Snapping Hip Syndromes and Peritrochanter Disorders

Craig S. Mauro

James E. Voos

Bryan T. Kelly

Snapping hip syndromes and peritrochanter disorders, including internal and external coxa saltans, trochanteric bursitis, and gluteus medius and minimus tears, have been well documented (1, 2, 3, 4, 5, 6, 7, 8 and 9). Since numerous intra-articular lesions that may cause hip pain and, occasionally, popping or snapping have been identified, the term internal coxa saltans is best reserved for iliopsoas tendon snapping and external coxa saltans for iliotibial band snapping (9). For this chapter, these entities will be the focus of the snapping hip syndromes. The peritrochanteric disorders have previously been grouped into the “greater trochanteric pain syndrome” (4,6,7). Conservative treatment is the primary therapeutic modality for these disorders and includes local corticosteroid and anesthetic injections combined with a structured physical therapy program (10). However, patients who fail conservative treatment may require surgery. While open surgical treatment for snapping hip syndromes and peritrochanter disorders has been utilized for many years, (11, 12, 13, 14, 15, 16 and 17) endoscopic treatment has more recently been described (18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28). This chapter reviews the clinical evaluation, treatment (including the authors’ preferred technique), complications of treatment, and rehabilitation of snapping hip syndromes and peritrochanter disorders.

CLINICAL EVALUATION

An in-depth patient history is one of the most effective tools for evaluating a complaint of hip snapping or pain. A historical description of hip pain can help to differentiate intra-articular from extra-articular pathology. Patients with intra-articular pathology often localize the pain to the groin and state that it is exacerbated with prolonged sitting or strenuous activity. Those patients with pathology involving the peritrochanteric compartment more often localize the symptoms to the lateral hip surrounding the greater trochanter. They may note lateral hip pain during strenuous activity or with activities as simple as lying on the affected side. However, intra-articular pathology can certainly present as isolated lateral hip pain, so a heightened suspicion and appropriate evaluation are always necessary. In addition, it is important to consider the lumbar spine, sacroiliac joint, and intrapelvic pathology in the differential diagnosis. The diagnostic differential can be narrowed with descriptive characteristics and physical examination findings specific to each snapping hip syndrome and peritrochanter disorder.

Internal coxa saltans occurs as the iliopsoas tendon subluxates from lateral to medial across the iliopectineal eminence or the anterior aspect of the femoral head and capsule when the hip is brought from a flexed, abducted, externally rotated position into extension and internal rotation. (1) Patients typically describe, and may be able to reproduce, a painful clicking or popping sensation coming from the anterior groin. However, they may also describe flank, buttock, or sacroiliac pain.

External coxa saltans has been attributed to an excessively thick, taut posterior border of iliotibial band or anterior gluteus maximus tendon moving over the greater trochanter (1). Anatomically, with the hip extended, the iliotibial band lies posterior to the greater trochanter and slips anteriorly over the greater trochanter during hip flexion. The tight anterior attachments of the tensor fascia latae, the presence of the gluteus maximus posteriorly, and the association with gluteus medius aponeurosis restricts the iliotibial band over the greater trochanter throughout hip range of motion (1). The slipping motion produces the snapping sensation and resultant lateral hip pain. Patients with external coxa saltans may describe a palpable or audible lateral snapping as the hip moves from flexion to extension. It most often occurs with athletic activity but may be symptomatic with activities of daily living.

Trochanteric bursitis and greater trochanteric pain syndrome have been described as overuse injuries occurring most commonly in older females. It has also been associated with long distance running, low back pain, coxa saltans, iliotibial band syndrome, and hip arthroplasty and osteotomy (2,12,29, 30 and 31). Symptoms are characterized by chronic, intermittent aching pain over the lateral aspect of the hip.

Tears at the insertions of the gluteus medius and minimus at the greater trochanter have been described
synonymously with tears of the rotator cuff tendons (3,5). Descriptions of calcific tendonitis of the hip have also included relationships with gluteus medius and minimus tears, thus further substantiating the rotator cuff similarity (32, 33 and 34). Tears were initially identified in the setting of open debridement for recalcitrant trochanteric bursitis, total hip arthroplasty, and treatment of femoral neck fractures (5,7,35). However, tears of the gluteus medius and minimus tendons at the greater trochanter may also occur with trauma in otherwise normal hips or in the setting of hip abductor tendinopathy (36,37). Symptoms are characterized by lateral hip pain and an ambulatory limp, likely related to hip abductor weakness.

