snapping and an increase in pain. Another 5 patients reported recurrence of snapping but with a reduced frequency and intensity of pain. Three patients reported subjective weakness in hip flexion; however, only a single patient had to modify his activity as a result of such weakness.
Gruen et al. reported 73% of patients returned to previous athletic activities with 45% also returning to their previous level of athletic participation following surgery. Hoskins et al. reviewed their experience with surgical correction by iliopsoas tendon fractional lengthening in 92 cases. Complications were noted in one third of patients and mostly included persistent hip pain, sensory deficits, and hip flexor weakness.
Other surgical options include resection of the bony prominence of the lesser trochanter, or a complete release of the iliopsoas tendon. Taylor et al. described release of the iliopsoas tendon in a case series of 14 patients (16 hips), which resulted in resolution of snapping in 63%, occasional snapping in 31%, and no change in snapping in a single patient. Pain resolved in 75% and was improved in the remaining 25% of patients at an average follow-up of 18 months. Two patients reported subjective weakness of hip flexion higher than 90°, but they regarded this to be a minor inconvenience. One possible explanation for these outcomes could be due to the description of regrowth of the psoas tendon after arthroscopic tenotomy which has been described previously.
Dobbs et al. reported outcomes for surgical fractional lengthening of the iliopsoas tendon in adolescents (mean age 15 yrs). At 4-year mean follow-up, all patients had returned to their preoperative level of activity without subjective weakness.
In a randomized study, Ilizaliturri et al. assessed the short-term results (minimum 1 year post-op) of two techniques for endoscopic iliopsoas tendon release for the treatment of internal snapping hip syndrome. Ten patients underwent endoscopic iliopsoas tendon release at the lesser trochanter and 9 matched patients underwent endoscopic transcapsular psoas release from the peripheral compartment. The investigators concluded that both endoscopic release techniques were effective, however, the authors did not comment on the patients' return to activity levels.
All of the aforementioned procedures generally have good outcomes in terms of decreased snapping and pain at follow-up.
Khan et al. concluded, in their systematic review of open versus arthroscopic management of internal snapping hip syndrome that arthroscopic management is the preferred surgical approach to internal snapping hip. Their review demonstrated that arthroscopic approaches resulted in lower failure rates, few complications, and decreased post operative pain when compared to an open surgical approach.
Consider referring those patients who are not responding well to medical and physical therapy for either an injection or potential surgical evaluation.
Other Treatment (Injection, manipulation, etc.)
A corticosteroid injection is indicated for patients with prolonged symptoms despite an adequate course of rehabilitation. The injection is administered under direct visualization via ultrasonic or bursographic guidance and consists of a combination of a corticosteroid (eg. betamethasone, triamcinolone) and local anesthetic (eg. lidocaine, bupivacaine). This combination may be injected either around the iliopsoas tendon or into the iliopsoas bursa.
Once symptoms have decreased and the patient is able to return to daily and athletic activities, a maintenance program of stretching and strengthening can be initiated. Programs typically consist of light aerobic activity (warmup) followed by stretching and strengthening. Maintenance of the proper hamstring, hip flexor, hip adductor, and iliotibial band length is important for reducing recurrences. Likewise, recommend a maintenance-level strength-training program at least twice a week to assist with lumbopelvic and lower extremity stability. Patients are typically started on a home program during the later stages of the recovery phase. The same home program can be modified for the maintenance phase of rehabilitation.
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