Clicking hip: symptoms, cause and treatment

Snapping hip or Snapping Hip Syndrome (SHS), also known medically as coxa saltans, is a condition characterized by a snapping sensation in the hip during daily activities and may or may not be accompanied by an audible click. This is usually caused by muscles jumping/rolling over bone structures like an elastic band. This is often just a source of frustration for the patient, but it can also lead to limitations in activity due to pain and muscle weakness. There are different forms of hip clicking, each with a different clinical picture.

  • Types of snapping hip
  • Extra-articular
  • Intra-articular
  • Occurrence and causes
  • Symptoms
  • Diagnosis
  • Therapy
  • Prognosis

 

Types of snapping hip

We can divide the syndrome in terms of localization into extra-articular (outside the joint) and intra-articular (inside the joint) structures. We can further divide extra-articular disorders into external and internal forms. Since more and more is known in 2020 about intra-articular problems (for example a labral tear) in the hip, more appropriate diagnoses can often be made and the term intra-articular snapping hip is no longer frequently described.

Extra-articular

External
In this type, the iliotibial band or gluteus maximus or medius snaps over the most lateral point of the thigh, also called the greater trochanter. The iliotibial band is a broad tendon that runs from the iliac crest to the top of the tibia. Another possibility is that the hamstrings rub on the ischial tuberosities. The external type is the most common.
Internal
Here the iliopsoas, a deep hip flexor, rubs over a bony prominence of the pubic bone and/or the front of the femoral head. The typical patient is the (young) adult athlete who performs repetitive activities such as dance, gymnastics, football or running. In almost half of the cases, an internal snapping hip is accompanied by intra-articular pathology.

Intra-articular

The various forms of intra-articular snapping hip largely involve the same structures as the extra-articular variant, but they are usually caused by cartilage damage, joint damage, ligament tears and/or labral injuries. As a result, this form is often more painful and results in more limitations. This type is the rarest of the three.

Occurrence and causes

Approximately 5% – 10% of the population suffers from this syndrome, with the majority experiencing no symptoms other than the snapping sensation and/or clicking. The typical age of a patient is 15-40 years. It appears to be slightly more common in women than in men and correlates strongly with groups that perform repetitive (and often extreme) hip movements, such as athletes. In a study of competitive ballet dancers, it was found that up to 90% of them could trigger the symptoms of a snapping hip. There could also be some anatomical variations that could more easily lead to clicking hips, such as a large distance between and/or a larger size of the ischial tuberosities, or a difference in leg length.
Overload
Muscle overload is the main cause of a clicking hip. Depending on the shape, different repetitive and/or extreme movements are the origin. As a result, muscle and tendon shortenings can occur or length structures can no longer relax sufficiently. Due to the frequent rubbing of the muscles over the bone structures, inflammation of the muscle-tendon apparatus itself or of the underlying mucous membranes (bursa) can occur. Also, other muscles around the joint may overcompensate for the affected structures and become painfully hypertonic.
Trauma
In most cases, a clicking hip is caused by overloading of muscular structures. Nevertheless, it can also be the result of trauma. For example, muscle injection in the gluteus maximus or surgery may be the culprit. A total hip prosthesis is a typical example of this, as there is often a reduction in the angle between the femoral head and neck. The altered biomechanics of the joint that follows can lead to a clicking hip.

Symptoms

This is a list of possible symptoms. They do not have to occur all, or in this exact form, as the clinical picture depends greatly on the patient’s unique story.
External snapping hip

  • A snapping sensation and/or audible click when flexing and extending the hip, such as while walking, cycling or climbing stairs. Twisting movements can also cause the feeling. Furthermore, carrying heavy groceries or playing golf are also typical activities that can trigger symptoms.
  • The clicking may be accompanied by a sudden, sharp pain on the outside of the hip/thigh. Sometimes “handsome” is even visible.
  • The (unjustified) feeling that the hip is going to dislocate.
  • Gradual progression of the pain: first only after activity and later also during activity or at rest.
  • Possibly associated with symptoms of greater trochanteric bursitis or iliotibial band syndrome.
  • Reduction of strength when bending, stretching and/or abducting the hip.

