Finding an effective treatment for Snapping Hip Syndrome

Ross Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C

Finding an effective treatment for Snapping Hip Syndrome

Snapping hip syndrome is a frustrating problem to the people who have it. If you are reading this article you are most likely one of those people. It is also likely that you are a runner or a dancer.

You finally went to the doctor because it was becoming too painful to run or dance or jump and nothing you were doing on a self-help basis was helping. An equally alarming concern was  that you  noticed that your hip had become “noisy.” It was making a “snapping,” popping,” noise. You may have heard this noise before on occasion, but now it is getting much louder and more frequent. You were probably told, “stay away from running for a couple days,” and were given anti-inflammatory medication. Probably a prescription strength dosage far in excess of the over-the-counter pain and anti-inflammatory medications you were taking when you went to the doctor.

You were then told that if the pain does not go away after rest and medication, come back and “we will get an MRI done.” Your pain did not go away, when you tried to resume running after a few days,  your hip “snapped,” “popped,” and remained painful. You went for an MRI, the result? “Negative.” How can that be? How can the MRI show nothing? Because in “Snapping Hip Syndrome,” the MRI may show “nothing.” That is in part the diagnosis criteria for Snapping Hip Syndrome – MRI shows nothing.

So now what? Physical Therapy, massage, stretching, more medications, more rest, stop running? Get on an exercise bike? Ice, Ice, and more ice?

If you are reading this article this problem has now gone on for months maybe a year or two. What was once a minor inconvenience, then an annoying problem has now become a big problem. You may have groin pain, low back pain, it hurts now when you walk.  Surgery is now being discussed. What are the options?

Snapping Hip Syndrome is a degenerative joint condition

Snapping is a form of crepitus, the medical term for any audible noise or internal sensation of popping, grinding, clicking or “snapping” in a joint.

Crepitus is not a normal condition and signs of it point an injury or degenerative joint condition.

In the 2018 publication, Stat Pearls, (1) doctors describe Snapping Hip Syndrome in this way:

• Snapping hip syndrome, also known as coxa saltans or dancer’s hip is the audible or palpable snap that is heard during movement of the hip joint.
• There are many causes to Snapping hip syndrome.
  • The snapping hip problem can either come from deep inside the hip or externally or outside of the hip joint.
• External snapping hip is the more common variety and involves the lateral hip. It is most commonly attributed to the iliotibial band moving over the greater trochanter of the femoral head during movements such as flexion, extension, and external or internal rotation.
  • Other causes include the proximal hamstring tendon rolling over the ischial tuberosity, either the fascia lata or the anterior aspect of the gluteus maximus rolling over the greater trochanter, and the psoas tendon rolling over the medial fibers of the iliacus muscle.
  • A combination of defects is also possible; for example, thickening of both the posterior iliotibial band and anterior gluteus maximus, which snap over the greater trochanter at the same time.
• Internal snapping hip is less common and involves the anterior hip. Typically, the iliopsoas tendon snaps over underlying bony prominences, such as the iliopectinal eminence or the anterior aspect of the femoral head. It should be noted, however, that in approximately 50% of internal snapping hip cases, an additional intra-articular hip pathology is identified.

Soccer players, weight lifters, runners, ballet dancers

In research from doctors in Poland, a detailed analysis of the diagnosis and determination of Snapping Hip Syndrome is given in the Journal of Ultrasound (2). Here is the summary of that research:

• The diagnosis of Snapping Hip Syndrome should be given consideration in youth athletes where incidences are greater.
• The symptoms tend to occur more frequently among soccer players, weightlifters, or runners, but the syndrome is the most common in ballet dancers.
• Snapping hip syndrome can be caused by a physical trauma, an intramuscular injection into the gluteus maximus muscle, a surgical knee reconstruction using a portion of the iliotibial band, or a total hip replacement.

There are two main forms of snapping hip: extra or intraarticular.

• Intra-articular hip pathologies include acetabular labral tears, cartilage defects, loose bodies floating in hips.
• Extra-articular snapping may occur in the side or front region of the hip, depending on which tendon is involved in the snapping movement.
  • The lateral form of extra-articular snapping hip (external snapping hip) is caused by a movement of the iliotibial band or gluteus maximus across the greater trochanter. Conversely, the anterior form (internal snapping hip) is attributed to the iliopsoas tendon snapping over the iliopectineal eminence.

