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Sonographic Evaluation of Snapping Hip Syndrome

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Sonographic Evaluation of Snapping Hip Syndrome 3206jum1online.qxp:Layout 1 5/21/13 11:48 AM Page 895 SOUND JUDGMENT SERIES Sonographic Evaluation of Snapping Hip Syndrome Nathalie J. Bureau, MD, FRCPC Invited paper Videos online at www.jultrasoundmed.org napping hip syndrome is characterized by a painful, palpable, and sometimes audible snap caused during certain move- ments of the hip.1 Painless occasional snapping phenomena S 2–4 can occur in asymptomatic people. These episodes are considered The Sound Judgment Series consists of physiologic occurrences and should not be a cause for concern, nor invited articles highlighting the clinical should they be investigated. value of using ultrasound first in specific The pathophysiologic mechanisms of snapping hips are diverse, clinical diagnoses where ultrasound has and the exact cause of the painful anatomic conflict or snap may be difficult to identify with diagnostic tests. Although imaging tech- shown comparative or superior value. The niques such as radiography, computed tomography, and magnetic series is meant to serve as an educational resonance imaging (MRI) may yield useful and complementary tool for medical and sonography students information in these patients, sonography, with its high resolution and clinical practitioners and may help and dynamic capabilities, is the imaging modality of choice in the integrate ultrasound into clinical practice. investigation of snapping hip syndrome.5–8 Popularized at the turn of the 20th century, the term snapping hip referred to the snapping of the iliotibial band on the greater trochanter until Nunziata and Blumenfeld9 published a series of 3 patients with internal snapping hip involving the iliopsoas tendon Received January 24, 2013, from the Department 10 Radiology, University of Montreal Medical Cen- in 1951. In 1995, Allen and Cope proposed a classification for snap- ter, Montreal, Quebec, Canada. Revision requested ping hip syndrome that distinguished intra- and extra-articular causes. February 8, 2013. Revised manuscript accepted According to this classification, various lesions, such as synovial for publication March 27, 2013. chondromatosis, loose bodies, labral tears, synovial plicae, and Dr Bureau is a recipient of a Canadian chondral defects, may present with snapping or catching symptoms, Institutes of Health Research training grant for caused by movement of the hip joint. These symptoms are usually evaluation and treatment of mobility and posture disorders (MENTOR Program). of low intensity and differ considerably from the more powerful Address correspondence to Nathalie J. snapping typical of the extra-articular type. Consequently, it is prob- Bureau, MD, FRCPC, Department of Radiology, ably more appropriate to reserve the term snapping hip syndrome for University of Montreal Medical Center, 1058 the extra-articular causes.11 Saint-Denis St, Montreal, QC H2X 3J4, Canada. The extra-articular type of snapping hip syndrome comprises E-mail: [email protected] 3 categories (Table 1): internal, which involves the musculotendi- nous iliopsoas unit; external, which involves the iliotibial band and Abbreviations 10 MRI, magnetic resonance imaging the gluteus maximus muscle ; and posterior, which is less common and involves the ischiofemoral region.12–15 Sonographic evaluation doi:10.7863/ultra.32.6.895 of this last entity has not been reported to date. ©2013 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2013; 32:895–900 | 0278-4297 | www.aium.org 3206jum1online.qxp:Layout 1 5/21/13 11:48 AM Page 896 Bureau—Sonographic Evaluation of Snapping Hip Syndrome Internal Snapping Hip Syndrome The terms iliopsoas tendon and psoas major tendon have been used interchangeably in the medical literature. Internal snapping hip syndrome affects predominantly At the level of the superior pubic ramus, the tendon involved young adults, especially women, athletes, and, more specif- in the snapping mechanism is the psoas major. The accessory ically, ballet dancers. Activities requiring repeated hip tendon of the iliacus muscle and the psoas major tendon abduction movements, such as ballet dancing, martial arts, merge distally to the superior pubic ramus to form the and gymnastics, increase the risk. In a study involving 87 iliopsoas tendon.18 dancers from the National Ballet of Canada, 91% of the A painful snapping iliopsoas tendon can occur in dancers presented with snapping hip phenomena. In 80% patients with total hip arthroplasty. This infrequent compli- of the dancers, both hips were affected, and in 58% of cases, cation of total hip arthroplasty tends to become apparent painful symptoms were associated with the snapping hip.16 during the postoperative period. The most common cause