Understanding and Treating the Snapping Hip

The Iliopsoas: Anatomy, Clinical Evaluation, and Its Role in Hip Pain in the Athlete: A Scoping Review

Disability due to iliopsoas (IP) pain and dysfunction is underdiagnosed in the athletic population. The IP unit consists of the psoas major and iliacus muscles converging to form the IP tendon and is responsible primarily for hip flexion strength but has a number of secondary contributions such as femoral movement, trunk rotation, core stabilization, and dynamic anterior stability to the hip joint. As the IP passes in front of the anterior acetabulum and labrum, the diagnosis of IP pain may be confused with labral tearing seen on magnetic resonance imaging. This is in addition to the low sensitivity of magnetic resonance imaging to detect IP tendinitis and bursitis. Resisted seated hip flexion as well as direct palpation of the IP tendon and muscle belly are useful to assess function and help determine whether the IP may be the source of pain, which is common in athletes. Both biomechanical and clinical investigations have demonstrated the role of IP as an anterior hip stabilizer. Patients with signs of hip microinstability, developmental dysplasia of the hip, and increased femoral anteversion are at risk of IP pain and poor outcomes after IP lengthening, highlighting the importance of the IP in providing dynamic anterior hip stability.

Clinical Outcomes Following Incomplete Arthroscopic Iliotibial Band Release for External Snapping Hip Syndrome: An Observational Study

OBJECTIVES

Arthroscopic treatment is indicated for external snapping hip (ESH) syndrome in patients refractory to conservative treatment, but snapping does not disappear completely in some case. No previous studies have described the clinical course of ESH syndrome in patients who presented with persistent snapping after an arthroscopic procedure. We demonstrated the clinical outcomes following an incomplete arthroscopic iliotibial band (ITB) release for ESH syndrome.

METHODS

This retrospective observational study was performed at two teaching hospitals between October 2015 and December 2021. We reviewed the data of 33 patients (34 hips) aged ≥18 years, diagnosed with ESH syndrome, who were treated with arthroscopic ITB release. Patients who presented with persistent snapping despite sufficient arthroscopic ITB release following systematic order were defined as having an incomplete release. We collected the data for recurrent symptomatic snapping hip as the primary outcome after a minimum 2-year follow-up. The visual analogue scale (VAS) and modified Harris hip (mHHS) scores were measured as secondary outcome.

RESULTS

"Incomplete release" was identified in three of the 34 hips (8.9%). Cases of recurrent symptomatic snapping or conversion to open surgery were not observed. The symptoms of residual snapping spontaneously disappeared in all cases following routine postoperative rehabilitation within a 3-month follow-up period. The VAS (4 ± 1) and mHHS (17 ± 6) scores of all the patients improved.

CONCLUSION

When refractory ESH syndrome is identified during arthroscopic surgery, appropriate ITB release and removal of the major lesion causing snapping are expected to lead to resolution of residual symptoms without conversion to open surgery.

A comprehensive review of hip arthroscopy techniques and outcomes

Transforming the orthopedic landscape, hip arthroscopy pioneers a minimally invasive surgical approach for diagnosing and addressing hip pathologies. With its origins dating back to Burman's 1931 cadaveric study, this groundbreaking technique gained clinical relevance in 1939 through Takagi's report. However, the 1980s marked the actual emergence of hip arthroscopy for treating a wide range of hip disorders. Now, a staple in modern orthopedics, hip arthroscopy empowers patients with previously undiagnosed and untreated hip conditions, enabling them to obtain relief and reclaim their lives. By employing a compact camera and specialized tools, surgeons expertly navigate the hip joint, performing procedures from excising loose bodies and mending labral tears to addressing femoroacetabular impingement and tackling other intricate issues. This innovative approach has dramatically elevated patients' quality of life, allowing them to embrace targeted treatments and resume daily activities without resorting to lifestyle alterations.

Hearing and Seeing Nerve/Tendon Snapping: A Systematic Review on Dynamic Ultrasound Examination

Nerve/tendon snapping can occur due to their sudden displacement during the movement of an adjacent joint, and the clinical condition can really be painful. It can actually be challenging to determine the specific anatomic structure causing the snapping in various body regions. In this sense, ultrasound examination, with all its advantages (especially providing dynamic imaging), appears to be quite promising. To date, there are no comprehensive reviews reporting on the use of dynamic ultrasound examination in the diagnosis of nerve/tendon snapping. Accordingly, this article aims to provide a substantial discussion as to how US examination would contribute to 'seeing' and 'hearing' these pathologies' different maneuvers/movements.

Snapping Hip Syndrome: Pathoanatomy, Diagnosis, Nonoperative Therapy, and Current Concepts in Operative Management

» Asymptomatic snapping hip affects 5% to 10% of the population; when pain becomes the primary symptom, it is classified as snapping hip syndrome (SHS).» The snap can be felt on the lateral side of the hip (external snapping hip), often attributed to an iliotibial band interaction with the greater trochanter, or on the medial side (internal snapping hip), often attributed to the iliopsoas tendon snapping on the lesser trochanter.» History and physical examination maneuvers can help distinguish the etiology, and imaging may help confirm diagnosis and rule out other pathologies.» A nonoperative strategy is used initially; in the event of failure, several surgical procedures are discussed in this review along with their pertinent analyses and key points.» Both open and arthroscopic procedures are based on the lengthening of the snapping structures. While open and endoscopic procedures both treat external SHS, endoscopic procedures typically have lower complication rates and better outcomes when treating internal SHS. This distinction does not appear to be as noticeable in the external SHS.