Many snapping hip syndrome incidences are underreported or misdiagnosed

In December 2018, doctors at George Mason University reported in the journal Medical Problems of Performing Artists (3) of the confusion surrounding hip pain in dancers.

They write that:

“Because snapping hip syndrome is poorly identified and can present similarly to other hip pathologies, many snapping hip syndrome incidences are underreported or misdiagnosed. Though snapping hip syndrome can begin as a harmless popping sensation, pain can become severe enough to limit dancers’ activities and potentially result in the development of concomitant issues.” Our note: concomitant issues are the degenerative hip problems related to hip instability.

In this video Ross Hauser, MD covers some of the problems we see in our clinic surrounding Snapping Hip Syndrome, and, our treatment options.

• Snapping hip syndrome is actually pretty common in athletes especially runners.
• The snapping hip occurs when the tensor fascia lata muscle of the thigh or the iliotibial band that runs along the greater trochanter, rubs against the hip bone and snaps, like finger snapping.
• When this happens people will get physical therapy and will focus on stretching the iliopsoas and iliotibial band.
• Stretching can help many people, but for many people this is not a long-term solution. The reason is that stretching does not tackle the problem of hip instability.
• Demonstrating how the hip works, Dr. Hauser points out that if the iliofemoral ligament and the ischiofemoral ligament, two strong ligaments that stabilize hip motion are damaged or weakened, this can cause hip instability which will lead to the problem of Snapping Hip Syndrome. That is the tensor fascia lata muscle of the thigh or the iliotibial band unnaturally rubbing against the hip bone.
• Prolotherapy, simple dextrose injections, strengthens these ligaments and helps stabilize the hip. Sometimes injections are given into the hip labrum because a torn labrum will also contribute to Snapping hip syndrome.
• Prolotherapy for these problems of the hip can take 3 – 5 treatments one month apart to achieve the strengthening of the joint capsule that can alleviate Snapping hip syndrome.

Finding an effective treatment for Snapping Hip Syndrome

Since snapping hip syndrome is commonly seen among athletes, the typical approach is to blame it on overtraining and tight muscles and tendons. As such, it involves at least part of the RICE protocol, which includes rest, ice, compression, and elevation.

Although some of these treatment components do indeed help with muscle injuries, they do not heal the soft tissue involved such as the ligaments, tendons, and hip labrum.

In addition, athletes must also stop training immediately, advice that is rarely popular, and when ligament laxity is involved, not even necessary for very long.

Another standard practice involves the use of steroids and anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration. Long-term side effects of these drugs can lead to other systemic health concerns.

When all else fails, patients who experience chronic snapping hip syndrome may be referred to a surgeon in order to lengthen the “tight” tendons thought to be involved. Unfortunately, surgery often makes the problem worse. Surgeons will use x-ray technology as a diagnostic tool, which does not always properly diagnose the pain source.

Treating the Iliotibial Band (IT Band) and iliopsoas tendon

Snapping hip syndrome involving the iliotibial band, or IT band.

• The IT Band is a thick, wide tendon that runs over the outside of the hip joint. Snapping hip syndrome occurs when the iliotibial band snaps over the bony prominence over the outside of the hip joint. Patients with this type of snapping hip syndrome may also develop trochanteric bursitis from the irritation of the bursa in this region.

Snapping hip syndrome involving the iliopsoas tendon,

• The iliopsoas tendon can catch on a bony prominence of the pelvis and cause a snap when the hip is flexed. When the iliopsoas tendon is the cause of snapping hip syndrome, patients typically experience no problems other than the annoying snapping.

Snapping hip syndrome involving involves a tear in the hip cartilage or bone debris in the hip joint (loose bodies). This type of snapping hip usually causes pain and may be disabling. In addition, a loose piece of cartilage can cause the hip to catch or lock up.

Snapping Hip due to Gluteus Medius Tendinopathy

Doctors from the National Taiwan University Hospital (4) presented a case of snapping hip syndrome in regards to gluteus medius and minimus tendon problems and dextrose prolotherapy in its treatment.

A 37-year-old male started to complain of right lateral hip pain after he had initiated weight training half a year ago. The physical examination revealed tenderness near the greater trochanteric region with a reproducible and palpable snapping during hip flexion and extension.

The ultrasound examination showed swelling and hypoechogenicity (a clear immune response to injury) in the gluteus medius tendon at its insertion (enthesis) on the lateral facet of the greater trochanter. The overlying iliotibial band appeared normal. In the short-axis view, a snapping was clearly visualized when the iliotibial band glided over the swollen gluteus medius tendon during hip flexion and extension.

