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Snapping Hip (Coxa Saltans)

Topic updated on 02/05/15 2:52pm
Introduction
  • A condition characterized by a snapping sensation in the hip
    • caused by motion of muscles and tendons over bony structures around the hip joint
  • Epidemiology
    • common in athletes and dancers in their teens or twenties
  • 3 types of snapping hip exist with different causes
    • external snapping hip
      • caused by iliotibial tract sliding over greater trochanter  
    • internal snapping hip
      • most common form
      • caused by iliopsoas tendon sliding over
        • femoral head 
        • prominent iliopectineal ridge
        • exostoses of lesser trochanter
        • iliopsoas bursa
    • intra-articular snapping hip
      • caused by 
        • loose bodies in the hip
          • may be seen with synovial chondromatosis
        • labral tears
Presentation
  • Symptoms
    • snapping sensation in and around hip joint
      • may be painful or painless
      • patient often able to reproduce snapping
      • aggravated by activity
    • clicking or locking sensation
      • more indicative of intra-articular pathology
  • Physical exam
    • external snapping hip is often visible while internal snapping is not, but may be audible ("external snapping one can see from across the room, while internal one may hear from across the room")
    • external snapping hip
      • palpate greater trochanter as hip is actively flexed
        • applying pressure will likely stop snapping, confirming diagnosis
      • tightness of tensor fascia lata diagnosed with Ober's Test
        • limited hip adduction when hip held in extension
    • internal snapping hip
      • snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position
Imaging
  • Radiographs
    • recommended views
      • AP pelvis/hip
    • findings
      • usually normal
      • may be useful to rule-out synovial chondromatosis
  • Ultrasound
    • dynamic study which may demonstrate the snapping band in either internal or external snapping
    • may be used to localize a diagnostic challenge injection into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.
  • MRI
    • useful to rule-out intra-articular pathology
    • often performed as an arthrogram study
    • may show inflamed bursa
  • Iliopsoas bursography 
    • iliopsoas tendon visualized under fluoroscopy after bursa injected with contrast dye
    • may add therapeutic injection after diagnosis is confirmed
Treatment
  • Nonoperative
    • often internal and external snapping are painless and require no treatment
    • activity modification
      • indications
        • acute onset (<6 months) of painful internal or external snapping hip
    • physical therapy, injection of corticosteroid
      • indications
        • persistent, painful snapping interfering with activities of daily living
  • Operative
    • excision of greater trochanteric bursa with Z-plasty of iliotibial band
      • indications
        • painful external snapping hip that has failed nonoperative management
        • snapping after total hip replacement
    • release of iliopsoas tendon 
      • indications
        • painful internal snapping hip that has failed of nonoperative management
    • hip arthroscopy with removal of loose bodies or labral debridement/repair
      • indications
        • intra-articular snapping hip that has failed nonoperative management and has MRI confirmation of 
          • loose bodies
          • labral tear
Surgical Techniques
  • Excision of greater trochanteric bursa with Z-plasty of iliotibial band
    • technique
      • lengthen the iliotibial band by Z-plasty
      • may be done endoscopically
  • Iliopsoas tendon release
    • approach
      • variety of open approaches have been described
        • anterior
        • medial
        • ilioinguinal
        • iliofemoral
    • technique
      • tendon is either partially or completely released
      • may be done with the arthroscope
        • trans-capsular from the central compartment
        • endoscopically off of the lesser trochanter)
    • post-operative care
      • avoid hip flexion strengthening for 6 weeks

 

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Qbank (3 Questions)

TAG
(SBQ07.15) A 16 year-old dancer has developed popping over the anterior hip. On exam, this can be reproduced by starting with the hip flexed, abducted and external rotated, and then slowly extending it back to a neutral position. She has no pain with internal rotation of the flexed hip. There is no tenderness or popping laterally. The diagnosis can be confirmed using which imaging modality? Topic Review Topic

1. Coventional MRI
2. CT arthrogram
3. Ultrasound
4. Weight-bearing radiographs
5. Fluoroscopy without contrast

PREFERRED RESPONSE ▶
TAG
(OBQ09.44) A positive Ober test for contracture of the tensor fascia lata and iliotibial band is characterized by which of the following? Topic Review Topic

1. Limited hip adduction when flexed
2. Limited hip adduction when extended
3. Limited hip abduction when flexed
4. Limited hip abduction when extended
5. Bow legged gait

PREFERRED RESPONSE ▶
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