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique

PURPOSE

External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique.

METHODS

An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated.

RESULTS

The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€).

CONCLUSION

This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.

The effect of iliotibial band surgery at the hip: a systematic review

BACKGROUND

Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases.

PURPOSE

The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery.

METHODS

The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed.

RESULTS

A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery.

CONCLUSION

ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

Effects of Contralateral Hip Flexion Angle on the Ober Test

The Ober test is an orthopedic evaluation procedure used to assess for tightness of the tensor fascia latae (TFL) and iliotibial band (ITB). Multiple versions of this test have been described using different degrees of contralateral hip joint flexion to stabilize the pelvis. The aim of this study was to analyze the hip range of motion (ROM) in the frontal plane and perceived tension produced during the Ober test using four different angles of contralateral hip flexion prepositioning. The secondary objective was to analyze the differences in the Ober test with different contralateral hip flexion angles according to limb dominance. This cross-sectional study included healthy individuals aged 18 years or older. The Ober test was performed on the right and left leg of each participant with the contralateral hip joint stabilized at 0° flexion, 45° flexion, 90° flexion, and maximal flexion. Hip range of motion in the frontal plane (abduction or adduction) was measured using a digital inclinometer. Three measurements were performed on each limb for every angle of contralateral prepositioning, using the average of the three measurements for statistical analysis. Participants were asked to report the location of any perceived tension and the intensity of tension using a Numeric Rating Scale during the test. Twenty-eight participants (17 men and 11 women) were examined. Significant differences in the Ober test hip ROM in the frontal plane ( $p<0.01$ ) were observed when comparing different angles of contralateral hip flexion prepositioning. Significant differences between tests were also present for intensity of perceived tension ( $p\le 0.001$ ), except for the intensity of perceived tension between 0° and 45°. No statistically significant differences were observed related to limb dominance ( $p>0.05$ ) or gender ( $p>0.05$ ), except for the Ober test at 0° ( $p<0.001$ ) which was higher in men (9.61° ± 5.01°) than in women (5.05° ± 2.87°). Greater contralateral hip flexion prepositioning during the Ober test results in decreased hip adduction ROM in the tested limb and greater perceived tension in the region of tensor fascia latae-iliotibial band.

Localized tenosynovial giant cell tumor: a rare case of snapping hip

We report on a 40-year-old male with a 9-month-long history of snapping of his right hip caused by a previously undescribed etiology of internal extra-articular snapping hip, namely due to a localized tenosynovial giant cell tumor. Both dynamic ultrasound evaluation and MRI proved to be crucial in the diagnosis of this rare entity. Auto-provocation of the snapping showed an anterior hip mass moving posteriorly to the psoas tendon which elucidated the pain and clicking sensation. Subsequent MRI demonstrated a peripheral low-intensity rim due to hemosiderin deposition around the synovial mass which is indicative for pigmented villonodular tenosynovitis. Treatment consisted of arthroscopic shaver burr resection. Immediately postoperatively, the snapping sensation could not be provoked anymore by the patient. The purpose of reporting on this case report is to emphasize several successive learning points. First, dynamic ultrasound aids in diagnosis and differentiation of the types of snapping hip. Second, specific MRI features are suggestive of tenosynovial giant cell tumor, recognizing these traits may prevent delayed diagnosis and subsequent aggravated clinical course. Third, localized pigmented villonodular tenosynovitis around the hip may present as an internal extra-articular snapping hip and is of consideration in the differential diagnosis of recurrent snapping hip.

Joint Hypermobility Is Associated With Increased Risk of Postoperative Iliopsoas Tendinitis After Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

To determine whether increased joint hypermobility, quantified by the Beighton score, is associated with a greater incidence of iliopsoas tendinitis (IPT) in postoperative hip arthroscopy patients treated for femoroacetabular impingement (FAI).

METHODS

We conducted a retrospective chart review of patients who underwent hip arthroscopy for labral repair and FAI from 2016 to 2020 for whom at least 12 months of follow-up data were available. The Beighton score was measured by a blinded, independent reviewer. IPT was clinically diagnosed by a sports medicine fellowship-trained orthopaedic surgeon through physical examination. Patients with a diagnosis of IPT were matched at a 1:1 ratio to controls based on age, sex, and body mass index. Demographic characteristics, radiographs and advanced imaging, surgical characteristics, and corticosteroid injection therapy data were obtained via chart review. Statistical analysis was conducted using Mann-Whitney testing and binary logistic regression.

RESULTS

Forty patients in whom postoperative IPT developed were identified and matched to 40 control patients in whom postoperative tendinitis did not develop. Increased joint hypermobility, quantified by the Beighton score, was associated with an increased risk of IPT. For each 1-point increase in the Beighton score, there was a 1.69 (95% confidence interval, 1.25-2.29; P < .001) increased odds of IPT development postoperatively. A high (≥4) versus low (<4) Beighton score was associated with an increased likelihood of tendinitis (odds ratio, 9.82; 95% confidence interval, 2.79-34.58; P < .001). However, there was no association between greater Beighton scores and patients' likelihood of receiving a corticosteroid injection (P = .173).