Under US guidance, 25% dextrose solution was administered into the gluteus medius tendon (1.5 mL) using the peppering technique and into the space between the iliotibial band and the gluteus medius tendon (2.5 mL). After two cycles of dextrose injections in 2 weeks, the patient became free of hip pain and snapping.

The doctors also reported that they did not use corticosteroid due to its weak benefit in treating chronic tendinopathy and its detrimental effect on tendon healing.

The snapping sensation in the front or the outer side of the hip occurs from a tightness or tensing of the iliopsoas muscle or the tensor fascia latae muscle. The muscles are compensating for ligament weakness or labral tear causing hip instability.

 Prolotherapy for Snapping Hip Syndrome

Prolotherapy for snapping hip syndrome gets at the root cause of the problem, damaged connective tissues like tendons and ligaments. The abnormal movement of these connective tissues rubbing over bony parts of the pelvis is due to these structures becoming lax or loose from repetitive use like in dance or sports or from a traumatic incident like a fall. The dextrose in the Prolotherapy solution, when injected around the injury, causes a mild inflammatory response, mimicking what the body does naturally in response to soft-tissue injuries. The immune system is drawn to the area of injury and immune cells and platelets release growth factors to build new healthy tissue.  The ligaments and tendons become thicker and stronger from this inflammatory response, proven decades ago in rabbit studies. When they do, the laxity or looseness of these structures is resolved and the snapping and pain goes away.

The intra-articular causes of snapping hip are usually more serious. But a Prolotherapy doctor, a specialist in this regenerative injection therapy like our team, can determine if Prolotherapy or surgery is called for. Loose bodies, usually bone or cartilage fragments, sometimes do have to be surgically removed if they are rubbing on other structures causing pain. If one has a tear of the labrum, a specialized structure/tissue that covers the joint capsules of hips and shoulders, it can cause pain and snapping. Then the doctor may have to use slightly more advanced techniques to resolve the problem. Platelet-rich plasma (PRP) is a type of Prolotherapy that uses a patient’s own blood, from which the platelets and their large concentrations of growth factors are used as part of the Prolotherapy solution. Labral tears usually respond well to PRP.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

Prolotherapy is an injection of a simple sugar, dextrose. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.

• This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
• This patient has a suspected labral tear and ligament injury.
• The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
• The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
• From the front of the hip (1:05) we can treat the pubofemoral ligament and the iliofemoral ligaments
• From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles  you’re obviously going to get some of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
• Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
• This athlete is training for a half marathon and did not want to have their training regiment stopped because of this injury and believe it or not within 10 days of this treatment the athlete was back to running. At the time of this video, they were scheduled to have another treatment. One treatment may not resolve a runner’s injury. Depending on the injury we get people sometimes back to their sport really quickly sometimes it takes a few treatments before they’re back to their exercise

Degenerative Joint Disease and Snapping Hip Syndrome

Degenerative joint disease, or osteoarthritis, is the long-term result/worst-case scenario of what initially begins as a minor injury like snapping hip syndrome. If your IT band or iliopsoas tendon becomes chronically weakend, it can lead to osteoarthritis. If these extra-articular problems are addressed in a timely manner, then the arthritic intra-articular problem is arrested. When caught early, normal dextrose Prolotherapy can help repair this cartilage damage. More severe cases, where x-rays and MRI’s show bone-on-bone, or basically no cartilage, then more sophisticated Prolotherapy may be needed.

References

1 Musick SR. Snapping Hip Syndrome. StatPearls Publishing, Treasure Island (FL) [29 Aug 2017]

2 Piechota M, Maczuch J, Skupiński J, Kukawska-Sysio K, Wawrzynek W. Internal snapping hip syndrome in dynamic ultrasonography. Journal of Ultrasonography. 2016;16(66):296-303. doi:10.15557/JoU.2016.0030. [Google Scholar]

3 Nolton EC, Ambegaonkar JP. Recognizing and Managing Snapping Hip Syndrome in Dancers. Medical problems of performing artists. 2018 Dec 1;33(4):286.

4. Hung CY, Chang KV, Özçakar L. Snapping hip due to gluteus medius tendinopathy: ultrasound imaging in the diagnosis and guidance for prolotherapy. Pain Medicine. 2015 Oct 1;16(10):2040-1. [Google Scholar]

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