The case of the clicky hip (AKA: Snapping hip syndrome)
Ever wondered what the click in your hip is?
Firstly you need to know a little about the anatomy of the
area.
Bones:
Ilium, Ischium, Pubis, Femur:
Ilium:
Acetabulum (lunate surface, margin of acetabulum)
Anterior inferior iliac spine
Anterior superior iliac spine
Ala (wing of ilium) (gluteal surface and iliac fossa))
Iliac crest (outer lip, tuberculum, intermediate zone, inner
lip)
Gluteal lines (anterior, inferior and posterior)
Posterior superior iliac spine
Posterior inferior iliac spine
Greater sciatic notch
Body of Ilium
Illiopubic eminence
Arcuate line
Auricular surface for the sacrum
Iliac tuberosity
Ischium:
Ischial spine
Lesser sciatic notch
Body of Ischium
Ischial tuberosity
Ramus of ischium
Obturator foramen
Acetabulum
Acetabular notch
Pubis:
Superior pubic ramus
Pubic tubercle
Obturator crest
Inferior pubic ramus
Acetabulum
Pecten pubis (pectineal line)
Symphyseal surface
Obturator groove
Femur:
Head
Fovea
Neck
Intertrochanteric crest
Intertrochanteric line
Trochanteric fossa
Greater trochanter
Lesser trochanter
Calcar Femorale
Pectineal line
Gluteal tuberosity
Shaft
Linea aspera (medial and lateral lip)
Joints of the hip:
Femoroacetabular:
Synovial: spheropidal. Closed packed
position: full extension, internal rotation and abduction.
Pubic symphysis:
Amphiarthrodial
Sacroiliac:
Synovial: plane
Ligaments:
Hip:
Iliofemoral: Anterior inferior iliac spine to
intertrochanteric line of femur. Limits extension of hip.
Ischiofemoral: Posterior inferior acetabulum to apex of
greater tubercle. Limits internal rotation and extension of the hip.
Pubofemoral: Obturator crest of pubic bone to blend with the
capsule of hip and iliofemoral ligament. Limits hip hyperabduction.
Ligament of head of femur: margin of acetabular notch and
transverse acetabular ligament to head of femur. Carries the blood flow to
supply to head of femur.
Pubic symphysis:
Superior pubic ligament: Connects superior aspect of right
and left pubic crests. Reinforces superior aspect of joint.
Inferior pubic ligament: Connects inferior aspect of right
and left pubic crests. Reinforces inferior aspect of joint.
Posterior pubic ligament: Connects posterior aspect of right
and left pubic crests. Reinforces the inferior aspect of the joint.
Sacroiliac:
Posterior sacroiliac: iliac crest to tubercles of S1-S4.
Limits movement of sacrum on iliac bones.
Anterior sacroiliac: Anterosuperior aspect of sacrum to
anterior ala of ilium. Limits movement of the sacrum on iliac bones.
Sacrospinous: Inferior lateral border of sacrum to ischial
spine. Limits gliding and rotary movement of sacrum on iliac bones.
Sacrotuberous: Middle lateral border of sacrum to ischial
tuberosity. Limits gliding and rotary movement of sacrum on iliac bones.
Muscles of the hip:
Posterior
Gluteus maximus: Posterior border of ilium, dorsal aspect of
sacrum and coccyx, and sacrotuberous ligament to iliotibial tract of fascia
lata and gluteal tuberosity of femur. Extension, external rotation and some
abduction of the hip joint.
Gluteus medius: External superior border of ilium and
gluteal aponeurosis to lateral aspect of greater trochanter of femur. Hip
abduction and internal rotation, maintains level pelvis in single leg stance.
Gluteus minimus: External surface of the ilium and margin of
the greater sciatic notch to anterior aspect of the greater trochanter of
femur. Hip abduction and internal rotation, maintains level pelvis in single
leg stance.
Piriformis: Anterior aspect of sacrotuberous ligament to
superior greater trochanter of femur. External rotation of extended hip,
abduction of flexed hip, steady femoral head in acetabulum.
Superior Gemellus: Ischial spine to trochanteric fossa of
femur. External rotation of extended hip, abduction of flexed hip, steady
femoral head in acetabulum.
Inferior Gemellus: Ischial tuberosity to trochanteric fossa
of femur. External rotation of extended hip, abduction of flexed hip, steady
femoral head in acetabulum.
Obturator internus: Internal surface of obturator membrane,
border of obturator foramen to trochanteric fossa of femur. External rotation
of extended hip, abduction of flexed hip, steady femoral head in acetabulum.
Quadratus femoris: Lateral border of ischial tuberosity to
quadrate tubercle of femur. Lateral rotation of hip and steadies the femoral
head in the acetabulum.
