Snapping Hip Syndrome 

Updated: Aug 30, 2017
Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Craig C Young, MD 

Overview

Background

Snapping hip syndrome is characterized by an audible snap or click that occurs in or around the hip. This syndrome is well recognized but poorly understood. Snapping hip syndrome may be due to an external cause (eg., snapping of the iliotibial band or gluteus maximus over the greater trochanter) or an internal cause (eg., snapping of the iliopsoas tendon over the iliopectineal eminence, acetabular labral tear, intra-articular loose body). Acetabular labral tears and intra-articular loose bodies are relatively uncommon causes of internal snapping hip syndrome and are not discussed in detail. Snapping hip syndrome may be painful or painless. While some athletes may seek attention for a painless audible snap, most do not seek medical attention unless the snapping hip is painful.

Epidemiology

Frequency

United States

No data are available on the prevalence or incidence of snapping hip syndrome. The syndrome occurs most often in individuals aged 15-40 years and affects females slightly more often than males.[1] In one clinic, the rate of some form of snapping hip syndrome in female ballet dancers with hip complaints was 43.8%, and approximately 30% noted pain with this condition.[2]

Functional Anatomy

The pelvis is the link between the trunk and the lower extremities. The ball-and-socket joint of the hip allows for three degrees of freedom; approximately 120° of flexion, 20° of extension, 40° of abduction, 25° of adduction, and 45° each of internal and external rotation. The lateral hip's greater trochanteric region is a complex region with the convergence of several tendons (insertion of the gluteus minimus, medius and overlying gluteus maximus), the tensor fascia lata, the greater trochanteric bursa and the overlying iliotibial band. The iliotibial band is a ligament that originates from the iliac crest and inserts on the lateral proximal tibia. Crossing two joints, this ligament functions to flex and rotate the thigh medially.

The most common cause of a snapping hip is the iliotibial band snapping over the greater trochanter. This may be associated with trochanteric bursitis or with increased varus of the hip. The finding of a tight iliotibial band is common. Sudden loading of the hip (eg., landing after a jump) may reproduce this sensation of the iliotibial band subluxing over the greater trochanter. With sudden loading, the hip typically is flexed, causing the iliotibial band to move anteriorly followed by the tendon snapping backward as the individual recovers and extends the hip.

The gluteus maximus is the largest of the gluteal muscles and functions as an extensor and external rotator of the hip. Originating along the posterior ilium, dorsal surface of the sacrum, and gluteal aponeurosis, the gluteus maximus inserts on the iliotibial tract and gluteal tuberosity of the femur. During extension of the hip, the distal border may snap over the greater trochanter of the femur. Jacobsen et al. described the finding of hip abductor weakness in eccentric strength as compared to healthy matched controls.[3] Whether this finding is causal or simply associated with symptomatic external snapping hip is unknown at this time.

The psoas and iliacus muscles originate from the lumbar spine and pelvis, respectively, and are innervated by the L1, L2, and L3 nerve roots. These muscles converge to form the iliopsoas muscle and insert onto the lesser trochanter of the proximal femur as the iliopsoas tendon. The psoas major tendon exhibits a characteristic rotation through its course, transforming its ventral surface into a medial surface and its dorsal surface into a lateral surface.[4] The iliac portion of this tendon has a more lateral position and the most lateral muscle fibers of the iliacus muscle insert onto the lesser trochanter of the femur without joining the main tendon.[4] The iliopsoas muscle passes anterior to the pelvic brim and hip capsule in a groove between the anterior inferior iliac spine laterally and the iliopectineal eminence medially.[4] The musculotendinous junction is consistently found at the level of this groove.

The iliopsoas muscle functions as a hip flexor and external rotator of the thigh. Furthermore, an iliopsoas-infratrochanteric muscular bundle has been described, which likely relates to the iliopsoas tendon. This muscular bundle arises from the anterior inferior iliac spine (above the origin of the rectus femoris muscle), courses along the anterolateral aspect of the iliacus muscle, and inserts without a tendon onto the anterior surface of the lesser trochanter of the femur.[4] The iliopsoas bursa lies between the musculotendinous junction of the iliopsoas and the pelvic brim. An internal cause of snapping hip has been described as the iliopsoas tendon snapping over the iliopectineal eminence, hip capsule itself, or less likely the lesser trochanter. The motion of extending a flexed, abducted, and externally rotated hip reproduces the snapping phenomenon.

