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

Snapping hip syndrome is a frustrating problem for 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. Your story may go something like this:

About two years ago my hip gave way. I am a long-distance runner, I run in competitions. One day during a run I heard a loud snap in my hip, it started to swell so I thought I tore something. I went straight off to an orthopedic surgeon and I was diagnosed with something I never heard of, snapping hip syndrome.

Treatments 

At the initial visit with the surgeon, I was given my treatment guidelines.

• Prescription for anti-inflammatory drugs
• Rest, ice, compression, elevation 
• Prescription for physical therapy

After a few weeks and no improvement, I was reassessed and given a cortisone injection. This did not help either. I was told that this may be a permanent problem and I need to give up the long-distance runs unless I wanted to consider surgery. This was unacceptable. Now I am looking for different treatment options because surgery is my last choice.

What do we do?

Below we will explain that we treat snapping hip syndrome by addressing ligament damage in the pelvic and hip area. Many people that reach out to us for treatment did not have this approach explained to them. We will document why that may have happened in the research below.

Snapping Hip Syndrome is not a problem in isolation

When people contact us with a diagnosis of snapping hip syndrome, many times it is a problem among many problems. In many cases, people will begin with a discussion of their hip labral tear, a paralabral cyst that may be causing sciatica-like symptoms, iliopsoas tendonitis, greater trochanteric pain syndrome, and snapping hip syndrome. The thinking many have, and they are mostly correct, is that the snapping is a symptom of many hip problems. Again, we will explain that we treat snapping hip syndrome by addressing ligament damage in the pelvic and hip area and restoring hip instability. In many cases restoring hip, instability will not only resolve the snapping but the concurrent conditions.

What are we seeing in this image?

The snapping sensation in the front and/or the outer side of the hip occurs from 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. This is explained at length below.

Finding an effective treatment for Snapping Hip Syndrome

Snapping hip syndrome is a frustrating problem for 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 were 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 of 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?

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

Guidelines for doctors treating snapping hip syndrome were offered in a paper published in the Sports medicine and arthroscopy review.(1) Here are the summary learning points:

• Snapping hip should normally be treated conservatively.
• Many people experience benign, asymptomatic snapping on an infrequent basis, and for this, no treatment is necessary.

Conservative care treatment guidelines

• If the snapping becomes painful, reduces rotation, and causes other symptoms, a program of conservative management should be attempted first.
  • Physical therapy evaluation focuses on identifying the source of the muscle tightness that is causing the snapping. This tightness can be due to applying a stretch to a muscle that is too short or attempting to lengthen a muscle that is too active.
    • Explanatory note: A too short muscle or an attempt to lengthen this muscle is many times in response to a muscle that has “rolled itself up into a tight ball.” Why would the muscle do this? It is injured in some way and it is not only trying to protect itself from further injury while it is trying to do its job of providing power and movement. If the hip is unstable because of hip ligament damage, the muscles also try to do the job of the ligaments of holding the bone together. So the muscle rolls itself up into a ball so it can function with less chance of damage to itself. This is one way of saying overuse syndrome.

When your muscles are rolled up into a ball or they have become “short”

• IF the muscle is too short or rolled up into a ball, the treatment should be directed at increasing muscle length through passive and active stretching.
  • Gains with stretching are more likely to be maintained if the causes of the initial muscle shortness, such as posture and habitual movement patterns (overuse), are also addressed.
  • If the problem is that excessive muscle activation (overuse) is increasing the tension in the muscle, the intervention is directed at modifying neuromuscular control. (This is an eccentric exercise which is the slow movement downward. For instance, eccentric hip flexion is when you lie on your back and lift your leg. The slow descending of your leg back to the floor is the eccentric exercise.) Most of you that have been through physical therapy has been through this routine. It may have helped, it may not have helped. Why it did not help we will explain below
  • Care must be taken to not exacerbate symptoms with exercise.
  • Rest, icing, and anti-inflammatories can be helpful with inflammation of the bursal tissues.
  • Occasionally, injection of hydrocortisone into the bursal tissue can give symptomatic relief
  • Under a controlled physical therapy program, it is possible to regain normal function of the hip without snapping over a period of 6 to 12 months. However, even after this, modification of movement patterns and consistent stretching is advocated to prevent a recurrence.
    • Explanatory note: So after all this, possibly taking a year. You may not be better off.

