Learning Objectives
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Learn the common causes of snapping hip.
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Develop an understanding of the unique anatomy of the hip joint.
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Develop an understanding of the bursae of the hip.
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Develop an understanding of the tendons of the hip.
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Develop an understanding of the causes of snapping hip.
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Develop an understanding of the differential diagnosis of snapping hip.
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Learn the clinical presentation of snapping hip.
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Learn how to examine the hip and associated bursae.
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Learn how to use physical examination to identify snapping hip.
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Develop an understanding of the treatment options for snapping hip.
Jimmie Kaline
Jimmie Kaline is a 27-year-old minor league baseball player with the chief complaint of, “My left hip keeps snapping.” Jimmie stated that ever since spring training, every time that he gets up from behind home plate, his hip snaps. He said that the snap is so loud that the home plate umpire, batter, and the guys in the dugout can hear it, and some of his teammates have taken to call him “Snap, Crackle, and Pop.” Jimmie states, “Doctor, this snapping is really driving me crazy! At first it was just the snap, but now my hip has started to hurt. I had really hoped to make it up to the majors this season, but I’m afraid that the snapping sound will make them think I am injured.”
I asked Jimmie about any previous injuries to the left hip and he said he couldn’t count the number of times he had been hit with thrown bats and wild pitches, but it was just part of the job. He didn’t know a baseball catcher who didn’t have all kinds of aches and pains. It just went with the territory. During the season, he pretty much lived on Advil and Icy Hot. “Doc, I can tough it through the pain, but the snapping is really freaking me out. What the hell is wrong with my hip?”
I asked Jimmie what made his hip snap, and he said, “Any time I go from squatting to standing, bam! There it is—snap—and then the pain. My left hip aches all the time now; it really hurts and the pain is really messing with my sleep. Every time I roll over onto my left side, the pain in my left hip wakes me up.”
I asked Jimmie to point with one finger to show me where the snap came from, and he pointed to the area just over the left greater trochanter. To further illustrate, he dropped into a squat and the jumped back up. Sure enough, as he stood, there was a loud snap!
On physical examination, Jimmie was afebrile. His respirations were 18 and his pulse was 64 and regular. His blood pressure was 118/70. Jimmie’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal, as was his abdominal examination. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the left lateral hip was unremarkable. The area over the left greater trochanter was warm but did not appear to be infected. There was subtle point tenderness over the greater trochanter, suggestive of a mild trochanteric bursitis. I performed a snap test, which was markedly positive on the left and negative on the right ( Fig. 7.1 ). There was both an audible and a palpable snap.
Range of motion of the hip joint, especially resisted abduction of the joint, reproduced Jimmie’s pain. The right hip examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. Specifically, there was no evidence of meralgia paresthetica, which is so common in baseball catchers.
Key Clinical Points—What’s Important and What’s Not
The History
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Onset of an audible snap sound from the left hip pain when rising from a squatting to a standing position
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Pain localized to the area of the left greater trochanter
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Pain associated with a snapping sensation
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No other specific traumatic event to the area identified
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No fever or chills
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Sleep disturbance
The Physical Examination
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The patient is afebrile
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There is an audible and palpable snap when rising from a squatting to a standing position
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Point tenderness to palpation of the area over the trochanteric bursa
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Palpation of the area overlying the left greater trochanter is warm to touch
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No evidence of infection
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Pain on resisted abduction of the affected left hip
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The snap test was positive on the left (see Fig. 7.1 )
Other Findings of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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No evidence of meralgia paresthetica
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Examinations of other joints other than the left hip were normal
What Tests Would You Like to Order?
The following tests were ordered:
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Plain radiographs of the left hip
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Ultrasound of the left hip and iliotibial band
Test Results
The plain radiographs of the left hip were reported as normal. Ultrasound examination of the left hip revealed an effusion around the trochanteric bursa and mild displacement of the iliotibial band ( Fig. 7.2 ).
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Snapping hip syndrome
The Science Behind the Diagnosis
Anatomy
The trochanteric bursa lies between the greater trochanter and the tendon of the gluteus medius and the iliotibial tract ( Figs. 7.3 and 7.4 ). The gluteus medius muscle has its origin from the outer surface of the ilium, and its fibers pass downward and laterally to attach on the lateral surface of the greater trochanter. The gluteus medius locks the pelvis in place when walking and running. The gluteus medius muscle is innervated by the superior gluteal nerve. The iliotibial band is an extension of the fascia lata, which inserts at the lateral condyle of the tibia ( Fig. 7.5 ). The iliotibial band can rub backward and forward over the lateral epicondyle of the femur and irritate the iliotibial bursa beneath it.
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Zoey Hart: A 25-Year-Old Female With Suprapubic Pain
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Meredith Grace: A 32-Year-Old Female With Right Ill-Defined Low Back and Buttock Pain
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