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

snapping hip 2
Snapping hip Ext 2
snapping hip 1
Snapping hip Ext 1

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.

Ileopsoas in extension
Ileopsoas in extension
Ileopsoas in flexion
Ileopsoas in flexion

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.

  • Acetabular tears most difficult to diagnose (even on MRI).
  • Beware Perthe's disease (acetabular tears)
  • Patient with intra articular causes may present with sudden traumatic trigger.
  • Pain is more prominent
  • Beware if history of giving way
  • Most have a history of limp at some time
  • Limp is not a feature of extra-articular causes(not typically seen
  • Beware pain on impingement during examination
  • MRI imaging of choice
  • Surgical management controversial

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)

Contents by Dr Íomhar O' Sullivan 23/09/2005. Reviewed Dr ÍOS 01/02/2007.   Last reviewed 12/16/2019.