CONCLUSIONS

Increased joint hypermobility, quantified by the Beighton score, is associated with an increased risk of IPT developing in the hip arthroscopy postoperative period in patients treated for FAI and labral pathology.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Patients With Concomitant Painful External Snapping Hip and Femoroacetabular Impingement Syndromes Reported Complete Snapping Resolution With Release of the Gluteus Maximus and Iliotibial Band, and Comparable Minimum 2-Year Outcomes to a Propensity-Matched Control Group

PURPOSE

To report minimum 2-year patient-reported outcome measures (PROMs) following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and painful external snapping hip (ESH) treatment and ESH resolution, and to compare these PROMs to a benchmark FAIS propensity-matched control group without ESH.

METHODS

Data were prospectively collected and retrospectively reviewed between November 2009 and April 2018. Patients were eligible if they were preoperatively diagnosed with FAIS and painful ESH and received primary hip arthroscopy to address these pathologies. ESH was treated with gluteus maximus and iliotibial band releases. Inclusion criteria were baseline and minimum two-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1 and previous hip conditions. A secondary subanalysis was performed to benchmark these outcomes to a FAIS propensity-matched control group without ESH, according to age, sex, body mass index (BMI), Tönnis grade, and preoperative lateral center-edge and α-angles using a 1:3 ratio. The minimal clinically important difference (MCID) and the maximum outcome improvement (MOI) rates were reported.

RESULTS

Twenty-two hips (21 patients) were included. The mean age, BMI, and follow-up were 31.3 years ± 14.0, 26 kg/m² ± 5.0, and 31.4 months ± 4.4, respectively, with 68.2% being female. ESH was resolved in 100% of patients. Significant improvement for all PROMs at a minimum two-year (P < .001) was reported. The minimum two-year PROMs and the rate of achieving the MCID and MOI threshold were comparable to the control group.

CONCLUSION

Following primary hip arthroscopy for FAIS and painful ESH, patients demonstrated significant improvement in all PROMs, and the rate of resolution of ESH was 100% at minimum two-year follow-up: with gluteus maximus and iliotibial band releases. Functional outcomes and rates of MCID and MOI achievement were comparable to a FAIS propensity-matched benchmark control group without ESH.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Physical Examination of the Hip: Assessment of Femoroacetabular Impingement, Labral Pathology, and Microinstability

Purpose of Review

Determining the correct diagnosis can be challenging in patients presenting with hip pain. The physical examination is an essential tool that can aid in diagnosis of hip pathology. The purpose of this review is to provide an updated summary of recent literature on the physical exam of the hip, particularly as it relates to diagnosis of femoroacetabular impingement (FAI) syndrome, labral injury, and hip microinstability.

Recent Findings

Physical exam findings consistent with the diagnosis of FAI include reduced supine hip internal rotation and positive flexion-adduction-internal rotation maneuvers. Labral tears can be detected on exam with the Scour test. Studies demonstrate altered hip biomechanics in patients with FAI during activities such as walking and squatting. Those with FAI have slower squat velocities, slower sit-to-stand tests, and increased hip flexion moments during ambulation. Hip microinstability is a dynamic process, which can occur after prior hip arthroscopy. For hip microinstability, the combination of the three following positive tests (anterior apprehension, abduction-extension-external rotation, and prone external rotation) is associated with a 95% likelihood of microinstability as confirmed by examination under anesthesia at the time of surgery.

Summary

A comprehensive hip physical exam involves evaluation of the hip in multiple positions and assessing hip range of motion, strength, as well as performing provocative testing. A combination of physical exam maneuvers is necessary to accurately diagnose FAI syndrome and labral pathology as individual tests vary in their sensitivity and specificity. While an elevated level of suspicion is needed to diagnose hip microinstability, the provocative tests for microinstability are highly specific.

External snapping hip: classification based on magnetic resonance imaging features and clinical correlation

BACKGROUND

With the increasing sport population, the number of patients with external snapping hip (ESH) has also increased. To detect and visualise pathological soft tissue changes, magnetic resonance imaging (MRI) has been 1 of the most useful modalities. However, only limited studies have investigated MRI and its clinical value in the treatment of ESH in the past.

MATERIALS AND METHODS

Between May 2017 and November 2018, 104 patients were diagnosed with ESH at our institution. We excluded patients who did not undergo an MRI (n = 11), had complaint of bilateral symptom (n = 17), were not diagnosed hip problems previously (n = 2), and were lost-follow-up within 6 months (n = 19). After applying the exclusion criteria, 55 patients remained. We classified the patients into 2 groups according-MRI findings: tensed iliotibial band (ITB) and hypertrophied gluteus maximus (GM). We investigated the clinical findings, such as mean age, symptom duration, pain score, grading based on symptom severity, and other radiological findings such as soft tissue signal change and ITB thickness. The variables were compared between the groups.

RESULTS

Between the 2 groups defined by MRI findings, the group characterised by tense ITB showed a relatively short symptom duration than the hypertrophied GM group (p < 0.001). No significant differences in the other variables were found between the groups.

