Snapping Hip Syndrome: Is it Dangerous?

Do your hips make an annoying snap, click, or clunking sound whenever you move your leg around in space?  As someone who has personally dealt with this for many years in both hips, I can relate to the inconvenience this causes during exercise. This syndrome is well recognized but poorly understood.

 Snapping hip or “Coxa Saltans” is quite common and effects 10% of the population. It is more prevalent in females and especially those that need to raise their legs through large ranges of motion in their sport. This includes dancers, martial artists, climbers, gymnasts, yogis, and even runners. However, this type of issue is not only limited to flexible types. Even stiff guys like me experience this. For instance, my hips used to make a “clunking” noise when trying to get up from laying down on the ground with my legs straight or when performing abdominal exercises at the gym.

 The most common movement that brings on the symptoms is bringing the leg from flexion down into extension. This is even more noticeable when the leg is abducted or turned out to the side then lowered back down to the midline of the body. Picture someone laying on their back with their knee up toward their chest and bringing that leg down toward the ground. Once the leg gets close to the ground the person may hear a clunk. Another example is an athlete warming up for sport with leg swings to the side. They will swing the leg up and out, and on the way down, they hear a loud clunk. Though this is more of an annoyance and rarely painful at first, it can sometimes lead to irritation around the front of the hip joint and interfere with an athlete’s functional mobility.

A common region that becomes inflamed and irritated after repeated snapping of the iliopsoas tendon without adequate recovery between exercise is the iliopsoas or iliopectineal bursa sac. The bursa is there to lessen the friction between two surfaces such as tendon and bone, ligament and bone, tendon and ligament, and between muscles.

 The iliopectineal bursa is located on the anterior surface of the joint capsule of the hip and below the iliopsoas tendon. The bursa sac can become inflamed and cause some local swelling in the anterior hip region due to repetitive snapping of the iliopsoas tendon over the bone. This can also lead to degeneration of the tendon itself in extreme cases which would be classified as an iliopsoas tendinopathy.

There are different classifications of snapping hip syndrome (SHS), so let’s define them, discuss the potential causes, and then go over some ways to mitigate the symptoms.

*Something important to preface here is that snapping hip syndrome is a NORMAL variant and does not mean there is anything inherently wrong with your hip and will not lead to any long term damage or is predictive of further issues. Even though it may feel like your hip is subluxing or dislocating especially when you hear loud clunks, that is not the case. There is no need to create a problem that doesn’t exist. For that reason, I like to drop the “syndrome” because it attaches a negative label to you.

Classifications:

External Snapping Hip

 This is attributed to the TFL or glute maximus snapping over a bony prominence on the side of the hip called the greater trochanter. The tendons of these two muscles meet down the thigh near the greater trochanter to become the iliotibial band. This can be felt on the outer part of you hip during side lying flexion and extension or weight bearing movements such as single leg deadlifts.

 Internal Snapping Hip

 This is the most common variant, also referred to as dancers’ hip. This refers to the iliopsoas tendon snapping over the femoral head or a bony prominence on the front of the pelvis called the iliopectineal eminence. This can be felt when the hip moves from a position of flexion, abduction, and external rotation to extension, adduction, and internal rotation.

 Intraarticular Snapping Hip

Patients with intra-articular snapping hip syndrome report a sudden onset of snapping or clicking from an injury or traumatic event to the hip capsule. The sources of this snapping can come from intra-capsular lesions, loose bodies settling in the acetabular fovea or synovial folds, or a torn acetabular labrum.

 Causes/ Etiology

 Snapping hip is commonly associated with poor flexibility, motor control, or strength of the tissues surrounding the hip joint. However, these are all gross oversimplifications especially in isolation. We can’t necessarily say it is due to flexibility issues when dancers get it, as dancers are typically very flexible. We also can’t say it is a strength thing if explosive athletes and sprinters have it. At the end of the day what is deemed “adequate” mobility or strength is specific to the sport or task someone is engaging with frequently. It is all relative. No one knows the exact cause but regardless of the reason, the goal is to reduce symptoms and improve overall function and movement variability of the hips to make symptomatic activities less bothersome.  At the end of the day, there is no guarantee that the snapping will completely go away.