Internal snapping hip

  • A snapping sensation and/or audible click while walking or when the hip is extended from a bent position (standing up after sitting, for example). External rotations (where the leg is turned away from the body) from a bent position can also be a provocative movement.
  • The clicking may be accompanied by a sudden, sharp pain in the front of the hip, deep in the groin.
  • Gradual progression of the pain: first only after activity and later also during activity or at rest.
  • Reduction of strength when bending and/or extending the hip.

Intra-articular clicking hip

  • Labral tear: shooting pain deep in the groin and snapping sensation with various hip movements, depending on the location of the injured part
  • Cartilage damage: cartilage reduces friction between the articulating bone pieces. It can become damaged due to sudden trauma or after osteoarthritis and lead to friction problems such as a snapping hip.
  • Joint mice: broken off pieces of cartilage or bone that reside in the joint and interfere with normal function. In addition to symptoms of a pinched hip, blockage in the joint can also occur during certain movements, depending on the location of the joint.

The symptoms usually occur suddenly after trauma.

Diagnosis

Since the clinical picture of snapping hip can be very diverse due to its various causes, the diagnosis will be based on coherent results from history, clinical tests and, if necessary, medical imaging. This always depends on the patient’s personal story.
History
Since the symptoms of a popping hip are fairly specific, a good interview is a very important step in arriving at the correct diagnosis. For example, the examiner may ask about frequency, location, timing and provocative movements of the snapping hip. The associated pain and limitations in activity are also explained. A medical history is necessary to identify factors that may influence the development and/or maintenance of the condition, such as operations, conditions from childhood, specific sports and the like. The patient’s story determines the choice of clinical tests and medical imaging.
Clinical tests

  • Palpation (external feeling with the hand) can provide an indication of the structures involved and the actuality (“sensitivity”) of the condition.
  • Inspection to identify abnormalities in gait, static (e.g. leg length discrepancy) and performance of activities of daily living.
  • Demonstration of the activities that cause hip popping.
  • Length and strength tests of the muscular structures around the hip.
  • Specific tests to confirm the previous: Ober’s test, Faber test, Thomas test, Iliopsoas stress test, …

Medical imaging
If necessary, medical imaging can precisely identify the structures that are causing the patient’s complaints. Especially with internal and intra-articular snapping hip, this can provide important extra information. The iliopsoas can be clearly visualized non-invasively with an ultrasound. The iliotibial band can also be visualized in this way if the external popping hip cannot be confirmed with clinical tests alone. MRI and radiography are also options, but are rarely used, especially in intra-articular pathology.

Therapy

There is no one-size-fits-all solution to cure a popped hip. Again, the appropriate choice of treatment will depend on the patient’s unique presentation. A good treatment plan is therefore drawn up in consultation with the parties involved (GP, patient and any other healthcare providers such as a specialist, physiotherapist, etc.) and may deviate from what is described below.
Conservative
Initially, an attempt is made to tackle the acute symptoms of the condition. This is achieved through relative rest, ice, NSAIDs (anti-inflammatories) and physiotherapy. A physiotherapeutic treatment plan may consist of stretching of the muscles involved, (ec entric) exercise therapy to restore strength and coordination and learning to manage the activities that trigger the complaints. In addition to resolving acute complaints, physiotherapy also aims to determine the underlying causes of the snapping hip. An orthopedic arch support can be important if there is a leg length difference. As a last resort, infiltrations with lidocaine or cortisone are considered.
Surgery
In the rare cases where conservative management fails, (keyhole) surgery may be necessary to remove damaged structures, bone protrusions and/or parts of the tendons involved, or to lengthen tendons.

Prognosis

In most cases, a popping hip can be cured with an efficient conservative policy. In recalcitrant cases, surgery can provide relief, but any resulting muscle weakness will also have to be actively addressed.

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