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Snapping Hip

SNAPPING HIP

 

My hip snaps when I run. Is that normal?

Snapping hip is a condition that affects 5% -10% of the population in the 15- 40 age group. It is mostly asymptomatic and tends to affect women more than men. The athletic population is more at risk for snapping hip as compared to non-exercising individuals due to repetitive hip movement. The snapping sensation is accompanied by a click or a popping sound when the hip moves from extremes of flexion to extension.

Initially an annoying sensation, the snapping may go on to become painful if it continues for a long time. Snapping hip is usually an overuse injury seen more often in runners, dancers and soccer players.

Why does my Hip snap

The hip makes a snapping sound when a tight tendon rubs over a bony prominence. A tight iliopsoas tendon (the main hip flexor) and a tight iliotibial band (thick band on the outer side of the thigh) are usually implicated in this condition. The other tendons that may cause snapping are the hamstring tendon and the rectus femoris tendon.

 

Anatomy of the hip joint

The hip is a ball and socket joint formed by the union of the head of femur (thigh bone) and the shallow acetabular socket of the ilium (pelvic bone). The socket is deepened by a rim of tough cartilage tissue called the acetabular labrum. The joint is designed to offer significant stability while facilitating mobility.

More than 25 muscles cross the hip joint. When one of these muscles become tight it can slide over a bony prominence in the ilium or femur, giving rise to a clicking sound.

There are small fluid filled sacs called bursae, between the tendons and adjacent bony prominences whose role is to reduce the friction between the surfaces. A chronic case of snapping hip can become painful when the underlying bursae gets irritated and inflamed. The pain may also arise due to tendinopathy (a degenerative condition of the tendon).

 

2 Main causes of Snapping Hip

The causes of snapping hip can be classified as either extraarticular (outside the joint) or intraarticular (inside the joint):

Extra-articular causes may be further classified as Lateral, Medial and Posterior

Lateral Snapping: This is the most common cause of a snapping hip. The individual complains of a clicking sound while walking, running or climbing stairs. The person may report a feeling that the hip is about to pop out of the joint. The pain that accompanies a snapping hip gets worse with activity. This can be differentiated from a tendinopathy pain which generally improves with activity.

Tendons that may cause external snapping are:

  • Tight Iliotibial band– The thick band on the side of the thigh, may make the clicking sound as it passes over the greater trochanter. The greater trochanter is the prominent part of the hip that protrudes to the outside of the thigh.

 

  • Tight gluteus maximus– The medial part of the muscle may also snap while moving over the greater trochanter.
Snapping hip causes & treatment at Newbridge & Naas Physio Clinic. Chartered Physio & Chiropractor.

Ross Allen is dual qualified as a Chartered Physiotherapist & Chiropractor.

 

Medial Snapping Hip: The main hip flexor (the iliopsoas muscle) slips over a prominence in the pelvic bone (iliopubic eminence) or the head of the femur (the lesser trochanter) as the hip moves from flexion to extension.

The athlete complains of pain when they get up from a sitting position or when they rotate the leg outwards. There may be sudden pain deep in the groin. Any activity that moves the hip from 90 degrees of flexion to full extension becomes painful. There may be an associated gluteus medius weakness in that leg. The patient may not be able to keep the pelvis parallel to the ground while standing on the affected leg (Trendlenberg sign positive)

There may be similar complaints when a tight rectus femoris – a 2 joint muscle and a part of the quadriceps group, moves over the femoral head.

 

Posterior snapping is one of the rarest types of snapping hip and may be caused by:

 

  • Tight hamstring muscleas it repeatedly moves over the ischial tuberosity (prominence at the back of the pelvis).

 

  • Ischiofemoral impingement, rarer cause of posterior snapping hip results from reduced space between the ischium and the lesser trochanter. Hip extension further reduces this space causing impingement of the quadratus femoris mucle that is located here.

 

Intraarticular: Just like the knee joint, the hip is also prone to locking. When bits of degenerated cartilage or a torn labrum break off and are released into the joint space then they act as loose bodies. These loose bodies may block smooth movement of the joint and cause a clicking sound. The pain and disability are more severe in this case.

 

Risk factors for a snapping hip

  • Gender:women are more prone to snapping hip as compared to men for the same sport. Anatomical differences like wider pelvis and difference in muscle fiber orientation may probably be the underlying cause for this.
  • Tight muscles:This is one of the main reasons for a snapping hip. A tight muscle does not slide easily over a bony prominence.
  • Adolescent athletes:when young athletes face sudden growth spurts, the bones may grow faster and the muscles can take time to adapt. This creates a muscle and bone length imbalance leading to perceived muscle tightness.
  • Repeated movement:All activities requiring repeated flexion above (90degrees) and extension or repeated outward rotation of the femur predispose to a snapping hip. This is particularly true for dancers, gymnasts, runners, golfers and soccer players.
  • Biomechanical alignment issues:imbalances in weight distribution over the two legs can cause muscles of either leg to become tight and function incorrectly. For example, genu valgum (knocked knees) and pronated foot (flat foot) may also predispose to snapping hip. Decreased neck shaft angle of the femur or coxa vara has also been seen to cause a snapping hip. A reduced neck shaft angle, makes the hip abductor complex inefficient. The tensor fascia latae and thus the ITB over works to compensate for weak hip abductors.