CONCLUSIONS

ESH has 2 types of MRI features. Compared with the hypertrophied GM group, the tense ITB group showed a shorter symptom duration and a more reversible status.

Female Athlete Hip Injuries: A Narrative Review

OBJECTIVE

In this narrative review, we highlight sex-specific anatomic and biomechanical features of the hip region in female athletes, as well as the potential impact of these characteristics on observed disparities in both intra-articular and extra-articular injury patterns between female and male athletes. It is our goal to broaden the scope of knowledge related to hip pathology in active female athletes among sports medicine providers with the hope of better optimizing sport participation and performance in female athletes.

DATA SOURCES

A literature review was conducted using PubMed database and Google Scholar search engine. Search terms included sport, female, athlete, sex differences, injury, hip, and all diagnoses discussed in this review. Cross-reference of these articles identified additional resources.

MAIN RESULTS

Sex-specific differences in both static design and dynamic function contribute to disparities in hip injury patterns between female and male athletes. Intra-articular injuries, including labral and ligamentum teres pathology, as well as extra-articular injuries, including iliopsoas tendon dysfunction, gluteal and proximal hamstring tendinopathy, ischiofemoral impingement, bone stress injuries, and certain nerve entrapment syndromes, seem to affect female athletes more commonly than male counterparts.

CONCLUSIONS

Given unique anatomic and functional considerations, the growing population of female athletes worldwide warrants specialized care and consideration. Potential predisposition to specific hip injuries should be taken into consideration during diagnostic evaluation of hip pain in the female athlete.

Endoscopic gluteus maximus tendon release for external snapping hip syndrome: a functional assessment

Purpose

The aim of this retrospective study was to investigate the clinical follow-up of patients with external snapping hip syndrome (ESHS) treated with endoscopic gluteus maximus tendon release and to compare the residual muscular strength and thigh circumference as an indirect outcome measure.

Methods

Patients of all ages with external snapping hip syndrome were treated with endoscopic gluteus maximus tendon release. Outcome measures evaluated included: visual analog scale (VAS), modified Harris Hip Score (mHHS), and Non-Arthritic Hip Score (NAHS). The gluteus maximus strength and the circumference of the thigh were also evaluated.

Results

Among 25 patients, 23 fulfilled the inclusion criteria and one patient was lost to follow-up. The series included 22 patients, 6 males and 16 females with a mean age of 27.9 ± 13.4 years (range 16–76 years). All patients had resolution of the snapping symptoms after the procedure. The mean follow-up was 18 ± 9.3 months. All outcomes improved in a statistically significant manner: VAS value decreased from 6.8 (range 6–8) to 0.6 (range 0–4) (p  < 0.001), mHHS increased from 48.6 (range 17.6–67) to 88.2 (range 67–94.6) (p  <  0.001), NAHS increased from 49.0 (range 21.5–66) to 90.8 (range 66–98.75) (p  <  0.001). A statistically significant reduction of operated limb thigh circumference compared to the contralateral side (3.7%) was also found, while there were no statistical differences regarding the strength of gluteus maximus muscles.

Conclusions

Endoscopic gluteus maximus tendon release is an excellent surgical option to treat snapping hip syndrome. The evaluated muscle strength revealed no functional impairment. The significance of the limb circumference reduction has yet to be determined.

Level of evidence

IV: retrospective comparative trial.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Ultrasound-Guided Percutaneous Iliotibial Band Release for External Coxa Saltans: A Cadaveric Study

The surgical treatment of external coxa saltans is not standardized. Many techniques for iliotibial release have been described, both open and arthroscopic. No technique describes ultrasound release. In this cadaveric study, we describe a minimally invasive technique for percutaneous iliotibial release with ultrasound guidance, designed to be performed under local anesthesia. The future objective would be to perform an active intraoperative test of the snapping hip to confirm adequate release, thus reducing the risk of recurrence.

External snapping hip syndrome is associated with an increased femoral offset

Background

External snapping hip syndrome (ESH) is postulated to be one of the causes of greater trochanteric pain syndrome, which also includes greater trochanteric bursitis and tendinopathy or tears of the hip abductor mechanism. However, it was not yet described what kind of bony morphology can cause the snapping and whether symptomatic and asymptomatic individuals have different imaging features.

Purpose

It was the purpose of this study to look for predisposing morphological factors for ESH and to differentiate between painful and asymptomatic snapping.

Methods

A consecutive cohort with ESH and available magnetic resonance imaging (MRI) between 2014 and 2019 was identified. The control group consisted of patients that underwent corrective osteotomies around the knee for mechanical axis correction and never complained of hip symptoms nor had undergone previous hip procedures. The following parameters were blindly assessed for determination of risk factors for ESH: CCD (corpus collum diaphysis) angle; femoral and global offset; femoral antetorsion; functional femoral antetorsion; translation of the greater trochanter (GT); posterior tilt of the GT; pelvic width/anterior pelvic length; intertrochanteric width. Hip and pelvic offset indexes were calculated as ratios of femoral/global offset and intertrochanteric/pelvic width, respectively. For the comparison of symptomatic and asymptomatic snapping, the following soft-tissue signs were investigated: presence of trochanteric bursitis or gluteal tendinopathy; presence of surface bony irregularities on trochanter major and ITB (Iliotibial band) thickness.

