Snapping Hip Syndrome Workup

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

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Imaging Studies

Plain radiographs

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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]
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Procedures

Lidocaine challenge test

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  • 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

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  • 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.
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