Semitendinosus: Ischial tuberosity to superomedial aspect of
tibia. Hip extension, knee flexion, medial rotation of knee in knee flexion.
Semimembranosus: Ischial tuberosity to posterior aspect of
medial condyle of tibia. Hip extension, knee flexion, medial rotation of knee
in knee flexion.
Biceps Femoris: Long head: ischial tuberosity and short
head: linea aspera and lateral supracondylar line of femur to lateral aspect of
head of fibula and lateral condyle of tibia. Knee flexion, hip extension and
knee external rotation with the knee flexed.
Anterior
Psoas Major: Lumbar transverse processes to lesser
trochanter of femur. Flexes the hip, assists with external rotation and
abduction. Plays a major role in
maintaining upright posture by supporting the Lumbar lordosis (inward
curvature). Iliopsoas as they are both
termed collectively also assists lumbar spine movement.
Psoas minor: Lateral bodies of T12 and L1 to iliopectineal
eminence and arcuate line of ilium. Flexion of pelvic on lumbar spine.
Iliacus: Superior iliac fossa, iliac crest and ala of sacrum
to lateral tendon of psoas major and distal to lesser trochanter. Flexes the
hip, assists with external rotation and abduction.The psoas and Iliacus muscles
are collectively termed Iliopsoas and this is best at producing inner range hip
flexion (knee up near hip height, and above). In this inner range, Iliopsoas is
far more mechanically effective in flexing the hip than Rectus Femoris.
Adductor Longus: Inferior to pubic crest to middle third of
linea aspera of femur. Hip adduction.
Adductor Brevis: Inferior ramus of pubis to pectineal line
and proximal linea aspera of femur. Hip adduction and assists with hip extension.
Adductor Magnus: Adductor part: inferior pubic ramus, ramus
of ischium, hamstring part: ischial tuberosity, to adductor part: gluteal
tuberosity, linea aspera, medial supracondylar line, hamstring part: adductor
tubercle of femur. Hip adduction, adductor part: hip flexion, hamstring part:
hip extension.
Gracilis: Inferior ramus of pubis to superomedial aspect of
tibia. Hip adduction and flexion, assists with hip internal rotation.
Pectineus: Superior ramus of pubis to pectineal line of
femur. Hip adduction and flexion, assists with hip internal rotation.
Tensor fasciae latae: Anterior superior iliac spine and
anterior aspect of iliac crest to iliotibial band that attaches to lateral
condyle of the tibia. Hip abduction, internal rotation and flexion, aid
maintaining knee extension.
Rectus femoris: Anterior inferior iliac spine to base of
patella through the patella tendon to the tibial tuberosity. Hip flexion and
knee extension. When the hip is in a mid and outer range flexed position then
Rectus Femoris has a far more effective lever-arm to flex the hip.
Sartorius: Anterior superior iliac spine and notch just
inferior to superomedial aspect of tibia. Flexes abducts and externally rotates
the hip, flexes the knee.
Obturator Externus: Margin of obturator foramen and
obturator membrane to trochanteric fossa of femur. Hip external rotation,
steadies the head of the femur in the acetabulum.
Bursae (There are as many as 20 bursae around the hip)
Iliopectineal bursa
Trochanteric bursa
Iliopsoas bursa
Gluteus medius bursa
Ischiogluteal bursa
Obturator externus bursa
And more…
Connective Tissue:
Iliotibial band (ITB): This is a connective tissue band that
Labrum:
This is a ring of cartilage that surrounds the acetabulum
(the socket of the hip joint). It deepens the acetabulum, making it more
difficult for the head of the femur to slip out of place. The Labrum increases
surface area of the acetabulum by 28%, aids stability: deepening the joint by
21%, shock absorption & joint lubrication.
So back to my original question what causes the click in myhip?
Basically it depends, as there a several different causes.
The Snapping sensation is felt when the hip is flexed and
extended. This can be audible and can be painful in some cases but for the most
part it doesn’t hurt. It is categorised as either extra-articular or
intra-articular, meaning inside the joint or outside the joint.
Extra-articular:
Lateral extra articular
This is the most common type and occurs when the iliotibial
band, tensor fascia lata, or gluteus medius tendon slides back and forth across
the greater trochanter. This actually is a normal thing but when the connective
tissue thickens and tightens it catches with motion. The Trochanteric bursa can
become inflamed, causing a painful external snapping hip syndrome and
Trochanteric bursitis.
Medial extra-articular
This is less common, the iliopsoas tendon catches on the
anterior inferior iliac spine (AIIS), the lesser trochanter, or the
iliopectineal ridge during hip extension. This can result in excessive friction
and may eventually cause pain from muscle trauma, bursitis, or inflammation in
the area.