Results

A total of 31 hips with ESH were identified. The control group (n = 29) consisted of patients matched on both age (± 1) and gender. Multiple regression analysis determined an increased hip offset index to be independent predictor of ESH (r =  + 0.283, p = 0.025), most likely due to the higher femoral offset in the ESH group (p = 0.031). Pearson correlation analysis could not identify any significant secondary factors. No differences were found between painful and asymptomatic snapping on MRI.

Conclusions

A high hip offset index was found as an independent predictor for external snapping hip in our cohort, mainly due to increased femoral offset. No imaging soft-tissue related differences could be outlined between symptomatic and asymptomatic external snapping.

Level of evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00590.

Mid- to long-term clinical outcomes of arthroscopic surgery for external snapping hip syndrome

This study evaluated the outcomes of arthroscopic surgery for the treatment of external snapping hip at 2- to 10-year follow-ups. Eighteen patients with refractory external snapping hip treated by arthroscopic surgery were enrolled in this prospective study. All patients underwent unsuccessful conservative treatment for more than 3 months before surgery. We made diamond-shaped defects on the iliotibial band and resected peripheral fibrosis tissues for iliotibial band release with an arthroscopic approach. The visual analog scale (VAS), modified Harris hip score and return to previous level of activity were evaluated as functional outcomes. In addition, residual discomfort or the presentation of complications was also investigated. The average follow up period was 7 years. The modified Harris hip score increased from 70.08 preoperatively to 93.14 postoperatively, and the VAS score decreased from 3.67 preoperatively to 1.17 2 weeks after the operation and declined to 0.33 at the last follow-up. Neither recurrence of snaps nor complications were recorded. Two patients complained of a tight sensation with tenderness after exertion. Our clinical outcomes were compatible with those of previous studies, and no long-term complications were noted, even with a relatively longer follow-up period than what was reported in previous studies. Arthroscopic surgery is a safe and effective treatment that can provide promising long-term clinical outcomes for patients with refractory external snapping hip.

Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated with Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement

PURPOSE

The purpose of this article was to report prevalence of iliopsoas pathology in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI), incidence of rendered tenotomy, and outcomes of hips with iliopsoas involvement compared with those with primary FAI.

METHODS

A cohort study from a hip arthroscopy study group using a prospectively-collected multicenter database was performed. Patients who underwent isolated hip arthroscopy for FAI from January 2016 to March 2017 were assigned to the Iliopsoas group (defined as preoperative diagnosis of coxa saltans internus, intraoperative anteroinferior labral bruising or tear, and preoperative positive psoas injection) or control group. The prevalence of iliopsoas pathology, radiographic and intraoperative findings, and rendered procedures between groups were compared. Mean 2-year (minimum 1.8 year) outcomes of iliopsoas groups with and without rendered tenotomy and a control group were compared.

RESULTS

There were 1393 subjects, of which 92 (7%) comprised the iliopsoas study group with 1301 subjects control subjects. Sixteen subjects in the iliopsoas group received tenotomy (17% of iliopsoas group, 1% of all subjects), whereas 76 subjects (83% of iliopsoas group) with iliopsoas involvement did not. There was significant effect on postoperative International Hip Outcome Tool-12 (iHOT-12) scores based on iliopsoas involvement and treatment, F(2,1390) = 3.74, P = .02. Compared with the control group (M = 73, standard deviation [SD] = 24), the non-tenotomized iliopsoas group (M = 69, SD = 32) had similar postoperative scores (P = .46), whereas the tenotomized iliopsoas group (M = 57, SD = 28) averaged lower postoperative scores (P = .03). In the tenotomy group, 25% achieved the iHOT-12 substantial clinical benefit and patient acceptable symptomatic state value for normal function and 100% satisfaction, compared to 49% and 41% for the without tenotomy and control groups.

CONCLUSIONS

Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for FAI is infrequently performed and is associated with poorer outcomes. Co-afflicted patients treated without tenotomy have similar successful outcomes to patients with primary FAI. Indiscriminate tenotomy for iliopsoas pathology in this setting should be cautiously considered.

LEVEL OF EVIDENCE

Level III, cohort study.

The Limited Reliability of Physical Examination and Imaging for Diagnosis of Iliopsoas Tendinitis

PURPOSE

To determine if any association exists between physical examination, imaging findings [ultrasound (US) and magnetic resonance imaging (MRI)], and iliopsoas tendinitis (IPT) to characterize the reliability of these diagnostic modalities.

METHODS

Patients who had undergone US-guided iliopsoas tendon sheath injection (of lidocaine and a corticosteroid agent) as well as MRI performed within 1 year of injection from 2014 to 2019 were retrospectively reviewed. Demographic data, response to physical exam maneuvers, and response to injection were queried from patient records. US and MRI were reviewed by 2 independent musculoskeletal-trained radiologists. Response to injection was considered positive if the patient improved by >2 points on a 0- to 10-point VAS score. Chi-squared and Fisher exact testing were used to assess for any associations. Sensitivities, specificities, positive predictive values, and negative predictive values were calculated.

