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Volume 176, Issue 1 >
Extraarticular Snapping Hip

January 2001, Volume 176, Number 1


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Musculoskeletal Imaging

Extraarticular Snapping Hip


Sonographic Findings
Vincent Pelsser1, Étienne Cardinal1, Roger Hobden2, Benoit Aubin1 and Michel
Lafortune1 Show less ... Show all Show less ... Show all
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January 2001, + Affiliations:
1Department of Diagnostic Radiology, CHUM-St-Luc Hospital, 1058 Saint-Denis
VOLUME 176
NUMBER 1 St., Montreal, Quebec, H2X 3J4 Canada.

Current | Available2Department of Family Medicine, University of Montreal, 3590, Ontario St. East,
Rm. 102, Montreal, Quebec, H1W 1R7 Canada.
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Citation: American Journal of Roentgenology. 2001;176: 67-73.
10.2214/ajr.176.1.1760067
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ABSTRACT Choose

Search for other OBJECTIVE. The aim of the study was to determine the sonographic findings of
articles: snapping hip and to correlate the findings with the presence or absence of pain.

By author MATERIALS AND METHODS. Twenty patients with snapping hip were
Benoit Aubin examined with sonography. Conventional and dynamic sonographic examinations of
Vincent Pelsserboth hips were performed using a 5.0- or 7.0-MHz transducer.
Roger Hobden
RESULTS. Conventional sonographic studies allowed identification of various
Michel
structural abnormalities (tendinitis, bursitis, synovitis) and helped to document
Lafortune tenderness along the course of specific tendons. Dynamic sonographic studies
Étienne revealed 26 cases of snapping hip. In 24 of these 26 cases, the underlying cause was
Cardinal clearly identified. Twenty-two snapping hips were caused by an abnormal movement
of the iliopsoas tendon, and two were caused by iliotibial band friction over the
Search in greater trochanter. One patient reported a bilateral snapping sensation that could not
AJR be documented on sonography. Snapping hip was elicited by a wide variety of hip
Google Scholarmovements. Sonography established an immediate temporal correlation between the
Search jerky tendon motion and the painful snap reported by the patient. Only 14 cases of
snapping hip were painful.
Recommend &
CONCLUSION. Conventional sonographic studies can identify signs of tendinitis,
Share bursitis, or synovitis. Dynamic sonographic studies revealed the cause of snapping
hip in most patients. Snapping hip is characterized on sonography by a sudden
abnormal displacement of the snapping structure. In our study, a significant
proportion of the cases of snapping hip were not painful.

Introduction Choose

Snapping hip was defined by Nunziata and Blumenfeld [1] as an audible snapping
sound of variable intensity produced during motion of the hip or during waking. It is
a challenging clinical condition to diagnose because it may have various intra- or
extraarticular causes. The extraarticular causes have been divided into the lateral and
the medial varieties. The most common extraarticular causes are the iliotibial band
or gluteus maximus snapping over the greater trochanter [2,3,4] and the iliopsoas
tendon snapping over the iliopectineal eminence [5, 6] (Fig. 1). A snapping iliopsoas
tendon can be revealed radiographically by iliopsoas bursography [7, 8] or
tenography followed by fluoroscopy [9]. However, these invasive procedures are
sometimes difficult to perform, especially if the bursa is not filled with fluid.
Recently, sonography has emerged as a nonivasive technique for examining a
snapping iliopsoas tendon [10,11,12] because it allows dynamic evaluation of soft
tissues during motion of the extremity.
Fig. 1. —Diagram shows transverse
section of right hip. Note relationship
among iliopsoas tendon, iliotibial
band, and surrounding structures.

View larger version (94K)

Snapping hip often comes to the attention of the physician because of a pain-with-
motion complaint by the patient. However, some authors have reported that snapping
hip could be a painless benign condition without any clinical implications in a
certain proportion of patients [1, 6, 13,14,15,16]. Consequently, the aim of the
present study was to determine the sonographic findings of an extraarticular
snapping hip and to correlate the cases of snapping hip with the presence or absence
of pain.

