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Snapping Hip Syndrome

A Review for the Strength and Conditioning Professional

Cheatham, Scott W. PT, DPT, OCS, CSCS, NSCA-CPT; Cain, Matt MS, CSCS; Ernst, Michael P. PhD

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Strength and Conditioning Journal: October 2015 - Volume 37 - Issue 5 - p 97-104
doi: 10.1519/SSC.0000000000000161
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Abstract

Musculoskeletal injuries to the hip region are often debilitating for the athlete due to the influence the hip has on lower extremity function. One injury that has become more recognized among athletes and active individuals is snapping hip syndrome (SHS) or coxa saltans. SHS is a condition characterized by a palpable or audible “snapping” that occurs around the hip with movement (1). This condition is further described as either internal snapping hip syndrome (ISHS) or external snapping hip syndrome (ESHS). With ISHS, the “snapping” is felt in the anterior hip region and often involves a tight iliopsoas muscle. With ESHS, the sensation is felt over the lateral hip region and often involves a tight iliotibial band (ITB) (20).

Of particular interest to the strength and conditioning (S&C) professional is the growing prevalence of SHS among athletes and active individuals. Published data estimate that SHS occurs in about 5–10% of the population, but current research suggests that the incidence may be higher than reported (5,7,20). More recent reports are showing that SHS occurs frequently in soccer players, dancers, runners, football players, golfers, and weightlifters (5,7,20). There is a need for the S&C professional to have a basic knowledge of SHS and management strategies within their professional purview. This article will provide a review of SHS, including prevalence, client profile, and mechanisms of injury, conservative management, training recommendations, and surgery. Information provided is not intended to diagnose SHS but rather to identify the condition and recognize potential management strategies. In cases where a diagnosis has not been established, it is recommended that the S&C professional refers the patient to a qualified health care professional.

ANATOMICAL REVIEW

The hip joint or coxa femoral joint is a mobile ball and socket joint that is composed of the acetabulum and the head of the femur (Figure 1). The joint's bony architecture and soft-tissue structures create a combination of mobility and stability that is unique to the lower extremity. This is illustrated by how the femoral head sits in the deep acetabulum and is further deepened by the acetabular labrum, which acts as a gasket that creates a snug fit for the femoral head. The extensive ligament structures around the hip add to the stability (23). Thus, the combination of joint design and ligamentous support creates a mobile structure that has stability, especially during weight-bearing activity.

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Figure 1:
X-ray of the hip joint showing the bony anatomy.

The hip joint provides 3 degrees of freedom, which includes flexion and extension, abduction and adduction, and internal and external rotation. The muscle groups around the hip work together to accomplish these motions. Table 1 lists the primary agonist muscles responsible for the motions mentioned above (23). When looking at lower extremity motor control, there are specific muscle groups that are of particular interest. Sagittal plane control is primarily accomplished anteriorly by the iliopsoas and rectus femoris and posteriorly by the gluteus maximus and hamstrings. The anterior hip region is where ISHS is most prevalent (Figure 2). Frontal plane hip control is primary accomplished by the lateral hip abductors (gluteal medius and minimus) and medial adductors (adductor magnus, longus, brevis, gracilis, pectineus). The abductors work together with the ITB to laterally stabilize the hip and knee, whereas the adductors provide medial stabilization. The lateral hip region is where ESHS is most prevalent (Figure 3). Transverse plane control is primarily accomplished by the ITB, hip external rotators, and the gluteus medius (anterior and posterior fibers) and minimus (anterior fibers) (23).

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Table 1:
Hip motion with corresponding agonist muscles
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Figure 2:
Region of pain in internal snapping hip syndrome.
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Figure 3:
Region of pain in external snapping hip syndrome.

PREVALENCE

Currently, there is no comprehensive data on the incidence or prevalence of SHS. The available data do show that SHS occurs in 5–10% of the population and most often among individual's aged 15–40 years with a female gender predilection (5,13,37). SHS is often related to repetitive activity and is common in sports, such as running, track, football, soccer, golf, weightlifting, and dance (8,12,13,15,19,36,37). The prevalence of SHS may be more than reported in these individuals and the lack of data creates a gap with knowing how common this condition occurs.

CLIENT PROFILE AND MECHANISM OF INJURY

For both ISHS and ESHS, clients may first report a “nonpainful” sensation or audible snapping, clicking, or popping with activity, which may eventually lead to discomfort (Table 2). SHS is rarely an acute injury and is often insidious in nature with the pain getting worse over time. With ISHS, the sensation may be provoked during deep squats (e.g., >90° hip flexion) and hip external rotation movements (18,20). Specific movements that may be difficult include getting in/out of a car, sit to stand, and running (20). This is primarily caused from snapping of the iliopsoas tendon over the iliopectineal eminence, anterior hip capsule, femoral head, or iliofemoral ligament (15,17,18). With ESHS, the sensation may be provoked during hip flexion, external, or internal rotation (20). Specific movements that may be difficult include carrying heavy loads, climbing stairs, playing golf, and running (20). The sensation may be caused by the ITB or gluteus maximus tendon snapping over the greater trochanter or the proximal hamstring subluxating over the ischial tuberosity during rotational movements (5,20,29,31,33).