Intra-articular:
Because the iliopsoas or hip flexor crosses directly over
the anterior suprior labrum of the hip, an intra-articular hip derangement
(i.e. labral tears, hip impingement, loose bodies) can lead to an effusion that
subsequently produces internal snapping hip symptoms. Interestingly 80% of
labral tears of the hip present with an audible or palpable click and this is
reiterated here: A clicking hip is strongly associated with acetabular labral
tears of the hip joint (Cleland & Koppenhaver 2005).
Who gets these problems?
Gymnasts, cyclists, dancers and track athletes commonly get
this due to repetitive hip flexion movements within their sport.
In Ballet dancers hip injuries are about 10% of orthopaedic
complaints & ‘snapping hip’ syndrome is 45% of these (Reid et al 1988).
Snapping hip syndrome most often occurs in persons who are
15 to 40 years old and is more common in females.
What are the contributing factors to getting a clicky hip?
Extra-articular snapping hip syndrome is caused by tightness
in the iliotibial band (ITB), weakness in the hip abductors and external
rotators, poor core stability and/or faulty foot biomechanics. Some people
believe leg length inequality can be a factor too but remember in normal people,
96.7% were found to have a difference in leg length (O’Brien et al 2010). Also
there is no evidence of an association between leg-length inequality &
greater trochanteric pain syndrome according to Segal et al (2008). However if
the difference is big enough then it could be significant.
With the Intra-articular type the pain tends to be more
intense as it is indicative of such injuries as a torn acetabular labrum,
recurrent hip subluxations, ligamentum teres tears, loose bodies, articular
cartilage damage, or synovial chondromatosis (cartilage formations in the
synovial membrane of the joint).
How do you diagnose it?
Intra-articular:
Many of these pathologies will be easily seen on X-ray or
MRI scanning but Acetabular labral tears are more difficult to see: Only 3 out
of 55 were found on MRI (Fitzgerald 1995).
Extra-articular:
MRI & ultrasound can show tendinopathy or bursitis. Iliopsoas
bursography & dynamic ultrasound can highlight subluxation of the tendon.
FABER test for medial (Iliopsoas or rectus femoris related).
Obers test for lateral (ITB related).
Another good test for lateral extra-articular is done in side
lying on unaffected side with pillow under the hip, flex and extend the hip and
palpate over greater trochanter for click (Brignall et al 1991).
Static hip extension flexibility (Thomas test) does not
appear to be reflective of functional dynamic movements (Schache et al 2000).
So how do you treat it?
Well it depends on the type. Extra articular is easier to
treat but intra-articular may be difficult and may require surgery in some
cases depending on the particular issue.
Obviously the key is to get to the root cause so potentially
you need to correct biomechanical abnormalities, stretch tightened muscles, and
strengthen weak muscles.
Most patients respond well to conservative management: This
generally involves avoidance of activities which cause a click, non-steroidal
anti-inflammatory drugs & physiotherapy.
Physiotherapy:
Eccentric strengthening exercises showed the greatest value
in decreasing pain & increasing function in tendinopathy (Andres et al
2008).
Myofascial release of the tensor fascia latae, gluteus
medius, gluteus maximus & adductor musculature with stabilisation &
strengthening had the best effect on external snapping hip syndrome (Spina
2007).
Stretching of any shortened structures may alleviate the
symptoms.
Injection?
Corticosteroid injections are usually administered to the
iliopsoas or trochanteric bursa. There effects are temporary and usually only
last weeks to months unless the root cause is corrected. However they cause weakening
of the connective tissue.
Surgery?
Surgical treatment may be needed if pharmacological or physiotherapy
are ineffective or abnormal structures are found that need surgical repair.
Medial extra-articular:
Lengthening of the iliopsoas tendon.
Resection of the bony prominence of the lesser trochanter.
Complete release of the iliopsoas tendon.
Surgical lengthening of the iliopsoas tendon has an 85%
success rate (Jacobson & Allen 1990).
Lateral extra-articular:
Z-plasty of the iliotibial band.
Resection of the posterior half of the iliotibial band.
Elliptical resection of a portion of the iliotibial band.
Intra-articular
Correction of intra-articular pathologies so the type of surgery will depend.
Clicky hip is not a term we've seen before, but we are familiar with snapping hip syndrome. At first, patients may laugh at the occasional click or snap coming from their body. Like you said, snapping hip can cause chronic hip pain though. If there is a massive amount of overuse in the joint, snapping hip pain presents itself. We usually see dancers and gymnasts with this condition, but any athlete is vulnerable.
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