Materials and Methods Choose

Over a 15-month period, we studied 20 consecutive patients with snapping hip (3


males and 17 females; age range, 12-39 years; mean, 22.1 years) referred either by
general physicians specialized in sports medicine or by orthopedic surgeons. Patients
had either painful snapping hip (11 patients) or painless snapping hip (7 patients) and
were referred for investigation of the origin of the snap.

Sonographic studies were performed by one experienced musculoskeletal radiologist


using a curved 5.0-MHz or a linear 7.0-MHz transducer (128-XP; Acuson, Mountain
View, CA). Sonographic evaluation of both hips was performed according to a
technique previously described [17]. The anterior aspect of the hip was examined
first using transverse and sagittal planes as the patient was lying supine with both
legs extended. Oblique sagittal images parallel to the femoral neck were also
obtained for evaluation of the hip joint capsule. The medial, lateral, and posterior
aspects of both hips were also examined using transverse and sagittal scanning. The
medial aspect of the hip was examined by asking the patient to flex, abduct, and
externally rotate the hip (frog-leg position). The hip was examined laterally by
turning the patient on the contralateral side. Then the posterior aspects of both hips
were examined with the patient lying prone.

The conventional sonographic study was followed by a dynamic evaluation of both


hips with simultaneous video recording as the patient was generating the hip motion
that reproduced the snap. For medial snap, this was performed with the patient lying
supine with the transducer in a transverse plane over the hip joint or oblique
transverse plane slightly proximal to the hip joint along the pelvic bone (Fig.
2A,2B). For lateral snap, the dynamic evaluation was made during flexion and
extension of the hip as the patient was lying on the contralateral hip, with the
transducer in the transverse plane over the greater trochanter.

Fig. 2A. —Diagram illustrating


“pathomechanics” of snapping
iliopsoas tendon. As hip is flexed,
abducted, and externally rotated,
iliopsoas tendon moves laterally with
regard to iliopectineal eminence.
Transducer may be placed either on
transverse over hip joint (A) or
oblique transverse over pelvic rim
(B) to accommodate movement of
hip.

View larger version (55K)

Fig. 2B. —Diagram illustrating


“pathomechanics” of snapping iliopsoas tendon.
When hip is moved back toward complete
extension, tendon impinges on iliopectineal
eminence. As extension continues, tendon at
some point is released from impingement,
moving abruptly medially. This abrupt abnormal
tendon motion is characteristic of snapping hip.

View larger version (44K)

Information about whether pain was associated with the snapping hip was obtained
by directly questioning the patient during the sonographic examination. This
information was binary: presence or absence of pain.

Results Choose

Two patients examined were excluded from the data analysis. Clinical information
on painful symptoms was incomplete for one patient when reviewing the cases, and
another patient could not reproduce the hip snap at the time of the sonographic study
(Table 1).

View Larger Version


TABLE 1 Results of Conventional and Dynamic Sonography Showing Type of
Snapping Hip and Presence or Absence of Pain

In the analyzed hips of the other 18 patients (n = 36), the conventional sonographic
examinations enabled identification of the hyperechogenic iliopsoas tendon
surrounded by hypoechogenic muscle, and the tendon's relationship with the
coxofemoral joint. The hyperechogenic iliopsoas tendon has a slightly oval shape on
a transverse image, and a fibrillar appearance is noted on a longitudinal section (Fig.
3A,3B). The iliotibial band is seen on sonography as hyperechogenic tissue just
superficial to the greater trochanter. Signs of iliopsoas tendinopathy (thickened,
heterogeneous, or hypoechogenic tendon) (n = 6) (Fig. 4), iliopsoas bursitis
(thickened bursa) (n = 1), rectus femori tendinopathy (thickened tendon) (n = 2),
iliotibial band tendinopathy (thickened band) (n = 1), or synovitis (thickened
synovial membrane) (n = 1) were identified on conventional examinations. Six hips
had no structural abnormalities of these tendons, but pain was elicited by pressure
with the sonographic transducer on the iliopsoas tendon (n = 2), rectus femori tendon
(n = 3), and gluteus maximus tendon (n = 1).