 Due to personal experience with this issue, I’d say the symptoms can be greatly reduced.

  Anatomy

 Hip Flexors

The psoas muscle is among the most significant muscles that overlie the vertebral column. It is a long fusiform muscle on either side of the vertebral column and the brim of the lesser pelvis.

 The iliopsoas muscle complex is made up of three muscles that includes the iliacus, psoas major and psoas minor. This complex muscle system can function as a unit or as separate muscles.

The iliopsoas muscle is the primary hip flexor and assists in external rotation of the hip joint.

 Origin:

Psoas major: The transverse processes and lateral surfaces of the vertebral bodies of L1 - L4 or T12 - L5 and the path involves the intervertebral discs.

 Psaos minor: It originates from T12 and L1 and lies anteriorly to the psoas major.

Iliacus: It originates on the upper two-thirds of the iliac fossa and the lateral parts of the wing of the sacrum.

Insertion:

Psoas major and iliacus: The psoas major and iliacus join together, pass under the inguinal ligament and insert onto the femoral lesser trochanter

Psoas minor: It inserts onto the iliopectineal eminence after converging with the iliac fascia and the psoas major tendon

Bursa: The iliopsoas or iliopectineal bursa lies between the bony surfaces of the pelvis and proximal femur and the musculotendinous unit. It is the largest bursa in humans. It has an average length of 5 to 6 cm and width of 3 cm and extends from the iliopectineal eminence to the lower portion of the femoral head

 IT Band

The iliotibial tract is a thick band of fascia that runs on the lateral side of the thigh from the iliac crest and inserts at the knee. It is composed of dense fibrous connective tissue that appears from the tensor fasciae latae and gluteus maximus. It descends along the lateral aspect of the thigh, between the layers of the superficial fascia, and inserts onto the lateral tibial plateau at a projection known as Gerdy’s tubercle.

Tests

 Hip Internal and External Rotation

 External Rotation                                                                

Knee flexed to 90 deg, Move heel inward. Place hand on outside to prevent knee from traveling outward. Ideally we are looking for about 60-75 degrees here

Internal Rotation

Knee flexed to 90 deg, Move heel outward. Place hand on inside to prevent knee from traveling inward. Ideally we are looking for about 30-45 degrees here.

This will give us the first indication of how much variability, or movement options the hip can express at the joint level. Typically with snapping hip syndrome, the hips will be limited in one or both of these directions or have a glaring difference side to side. External rotation is usually limited with internal snapping hip as the popping usually happens coming out of an externally rotated and abducted position to an internally rotated one. If external rotation is limited, the pelvis will usually be pulled into an anterior pelvic tilt to buy more space in the hip joint. This puts the hip flexor muscles in a shorter position and more likely to have to jump over the bony parts in the hip when moving the lower limb in space. In theory this is because the iliopsoas has to work harder than it needs to stabilize the spine and pelvis to make up for the lack of movement of the hips. Therefore instead of flowing softly over the bones, it is already pulled taught and “clunks” over the bones.

 This goes with our next assessment

Hip Extension/ Thomas Test

Sit toward edge of table, pull non testing knee toward chest to place pelvis in a posterior tilt. Let testing thigh extend down toward table. A passed test is the back of the thigh is flush with the table.

 Tight/ restricted/ or short hip flexors… however you want to call it… will limit the ability to extend the hip. Most people who lack hip rotation will have limited hip extension as well so improving flexibility of the hip flexors is only one side of the coin. Full hip extension here with this test is the ability to get the proximal part of the back of the thigh flush on the table with a posterior pelvic tilt. If you cannot get to a neutral level of hip extension meaning hip, knee, and ankle are in a straight line with a posterior pelvic tilt then that will mean the low back will end up compensating into extension to fake hip extension.

Here is how this can be an issue with snapping hip syndrome: Imagine you are on your back and you bring your leg down from a hip flexed position into an extended position. if the pelvis has to anteriorly tilt before the leg gets down to the ground, this will shorten the hip flexors. Shortened hip flexors will now have to work harder to stabilize the spine and will be overly active when they don’t necessarily need to be. This excessive tension can cause the iliopsoas tendon to snap over the bony prominence in the pelvis during active leg movement instead of gliding over it smoothly.

