FIGHTING FIT FOREVER

Snapping hip syndrome

This case study highlights the influence that abnormal joint positioning and
altered postural states have on musculoskeletal pathology. It describes a
goal-kicking rugby player suffering from a recalcitrant internal snapping hip.
The associated pathology with this particular problem is clearly evident.
However, what is initially missed is the aberrant musculoskeletal cause.

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As therapists we often encounter patients who show up with clear postural
abnormalities, but it is sometimes harder to work out the relationship between
cause and effect. It is the proverbial chicken v egg argument: is the postural
muscle change a result of the offending pathology or is it causing the
pathological insult?

In this instance the outcome justified the philosophical approach which
advocates treating an abnormal musculoskeletal issue when the therapist
encounters it, whether or not you believe it is the cause of the problem, or
simply an effect.

The problem

A 24 year old left-footed rugby player presented to the clinic, referred
from an independent sports physician after two months of failed treatment for
an internal snapping left hip.

The patient recalled that before he had been to see the sports physician his
hip had being giving him pain for two months, with an associated
‘snapping’ sensation when performing hip rotation drills as part of
his individual goal-kicking sessions. He had at the time also been undergoing a
lot of speed and agility training involving hurdling and rotational movements
over hurdles.

He continued to train with this discomfort for a number of weeks but it
gradually worsened until he could no longer perform the warmup drills necessary
for his goalkicking sessions – although running and sprinting were
painless. At this point he sought medical treatment.

His sports physician says that on initial physical examination, his client
demonstrated a palpable ‘snapping’ sensation in the hip as it was
brought from a flexion-abductionexternal rotation (FABER) position to
extension-adduction-internal rotation (EADDIR). Initial X-rays proved
unremarkable. The doctor referred the patient on for an MRI to exclude labral
injuries to the hip and loose bodies. The findings from the MRI were as
follows:

  • Increased signal density of the iliopsoas tendon at the level of the
    femoral head;
  • Presence of fluid within the iliopectineal bursa;
  • Thickening of the anterior hip joint capsule with associated
    synovitis.

The sports doctor initially prescribed a course of oral non-steroidal
anti-inflammatories, with cessation of hip rotation drills in warm-up. The
player was referred to a physiotherapist for psoas lengthening and
strengthening exercises. The pain quickly settled and three weeks later he
recommenced hip rotation drills. The pain and snapping recurred almost
immediately.

The sports doctor was again consulted and recommended an ultrasound-guided
local anaesthetic and hydrocortisone injection. The iliopectineal bursa and
iliopsoas tendon sheath were injected, with immediate relief of pain but with
continued snapping of the hip. For the next three weeks the athlete excluded
hip rotation exercises from his warm-up with continued treatment to the psoas
muscle. During this time the hip was pain-free and the snapping had almost
completely resolved.

He recommenced rotation drills three weeks after injection, which initially
was pain-free. However, within two weeks the snapping and pain had returned.
That’s when the frustrated player was referred to the clinic for
evaluation of mechanical faults that might be predisposing him to internal
snapping hip syndrome.

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The offending piriformis

After a thorough discussion of the history of the problem, we undertook a
physical evaluation. The most striking initial feature of the player’s
posture in standing was an externally rotated left lower limb. This was present
both in neutral stance and walking. He was able to squat pain-free and kick
pain-free. Of real interest was the fact that he had changed his squat
technique three months previous to the onset of symptoms.

He was finding it more comfortable to squat heavy with a wider and more
externally rotated stance. It is commonly known in strengthtraining circles
that this technique places more load on the external rotators of the hip, in
particular the piriformis.

In supine the left lower limb continued to demonstrate an externally rotated
position. The pelvis also demonstrated a posterior rotation of the left ilium
with restricted antero-posterior glide of the ilium on the left, indicating a
blocked left sacroiliac joint (SIJ).

Left hip flexion-abduction-external rotation to extension-adductioninternal
rotation reproduced the internal painful snapping. Hip quadrant (combined
forced flexion/ adduction/internal rotation) also reproduced internal hip pain.
Muscle length testing proved unremarkable (including psoas muscle) except for
the left piriformis. This was more evident in prone when the hips were
internally rotated whilst in neutral. On palpation the piriformis demonstrated
increased tone and a ‘thickened and woody’ feel.

Provisional diagnosis

We agreed with the initial sports doctor’s diagnosis of internal
snapping hip with inflamed iliopectineal bursa and psoas tendon sheath.
However, it was felt that the offending mechanical cause was the
piriformis.

It was hypothesised that the tight hypertonic piriformis was causing the
femoral head to assume a more anterior translated and externally rotated
position, similar to how a hypertonic infraspinatus can cause an anteriorly
translated humeral head in the shoulder. We believed that this was causing the
iliopsoas tendon to be more disposed to friction and movement across the
femoral head as the hip went from FABER to EADDIR. With the anterior femoral
head position, the tendon was always going to suffer from friction and a
snapping sensation as it moved over the femoral head. Direct medical
intervention in the form of cortisone injection would resolve inflammation in
the tendon and bursa, but the irritation would tend to recur once the
rotational movement was reintroduced.

Treatment

Initial treatment was directed at myofascial therapy to the left piriformis
muscle. This consisted of direct ischaemic pressure type therapy (direct
pressure which is held) and pressure with combined passive hip internal
rotation as a myofascial release technique. Remarkably the patient’s
internal snapping with FABER to EADDIR completely resolved within the first
treatment session, as did the painful quadrant.

Obviously encouraged by the sudden improvement, the patient was warned that
it was likely the piriformis would ‘re-tone’ in the next few days
and cause problems again. Progression with this sort of treatment can result in
a ‘two steps forward, one step back’ improvement. It is important
to avoid the offending movements such as hip rotation and externally rotated
squat positions.

Treatment continued thus for the next two sessions (all within seven days).
We also felt that the thickened anterior capsule evident on the MRI would cause
problems with the position of the femoral head, so we started antero-posterior
glides of the femoral head to improve hip joint mobility. This was performed in
prone lying with the hip in a neutral position. A seat belt was placed around
the upper thigh and a posterior directed force was applied to induce posterior
translation. This was done both as a mobilisation oscillation and as a
sustained stretch.

The patient was treated for the next month, with squatting and hip rotation
movements re-introduced. He was shown self management techniques for the
piriformis and hip joint capsule. He was completely pain-free within a month
and suffered no exacerbations of the pain or internal clicking.

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