RESULTS

Sixty-three patients, age 52.3 ± 17.3 years (mean ± standard deviation), body mass index 27.4 ± 4.3 kg/m², and follow-up 33.6 ± 20.6 months, met inclusion criteria. No physical exam maneuvers, sonographic features, or MRI findings were significantly associated with response to iliopsoas tendon injection (P > .05). Groin pain had a sensitivity of 100% but a specificity of 7%. Snapping hip had a specificity of 82% but a sensitivity of 24%. Pain with resisted straight leg raise (SLR) (sensitivity 62%, specificity 25%) and weakness with resisted SLR (sensitivity 15%, specificity 71%) both were nonreliable. Sonographic bursal distension and tendinosis had low sensitivities (67% and 63%, respectively) and specificities (35% and 32%). Bursal distension on MRI had sensitivity and specificity of 64% and 45%, respectively. Tendon thickening had sensitivity and specificity of 55% and 60%, respectively, and heterogeneity had sensitivity and specificity of 52% and 65%.

CONCLUSION

Neither physical examination nor US or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected IPT.

LEVEL OF EVIDENCE

III, retrospective comparative trial limited by lack of a reference standard for iliopsoas tendonitis diagnosis.

The identification and treatment of snapping posterior tendons of the knee improves patient clinical outcomes

PURPOSE

To assess the most common presenting symptoms, clinical outcomes, and patient satisfaction following treatment of either snapping medial pes anserinus hamstrings or snapping lateral biceps femoris tendons.

METHODS

Consecutive patients with a minimum 2-year follow-up after isolated medial hamstring release for a diagnosis of medial snapping pes anserinus tendons or patients treated with primary biceps repair for lateral snapping biceps femoris tendons were evaluated. Clinical outcome scores of the following domains were collected: SF12, WOMAC score, Lysholm Knee Survey, and a simple numeric patient satisfaction score (0-10). Statistical analysis was performed with paired t-tests between preoperative and postoperative scores.

RESULTS

At an average follow-up of 4.6 years (range 2.0-8.6 years) with two patients lost to follow-up, six consecutive patients (three male, three female) with seven knees were diagnosed with medial snapping pes anserinus tendons and treated with semitendinosus and gracilis tenotomies. Seven knees in seven patients (three male, four female) were diagnosed with lateral snapping biceps femoris tendons and were treated with an isolated biceps femoris repair. Nine of 13 patients were able to return to full desired activities/pre-operative level of sporting activities (4/6 medial, 5/7 lateral. Lysholm and SF-12 scores improved from preoperative to post-operative status for patients with snapping biceps femoris. Only patients undergoing primary biceps repair showed improvement across all WOMAC domains. Patients with medial hamstring tenotomy demonstrated improvement in Lysholm scores. Median postoperative satisfaction for both pathologies was 7 out of 10.

CONCLUSION

Medial hamstring release for snapping pes anserinus and isolated biceps repair for lateral snapping biceps femoris yields improvement in patient satisfaction and clinical outcomes at mid-term follow-up.

LEVEL OF EVIDENCE

IV.

Hip Flexor Injuries in the Athlete

Athletic injuries to the hip flexors and iliopsoas have been described in populations across all levels of competitive sports. Overall estimates of hip flexor pathology have ranged from 5% to 28% of injuries among high-risk sport specific groups. Although most of these injuries are successfully treated with conservative management, and high rates of return to play are observed, significant rehabilitation time can be involved. As the understanding of hip pathology with imaging modalities such as MRI has advanced, greater importance has been placed on accurately diagnosing hip flexor injuries and initiating rehabilitation protocols early to minimize time loss from sport.

VIDEO: Dynamic Ultrasound for Snapping Hip Syndrome

OBJECTIVE. The purpose of this video article is to review the dynamic sonographic assessment of snapping hip syndrome. The video focuses on the extraarticular forms of snapping hip and discusses their possible causes, ultrasound features, and treatment options. The dynamic sonographic technique for evaluating snapping hip syndrome is shown with live scanning videos. CONCLUSION. Dynamic ultrasound is well suited for the assessment of snapping hip syndrome and is essential for confirming the clinical diagnosis of the condition.

Physical Examination of the Hip

The hip and pelvis have a complex anatomy and are a common source of pain and injury in the athletic population. The clinical examination of the hip requires a systematic approach to differentially diagnose hip problems with overlapping pain referral patterns. Because of the complex anatomy of the hip, the physical examination is a comprehensive evaluation of the 4 main pain generators of the hip from deep to superficial: the osteochondral, capsulolabral, musculotendinous, and neurovascular elements of the hip. The hip examination begins with the standing examination and gait analysis followed by a seated, supine, lateral, and prone examination. A targeted physical examination used in conjunction with a layered understanding of the hip and pelvis can help guide diagnostic testing, distinguish hip-specific diagnoses from similar presenting pathologies, and inform treatment.

External Snapping Hip Syndrome Endoscopic Treatment: "Fan-like" Technique as a Stepwise, Tailor-made Solution

Classically, external snapping hip syndrome (ESHS) is considered to be caused by friction of a tight iliotibial band (ITB) over the greater trochanter (GT), which leads to pain, inflammation, and palpable or audible snapping. Surgical treatment remains a gold standard in patients resistant to conservative measures. Many surgical procedures addressing ESHS exist in the literature, but the vast majority of them involve only plasties of the ITB. However, observations led us to the conclusion that friction of the ITB over the GT may not be the only cause of ESHS and other structures like gluteal fascias or an anterior scarred part of gluteus maximus may be involved. The aim of this article is to provide a detailed description and video demonstration of an endoscopic surgical procedure using a "fan-like" cut to treat the ESHS. Its greatest advantage is the ability to gradually increase the extent of surgery based on intraoperative observations. It turns the procedure into a tailor-made surgery, which offers good and reproducible results.