The musculotendinous unit of the iliopsoas is most is overlap of the prosthetic cup at the anterior acetabular often involved in causing internal snapping hip syndrome. margin, over which the iliopsoas tendon extends as it leaves The anatomy of the iliopsoas is complex and important the pelvis.23,24 Other causes include lengthening and conse- to know to understand the physiologic characteristics and, quent tension on the iliopsoas tendon caused by a prosthetic secondarily, the pathophysiologic mechanisms of internal femoral neck that is too long, the presence of cement debris snapping hip syndrome.17 This anatomy has been recently in front of the acetabular cup, and acetabular cup screws or redefined by cadaver studies18 and detailed using MRI.19,20 bone grafts protruding from the acetabulum.25,26 Furthermore, using static and dynamic sonography, Guillin The sonographic examination of the internal hip com- et al2 documented the sonographic anatomy of the iliop- partment begins with a static evaluation in the longitudinal soas at the inguinal level and its physiologic motion during and transverse planes, using a multifrequency 5–12-MHz flexion-abduction-external rotation followed by extension linear array transducer with the patient lying supine (Fig- of the hip in 21 asymptomatic volunteers (Figure 1 and ure 1). In some patients with larger body habitus, the use Video 1). Interestingly, the authors found a snapping hip phenomenon in 40% of this asymptomatic sample. Table 1. Causes of Snapping Hip Syndrome The initially proposed pathophysiologic mechanism of Internal internal snapping hip was impingement of the iliopsoas ten- Psoas major tendon snapping on the superior pubic ramus after 1,3 don on the iliopectineal eminence or the lesser trochanter. release of the medial fibers of the iliacus muscle from a However, this presumed mechanism has never been transient position between the psoas major tendon and the shown by direct visualization of the anatomic structures superior pubic ramus on imaging, and it remains hypothetical. Sonography has Psoas major tendon impingement on an anterior paralabral cyst Conflict between the two components of a bifid psoas helped identify various pathophysiologic mechanisms major tendon 7,8,16,21 underlying internal snapping hip. The most fre- Psoas major tendon impingement on the anteroinferior iliac spine quently reported mechanism is snapping of the psoas Iliopsoas tendon impingement on a protruding acetabular major tendon on the superior pubic ramus after release of component of total hip arthroplasty Iliopsoas tendon impingement on the iliopectineal eminence the medial fibers of the iliacus muscle. During flexion- (to date, this presumed mechanism has not been shown by abduction-external rotation of the hip, the medial fibers of direct visualization on imaging) the iliacus muscle become confined between the psoas Friction of the iliofemoral ligament on the femoral head (to date, major tendon and the superior pubic ramus. On extension this presumed mechanism has not been shown by direct and adduction of the hip, the medial fibers of the iliacus visualization on imaging) External muscle suddenly free themselves from this position, which Friction or subluxation of the iliotibial band or gluteus maximus causes the psoas major tendon to return abruptly against the muscle on the greater trochanter superior pubic ramus, generating a painful snap (Video 2). Iliotibial band impingement on a femoral osteochondroma Other mechanisms that have been reported to cause Venous hemangioma of the gluteus maximus muscle painful snapping hip include the conflict between the two Posterior 7,22 Subluxation of the tendon of the long head of the biceps femoris components of a bifid psoas major tendon, snapping of muscle (to date, this mechanism has not been shown by direct the psoas major tendon at the level of the anteroinferior visualization on imaging) iliac spine while in the flexion-abduction-external rotation Ischiofemoral impingement with abnormalities of the quadratus (frog leg) position, and impingement of the psoas major femoris muscle (to date, this mechanism has not been shown tendon on a paralabral cyst.7 by direct visualization on imaging) 896 J Ultrasound Med 2013; 32:895–900 3206jum1online.qxp:Layout 1 5/21/13 11:48 AM Page 897 Bureau—Sonographic Evaluation of Snapping Hip Syndrome of a 3–5-MHz curvilinear transducer may be indicated. to make a video recording of the dynamic study to be able Although infrequent in the presence of internal snapping to review the images more closely. hip syndrome, anomalies such as iliopsoas tendinopathy, The investigation of the painful hip should begin with bursitis, coxofemoral synovitis, and a paralabral cyst are radiographs of the pelvis and hip to exclude congenital, systematically sought.4,7,8,27 During the
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