1.0 ANCC Contact Hours Snapping Syndrome

Elizabeth Badowski

Coxa saltans, or snapping hip syndrome, is a common or- Thomas sign when each individual leg was fl exed up to thopaedic problem that can easily be diagnosed and treated the chest while the opposite leg remained in place on when the proper evaluation and management are utilized. the examination table. She did experience and ten- It is often seen in growing adolescents, athletes, and people derness with resisted fl exion and palpation over the an- with sudden increase in physical activity. A thorough physi- terior aspect of her bilaterally. She was otherwise cal examination will help decipher whether the snapping neurovascularly intact to bilateral lower extremities. hip is intra-articular or extra-articular and will help guide treatment options. This article reviews how to perform a Radiographic Imaging physical assessment and treatment options such as medi- The radiographs that were obtained in the offi ce, in- cations, stretching, physical therapy, articular injections, cluding false profi le views and standing anteroposterior and possible surgical interventions. Complications from pelvis, as well as her previous magnetic resonance im- conservative treatments are rare, but weakness, infection, ages, were reviewed and showed no evidence of any an- nerve damage, and atrophy may occur following surgical atomical abnormalities such as hip dysplasia, labral procedures. tear, Cam impingement (abnormal shape of the femoral head–neck junction), or Pincer hip impingement (exces- sive coverage of the femoral head by the acetabulum). Patient History P.W., a 16-year-old adolescent girl, presented to a pediat- Diagnosis/Treatment ric orthopaedic clinic for evaluation of bilateral anterior On the basis of the patient’s clinic examination and ra- hip pain and questionable labral pathology. She re- diographic images, it was determined that P.W. was ex- ported pain to bilateral hips that started approximately periencing internal snapping hip syndrome related to 2 years ago but increased in severity within the last few her tendon. The patient was given the choice to months. P.W. reported no known injury to the hips or restart PT and anti-infl ammatory medications or have pelvis. P.W. had seen a community orthopaedic surgeon an ultrasound-guided medicated injection to the iliop- 2 months prior, who had obtained a magnetic resonance soas tendon. The patient chose the injection, and it was image and felt the patient needed surgical intervention scheduled accordingly. In addition, it was recommended for a questionable labral tear. Family arrived today for that the patient stretch frequently, both in the morning evaluation and a second opinion. and in the evening, to help with tightness and pain. P.W. described her hip pain as intermittent and P.W. underwent ultrasound-guided injection 1 week mainly localized to the anterior aspect of her hip, right later in the hospital’s interventional radiology depart- side greater than her left. She reported the pain to be ment. A combination of lidocaine 1%, Kenalog-40 (tri- associated with a popping sensation. Family stated that amcinolone acetonide ), and bupivacaine 0.25% was in- P.W. had not found pain relief after two rounds of phys- jected into the iliopsoas tendon. The patient reported ical therapy (PT) over the last 1–2 years and had tried majority of her pain relieved at the 2-week follow-up over-the-counter anti-infl ammatories, though not on a appointment and was discharged from the orthopaedic regular basis, without relief. clinic with instructions to continue to do daily stretches and be seen back only as needed. Physical Examination On physical examination, P.W. was a pleasant, healthy, Overview of Diagnosis/Assessment slightly overweight, age-appropriate female. She ambu- Coxa saltans, or snapping hip syndrome, is a common lated without any obvious deformity or limp and a nega- condition where the patient feels or hears a snapping tive Trendelenburg sign. A reproducible painful audible clunk could be heard to the anterior aspect of her right hip with routine maneuvering. She had equal range of Elizabeth Badowski, MSN, RN, CRNP, Department of Orthopedics, motion to both her right and left hips with abduction Nationwide Children’s Hospital, Columbus, OH. and adduction. P.W. had full range of motion of her The author has no confl icts of interest to disclose, fi nancial or otherwise. bilateral knees and ankles. The patient had a negative DOI: 10.1097/NOR.0000000000000499

© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2018 • Volume 37 • Number 6 357 Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. TABLE 1. S NAPPING HIP LOCATION AND CAUSE Internal Snapping Hip Location External Snapping Hip Extra-articular Extra-articular Intra-articular Snapping Hip Cause IT band sliding over the greater trochanter Iliopsoas tendon sliding over the: Loose body • Femoral head tear

• Prominent iliopectineal ridge Osteochondral fracture

• Iliopsoas bursa Note . IT = iliotibial.