Is progressive resistance training feasible in patients with symptomatic external snapping hip?

BACKGROUND

Little is known about the feasibility of applying progressive resistance training (PRT) to patients with symptomatic external snapping hip (SESH).

PURPOSE

To investigate whether PRT is feasible in patients with SESH and to report changes to hip function, awareness of the hip joint and muscle strength following PRT.

METHODS

Feasibility was measured by drop-out rate, adverse events, pain exacerbation (VAS) and adherence to PRT. At baseline and the end of treatment, patients completed the Copenhagen Hip and Groin Outcome Score (HAGOS), the Forgotten Joint Score (FJS), maximal voluntary isometric (MVC) and dynamic hip muscle strength and a loaded stair test (LST).

RESULTS

Three out of nine included female patients (33%) dropped out. Pain scores were acceptable (VAS ≤ 50 mm) in 76% of all training sessions, and an overall decrease in pain during PRT was found (-10 mm, 95% CI [-3; -18]). For those who completed the intervention, training adherence was 97 ± 4%. Paired analyzes showed improvements in all HAGOS subscales, FJS, muscle strength and the LST.

CONCLUSION

Progressive resistance training seems feasible in a subset of patients with SESH despite a high drop-out rate. The present study suggests large effect sizes for hip pain, function, awareness and muscle strength.

Bifid iliopsoas tendon as a cause for internal snapping hip syndrome: A case report

Snapping hip syndrome, or coxa saltans, can result in significant clinical manifestations in patients including pain and limited mobility. A variety of both intra- and extra-articular pathologies have been implicated in snapping hip, including an anatomic variant known as the bifid iliopsoas tendon which has been briefly described in the literature. We report a case of a bifid iliopsoas tendon leading to internal snapping hip syndrome which was ultimately successfully treated with surgical release, including review of the clinical presentation, pathophysiology, and dynamic sonographic findings.

Iliopsoas Release in Hip Arthroscopy: Assessment of Muscle Atrophy

Iliopsoas release is a common procedure for coxa saltans interna of the hip. The possible sequelae from this surgery have not been well studied. The purpose of this study was to determine postoperative atrophy and morphology of the cut tendon. This retrospective review included patients who underwent arthroscopic iliopsoas release and had magnetic resonance imaging of the ipsilateral hip before and after surgical intervention. Cross-sectional area measurements were obtained of the iliopsoas muscle at the level of the distal anterior inferior iliac spine as well as at the L5 vertebral pedicle in patients who had imaging that included the lower lumbar spine. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and the Hip Outcome Score subscales for activities of daily living (HOS ADL) and sport (HOS Sport). A total of 44 patients met inclusion criteria for this study; 26 patients had additional advanced imaging that included the lumbar spine. The cross-sectional area of the iliopsoas at the level of the anterior inferior iliac spine decreased postoperatively by a mean of 191.4 mm²;, this difference was statistically significant (P<.0001). Mean area at the L5 pedicle was 628.9 mm² on the released side and 1216.2 mm² on the nonoperative side (P<.05). Mean Goutallier-Fuchs score of the released iliopsoas at the L5 pedicle was 1.3 (SD, 0.7). Mean mHHS, HOS ADL, and HOS Sport scores for patients at least 1 year postoperatively were 51, 56, and 42, respectively. [Orthopedics. 2020;43(3):e171-e176.].

Mechanics of Psoas Tendon Snapping. A Virtual Population Study

Internal snapping of the psoas tendon is a frequently reported condition, especially in young adolescents involved in sports. It is defined as an increased tendon excursion over bony or soft tissue prominence causing local irritation and inflammation of the tendon leading to groin pain and often is accompanied by an audible snap. Due to the lack of detailed dynamic visualization means, the exact mechanism of the condition remains poorly understood and different theories have been postulated related to the etiology and its location about the hip. In the present study we simulated psoas tendon behavior in a virtual population of 40,000 anatomies and compared tendon movement during combined abduction, flexion and external rotation and back to neutral extension and adduction. At risk phenotyopes for tendon snapping were defined as the morphologies presenting with excess tendon movement. There were little differences in tendon movement between the male and female models. In both populations, abnormal tendon excursion correlated with changes in mainly the femoral anatomy (male r = 0.72, p < 0.001, female r = 0.66, p < 0.001): increased anteversion and valgus as well as a decreasing femoral offset and ischiofemoral distance. The observed combination of shape components correlating with excess tendon movement in essence presented with a medial positioning of the minor trochanter. This finding suggest that psoas snapping and ischiofemoral impingement are possibly two presentations of a similar underlying rotational dysplasia of the femur.

Hip and Knee Injuries

Hip and knee injuries are a common presenting concern for patients to a primary care office. This pathology represents a large differential and it can often be a diagnostic challenge for providers to determine the etiology of a patient's symptoms. This article discusses several of the most common causes for hip and knee pain while providing an evidence based review of physical examination maneuvers, imaging studies and treatment modalities to assist a primary care provider when encountering active patients with underlying hip or knee pain.

