Clicking / Snapping Hip (coxa saltans)

Background

• Audible ‘snap’ around the hip on certain movements (often painless)
• Problematic in athletes (F>M particularly dancers)
• May become painful in more chronic cases
• Categorised as either ‘external’, ‘internal’ or intra-articular

External clicking hip

• Commonest cause of coxa saltans
• Thickened band of the iliotibial tract or gluteus maximus tendon slipping over the gr trochanter
• On hip flexion, the band moves anteriorly; then as gluteus maximus contracts, it is pulled posteriorly and snaps back across the greater trochanter
• Usually gradual onset months), mild discomfort (may be bilateral)
• Occasionally associated bursitis develops
• Patient can usually demonstrate click/snap
• Brignall test
  • Patient lying on the unaffected side
  • Pad under the buttock to keep affected hip in adduction
  • Keeping the knee in extension, the hip is then actively flexed and extended
  • Iliotibial band may be felt flicking over the greater trochanter
• With uncomplicated Hx / examination no investigations indicated
• Ask ED senior for advice if you are thinking of imaging

Internal clicking hip

• Usually iliopsoas tendon snapping over the iliopectineal eminence or femoral head
• Gradual onset (months)
• Must distinguish it from intra-articular causes for clicking and pain
• May be tenderness in adductor triangle
• Clinical Dx if snap can be triggered (see diagram)
  • Iliopsoas snaps over femoral head when moving from flexion to extension (keep hip in external rotation during movement)
• Otherwise MRI
• Treat with physio (stretching)
• NSAIDs

Intra-articular causes

These include loose bodies, synovial chondromatosis, osteo-cartilaginous exostoses and acetabular labral tears. Keep a high index of suspicion.

Management

• Conservative management, involving rest, NSAIDS and physiotherapy (mainly stretching exercises)
• There are a variety of surgical procedures available for refractory cases (refer to EM senior for advice)