Fig. 3A. —18-year-old woman with


asymptomatic normal right hip.
Transverse (A) and longitudinal (B)
sonograms show hyperechogenic
iliopsoas tendon (arrows) and
hyperechogenic margins of
acetabulum (A) and femoral head
(F). Note overlying hypoechogenic
cartilage (c). Also note fibrillary
appearance of iliopsoas tendon on B.
View larger version (91K)

Fig. 3B. —18-year-old woman with


asymptomatic normal right hip.
Transverse (A) and longitudinal (B)
sonograms show hyperechogenic
iliopsoas tendon (arrows) and
hyperechogenic margins of
acetabulum (A) and femoral head
(F). Note overlying hypoechogenic
cartilage (c). Also note fibrillary
appearance of iliopsoas tendon on B.

View larger version (115K)

Fig. 4. —12-year-old girl with


iliopsoas tendinopathy of left hip.
Split image with transverse
sonograms of right (on left) and left
(on right) hips. Left iliopsoas tendon
(right arrow) is hypoechogenic
compared with normal right
hyperechogenic iliopsoas tendon (left
arrow). A = acetabulum; F = femoral
head.
View larger version (123K)
Of the 36 hips analyzed, 26 cases of snapping hip were identified on dynamic
sonographic evaluations. The cause of the snap could be identified in 24 of the 26
cases. Twenty-two snapping hips were caused by an abnormal motion of the
iliopsoas tendon. In a normal hip, during joint motion the tendon glides smoothly
over the pelvic bone from side to side on a transverse plane (Fig. 5A,5B). In the case
of a snapping iliopsoas tendon, this tendon suddenly displays an abrupt abnormal
displacement (lateromedial or mediolateral) during hip motion (Figs. 2A,2B and
6A,6B). Occasionally, this abrupt tendon jerk was associated with a change in the
shape of the tendon. Hip movements that reproduced the snapping iliopsoas tendon
were from flexion, abduction, and external rotation to extension (n = 10); from
extension to flexion, abduction, and external rotation (n = 5); from extension to
flexion, abduction, external rotation, and back to extension (n = 2); from flexion to
extension (n = 4); and from extension to flexion with internal rotation (n = 1).

Fig. 5A. —27-year-old woman with


normal iliopsoas tendon motion.
Transverse sonogram of right hip
shows normal, oval-shaped,
hyperechogenic iliopsoas tendon
anterior to acetabulum (A) and
femoral head (F). As hip is flexed,
abducted, and externally rotated,
iliopsoas tendon moves laterally in
direction indicated by arrow. Lateral
displacement of tendon is smooth
with mild rotatory motion
(counterclockwise for right hip).

View larger version (122K)

Fig. 5B. —27-year-old woman with


normal iliopsoas tendon motion. As hip
is moved back to complete extension,
iliopsoas tendon smoothly glides back
medially in direction shown by arrow.
There is mild rotatory motion of tendon
(clockwise for right hip). A =
acetabulum; F = femoral head.

View larger version (100K)

Fig. 6A. —15-year-old girl with


right snapping iliopsoas tendon.
Oblique transverse sonograms just
above coxofemoral joint during
video recording of right hip motion
show changes in iliopsoas tendon
after snapping has occurred.
Iliopsoas tendon (straight arrow) is
anterior to pelvic bone (curved
arrows). Flexed and abducted hip is
moved toward extension and rotated
from external position (A) to more
internal position (B). During motion,
tendon suddenly displays abrupt
abnormal displacement getting
suddenly closer to pelvic bone and
View larger version (117K) change in its shape (from round in A
to ovoid in B), which are correlated
with painful snap felt by patient.

Fig. 6B. —15-year-old girl with right


snapping iliopsoas tendon. Oblique
transverse sonograms just above
coxofemoral joint during video
recording of right hip motion show
changes in iliopsoas tendon after
snapping has occurred. Iliopsoas
tendon (straight arrow) is anterior to
pelvic bone (curved arrows). Flexed
and abducted hip is moved toward
extension and rotated from external
position (A) to more internal position
(B). During motion, tendon suddenly
displays abrupt abnormal
displacement getting suddenly closer
to pelvic bone and change in its
shape (from round in A to ovoid in
View larger version (133K) B), which are correlated with painful
snap felt by patient.