Iliopsoas tendonitis after hip arthroscopy: prevalence, risk factors and treatment algorithm

The incidence of iliopsoas tendonitis (IPT) has not previously reported following hip arthroscopy for femoroacetabular impingement with or without labral tears. (i) What is the incidence of IPT following hip arthroscopy; (ii) are there any demographic risk factors and (iii) are there any operative techniques that are risk for IPT? Retrospective study. Hip arthroscopy patients from 2005 to 2012 were included. Patients were diagnosed via physical examination findings and were excluded if they had pre-operative IPT. Records were reviewed for demographics, operative reports and operative procedures. All patients received either labral debridement, labral repair, osteoplasty or a combination of those procedures. A standardized rehabilitation protocol was used. Of 252 patients, 60 (24%) had IPT. Twenty-eight (47%) had symptom resolution with activity modification, physical therapy and NSAIDs. Thirty-two (53%) required corticosteroid injection at a mean of 25 weeks after surgery. Seven (12%) required revision arthroscopy and iliopsoas release to resolve the symptoms. There were no patient-specific risk factors, differences based on surgical technique, and number of portals did not matter. Patients should minimize exercises that activate the iliopsoas after hip arthroscopy. The cause of IPT could be related to unaddressed abnormal mechanics, tendon scarring or improper physical therapy. Further studies are needed to investigate the reasons for this, as well as specific techniques to lower its incidence. The incidence of IPT after hip arthroscopy has an incidence of 24%. Additionally, we provide readers with a rehabilitation protocol to minimize this complication.

Snapping Hip Syndrome

Coxa saltans, or snapping hip syndrome, is a common orthopaedic problem that can easily be diagnosed and treated when the proper evaluation and management are utilized. It is often seen in growing adolescents, athletes, and people with sudden increase in physical activity. A thorough physical examination will help decipher whether the snapping hip is intra-articular or extra-articular and will help guide treatment options. This article reviews how to perform a physical assessment and treatment options such as medications, stretching, physical therapy, articular injections, and possible surgical interventions. Complications from conservative treatments are rare, but weakness, infection, nerve damage, and atrophy may occur following surgical procedures.

External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review

PURPOSE

To evaluate the outcomes of surgical management for external snapping hip in terms of: (1) recurrence; (2) complications; and (3) return to pre-injury activities.

METHODS

A thorough review of 4 electronic databases- EMBASE, CINAHL Plus, PubMed, and Scopus was performed to find all relevant studies for this review that were published between January 2000 and January 2017 that addressed surgical treatment for external snapping hip. The following reports were excluded: (1) non-English manuscripts; (2) n ⩽ 5; (3) clinical reviews; (4) surgical technique notes; (5) studies only analysing diagnosis; and (6) nonoperative management studies. After cross-referencing, a total of 7 reports were included. Each of these studies was analysed for the incidence of recurrence, revision surgery, complications, and return to pre-injury activity level.

RESULTS

There was a recurrence rate of 7% ( n = 8 of 113 hips) with only 1 requiring revision surgery (1%). The cumulative complication rate was 9% ( n = 10 of 113) with all complications being residual weakness. Additionally, we found 98% ( n = 58 of 59) of the patients returned to their pre-injury level of activity.

CONCLUSIONS

We found operative treatment for external snapping hip to be both safe and efficacious for returning patients to their pre-injury activities. When recurrence does occur, it often is painless and does not require revision surgery. Future studies should be larger and evaluate different surgical techniques to further elucidate the safety and efficacy of surgical treatment for external snapping hip.

The Hip Restoration Algorithm

BACKGROUND

Despite the rapid advancement of imaging and arthroscopic techniques about the hip joint, missed diagnoses are still common. As a deep joint and compared to the shoulder and knee joints, localization of hip symptoms is difficult. Hip pathology is not easily isolated and is often related to intra and extra-articular abnormalities. In light of these diagnostic challenges, we recommend an algorithmic approach to effectively diagnoses and treat hip pain.

METHODS

In this review, hip pain is evaluated from diagnosis to treatment in a clear decision model. First we discuss emergency hip situations followed by the differentiation of intra and extra-articular causes of the hip pain. We differentiate the intra-articular hip as arthritic and non-arthritic and extra-articular pain as surrounding or remote tissue generated. Further, extra-articular hip pain is evaluated according to pain location. Finally we summarize the surgical treatment approach with an algorithmic diagram.

CONCLUSION

Diagnosis of hip pathology is difficult because the etiologies of pain may be various. An algorithmic approach to hip restoration from diagnosis to rehabilitation is crucial to successfully identify and manage hip pathologies. Level of evidence: V.

Core Injuries Remote from the Pubic Symphysis

The core, or central musculoskeletal system of the torso, is essential for participating in sports and other physical activities. Core injuries are commonly encountered in athletes and active individuals. The importance of the midline pubic plate and rectus abdominis-adductor aponeurosis for core stability and function is discussed in the literature. This review article examines other important core injuries remote from the pubic symphysis, relevant clinical features, and preferred approaches to imaging. Several specific syndromes encountered in the core are reviewed. By protocoling imaging studies and identifying pathology, radiologists can add value to the clinical decision-making process and help guide therapeutic options.