TABLE 2. E XTRA-ARTICULAR PHYSICAL EXAMINATION DIFFERENCES Extra-articular External Snapping Hip Internal Snapping Hip Palpation + Pain with palpation to the greater trochanter + Snapping felt at the anterior hip Range of motion + Pain with femoral rotation/fl exion + weakness Sound + Snapping sensation visualized + Audible snap of the hip TEST + OBER TEST

sound or sensation to the hip, especially when doing side’s knee to 90° . The knee is then extended and hip is physical activity or movement to the lower extremities abducted, with the knee support being released. A posi- ( Musick & Bhimji, 2017). Approximately 5%–10% of the tive Ober test is seen if the knee fails to adduct. population has some form of coxa saltans ( Byrd, 2005). Often the patient will complain of tightness and pain Usually, the condition is painless and does not cause any to the hip and is due to a tight tendon moving over a long-term problems. However, for higher level athletes bony prominence. The patient will usually state the pain and dancers, this condition may cause pain, weakness, is worse with activity. Some patients are able to visibly and interference with performance. Women tend to be reproduce the popping sensation under the skin. The hip affected more frequently than men. In addition, it is may be painful with palpation due to . This bur- often seen in young adults who have undergone sudden sitis is caused by the thickening and infl ammation of the growth spurts ( Musick & Bhimji, 2017). bursa as it moves over the boney prominence frequently. Coxa saltans can occur within two main categories: Intra-articular snapping hip usually manifests with (1) extra-articular or (2) intra-articular. Within the pathology showing a loose body within the hip joint. The extra-articular category, two subcategories can occur: two tests that are performed to help assess and verify in- (1) external or (2) internal. The cause(s) of snapping hip tra-articular snapping hip are the FADIR test and FABER syndrome varies depending on location within the hip test (see Table 3 ; Figures 3 and 4 ). The FADIR (fl exion, (see Table 1 ). Patients present with different clinical adduction, and internal rotation) test involves the patient presentation between the two subcategories of snap- lying fl at, with the knee and hip bent to 90° . The exam- ping hip (see Table 2 ). The most common type of snap- iner then pushes the entire leg across midline of the body ping hip is extra-articular external. External snapping (adduction). While keeping knee in that position, the hip involves the lateral hip at the site of the iliotibial (IT) practitioner rotates the and the lower calf away from band where it passes over the greater trochanter body (abduction). The FABER (fl exion, abduction, and (American Academy of Orthopaedic Surgeons, 2013; external rotation) test is similar to the FADIR test, but the Zelman, 2017). External snapping hip often presents with pain on palpation to the greater trochanter and with femoral rotation and fl exion along with the sensa- tion of the hip dislocating ( Yen, Lewis, & Kim, 2015 ). External snapping hip (IT band passing over the greater trochanter) can often be visualized. Internal snapping hip involves the anterior hip at the iliopsoas tendon site. This form of snapping hip is less common but more fre- quently symptomatic. Often positive gluteus medius weakness is seen with internal snapping hip. Internal snapping hip is more audible in nature (see Figure 1 ). The Ober test (see Figure 2 ) may help differentiate be- tween the two subcategories (“Snapping Hip FIGURE 1. Anatomic illustration of hip joint, bones, ligaments, Syndrome—Understand,” n.d.). This test is done by tendons, and bursae. Reproduced with permission from having the patient lie on the unaffected side laterally OrthoInfo. © American Academy of Orthopaedic Surgeons. while the examiner supports and fl exes the affected http://orthoinfo.aaos.org

358 Orthopaedic Nursing • November/December 2018 • Volume 37 • Number 6 © 2018 by National Association of Orthopaedic Nurses Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. TABLE 3. I NTRA-ARTICULAR PHYSICAL EXAMINATION DIFFERENCES Intra-articular FADIR Test FABER Test 1. Passively move the affected 1. Flex the affected leg/side leg/side into full fl exion 45° and then externally rotate and abduct 2. Adduct and internally 2. Rest ankle on the rotate the leg contralateral leg proximal to the knee patient’s knee is rotated outward and the foot and the lower calf are rotated inward. If impingement is present, pain will often occur. These tests help with diagnosing a hip labral tear, loose bodies, chondral lesion, or femoral acetabular impingement within the hip joint. However, these two tests do not confi rm the diagnosis.