 FABER Test

 Stands for “flexion, abduction, external rotation” test. We can use this test to cluster hip extension with rotation. I find this to be a pretty good test to indicate if there is pathology of the hip related to internal snapping hip symptoms. Since snapping hip typically occurs with eccentric hip flexion (moving into extension) during abduction and external rotation, this test will highlight if there is pain or movement restriction when moving into all three of those planes. Any muscle guarding in the pelvic region during this test can potentially contribute to snappy hips.

 Ober’s Test

Lay in side lying. Bring bottom knee toward chest to tuck the pelvis under, extend thigh and drop knee toward the table. A passed test is a straight line between the hip and knee is achieved with the top knee touching the table.

This test is used commonly to test for TFL tightness but can also be used to assess whether the hip can move through adduction/ Internal rotation, and extension. Stiffness here will typically show up in external snapping hip presentations.

Leg Raise Test

This test will be performed by starting with a bent or straight leg position with hips maximally flexed, toes turned out (ER), and abducted to the side slightly. From here, lower the leg slowly toward the table without change in pelvic position. If there is either pain, clunking or a snapping sensation then this indicates a positive test.

Conservative Treatments

 Exercise modification: Range of motion, speed, coordination,  

 If you are noticing excessive snapping occurring during your training, then we must first ask ourselves why. Has it always been this way? Maybe we need to improve some range of motion and strength in specific ranges. Is this happening out of the blue? Maybe this is indicating that you are not recovering from your current training or your current exercises aren’t suiting your anatomy. Often inflammation in the hip joints from under recovery will cause reduced space between the psoas tendon and the bony prominences it runs over. This may increase the likelihood of snapping back and forth during open chain exercises. If this is the case, we need to modify training to: 1) introduce novelty 2) improve recovery of overworked tissues and 3) allow for an adequate training stimulus without irritating the hip further.

 For instance, we can modify range of motion, speed, and the coordinative aspects of the movements. Say you are experiencing an annoying internal snapping hip with hanging leg raises. An option is to do them with bent knees to decrease the lever arm and overall loading on the hip flexors so that the low abs can take over. Then on the side, you can work on slow and controlled eccentric straight leg raises with a posterior pelvic tilt to focus on improving the hip flexors capacity to manage forces from full range hip flexion to extension.

For my gymnastics peeps, you may notice snapping hip occurring in straddle handstand variations especially press to handstand. For a modification, try not closing the legs to a straight handstand at the top of the press and straying in a straddle. It is the motion of moving from hip flexion/ abduction to hip extension/ adduction that causes the snapping, so if we avoid that for the time being we can still focus on the hardest part of the press to handstand (bringing feet off the floor and stacking hips over shoulders) and not worry about any hip pain.  Or in the meantime work on pressing variations with legs closed such as pike press and L- sit pull through variations to build press strength.

 Simultaneously, you may need to work on improving hip external rotation, and abduction range of motion if this is a limitation. This will ensure the joints can display the movement variability needed to carry out the demands or the exercises chosen to perform.

Incline Bench Pigeon Stretch Regression

Loaded Floor Pigeon

 If you are experiencing external snapping hip with single leg movements such as single leg RDL’s, maybe you can switch to a bilateral RDL while simultaneously improving your ability to genuinely adduct, internally rotate and extend the femur which are of high demand for single leg strength exercises. We can use range of motion development exercises as accessories to main strength exercises.

*Seated Band Hip Internal Rotation 

* Long Lunge Active Hip Extension      

   Adductor Muscle Guarding

 One of the keys to fixing my snapping hip was reducing the resting tone in my adductors. Whenever my adductors are loosened up, I experience much less snapping when performing straddle handstand variations or straddle leg raises. The adductors not only adduct the femur, but are also hip flexors and hip extensors depending on the amount of flexion the femur is in. Therefore tight and restricted short adductors can prevent you from extending the hip in abduction as the leg moves from flexion…. Leading to overactive iliopsoas to work much harder to maintain femoral external rotation and support the pelvis in an anterior pelvic tilt. Which will in turn cause potential snapping over the iliopectineal eminence with leg movement up and down. Sick of hearing my snapping hip physiology theory yet??