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 to an injury or degenerative joint condition.

In the 2018 publication, Stat Pearls, (2) 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 of 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 (3). 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 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 the 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 (4) 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.

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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.

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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.

 Surgery for snapping hip syndrome

At the beginning of this article, we suggested that snapping hip syndrome is not a problem that sits in isolation. There are many problems happening in the hip, snapping hip syndrome may only be one of many.

An October 2020 study published in the journal Arthroscopy Techniques (5), offers this same assessment. In this paper, surgeons offer a technique that allows them to see and repair the various problems that may be discovered in the hip while treating the snapping hip problem. Here are the summary points:

• “Classically, external snapping hip syndrome is considered to be caused by friction of a tight iliotibial band (ITB) over the greater trochanter, 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 external snapping hip syndrome exist in the literature, but the vast majority of them involve only (surgical repair) of the ITB.
• However, observations led (the authors) to the conclusion that friction of the iliotibial band over the greater trochanter may not be the only cause of snapping hip syndrome and other structures like gluteal fascias or an anterior scarred part of gluteus maximus may be involved”

Psoas Tendon Snapping

Similarly, a group of orthopedic surgeons combined their results in the journal Frontiers in Bioengineering and Biotechnology (6) and found that psoas snapping and ischiofemoral impingement are possibly two presentations of a similar underlying rotational dysplasia of the femur.

More pain after surgery

I wanted to run. Now I have more pain after the surgery. My pre-surgery pain centered on my hip, groin, and pelvis. I had limited rotation and my hip made a snapping sound. When it happened it felt like a “snapping my fingers” sensation. I was diagnosed with enthesopathy at various points in my hip. I had a small hip labrum tear and my orthopedist thought that if we fixed that up I could run again. It got worse after the surgery. Pain is severe. I am now on painkillers and “heavy-duty,” anti-inflammatories. My doctors do not know how to help me at this point because I no longer have any inflammation.

First, many people have very successful surgeries for problems related to snapping hip and/or hip labral tears. This person’s story is just one story where the surgery did not work. It is more typical of the patients we see as we usually do not see successful surgery people, we see the not so successful surgery people at our center.

Prolotherapy for Snapping Hip Syndrome

In this section, we will discuss and describe the use of Prolotherapy for snapping hip syndrome. Prolotherapy is a series of simple dextrose injections.

In more than 28 years of helping patients with various disorders, we have found Prolotherapy injections to be a safe, reliable treatment in helping to alleviate various problems of the hip, spine, and joints. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.

Snapping Hip due to Gluteus Medius Tendinopathy

Doctors  (7) 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 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 corticosteroids due to their weak benefit in treating chronic tendinopathy and its detrimental effect on tendon healing.

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 go 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.

• 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 weakened, 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. In more severe cases, where x-rays and MRIs show bone-on-bone, or basically, no cartilage, then more sophisticated Prolotherapy may be needed.

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Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your Snapping Hip Syndrome.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Yen YM, Lewis CL, Kim YJ. Understanding and treating the snapping hip. Sports medicine and arthroscopy review. 2015 Dec;23(4):194. [Google Scholar]
2 Musick SR. Snapping Hip Syndrome. StatPearls Publishing, Treasure Island (FL) [29 Aug 2017] [Google Scholar]
3 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]
4 Nolton EC, Ambegaonkar JP. Recognizing and managing snapping hip syndrome in dancers. Medical problems of performing artists. 2018 Dec 1;33(4):286-91. [Google Scholar]
5 Malinowski K, Kalinowski Ł, Góralczyk A, Ribas M, Lund B, Hermanowicz K. External Snapping Hip Syndrome Endoscopic Treatment:“Fan-like” Technique as a Stepwise, Tailor-made Solution. Arthroscopy techniques. 2020 Oct 1;9(10):e1553-7. [Google Scholar]
6 Audenaert EA, Khanduja V, Claes P, Malviya A, Steenackers G. Mechanics of Psoas Tendon Snapping. A Virtual Population Study. Frontiers in Bioengineering and Biotechnology. 2020;8. [Google Scholar]
7 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]

This article was updated January 9, 2021

 

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