Among ballet dancers, those with snapping hip have a narrow bi-iliac width, greater range of movement in hip abduction, decreased range of motion in external rotation, and greater strength in the external rotators of the hip.[5] These findings suggest that skeletal or biomechanical conditions may predispose an individual to the development of a snapping hip.

Sport-Specific Biomechanics

In snapping hip syndrome, slightly different biomechanics are involved with the iliotibial band than with the iliopsoas musculotendinous unit.[6] This condition may develop as the result of an acute injury leading to subsequent bursitis, tendinitis, or biomechanical changes. More commonly, snapping hip syndrome is the result of repetitive overuse.

External snapping hip syndrome may be caused by either the iliotibial band or gluteus maximus snapping over the greater trochanter. Subluxation of the iliotibial band over the greater trochanter may occur while the hip extends from a flexed position (in which the iliotibial band moves from a position anterior to the greater trochanter to a position posterior to the greater trochanter). This action is most pronounced with sudden loading of the hip joint into a flexed position, such as occurs when landing a jump (eg. dismounting from an apparatus in gymnastics, rebounding in basketball, long jumping in track-and-field competitions).

The gluteus maximus is a powerful extensor of the thigh and trunk when the lower extremities are fixed. However, it is posturally unimportant, relaxed with standing, and used little in walking. The gluteus maximus is used in activities such as running, climbing, and rising from a seated or stooped position. It also regulates flexion at the hip (a paradoxical action).[6]

Internal snapping hip syndrome is most commonly caused by a snapping of the iliopsoas tendon over the iliopectineal eminence. As an overuse phenomenon, this condition may occur in any activity resulting in repeated hip flexion or external rotation of the femur. Activities that may predispose to iliopsoas tendinitis include dancing, ballet, resistance training (eg. squats), rowing, running (particularly uphill), track and field, soccer, and gymnastics.

During the adolescent growth spurt, a tendency exists for the hip flexors to become relatively inflexible. For younger athletes, this can lead to problems as increased stress is placed on the iliopsoas musculotendinous unit and general biomechanics are altered. Tightness of the iliopsoas, tensor fascia lata, or rectus femoris can lead to inhibition of the gluteus maximus, allowing for an anterior pelvic tilt, which can lead to adverse affects on the kinetic chain.

Excessive anterior tilt due to a tight iliopsoas muscle, tight hip adductors, and a relatively weak rectus abdominis can lead to increased lumbar lordosis with subsequent increased stress on the lower lumbar disks, facet joints, and sacroiliac joints. This also may result in increased knee flexion during gait at the heel-strike and midstance phases. The increase in eccentric load across the knee extensor mechanism may result in patellar tendon injuries (eg. patellar tendinitis, Osgood-Schlatter disease). With increased knee flexion, compressive forces at the patellofemoral articulation increase and may predispose to patellofemoral problems.

 

Presentation

History

See the list below:

  • The location may be described as lateral (indicating the iliotibial band or gluteus maximus) or anterior and deep in the groin (indicating the iliopsoas tendon).

  • Often the sensation of the hip subluxing or dislocating is described and is associated with the iliotibial band or external snapping hip. This can be quite a dramatic presentation and accounts for the description that external snapping hip is the condition that you "see".

  • Individuals with internal snapping hip present with reports of an audible snap or click in the hip, which may be either painless or painful. The audible snap is due to the snapping of the iliopsoas tendon and accounts for the description that iliopsoas snapping hip is the condition that you "hear".

  • Patients reporting anterior groin pain usually note that the pain is dull or aching in nature and is exacerbated by extension of the flexed, abducted, and externally rotated hip.

  • The pain and snapping may subside with decreased activity and rest.

  • The duration of symptoms at presentation more commonly is several months or years rather than days or weeks.

Physical

An individual with hip pain should undergo a careful examination of the abdomen, pelvis, groin, and thigh. Additionally, consider a gynecologic examination for women presenting with groin pain.

