Snapping Hip Syndrome

Written by Marek Kolarik

Snapping Hip Syndrome (SHS) also known as Dancer’s hip is mostly recognised by patients as a sound of a “click” or “snapping” sound/sensation in the hip when the hip joint is being moved in certain directions. It can mostly develop when muscles and tendons around the hip are tightened or imbalanced. Most people experience it when going from sitting to standing, walking, swimming, practicing yoga or simply when moving the leg from side to side or swinging front to back.

In most cases, it is rather more of an irritation than a painful sensation, nonetheless it may lead to pain-related conditions like Bursitis if overlooked. The most common area of the body where the affected population feels the “snapping” sounds or sensations is, on the outside of the hip (just around the bony area, when you put your hands on the hips), but it can also appear on the inside of the hip (closer to the groin area).

In most cases the symptoms of SHS are the clicking and snapping sound, it can also be felt by touch (palpation) predominantly on the side of the hip and upper part of the leg. There are cases where the “snapping/clicking” can be followed by pain and this has to be investigated further, to rule out any serious complications which could lead to prolonged inactivity. This may have a negative influence on lifestyle and further complications for the patient’s full recovery.

There are two main categories of Snapping Hip Syndrome: Extra- articular (outside of the hip capsule) and Intra-articular (within the hip capsule).

The Intra-articular (least common) hip syndrome term is not used as much due to better understanding of intra-articular pathologies, which is caused by loose bodies or labral tears within the deep structures of the hip joint. These pathologies are almost always present as pain on movements and can cause reduced movement in the hip joint. Pain on weight bearing may also be present, due to further joint damage if it is neglected for a longer period of time.

Extra-articular hip syndrome is divided into External snapping hip and Internal Snapping hip.

External Snapping Hip (most common) is generally connected to the Iliotibial Band (tough fascial tissue running from the outside of the hip towards the knee). The Iliotibial Band (ITB) runs over a bony prominence on the top side of the leg known as the greater trochanter. In movements such as flexion (bringing the leg forward and the knee up) and extension (bringing the leg backwards) theITB crosses from one side of greater trochanter to another which if taught can result in “snapping/clicking” sounds.

Less common causes of external snapping are: the gluteus muscles (buttock muscles) anterior (front) part of the muscle fibres along with fascia lata going over a greater trochanter. This will have a similar presentation as ITB. Another presentation might be related to the hamstring tendon which can be scraping over the ischial tuberosity ( a bony prominence known more commonly as the sitting bones). Where patients may experience snapping a sound/sensation around the buttock folds.

Internal Snapping Hip is mainly caused by the Iliopsoas tendon running over the bony prominence on the top and side of the femur, anatomically known as the Iliopectineal eminence and anterior Femoral head. This can be similar to an Intra-articular pathology, and patients will feel the sensation of clicking deep in the groin area. For this reason, it has to be examined more closely to differentiate between the two syndromes. The thorough diagnosis has to be done specially when SHS is painful, simply because poor or overlooked diagnosis may lead to further complications.

The symptoms in SHS don’t usually occur as a result from sudden trauma to the hip joint. Patients are usually able to pinpoint the exact area of pain or snapping, generally because it develops over a longer period of time. It is caused by certain repetitive movements, hence the nickname Dancers hip. In the most common External SHS it is easily visible and naturally easily palpable. In non-painful SHS physical clinical tests are suggestive to confirm what anatomical regions are involved in each presentation.

The standard orthopedic test for External SHS involving the ITB is Ober’s test. A positive test is confirmed when a snapping sensation is reproduced when the leg is moved towards the midline of the body. The complications may be if pain and swelling is present along with snapping which can suggest bursitis, tendon pathology, or inflammation of the Iliotibial band. All of the signs and symptoms along with patient history have to be considered for further investigation and management.

In the internal snapping test, a positive sign is when the snapping sound is felt/ or heard when the patient is supine (laying on his/her back) and the affected leg is flexed and externally rotated (knee to chest, with foot pointing outside), then the leg is just extended (straighten out) next to the opposite leg.