After obtaining the patient history, the physician should perform thorough examination of the entire hip joint. Diagnosis of internal coxa saltans begins by placing the patient supine. The examiner moves the hip from flexed, abducted, externally rotated position into extension with internal rotation. This motion may elicit an audible popping sound that corresponds to the sensation experienced by the patient. However, the popping may be difficult to reproduce passively and sometimes the patient may be able to better actively demonstrate it. The diagnosis of external coxa saltans may be distinguished from internal coxa saltans on physical examination by demonstrating a lateral palpable or audible snapping as the hip is moved from flexion to extension. This examination maneuver should be performed with the patient lying on his or her side and while standing.

A more focused evaluation of the lateral aspect of the hip should then be used to further define an offending peritrochanter disorder. Lateral hip pain can arise from pathology in the peritrochanteric space or be referred pain from intra-articular pathology. Palpation of the lateral hip aids in this differential as referred pain may be reproduced with passive and active joint motion but should not produce tenderness with direct palpation. In this vein, palpation should begin with the origin of the gluteus maximus at the inferior-posterior aspect of the ileum and sacrum. The insertion can then be examined in two locations: the lateral base of the linea aspera on the proximal femur and the tensor fascia latae. Next, the gluteus medius should be palpated from its origin on the anterior and middle aspect of the ileum to its two insertions on the middle and superoposterior facet of the greater trochanter. The gluteus minimus can be examined from its origin deep to the gluteus medius to its insertion at the greater trochanter anterior facet. The greater trochanteric bursa should also be appreciated overlying the greater trochanter at the mid posterior proximal aspect of the femur. Patients with trochanteric bursitis demonstrate point tenderness over the greater trochanter with occasional warmth and/or swelling.

Physical examination of muscle strength should be conducted with the hip in flexion to assess the tensor fascia latae, in neutral to evaluate the gluteus medius, and in extension to evaluate the gluteus maximus. This examination should be performed with the knee both flexed and extended to allow tension and relaxation of the iliotibial band, respectively. Weakness may be seen with all entities because of pain, but significant weakness may be suggestive of a gluteus medius and/or minimus tendon tear. Also, the 30-second single-leg stance and resisted external derotation tests have been shown to have very good sensitivity and specificity for identifying tendinous lesions in patients with peritrochanteric pain (38).

Ober’s test may be used during the physical examination to evaluate for contractures of the abductor muscles. This test should also be conducted with the hip in flexion, neutral, and extension. Classically, Ober’s test is performed in hip extension to assess tension across the tensor fascia latae. The knee should then be flexed to relax the iliotibial band and allow effective evaluation of possible gluteus medius contracture. In this position, the knee should be able to internally rotate such that it can touch the table in the absence of pathologic tension.

All patients presenting with hip pain are evaluated with an anteroposterior (AP) radiograph of the pelvis as well as a Dunn lateral radiograph (90° of hip flexion with 20° of abduction and the beam centered on and perpendicular to the hip) to assess for avulsions of the greater trochanter, cam and pincer lesions, loss of joint space, cross-over sign, acetabular dysplasia, and sacroiliac joint pathology. Our AP pelvis radiographs are performed according to Siebenrock et al. (39) who recommended taking radiographs of the pelvis in neutral rotation and in a standardized position of pelvic inclination, which is indicated by the distance between the symphysis and the sacrococcygeal joint (approximately 32 mm in men and 47 mm in women).

MRI provides the most information regarding the soft tissues surrounding the hip (40). At our institution, we utilize noncontrast MRI to evaluate the hip joint (41). Every MRI study of the hip performed at our institution includes a screening examination of the whole pelvis, acquired with use of coronal inversion recovery and axial proton density sequences. Detailed hip imaging is obtained with use of a surface coil over the hip joint, with high-resolution cartilage-sensitive images acquired in three planes (sagittal, coronal, and oblique axial) with use of a fast-spin-echo pulse sequence and an intermediate echo time (42). Other authors have advocated the use of magnetic resonance arthrography of the hip for evaluation of hip pathology (43, 44 and 45). Cvitanic et al. concluded MRI showed good accuracy for the diagnosis of tears of the gluteus medius and gluteus minimus tendons. The identification of an area of T2 hyperintensity superior to the greater trochanter had the highest sensitivity and specificity for tears at 73% and 95%, respectively (46). Suspected gluteus medius tendon tears in patients with trochanteric bursitis may be confirmed with MRI (47). This modality aids to confirm the clinical suspicion in patients with refractory
trochanteric bursitis with lateral hip pain and an ambulatory limp likely related to hip abductor weakness (48).

Only gold members can continue reading. Log In or Register to continue