Inspection

See the list below:

  • Examine the gait for abnormalities in biomechanics.

  • If associated iliopsoas tendinitis is present, the patient may have a flexed knee in the heel-strike and midstance phases of gait.

  • Observe reproduction of the snapping.

  • External snapping hip syndrome associated with subluxation of the iliotibial band over the greater trochanter may be dramatic and appear as if the patient is subluxing their hip.

Palpation

See the list below:

  • Those with external snapping hip syndrome may have tenderness over the proximal iliotibial band, lateral margin of the gluteus maximus, or trochanteric bursa.

  • Those with internal snapping hip syndrome associated with a tight iliopsoas tendon may demonstrate an anterior pelvic tilt with resulting hamstring inflexibility. Snapping occurs with extension of the flexed, abducted, and externally rotated hip. Tenderness may be elicited in the femoral triangle, and the actual snapping is often palpable in conjunction with the audible snap.

Functional testing

See the list below:

  • External snapping hip syndrome symptoms can often be reproduced with passive internal and external rotation of the hip with the patient in the side-lying position.

  • Internal snapping hip syndrome symptoms (i.e. snapping and associated pain, if present) can be reproduced with extension of the flexed (30°), abducted, and externally rotated hip. The authors have also noted that active movement of the affected hip from a neutral position to one of flexion, abduction, and external rotation may also reproduce the snapping. Additionally, if the patient has associated iliopsoas tendinitis, resisted hip flexion at 15° with the patient seated and the knee extended, palpation of the psoas muscle just below the lateral half of the inguinal ligament reproduces the pain, if not the snapping.

Causes

Snapping hip syndrome has been attributed to multiple mechanisms associated with the skeletal architecture of the hip and pelvis and with the muscles, tendons, and ligaments around the hip. Snapping hip has been described according to the location of the mechanism as external, internal, or posterior. Despite the many descriptions of possible mechanisms, the most common causes of snapping hip syndrome include either subluxation of the iliotibial band over the greater trochanter or sudden movement of the iliopsoas tendon over the iliopectineal eminence.

  • External snapping hip syndrome is primarily caused by subluxation of the iliotibial band over the greater trochanter of the femur. It has also been described as a snapping of the outer border of the gluteus maximus over the greater trochanter.[7] Eccentric hip abduction strength has been described in individuals with external snapping hip and may be a contributing factor, though a clear causal relationship has not been determined.[3]

  • Internal snapping hip syndrome occurs by one of several mechanisms.

    • The most common cause is believed to be the iliopsoas tendon sliding over the iliopectineal eminence, resulting in an audible "snap" or "pop". This typically occurs while the hip suddenly moves into extension from a flexed and externally rotated position.

    • The iliopsoas tendon also may produce snapping with sudden movement over the anterior inferior iliac spine or possibly the bony ridge on the lesser trochanter.

    • Less common causes of internal snapping hip syndrome include movement of the iliofemoral ligaments over the femoral head or anterior capsule of the hip.[8]

  • Posterior snapping hip syndrome is uncommon and is caused by movement of the long head tendon of the biceps femoris over the ischial tuberosity.

 

DDx

Diagnostic Considerations

Acetabular labral tear

Bursitis; greater trochanteric (external), or iliopsoas (internal)

Intra-articular loose body of the hip

Synovitis

Differential Diagnoses

 

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

See the list below:

  • 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

See the list below:

  • Ultrasound is a useful, noninvasive diagnostic adjunct because it may demonstrate changes in anatomy and provide an assessment of function.[9] 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.[7] 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.[10]

  • Deslandes et al. demonstrated other mechanisms of the snapping iliopsoas tendon with dynamic ultrasound.[8] Among their findings of causes of snapping hip: sudden iliopsoas tendon flipping over the iliac muscle (4 of 18) (most common cause); bifid iliopsoas tendon heads flipping over one another (3 of 18); and iliopsoas tendon impingement over an anterior paralabral cyst (1 of 18).[8]

  • 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 and 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

See the list below:

  • 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).[11]

  • Reproduction of symptoms associated with abnormal movement of the iliopsoas tendon has been considered by some to be diagnostic of internal snapping hip syndrome.