Two cases of snapping hip were caused by the iliotibial band friction over the greater
trochanter. An abrupt posterior movement of the iliotibial band was observed on
sonography when the flexed hip was extended (Fig. 7A,7B).

Fig. 7A. —36-year-old man with


snapping iliotibial band of left hip.
Transverse sonograms at level of left
greater trochanter (T) as patient is
lying on right side. When hip is
flexed (A), iliotibial band (arrows)
presents as stripe overlying
trochanter. During extension of hip
(B), abrupt displacement of iliotibial
band (arrows) occurs as it gets closer
to trochanter and coincides with
snap.
View larger version (113K)

Fig. 7B. —36-year-old man with


snapping iliotibial band of left hip.
Transverse sonograms at level of left
greater trochanter (T) as patient is
lying on right side. When hip is
flexed (A), iliotibial band (arrows)
presents as stripe overlying
trochanter. During extension of hip
(B), abrupt displacement of iliotibial
band (arrows) occurs as it gets closer
to trochanter and coincides with
snap.

View larger version (113K)

The cause of two snapping hips could not be clearly identified on sonography. The
motion of both iliopsoas tendons was normal, but an abnormal tissue displacement
was observed anterior to the coxofemoral joint and medial to the iliopsoas tendon
when the hip was externally rotated. Presumably, this was an iliofemoral ligament
moving abnormally. In two hips, sonographic evaluation could not enable objective
identification of any abnormal motion of the soft tissues surrounding the hip even
though the patient was reporting a subjective snapping sensation.

The sonographer was able to establish a temporal correlation between the abnormal
motion of the structure coinciding with a click felt by the examiner's hand through
the transducer and the painful hip snap reported by the patient. The pain was felt by
the patient at the exact moment the tendon was snapping on sonography. Painless
snaps were also felt through the transducer by the examiner. Fifty percent of the
snapping hips (12 snapping iliopsoas tendons and 2 snapping iliotibial bands) were
painful. All of the normal nonsnapping hips (n = 8) showed smooth mediolateral
tendon motion during hip movement without abnormal tendon jerk.

Discussion Choose

Snapping hip is described as a painful and audible snap of the hip felt with motion.
This syndrome has a wide variety of causes of intraarticular or of extraarticular
origin. Intraarticular snapping hip has been attributed to synovial
osteochondromatosis, loose bodies, acetabular labral tears, osteochondral fractures,
and transient subluxation of the femoral head [18,19,20]. Extraarticular snapping hip
can be caused by friction of the iliotibial band [3, 4] or gluteus maximus [20] over
the greater trochanter, by the iliofemoral ligament snapping over the femoral head
[14], or by the iliopsoas tendon impinging on an osseous prominence [5,6,7].

From a clinical standpoint, snapping hip becomes a diagnostic possibility when the
patient reports a click or a snap in the hip with motion. On physical examination, the
clinician may either hear the click, feel the snap through his hand, or actually feel a
band of tissue passing abruptly under his hand. Classically, when a snapping
iliopsoas tendon was suspected, bursography or tenography could be performed as
preoperative procedures to confirm the diagnosis [7,8,9]. Recently, sonography has
been used in the diagnosis of this entity [10,11,12]. Sonographic studies are
advantageous when compared with bursography and tenography because they allow
direct noninvasive real-time visualization of soft tissues surrounding the
coxofemoral joint in a single examination. Because sonography cannot allow
evaluation of the intraarticular space, radiography, arthrography, CT, or MR imaging
may still be required to confirm the diagnosis of an intraarticular cause of snapping
hip [10].

For painful snapping hip, conservative treatment such as rest, stretching exercises, or
oral antiinflammatory drugs are often sufficient to alleviate the symptoms [21].
Steroid injection represents another alternative [7]. In refractory cases, surgical
lengthening can be performed [21].