 

Abductor weakness:Gluteus medius weakness has been observed in 16% of the patients with snapping hip. A weak abductor complex increases the strain on the muscle to the outside of the hip i.e. the tensor fascia latae, which can result in tightness and snapping.

  • Training errors: Overtraining or inefficient running technique such as increased hip adduction can cause tightness, pain & snapping in the ITB.

 

  • Labral tears increase the risk of iliopsoas dysfunction and consequent snapping hip. Conversely a weak iliopsoas, ups the risk of labral tear, as the femoral head pushes more on the acetabulum. This increases the risk of intraarticular loose bodies and snapping hip.

 

How is a snapping hip diagnosed?

A complete physical examination helps to replicate the snapping of the tendons around the hip. The therapist should be able to pinpoint the area of pain and snapping while performing the inciting movement. The physiotherapist or chiropractor may also check the hip range of motion, muscle strength & lower limb biomechanics. He may go on to check the low back and knee to eliminate any causes of referred pain.

An x-ray may help to rule out any arthritic changes or loose bodies as the cause of restricted mobility in the joint. An MRI is generally more useful as it also shows the soft tissue structures around the joint.

There are a few specific tests that can help isolate the involved tendon. To diagnose an external snapping hip, the clinician will place the patient in a side lying position on the unaffected hip. This puts the affected/top hip in adduction. Keeping the knee straight, the patient is asked to flex and extend his hip. The Iliotibial band can be heard clicking over the greater trochanter.

A modified version of the FABER test (Flexion-Abduction-External rotation) can be used to differentiate between an internal (Iliospoas) and an external (IT Band) snapping hip. The affected hip is passively moved from FABER position into extension, adduction and internal rotation position. A palpable or audible snap may be heard to confirm Iliopsoas involvement.

 

How do I get rid of my snapping hip?

According to some researchers, a snapping hip can take up to two years to recover completely. If you are an athlete, activity modification, reducing the intensity of running or doing more cross training in the acute phase of the pain can also help to decrease the stress on the inflamed tendon or bursa.

 

How does Physiotherapy help a Snapping Hip?

Myofascial release of the muscles on the lateral side of the hip – the tensor fascia latae, gluteus medius and gluteus maximus is effective in reducing the pain and snapping according to a case study published in 2007.  The same case study advocates adding stretching of adductors (inner thigh muscles), strengthening and stabilisation of outer hip muscles for complete resolution of symptoms.

Myofascial release is a deep tissue manipulation technique that helps to release the adhesions between the muscle fibers and their fascia. A self-myofascial release for the gluteal muscles involves placing a tennis ball under the buttocks and moving up and down for not more than 5-7 minutes. For the tensor fascia latae (IT Band), the same can be done with the patient lying on the side with the ball just under the mid-thigh.

Active release techniques applied on the abductors and adductors of the affected hip also works on a similar basis. ART, is a soft tissue treatment that focuses on relieving tissue tension by removing fibrosis/adhesion that develops in an overloaded tissue due to repeated overuse.

Muscle release techniques can be complemented by a lateral pelvic stability program to correct hip abductor weakness and faulty pelvic muscle firing patterns (TFL substitution). According to another study by Henning (2014), decreased hip abductor strength/dysfunction leads to an increase in hip adduction and internal rotation during weight bearing activity placing the iliotibial band (ITB) complex under increased tension. These deficits are believed to cause fibrosisby increasing friction between the lateral ITB complex and the greater trochanter.

Chronic cases of snapping hip usually result in degenerative changes in the involved tendon. Andres et al (2008) conducted a systematic review of interventions for the management of tendinopathy. They concluded that eccentric strengthening exercises were more effective in relieving the pain and improving function as compared to any other form of exercise.

Once the muscles have achieved their normal flexibility and strength, neuromuscular control exercises are added to improve muscle fiber recruitment patterns. These exercises help to improve dynamic balance on uneven surfaces or during quick movements.

 

References:

  1. Spina AA. External coxa sultans (snapping hip) treated with active release techniques: a case report. J Can Chiropr Assoc. 2007; 51(1):23-29
  2. Byrd JW. Snapping Hip. Oper Tech Sports Med. 2005: 13:46-54
  3. Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 1990; 18 (5): 470-4.
  4. Gose JC, Schweizer P. Iliotibial Band Tightness. J Orthop Sports Phys Ther. 10(10):399-407.
  5. Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis (Review). Cochrane Library 2009; 1.
  6. Andres BM, Murrell GA. Treatment of Tendinopathy. What Works, What Does Not, and What is on the Horizon. Clin Orthop Relat Res. (2008) 466:1539-1554
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924651/#!po=3.33333
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445103/#!po=15.4412
  9. Troy Henning, DO, “The Running Athlete- Stress Fractures, Osteitis Pubis, and Snapping Hips Sports Health.” 2014 Mar; 6(2): 122–127. doi:  10.1177/1941738114523381

To find out more, contact the Naas Physio Clinic on:
(045) 874 682


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