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Ultrasonography of Snapping Hip Syndrome

Azizi, Hana F. MD; Lee, Se Won MD; Oh-Park, Mooyeon MD, MS

American Journal of Physical Medicine & Rehabilitation: January 2015 - Volume 94 - Issue 1 - p e10–e11
doi: 10.1097/PHM.0000000000000217
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From the Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (HFA, SWL, MO-P); Kessler Foundation, Kessler Institute for Rehabilitation, West Orange, New Jersey (MO-P); and Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, The State University of New Jersey (MO-P).

All correspondence and requests for reprints should be addressed to Hana F. Azizi, MD, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

A 43-yr-old woman presented with the insidious onset of left groin pain for several months. She reported that her pain was sharp with an intensity of 5 of 10 and was primarily elicited during activities including squatting, prolonged sitting, and stair climbing. She also reported occasional “clicking” along the anterior aspect of the left hip associated with pain while extending the hip. Upon examination, passive range of motion of the hip was normal without gross swelling in the anterior hip region. Maximum tenderness was noted over the left anterior inferior iliac spine (AIIS) with appreciable snapping of a firm cord-like structure during extension and external rotation of the hip. The flexion, adduction, and internal rotation test was negative for femoroacetabular impingement. The Ely test (passive flexion of the knee in prone position and bringing the heel toward the buttock) was positive for tightness of the left rectus femoris muscle. A plain radiograph of the left hip was unremarkable except for calcification along the acetabular rim.

Ultrasonography examination of the left hip was performed using an 8- to 15-MHz broadband linear transducer and a LOGIQ S8 scanner (General Electric Healthcare, Milwaukee, WI). A hyperechoic calcification, 1.3 × 0.6 × 0.9 cm in size, was appreciated in the direct head of the rectus femoris at the AIIS with increased vascularity on Doppler compatible with calcific tendinitis (Figs. 1, 2). There was no hip joint effusion or osteophyte and no other tendon pathologies noted. Her symptoms improved with nonsteroidal anti-inflammatory medications and stretching exercise, and there was no tenderness over the left AIIS at the 6-month follow-up.





The authors were able to estimate the acuity of calcific rectus femoris tendinitis by additional Doppler examination and visualize the snapping structures by dynamic evaluation.1,2 The audible or perceived snapping is mediated by either the direct head impinged against the overlying iliacus muscle or the indirect head of the rectus femoris surrounding the acetabular roof.3 The involvement of the indirect head was reported to be more common with painful limitation of range of motion caused by the overlap of insertion of the indirect head with capsular attachment3,4; however, in this case, involvement of the direct head of the rectus femoris was the primary source of the patient’s symptoms. This case highlights the diagnostic role of ultrasonography in evaluating snapping hip syndrome.

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1. Bureau NJ: Sonographic evaluation of snapping hip syndrome. J Ultrasound Med 2013; 32: 895–900
2. Pelsser V, Cardinal E, Hobden R, et al.: Extraarticular snapping hip: Sonographic findings. Am J Roentgenol 2001; 176: 67–73
3. Pierannunzii L, Tramontana F, Gallazzi M: Case report: Calcific tendinitis of the rectus femoris: A rare cause of snapping hip. Clin Orthop Relat Res 2010; 468: 2814–8
4. Pope TL, Keats TE: Case report 733. Calcific tendinitis of the origin of the medial and lateral heads of the rectus femoris muscle and the anterior iliac spine (AIIS). Skeletal Radiol 1992; 21: 271–2

Snapping Hip; Calcific Tendinitis; Groin Pain; Ultrasound

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