The conventional sonographic study of the hip is an important part of the


examination because it can allow identification of structural abnormalities.
Sonographic findings of tendinitis, bursitis, synovitis, or local tenderness over the
course of a tendon, for example, may orient the clinician toward the appropriate
diagnosis. There are no normal thickness values established for the tendons around
the hip in the literature. Based on the premise that these structures are symmetric on
the left and right sides of a given patient, structural abnormality was suspected when
corresponding tissues were asymmetric or when they had an abnormal echogenicity.

Dynamic sonographic evaluations allowed identification of an abnormal


displacement of the iliopsoas tendon with or without dynamic change in its shape in
22 hips. These findings are similar to those described by Janzen et al. [12] who
reported a “distinct momentary mediolateral or rotatory motion of the iliopsoas
tendon.” Sonographic signs of tendinopathy are not a common feature; only six of
22 hips with a snapping iliopsoas tendon showed such abnormality in our study.
Similarly, in the series of Janzen et al. sonography revealed a thickened tendon in
only two of eight snapping iliopsoas tendons. Also, iliopsoas bursitis does not seem
to be an essential feature of the syndrome as thought by other researchers [22]. In
fact, only one of 22 snapping iliopsoas tendons was associated with a thickened
iliopsoas bursa in our study. In another study [7], six of eight snapping hips were not
associated with bursal fluid. In our study, no definite correlation was found between
the findings of the conventional static sonographic studies and the presence of
snapping hip.

The bony landmarks on which the iliopsoas tendon may impinge are several: the
iliopectineal eminence, the anteroinferior iliac spine, or an osseous ridge on the
lesser trochanter [7]. Because the location of the mechanical restraint cannot be
clearly delineated on sonography during hip movement, iliopsoas bursography or
tenography [7,8,9] or CT [9,10,11,12,13,14,15] may still be indicated as
complementary examinations to determine the exact location of the impingement.

Sonography also allowed diagnosis of two iliotibial bands snapping over the greater
trochanter. This entity, described in the orthopedic literature [3, 13, 16], has never to
our knowledge been imaged or described in the radiology literature. In the two cases
of snapping hip in which the cause could not be precisely identified, considering the
anatomic location of the snapping structure (see Results), it was hypothesized that
the iliofemoral ligament was impinging over the femoral head, a potential cause of
snapping hip mentioned by Howse [14]. Snapping hip in both hips of one patient,
not documented on sonography but subjectively present according to the patient,
may have represented false-negative outcomes or may have had an intraarticular
origin. This patient is a good example of a case in which the investigation could
have been pursued further with CT or MR imaging. However, because the patient
had no pain associated with snapping hip, additional higher cost testing was not
performed.

The most commonly recognized movement of the hip that reproduces the snap is
extension of the flexed abducted and externally rotated hip. Dynamic studies to
evaluate a snapping iliopsoas tendon should not be limited to only that movement
because, in some patients of our study, other movements were needed to elicit the
snap. The patients examined in our study were able to reproduce the hip snap in the
recumbent position, with snapping iliopsoas tendons observed in the supine position
and the snapping iliotibial band seen in the lateral position. Although this was not
necessary in our study, there might be instances when the patient would better or
only reproduce the hip snap when standing up. This might especially be the case for
snapping iliotibial band for which weight-bearing and contraction of the gluteus
muscle might be important to generate the hip snap. It is known from the orthopedic
literature that iliotibial band or gluteus muscle snap may not be reproduced with
mobilization of the hip when the patient is under general anesthesia unless the
gluteus muscle is electrically stimulated [2, 13]. Sonography is a modality well
suited for dynamic examination of patients as they are standing up, if weight-bearing
is needed to observe the abnormality.