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Table 2:
Types of snapping hip syndrome

For the S&C professional, it is worth noting that SHS is most commonly an extra-articular pathology. However, individuals with intra-articular pathologies such as acetabular labral tears or femoral acetabular impingement may describe similar symptoms but most often will describe more “deep” joint mechanical symptoms, such as catching, locking, or painful clicking (20). Clients with either ISHS or ESHS may have one or a combination of hip and abdominal core weakness, myofascial restriction, and decreased muscle length (20). Clients with ISHS may also have a more anterior tilted pelvis (e.g., pelvic cross syndrome) due to tightness in the anterior hip musculature (7,17).

CONSERVATIVE MANAGEMENT

SHS may have an insidious onset and may eventually worsen with prolonged repetitive movements. These individuals may seek medical consultation if the condition begins to reduce their ability to function or becomes painful. The physician may impose activity restrictions, prescribe oral medications, and administer a cortisone or anesthetic injection, and order imaging as needed (e.g., magnetic resonance imaging, ultrasound) (5,20). Physical therapy is often prescribed with a focus on decreasing pain with modalities (e.g., ice), restoring myofascial mobility, muscle length, strength, and function of the lower kinetic chain (5,20). The S&C professional should communicate with the physician or physical therapist to obtain activity guidelines for the client. This section will discuss client education and suggested therapeutic interventions, including massage, stretching, self-myofascial release, strengthening, and functional activity. The intervention strategies discussed are specific to SHS and should be part of a complete exercise program designed to meet the goals of the client.

CLIENT EDUCATION

The S&C professional should educate the client on the following: avoid movements that cause symptoms or pain, proper training techniques, reinjury recognition, and restorative techniques after activity (e.g., stretching, foam rolling). Clients may tend to ignore the “snapping” sensation, which may eventually lead to discomfort during activity. The patient should be symptom-free with activity. Proper warm-up and cool down activity should be reinforced, especially stretching after activity (20).

MASSAGE

Massage may be an effective intervention that the S&C professional can recommend to their clients. Each type of SHS may have specific soft-tissue restrictions that contribute to the problem. For ISHS, soft-tissue techniques targeting the iliopsoas should be suggested since it is the primary muscle involved (20). For ESHS, soft-tissue massage techniques targeting the gluteus maximus, tensor fascia lata (TFL), and ITB complex may be effective interventions (19). Research has demonstrated the effectiveness of soft-tissue massage in treating ISHS and ESHS by reducing pain and symptoms (e.g., snapping) (8,9,12,19). Other muscles that may have soft-tissue restriction include the hamstrings, hip external rotators, and adductors, which may need to be addressed during treatment.

STRETCHING AND SELF-MYOFASCIAL RELEASE

To augment massage therapy, the S&C professional can teach the client various stretching and self-myofascial techniques (Table 3). For ISHS, stretching of the iliopsoas and rectus femoris is an effective intervention along with self-myofascial release techniques, such as foam rolling to the anterior hip muscles (17,19,31,35). Foam rolling has been shown to increase both hip flexion and extension range of motion (ROM) using 1 minute bouts for 3 repetitions (30-second rest in between bouts) (Figure 4A and 4B) (4,22). For ESHS, the gluteals, hip abductors, and external rotators may need stretching and myofascial release with the foam roller (Figure 5A and 5B) (Figure 6) (7,20). The stretching program can include different stretching techniques, such as static stretching (e.g., 3 sets of 30 seconds) and proprioceptive neuromuscular facilitation stretching, which may be effective in achieving increased muscle length (2,25,34). Dynamic stretching may also be beneficial but should be done with caution (2,16). Certain dynamic stretching patterns require multiplane hip movements that could elicit the “snapping” and possible discomfort. It is recommended that the client performs symptom-free activity. Consistent daily stretching and foam rolling should be emphasized to promote tissue lengthening. The stretching and myofascial mobility program should first address the tight tissues and then progress to a global maintenance program once the desired mobility is obtained.

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Table 3:
Recommended interventions for snapping hip syndrome
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Figure 4:
(A and B) Foam rolling the anterior hip for internal snapping hip syndrome.
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Figure 5:
(A and B) Foam rolling the lateral hip for external snapping hip syndrome.
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Figure 6:
Foam rolling external hip rotators for external snapping hip syndrome.