  • 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

See the list below:

  • 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.[12]

  • For cases involving the iliotibial band, fluid may be found in the trochanteric bursa and is typically seen best on STIR or T2-weighted images.

  • In cases involving the iliopsoas tendon, the tendon may be thicker relative to the contralateral side; the iliopsoas bursa may demonstrate fluid. Additionally or independently, changes may occur that are consistent with an iliopsoas tendinitis, tendinosis, or both.[10] Most of these findings are suggested by increased signal intensity on STIR or T2-weighted images.

Magnetic resonance arthrogram

See the list below:

  • 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 or intra-articular loose bodies 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.[13]

Procedures

Lidocaine challenge test

See the list below:

  • This is performed under direct visualization of the iliopsoas tendon via bursography or ultrasound.[14]

  • 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

See the list below:

  • 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.[15, 13]

  • Labral tears may result from more subtle causes, such as minor trauma, hip subluxation, underlying acetabular dysplasia, or femoral acetabular impingement.

  • 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 treatment via hip arthroscopy.

 

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

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.

Medical Issues/Complications

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.

Recovery Phase

Rehabilitation Program

Physical Therapy

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.

Medical Issues/Complications

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.

Surgical Intervention

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.[16] 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:[17, 18, 19, 20, 21, 22]

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.[17, 22] 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.[17] 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.[18, 19] Brignall and Stainsby described this technique in 6 patients.[18] 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.[19] 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.[20]

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.[21]

A study on 229 bilateral and 19 unilateral external snapping hips by Shrestha et al reported arthroscopic surgery as an effective procedure with less operating time, a small scar, fast postoperative recovery and complete contracture release.[23]

INTERNAL SNAPPING HIP

Several options are also available for surgical treatment of internal snapping hip syndrome.[24, 25, 26, 27, 28, 29] 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.[24] 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.[24] 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.[25] Hoskins et al. reviewed their experience with surgical correction by iliopsoas tendon fractional lengthening in 92 cases.[26] 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.[29] Pain resolved in 75% and was improved in the remaining 25% of patients at an average follow-up of 18 months.[29] Two patients reported subjective weakness of hip flexion higher than 90°, but they regarded this to be a minor inconvenience.[29] 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.[30]

Dobbs et al. reported outcomes for surgical fractional lengthening of the iliopsoas tendon in adolescents (mean age 15 yrs).[27] 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.[28] 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.[28]

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.[31] 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.[31]

Consultations

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.

Maintenance Phase

Rehabilitation Program

Physical Therapy

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.

 

Medication

Medication Summary

NSAIDs are the drugs of choice for treating pain associated with snapping hip syndrome. This class of drugs provides good analgesia and possible anti-inflammatory effects for concomitant conditions.

Nonsteroidal anti-inflammatory drugs

Class Summary

These drugs have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known, but NSAIDs may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may coexist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of COX, which is responsible for prostaglandin synthesis. May demonstrate more analgesia compared to ibuprofen.

Cyclooxygenase-2 inhibitors

Class Summary

Although increased cost can be a negative factor, the incidence of expensive and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define populations that will benefit most from COX-2 inhibitors.

Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek lowest dose for patient.

Analgesic agents

Class Summary

Simple analgesics may be preferred for conditions in which NSAIDs are not advised or for which an underlying inflammatory process is doubtful.

Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs or those diagnosed with upper GI disease or on oral anticoagulants.

 

Follow-up

Return to Play

Patients may return to activities as tolerated. The return to sports activities is safe once the patient is free from pain and is capable of demonstrating sports-specific activities. This generally requires full flexibility at the involved hip, and recovery of at least 90% of the strength of the involved lower extremity as compared to the uninvolved lower extremity.

For individuals who present with internal snapping hip in the absence of any pain or limitation, activity is generally not restricted; however, the authors find it prudent to fully assess the iliopsoas complex and implement an appropriate course of flexibility training and strengthening of the hip stabilizers (with attention to the iliopsoas and hip flexors) in order to prevent further problems.

Prevention

The primary goal for prevention of snapping hip syndrome is maintenance of good flexibility and strength in the hip and pelvis.[2]