If the clinical tests are positive and there is continuation and an increase of a painful sensation especially in the Internal snapping, then the physical examination is not the conclusive diagnostic tool. Dynamic ultrasound is one of the most prevalent imaging diagnostic tools to distinguish tendon translation in hip movement. Other diagnostic tools for SHS are Ultrasonography, MRI, Bursography with Fluoroscopy.

If a patient is experiencing SHS without painful stimuli then appropriate individually based exercises and stretching, is considered as one of the most appropriate management and preventive care.

There are few treatment options if pain is present along with SHS. What has to be considered before treatment is the length and severity of pain, and the site where the pain is present (outside of the hip vs. inside/groin pain). Usually amongst the first treatment options the conservative treatment options are most likely in many cases. Conservative options can include:

Medication management: Anti-inflammatory medication (oral medication) or Steroid injections (corticosteroid injection) into the painful area can be used to help with reducing any inflammation and to give pain relief.

Self management: Rest and Icing the area with a cold compress for 20 minutes a few times a day can be done as this may help to reduce any inflammation.

Physical therapy (Osteopathy or Physiotherapy): The aim of hands-on treatment is to identify if the problem is due to tight muscles or muscles which are overworking (disproportionate activation) and causing heightened tension in the muscle. In addition, posture and some anomalies (such as leg length discrepancy), and repetitive movement has to be considered also in restoring the muscular balance in hip joints. The therapist will focus on helping to stretch the short or tight muscles and improve/strengthen the underworking or weak muscle structures.

In cases where conservative treatment has not helped then surgical intervention may be appropriate. Surgery is considered as a last resort intervention in SHS.

Surgical procedures are divided into two categories relating to External/Internal snapping and type of intervention Arthroscopic vs. Open surgery.

• External snapping is predominantly focusing on releasing the Iliotibial band where both open or arthroscopic surgery is an acceptable procedure.
• Internal snapping also focuses on releasing the Iliopsoas tendon, but arthroscopic surgery is a more preferred option to prevent complications from open surgery.

As with every surgical procedure there are certain risks and negative effects, and most common in SHS may be exaggerated release in affected tendons by surgery which may lead to muscle weakness. Therefore, it is always advisable to discuss risks and benefits with a surgical consultant, the consideration needs to be emphasised on what are the patient’s expectations and if they meet with the surgeon’s expectations and outcomes from surgery.

Yes, it is preventable and similarly as in the treatment the exercise modalities will be the most effective measure.

• Warming up before physical activity (sport, work etc.) this should include active and passive stretches which were advised by a physical therapist, and are effective for each patient’s individual needs.
• Gradual loading in intensity of any physical activity
• Consistency and maintaining good conditioning
• Using the most appropriate footwear, clothing for support and most comfortable movement
• Adapt the activity level.

The aim of the exercises for SHS is to release the tension in overworking muscles or stretch the shortened muscles around the hip joint.

Hip Flexor Stretch. Start in a deep lunge position with the knee of the affected side bent to 90 degrees and touching the ground (some support under the knee might be needed). The front leg is bent to 90 degrees with the foot flat on the ground and hips straight. Begin by slightly tucking the tailbone underneath a stretch should be felt down the front of the thigh in the back leg. Hold for 30 to 45 seconds and repeat 5 times. This exercise should be done daily.

Gluteal/ IT Band stretch. Stand straight with the affected leg crossed in front of the opposite side. Begin by leaning/ side-bending to the opposite side away from the affected leg forming a bow or banana shape with the body. A stretch should be felt on the outside of the affected side. Hold the stretch for 30 to 45 seconds and repeat 2-3 times a day.

Side lying leg lift. Lie on the opposite side of the affected hip/leg with support or cushion under the head. maintain a straight back making sure the hips are in one line with head and legs. Begin by squeezing the glutes to activate and lift the affected leg against gravity to about 30-60cm high. Lower the leg back down and repeat 10-15 times, 2 times a day.

*It is recommended to get the OK from your GP, physiotherapist or osteopath before carrying out any of the above exercises.