What is snapping hip syndrome?

Snapping hip syndrome is characterized by snapping of the hip that can be heard by the athlete, and often others; this may be due to one of many causes. The two most common causes of this syndrome are due to tendons snapping over bony bumps (prominences):

1.···· The iliotibial band that travels from the pelvis to the knee can snap over the greater trochanter (hip), causing irritation of the trochanteric bursa (a bursa that reduces friction between the iliotibial band and the greater trochanter)

2.···· The second major cause is inflammation of the iliopsoas tendon where it attaches to the hip; in addition, the iliopsoas tendon may catch over a bony bump (iliopectineal eminence).

Other causes include loose pieces of bone or cartilage within the hip joint and a hamstring tendon (biceps femoris) snapping over the ischial tuberosity (bony bump of the buttocks).

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How does snapping hip syndrome occur?

This condition may occur without any injury or may be caused by strain from a sudden increase in amount or intensity of activity or overuse of the lower extremity. Repetitive motion (hip bending and straightening) may lead to inflammation of the tendon as it passes the bony prominences, leading to thickening and scarring of the tendon and increasing the snapping. It is associated with tight muscles and tendons. Iliotibial band inflammation may also be due to a direct blow to the outer hip.

What increases the risk?

• Contact or collision sports (football, hockey or soccer)
• Inadequate protection of exposed areas during contact or collision sports
• Endurance sports (distance running, triathlon, or race walking)
• Activities that require bending, lifting or climbing
• Poor physical conditioning (strength and flexibility)
• Inadequate warm-up before practice or play
• Flat feet
• Lower extremity alignment, in which your knees point toward each other while your feet are straight ahead
• Compensation for other extremity injuries

What are the symptoms of snapping hip syndrome?

Hearing the hip snap, often without discomfort, is the major symptom. The placement of snap occurs on the outer part of the hip if the iliotibial band is the cause and in the groin or front of the hip if the iliopsoas muscle is the cause. Tenderness over the outer hip is due to iliotibial band.

How is snapping hip syndrome diagnosed?

History and physical exam are the most important tests to establish snapping hip syndrome. The most significant differential diagnosis when considering a snapping hip is a problem within the hip joint, known as “intra-articular.” Such problems include labral tears, injury to the articular cartilage and injury to the ligament within the hip, known as the ligamentum teres. Intra-articular conditions can present with painful snapping, and must be considered in the differential of the snapping hip syndrome.

Are there any special tests?

MRI is a very good test to evaluate the intra-articular structures, though it still may miss up to 25 percent of labral tears and is poor at detecting ligamentum teres injuries.

The addition of Gadolineum (contrast dye) within the hip joint enhances detection of labral tears. Even with contrast dye, MRI is a poor test for evaluation of snapping hip syndrome. Because snapping hip is a dynamic phenomenon, a static image such as an X-ray, CT or MRI are unhelpful in confirming the diagnosis.

The best imaging study for snapping hip is to inject contrast dye into the sheath around the suspected snapping hip. While the patient then actively moves their hip to reproduce the snap, fluoroscopy (live X-ray) can show the dramatic and sudden movement of the tendon as it snaps over the bony prominence.

How is snapping hip syndrome treated?

Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities. Initial treatment consists of medication and ice to relieve the pain, stretching and strengthening exercises, and modification of the activities that caused the symptoms. These all can be carried out at home, although referral to a physical therapist or athletic trainer for further evaluation and treatment may be helpful. An orthotic (arch support) may be prescribed for those with flat feet. An injection of cortisone to the area where the tendon inserts into bone may be helpful for iliotibial band inflammation.

Operative treatment: Surgery to remove the inflamed tendon lining or degenerated tendon tissue and move the tendon is rarely needed and usually only considered after at least 6 months of conservative treatment. Surgery is usually reserved for the small number of patients with painful snapping that is resistant to non-operative treatment. Historically, open releases were relied upon to decrease tension by surgically incising the relevant tendon responsible for the snapping. Advances in arthroscopic techniques for the hip have led to the ability to not only release the tight tendon arthroscopically with the aid of the small camera, but also to evaluate and treat any associated pathology within the joint.

What are the complications of treatment?

Possible complications of non-operative treatment include:

• Persistent symptoms and impairment

Possible complications of operative treatment include:

• Surgical complications not specifically associated with tendon release, including pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity-level.·
• Complications specific to surgical treatment of this condition, which include persistent symptoms, failure to return to previous level of activity, nerve injury, and stiffness.·

When can you return to your sport/activity?

This condition is usually curable with time and appropriate treatment. Healing time varies but usually averages two to six weeks.

How can snapping hip syndrome be prevented?

• Wear appropriate protective equipment (hip pads) and ensure correct fit
• Appropriately warm up and stretch before practice or competition
• Allow time for adequate rest and recovery between practices and competition
• Maintain appropriate conditioning:
  • Hip, pelvis, and trunk strength
  • Flexibility and endurance
  • Cardiovascular fitness
  • Use proper technique
  • Those with flat feet should wear arch supports (orthotics)