Snapping hip syndrome, frequently referred to as dancer’s hip or coxa saltans, is a condition characterized by a distinct snapping sensation, either audible or palpable, during hip joint movement. Often stemming from overuse, it can also be triggered by trauma, including intramuscular injections into the gluteus maximus or surgical interventions. Affecting approximately 5-10% of the general population, the majority of individuals experience this snapping without pain. This article delves into the evaluation and treatment of snapping hip syndrome, emphasizing the crucial role of a collaborative healthcare team in optimizing patient care.
Objectives:
- Explore the injury mechanisms and underlying pathophysiology of snapping hip syndrome.
- Outline the essential components of a physical examination for diagnosing snapping hip syndrome, including relevant imaging techniques.
- Summarize the available treatment options for snapping hip syndrome, encompassing both conservative and surgical approaches.
- Highlight the significance of enhanced care coordination among interprofessional team members to improve healthcare delivery for patients with snapping hip syndrome.
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Introduction to Dancer’s Hip (Snapping Hip Syndrome)
Dancer’s hip, medically known as snapping hip syndrome or coxa saltans, is a clinical condition defined by a snapping sound or feeling around the hip joint during movement. This phenomenon is categorized based on its anatomical origin. Historically, snapping hip was broadly divided into two categories:
- Extra-articular snapping hip
- Intra-articular snapping hip
However, the term “intra-articular snapping hip” has become less favored due to increased understanding of pathologies within the hip joint itself. These include issues like loose bodies, often from synovial chondromatosis, or labral tears.
As medical understanding advanced, extra-articular snapping hip was further classified into:
- External snapping hip
- Internal snapping hip
External snapping hip commonly arises from the iliotibial band moving over the greater trochanter during hip flexion, extension, and rotation. Other causes include the hamstring tendon rolling over the ischial tuberosity, the fascia lata or gluteus maximus moving over the greater trochanter, and the psoas tendon over the iliacus muscle. Complex scenarios involving multiple factors, such as thickened iliotibial band and gluteus maximus, simultaneously snapping over the greater trochanter, are also possible.
Internal snapping hip typically occurs when the iliopsoas tendon snaps over bony prominences like the iliopectinal eminence or the femoral head. Paralabral cysts and iliopsoas tendon variations can also contribute. Distinguishing internal snapping hip from intra-articular issues can be challenging due to their similar anterior hip origin, requiring careful physical exams and imaging. Notably, about half of internal snapping hip cases also present with additional intra-articular hip pathologies.
What Causes Dancer’s Hip? (Etiology)
Dancer’s hip is frequently an overuse injury, but it can also be triggered by trauma, such as intramuscular injections or surgical procedures. For instance, a smaller femoral neck angle (coxa vera) after hip replacement has been linked to external snapping hip syndrome. Anatomical variations such as greater trochanter width, prominent trochanters, and narrow pelvic width can also predispose individuals to coxa saltans. Furthermore, iliotibial band tightness, shortened muscles or tendons, muscle stiffness, or inadequate muscle relaxation can contribute to the development of dancer’s hip. In some cases, the cause remains unidentified, leading to a diagnosis of idiopathic snapping hip syndrome.
How Common is Dancer’s Hip? (Epidemiology)
Snapping hip syndrome affects approximately 5% to 10% of the population, with most experiencing painless snapping. It appears slightly more prevalent in women. Groups at higher risk include those performing repetitive, extreme hip movements, such as ballet dancers, weightlifters, soccer players, and runners. Notably, almost 90% of competitive ballet dancers report symptoms of snapping hip syndrome, with 80% experiencing it bilaterally. Ballet movements like extreme hip rotation and abduction beyond 90 degrees are particularly provocative.
Pathophysiology of Snapping Hip Syndrome
External snapping hip syndrome is most often caused by the iliotibial band clicking over the greater trochanter during hip movements like flexion, extension, and rotation.
Internal snapping hip syndrome is typically due to the iliopsoas tendon snapping across bony structures such as the iliopectinal eminence or the front of the femoral head.
Identifying Dancer’s Hip: History and Physical Examination
Patient history and physical examination are crucial in determining the anatomical source of the snapping in dancer’s hip. Patients can often pinpoint the painful snapping area and may be able to reproduce the snap during examination. Symptoms usually develop gradually over months or years.