Even though bilateral snapping hip was reported to be rare by Dickinson [13], our
data suggest that it is relatively common, occurring in 56% of our patients. Also, in
our study the most frequent cause of bilateral snapping hip was an abrupt
displacement of the iliopsoas tendon (79%). This is in contrast with the literature,
which indicates that the iliotibial band is the most frequent cause [5]. This may
represent a selection bias in our study. Patients with snapping iliotibial band, which
is more easily diagnosed clinically than a snapping iliopsoas tendon, may be less
often referred to a radiologist for investigation, thus contributing to the under
representation of patients with snapping iliotibial band in our study. Further studies
would be required to precisely determine the relative prevalence of snapping
iliotibial bands and snapping iliopsoas tendons.

In cases in which the patient cannot reproduce or can reproduce only intermittently
the snap during sonographic evaluation, sonography may not identify the underlying
cause of the snap (as in one of our patients).

Other researchers [6, 13,14,15] have mentioned that snapping hip could occur in
patients without pain, but they have not reported such asymptomatic patients.
Nunziata and Blumenfeld [1], who in 1951 were the first to describe a snapping
iliopsoas tendon, reported a case of a patient clinically diagnosed with this condition
who had no pain and who refused to undergo surgical exploration. Binnie [16], in
1913, also reported one patient with bilateral painless snapping hips caused by the
gluteus maximus. In his review of the literature, Binnie estimated that 12 of 41
patients previously reported with snapping hip had no disability [16]. It is probable
that the number of cases of asymptomatic snapping hip is underestimated in the
literature because patients without pain would not seek medical attention.

In our study, sonography enabled us not only to identify the cause of the snap but
also to establish an immediate temporal correlation between the abnormal tendon
motion and the generation of painful symptoms. Fourteen cases of snapping hip
(50%) were painful, and the other half of the cases were painless. It is important to
establish this correlation because the pain may originate from conditions other than
extraarticular snapping hip, which may be painless. After the exact origin of the
symptoms has been identified, appropriate treatment can be offered to the patient.
Bilateral snapping hip can be bilaterally painful, bilaterally painless, or painful in
one hip and painless in the other. Our data confirm that snapping hip can be painless.
We suggest that the term “snapping hip syndrome” be used for painful snapping hip
only. The term “snapping hip” could simply refer to the painless condition.

We believe that sonographic investigation of snapping hip may not be needed if the
diagnosis is clinically obvious. However, sonography should be performed when
clinical diagnosis is uncertain because an extraarticular cause can be mistaken for an
intraarticular one. Other imaging modalities such as CT or MR imaging could be
used when sonographic findings are negative.

In conclusion, we believe that sonography should be the first imaging modality used
to evaluate snapping hip. Conventional sonographic evaluations can reveal signs of
tendinitis, bursitis, or synovitis. Dynamic sonographic studies can help to identify
the structure involved in extraarticular snapping hip by showing the abnormal
displacement of this structure with hip motion. This study also shows that snapping
hips can be painless, which emphasizes the need to establish a temporal correlation
with sonography between the abnormal motion of the structure and the presence or
absence of pain.

Address correspondence to É. Cardinal.

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Abstract | Full Text | PDF (887 KB) | PDF Plus (822 KB)
Pictorial Essay. Ankle Ligaments on MRI: Appearance of Normal and
Injured Ligaments
Kiley D. Perrich, Douglas W. Goodwin, Paul J. Hecht, Yvonne Cheung
American Journal of Roentgenology. 2009;193:687-695.
10.2214/AJR.08.2286
Abstract | Full Text | PDF (1080 KB) | PDF Plus (1130 KB)
Review. Hip Anatomic Variants That May Mimic Abnormalities at MRI:
Labral Variants
Mike S. Nguyen, Valeriy Kheyfits, Brian D. Giordano, Gregory Dieudonne,
Johnny U. V. Monu
American Journal of Roentgenology. 2013;201:W394-W400.
10.2214/AJR.12.9860
Abstract | Full Text | PDF (1081 KB) | PDF Plus (1149 KB)
Review. Imaging of Anterior Cruciate Ligament Repair and Its
Complications
Arthur B. Meyers, Andrew H. Haims, Kirsten Menn, Hicham Moukaddam
American Journal of Roentgenology. 2010;194:476-484.
10.2214/AJR.09.3200
Abstract | Full Text | PDF (1011 KB) | PDF Plus (1038 KB)

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