Treatment Options Treatment options range from observation, medication, PT, injections, and/or surgical intervention, depending on the category of snapping hip (Karadesheh & McCulloch, n.d; Yen et al., 2015). Usually, conservative treatment will help treat the pain and symptoms, thus eliminating the problem. Utilizing nonsteroidal F IGURE 3. A and B, The FADIR test.

FIGURE 2. A and B, The Ober test . FIGURE 4. A and B, The FABER test.

© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2018 • Volume 37 • Number 6 359 Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. anti-infl ammatory medications and ice will help with iliopsoas release, weakness in abduction with the IT pain and bursitis (Yen et al., 2015). Modifying activities band release, nerve damage, infection, muscle atrophy, or stopping repetitive physical activities for a short pe- and heterotopic ossifi cation. riod of time usually alleviates symptoms. Some people benefi t from formal PT, which will help the patient learn appropriate exercises and stretches that strengthen the Conclusion muscles around the affected hip area (Yen et al., 2015). Snapping hip syndrome is a common problem, espe- These exercises include IT band, iliopsoas tendon, piri- cially in the growing active teenagers and athletes. Most formis, , and quadriceps stretches ( American patients who experience this problem can be treated Academy of Orthopaedic Surgeons, 2013; Zelman, 2017). appropriately after a thorough clinical examination If after all conservative treatment options have been with conservative measures such as modifi ed activity, attempted without alleviation of pain or pain interferes ice, nonsteroidal anti-infl ammatory drugs, and stretch- with daily living, a corticosteroid injection is usually ad- ing. However, if those measures do not seem to provide ministered ( Garry, 2014; Yen et al., 2015). This injection adequate pain relief, then more invasive techniques and helps decrease the painful infl ammation that is occur- procedures may need to be utilized and an orthopaedic ring around and in the bursa. The injection is usually referral would be appropriate. administered with ultrasound guidance and includes medication combinations of a corticosteroid and a local REFERENCES anesthetic (Garry, 2014). If this option is utilized, usu- American Academy of Orthopaedic Surgeons . ( 2013 ). ally the combination of the injection and appropriate Snapping hip . Retrieved from http://orthoinfo.aaos. stretching exercises will eliminate the pain. Although org/topic.cfm?topic= a00363 side effects from injections are rare, practitioners need Byrd , J. W. ( 2005). Snapping hip. Operative Techniques in to be vigilant regarding the signs and symptoms of Sports Medicine , 13 , 46 – 54 . intra- or extra-articular infection. These may include Garry , J. ( 2014 ). Snapping hip syndrome treatment & man- edema, erythema, swelling, fevers, malaise, chills, or agement . Retrieved from http://emedicine.medscape. pain at the site of injection. com/article/87659-treatment Karadesheh , M. , & McCulloch , P. (n.d.). Snapping hip When in rare instances snapping hip does not re- (Coxa saltans). Orthobullets . Retrieved from http:// spond to conservative treatment options or if pathology www.orthobullets.com/sorts/3096/snapping-hip-coxa- involves a torn labrum, surgery may be required. The saltans?expandLeftMenu= true type of snapping hip, the extent of the problem, and Musick , S. , & Bhimji , S. (2017 ). Snapping hip syndrome . surgeon preference will determine whether the proce- Retrieved from https://www.ncbi.nlm.nih.gov/books/ dure will be a hip arthroscopy versus an open proce- NBK448200 dure. Some surgical options include excision of the Snapping hip syndrome—Understand in order to correct . bursa, Z-plasty of the IT band, release of the iliopsoas (n.d.). Retrieved from http://www.osteopathicmanual- tendon, removal of loose bodies, and/or labral debride- medicine.com/2016/11/15/snapping-hip-syndrome- ment and repair (Karadesheh & McCulloch, n.d). understand-in-order-to-correct Yen , Y. , Lewis , C. , & Kim , Y. ( 2015). Understanding and treating the snapping hip. Sports Medicine and Arthroscopy , 23 ( 4 ), 194 – 199 . Side Effects/Risks Zelman , D. (2017 ). Snapping hip syndrome . Retrieved from Common side effects and complications from these sur- https://www.webmd.cm/a-to-z-guides/snapping-hip- gical interventions can include hip fl exor weakness after syndrome-causes-symptoms-treatment

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360 Orthopaedic Nursing • November/December 2018 • Volume 37 • Number 6 © 2018 by National Association of Orthopaedic Nurses Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.