External snapping hip is often evident during a physical exam. Patients may describe a snapping or hip subluxation sensation (pseudosubluxation). In some cases, the snapping can be seen or felt under the skin. The greater trochanter area might be painful due to trochanteric bursitis, abductor tendon issues, or iliotibial band inflammation. Provocative tests involve femoral rotation and flexion. Examination includes placing the patient laterally and performing the Ober test to assess iliotibial band tightness. Hip flexion and extension cycles in this position can also elicit the snapping.
Internal snapping hip is typically described as a hip snapping or locking with an audible sound. Gluteus medius weakness may also be present. Examination involves placing the patient supine and guiding the affected hip into external rotation and flexion. From this position, the leg is extended to a neutral position. Reproduction of the snapping in the anterior hip indicates a positive test. It’s important to remember that nearly half of patients with internal snapping hip also have intra-articular pathologies, which can complicate physical exam findings.
Diagnosing Dancer’s Hip: Evaluation Methods
If history and physical examination are inconclusive for diagnosing coxa saltans, imaging can help rule out other hip pathologies and confirm the diagnosis. Plain radiographs are generally not useful for confirming snapping hip, but are important to exclude anatomical variations, dysplasia, or other hip issues. Additionally, a positive response to an anesthetic injection into the affected area can aid in differentiating between external and internal snapping hip syndrome.
Clinically visible external snapping hip syndrome can be confirmed on T1-weighted axial MRI by identifying a thickened iliotibial band or a thickened anterior edge of the gluteus maximus muscle. If snapping is not visible during a physical exam, dynamic ultrasonography can demonstrate the iliotibial band snapping over the greater trochanter. Dynamic ultrasound can also reveal associated tendinitis, iliopsoas bursitis, or muscle tears.
Diagnosis of internal snapping hip syndrome can be confirmed using iliopsoas bursography with fluoroscopy, dynamic ultrasonography, MRI, or magnetic resonance arthrography. Magnetic resonance arthrography is often preferred as it can also detect intra-articular hip pathologies, which commonly accompany internal snapping hip syndrome.
Management and Treatment of Dancer’s Hip
If dancer’s hip is painless, treatment is usually unnecessary. However, when pain is present, conservative treatment is the initial approach. This includes rest, stretching, steroid injections, oral anti-inflammatory medications, physical therapy, and activity modification. Most patients find relief with these conservative measures.
If pain persists despite conservative treatments, surgical intervention may be considered. For external snapping hip syndrome, surgery aims to loosen the iliotibial band, which can be done through open or arthroscopic procedures. The iliotibial tendon is lengthened or released using techniques such as Z-lengthening, cross-shaped release, Z-shaped release, or gluteus maximus release. Excessive release or damage to surrounding tissues can lead to abduction weakness as a complication.
For internal snapping hip syndrome, open or arthroscopic procedures are also available to lengthen or release the iliopsoas tendon. Arthroscopic methods are generally favored to minimize complications associated with open surgery. Hip flexor weakness is the most common adverse effect of iliopsoas release, potentially occurring with excessive release or damage to surrounding tissues. Corrective surgeries for both types of snapping hip can also result in complications such as infection, heterotopic ossification, muscle atrophy, persistent symptoms, or nerve damage.
Differential Diagnoses for Dancer’s Hip
- Acetabular Labral Tear
- Bursitis (Greater Trochanteric or Iliopsoas)
- Femoral Head Avascular Necrosis
- Hip Tendonitis
- Iliopsoas Tendinitis
- Iliotibial Band Syndrome
- Intra-Articular Loose Body of the Hip
- Synovitis
Enhancing Healthcare Team Outcomes for Dancer’s Hip
Effective management of patients with snapping hip syndrome requires a multidisciplinary team, including sports physicians, nurse practitioners, orthopedic surgeons, emergency department physicians, physical therapists, and pain specialists.
Treatment strategies depend on symptom presence. Asymptomatic patients do not require treatment. Symptomatic patients should be advised to rest and participate in a physical therapy program. Various treatment modalities are used, but no single approach has been definitively proven superior. Surgery is a last resort, considered only after conservative treatments have failed.
Most patients experience symptom relief through activity adjustments, rest, ice, and stretching.
Review Questions
References
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Disclosure: Sierra Musick declares no relevant financial relationships with ineligible companies.
Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.