STRENGTHENING EXERCISES

The S&C professional many need to prescribe a strengthening program if muscle weakness is present and contributing to the client's problem. For both ISHS and ESHS, specific strengthening exercises should be prescribed that help restore proper strength and control to the hip and abdominal core (Table 3). For ISHS, strengthening of the gluteals and hip external rotators may provide some benefits. Trying to strengthen the iliopsoas may elicit the “snapping” sensation and ultimately irritate the iliopsoas tendon. Recommended exercises include double leg bridges, single leg bridges, resisted hip extension, sidelying hip abduction, and hip clam exercises, which focus on the major muscles of the hip which may not irritate the iliopsoas since it is not a prime agonist during those movements (21,26,30). Recommended closed kinetic chain (CKC) exercises for ISHS include the single-leg squat and deadlift exercises, which have been found to create high activity in the gluteus maximus (6). This may be beneficial for ISHS due to the antagonistic activity of the gluteus maximus to the iliopsoas.

For the ESHS, the hip abductors and external rotators should be the focus of strengthening in the presence of weakness. Recommended exercises include sidelying hip abduction, clams, and side bridges (3,10,30). Sidestepping is a recommended CKC exercise due to its strong activation of the hip abductors while minimizing TFL activity (32,38). Exercises that elicit the “snapping sensation” or discomfort should be avoided. For example, multiplane CKC movements may elicit an internal or external snapping.

TRAINING RECOMMENDATIONS

The interventions mentioned above may be part of a comprehensive program for the client with SHS. However, one concern for the S&C professional is how to design and modify an effective program for these clients. One approach to program design is through the ARREST model (Table 4). This model provides a structured approach, which will be discussed below.

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Table 4:
ARREST model for managing snapping hip syndrome

The “A” in the model represents the avoidance of painful movements. This may be the most important step for the client. The S&C professional must determine which exercise movements are painful and establish movement limitation to avoid aggravating the condition or possible reinjury. For example, if a client with ISHS experiences pain with squats deeper that 90° of hip and knee flexion, then the depth of the squat should be more shallow to avoid the painful ROM. The first “R” represents restoring soft-tissue mobility. For both ISHS and ESHS, stretching and self-myofascial release of the involved structures may provide the most effective benefits (20). For example, self-myofascial release with a foam roll combined with a dynamic warm-up may provide a greater benefit to the SHS client than a standard cardiovascular warm-up (11,16). The second “R” represents restoring adequate strength in the hip and pelvis musculature. The S&C professional can determine such weaknesses by administering tests and measures for muscle strength, endurance, and the client's movement patterns (e.g., functional movement screen). The “E” represents educating the client on how to avoid reinjury. Education should include recognition of symptoms, exercises to avoid, and proper warm-up and cool down activity. The “S” represents setting measurable return to activity goals. The goals for the client should be objective and measurable. They should reflect the client's current state of fitness and their functional abilities. Often, when clients are injured, they participate in less activity, which creates a systemic loss of fitness and requires more time for them to return to their preinjury level of fitness. The “T” represents teaching the client a self-maintenance program that compliments their primary program. For example, the client may be working within a structured periodization program but may need some ancillary restorative exercises such as stretching and foam rolling daily to maintain an adequate amount of soft-tissue mobility to avoid future occurrences of SHS. The client should be taught such a program to avoid reinjury. This model presents a simple strategy for the S&C professional to conservatively manage a client with SHS.

SURGICAL INTERVENTION

If conservative management fails, then surgery is an option for both ISHS and ESHS. For ISHS, an arthroscopic or open iliopsoas tendon release is conducted at the level of the hip joint or at the insertion at the lesser trochanter (14). Khan et al. conducted a systematic review looking at the success rate of both open and arthroscopic procedures for ISHS. The authors found that 100% of patients reported a resolution of symptoms after arthroscopic release and 77% of open procedures. The complication rate was 21% for the open procedure compared with 2.3% for the arthroscopic (18).

For ESHS, the arthroscopic or open technique is meant to release the ITB by producing a diamond shape defect lateral to the greater trochanter, which allows the trochanter to move freely without snapping or a z-plasty is conducted to lengthen the ITB (14,24,28). The research on outcomes of both procedures is still emerging. Preliminary investigations of the z-plasty for ESHS have shown good short-term outcomes (24,27,28,39). S&C professionals encountering clients who have had this procedure should consult with the surgeon and rehabilitation staff regarding postsurgical guidelines before implementing an exercise program.

SUMMARY

SHS is commonly caused by repetitive overuse activity and has a higher predilection among athletes and active individuals. The S&C professional needs to have an understanding of the basic hip anatomy, hallmark symptoms, mechanisms of injury, conservative management, and training strategies. The conservative management of SHS often includes a multimodal program consisting of patient education (e.g., reducing risk factors), massage, stretching, self-myofascial release, and muscle strengthening exercises. The ARREST model provides the S&C professional with a structured training approach for clients with SHS. Surgical intervention is an option only if conservation management has failed. The reader is encouraged to review the reference list at the end of this article for a more comprehensive discussion on this topic.

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Keywords:

coxa saltans; hip pain; iliopsoas

© 2015 by the National Strength & Conditioning Association