 Below are two of my favorite exercises for improving adductor flexibility and strength through range.

*Supine Butterfly Lifts       

  *Supine Wall Loaded Frog Lifts

Antagonist Strength

Since excessive muscle guarding of the hip flexors, TFL, and iliopsoas tend to be contributing factors to snapping hip, then strengthening the opposing muscles can help decrease these nagging muscle’s resting tone. Strengthening the glutes through hip hinging variations allowing the pelvis to rotate fully through internal and external rotation, and strengthening the hamstrings to facilitate posterior pelvic tilt can reduce guarding in the hip flexors.

Here are some cool exercises I have had great results with.

Banded Hip Extension with Hip External Rotation

*Ipsilateral Loaded Closed Chain Airplane (with optional band resistance)

* Foam Roller Hamstring Bridge

 Hip Flexor Loading

 At the end of the day, we need to load the hip flexors through full range of motion especially in the case of tendinopathy. This is the only way to restructure the tendon over time. The ideal is heavy and slow tempo resistance which has been shown to illicit a proper stimulus to cause strength adaptations to tendons. Tendons respond to tension, so the load has to be high enough to cause enough mechanical tension to elicit changes to the mechanical properties of the tendon.

*Open Kinetic Chain: Loaded Thomas Stretch 

     *Closed Kinetic Chain: Hip Flexor Sit Up

 Surgery

 Often surgery will be recommended as a last resort when patients fail with conservative management of symptoms. The criteria for “failed conservative management” is honestly a joke in my opinion as most Physical Therapist rehab plans are quite generic for this syndrome.

The goal with surgery is to lengthen or relax the tight tendon or ligament to eliminate the snapping as well as to correct any associated/contributing pathologies which are very common in SHS. Here are some common surgical procedures:

• External Snapping Hip

• Z-plasty of the iliotibial tract

• Resection of the posterior half of the iliotibial tract

• Elliptical resection of a portion of the iliotibial band

• Internal Snapping Hip

• Lengthening of the iliopsoas tendon 

• Resection of the bony prominence of the lesser trochanter

• Complete release of the iliopsoas tendon

 Seems so straight forward, right?? If the hip flexor is short, just surgically lengthen it! Unfortunately, I have never seen this pan out successful in clinic. Most of the time, muscle stiffness is neurologic in nature, so mechanical lengthening of a muscle typically has no effect. Once the surgery occurs to lengthen the muscle, the nervous system STILL holds guarding in the muscle and it shrinks right back up when the brain comes back online. The underlying cause of stiffness was never addressed in the first place.

 Conclusion

 Snapping hip syndrome is a common variant in both the male and female population, as well as both hypermobile and stiff folks. It is a painless sensation most of the time but can also be irritable in the case of a coexisting tendinopathy or bursitis. The cause of snapping hip is still unknown, but there can be contributing factors that have to do with strength, flexibility, and overall motor control relative to the activities we engage in. At the end of the day, we may never be able to completely resolve the snapping hip, however it is worth exhausting options conservatively to reduce symptoms. Simultaneously, it is extremely important you are scaling exercises appropriately so that overall snapping instances are minimized. If you go through the assessments from this article and you find you fail some of the tests, then you have work to do. If there is room for improvement, then might as well work on your weaknesses. Trust me, it beats undergoing an unsuccessful surgery…

 I really hope this article provided a unique insight into snapping hip syndrome. This is a condition I have dealt with myself and have helped many patients/ clients manage over the years. The traditional approaches never worked for me. Many of the exercises shown can be found on my YouTube page for a more detailed visual if needed.

 If you are having issues with your hips, check out my hip mobility program here on my website. I also offer 1-1 online coaching where I make programs tailored to the individual based on a full body assessment. If you made it this far, thank you so much for reading.

 Any questions on the article or hip pain in general, please reach out!