PT Classroom - Understanding Snapping Hip Syndrome  ׀ by Lauren Hogan, PT, DPT, ATC

 

Lauren Hogan, PT, DPT, ATC, graduated with her Doctor of Physical Therapy degree from Marquette University in May of 2010. She also received her bachelor of science degree in athletic training from Marquette University in 2008. Lauren works as a physical therapist at Froedtert and The Medical College of Wisconsin in outpatient orthopedics and has a special interest in the treatment of post-concussive syndrome.

 

Understanding Snapping Hip Syndrome

Snapping hip, or coxa saltans, is a common complaint of patients seeking physical therapy. Patients generally complain of hip pain and a “snapping” sensation around the joint with activity (1). A clinician may be able to feel or hear snapping or clunking palpating while the patient moves. Coxa saltans may be intra-articular or extra-articular, and determining the specific cause will affect treatment.
 

    Source of Snapping   Aggravating Activities   Conservative Treatment   Other Treatment
Intra-Articular   Derangement within the joint - labral tears, chondral tears, loose bodies, etc.   Often combined flexion and internal rotation activities   Hip mobilization, pain free stretching, core and hip strengthening   Surgery to repair or address intra-articular pathology
Internal   Iliopsoas tendon moves over the iliopectinal eminence, femoral head, or lesser trochanter   Moving from flexion and external rotation to extension and internal rotation (may be palpable by PT) or activities that require high flexion or contraction of the hip flexors while in hip extension--often soccer, gymnastics, dance, martial arts, football, running   Hip flexor stretching, strengthening internal and external rotators, eccentric hip flexor strengthening, possibly ultrasound to iliopsoas tendon   Injection of lidocaine and corticosteroids to iliopsoas bursa under fluoroscopy, fractional lengthening of iliopsoas tendon
External   Iliotibial (IT) band rubbing over the greater trochanter leading to irritation of the greater trochanteric bursa   Direct pressure (lying on involved side), sit-to-stand, running, stair navigation, walking on inclines   Rest, gentle stretching, internal/external rotator and core strengthening, inflammation control, including ice, modalities and NSAIDs   Corticosteroid injection to the greater trochanteric bursa

(Table Sources - 1,4)

Intra-articular coxa saltans is caused by derangement within the hip joint, and is often due to a labral tear, chondral damage, or loose bodies (1). These patients may have a non-capsular limitation in range of motion, often into internal rotation and adduction (4). Treatment may consist of hip mobilization, stretching, core and hip strengthening. In cases that are not responding to conservative care, surgical management is often considered (4).

Internal snapping hip occurs when the iliopsoas tendon rubs over the iliopectinal eminence, femoral head, or lesser trochanter. The patient generally complains of a painful clicking or “clunking” through the front of the hip with activity. This condition often affects athletes that repetitively move into positions of hip flexion with internal or external rotation, such as gymnasts, dancers, football players, runners and those in the martial arts (1). The “clunk” can often be reproduced with active movement by the patient or when being passively moved from combined hip flexion and external rotation to hip extension and internal rotation. There is generally no loss of hip range of motion (4). Symptoms may be similar to intra-articular derangement, which can make diagnosis challenging. Applying pressure to the iliopsoas tendon while the patient attempts to reproduce the snapping may inhibit the clunking and can help confirm the diagnosis (1).

During the evaluation, the physical therapist should assess the lower extremity flexibility and core strength, and treat deficits present in that that individual patient. Research has found that hip flexor stretching, strengthening the hip internal and external rotators is helpful in treating this condition (1). Eccentric hip flexor and extensor strengthening may also assist with improved symptoms (3). Other studies recommend incorporating ultrasound to the iliopsoas tendon (5). If a patient continues to have symptoms following a course of conservative treatment, more invasive treatments may be considered. Some physicians will inject lidocaine and corticosteroids into the iliopsoas bursa under fluoroscopy, which can be helpful. If symptoms persist, surgical treatment with fractional lengthening of the psoas is an option (1)

External coxa saltans is caused by the iliotibial band moving over the greater trochanter, leading to irritation and inflammation of the greater trochanteric bursa (1). Pain and snapping sensation is generally localized over the lateral aspect of the hip and it is usually tender to palpation. Patients often complain of pain with direct pressure, including lying on that side, and with transitional movements such as sit-to-stand. More dynamic activities, such as running, stair navigation, and walking on inclines often causes pain as well (1).

A clinician should assess flexibility of the hip and IT band. The sensation of IT band "snapping" may be reproduced with the Ober test or with augmentation of the test with internal and external rotation at the hip while in the testing position (1).




Treatment for external coxa saltans generally begins with inflammation control, including rest, ice, modalities and NSAIDs , followed by gentle stretching, hip and core strengthening. If symptoms persist, a corticosteroid injection into the bursa may be considered. After the acute inflammation decreases, gentle IT band stretching may be included in treatment (2).

In all cases of snapping hip, proper management begins with identifying the source of symptoms, followed by assessing the patient’s specific deficits. In many cases, these patients can be successfully treated conservatively with stretching, hip and core stabilization and inflammation control as appropriate.


Last revised: May 20, 2013
by Lauren Hogan, PT, DPT, ATC

 

References
1) Brotzman, S. B., & Manske, R. C. (2011). Clinical orthopaedic rehabilitation: an evidence-based approach. (3rd ed.). Mosby.
2) Fredericson M. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil 83: 589-592.
3) Gruen et al., 2002. Gruen G.S., Scioscia T.N., Lowenstein J.E.: The surgical treatment of internal snapping hip. Am J Sports Med 2002; 30:607-613.
4) Sizer, P. S., McGalliard, M., & Azevedo, E. (2011). The hip: Physical therapy management utilizing current evidence. In C. Hughes (Ed.), Current Concepts of Orthopaedic Physical Therapy (3rd ed.). LaCrosse, WI: APTA Orthopaedic Section.
5) Taylor and Clarke, 1995. Taylor G.R., Clarke N.M.: Surgical release of the “snapping iliopsoas tendon,”. J Bone Joint Surg Br 1995; 77:881-883.



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