What is the treatment for external snapping hip syndrome (external coxa saltans)?

Treatment for External Snapping Hip Syndrome (External Coxa Saltans)

Conservative management should be the first-line treatment for external snapping hip syndrome, with surgical intervention reserved only for cases refractory to non-operative measures. 1

Pathophysiology and Diagnosis

External snapping hip syndrome (external coxa saltans) is characterized by an audible or palpable snap on the lateral aspect of the hip, typically caused by the iliotibial band or anterior gluteus maximus sliding over the greater trochanter during hip movement. Ultrasound can be effectively used to evaluate snapping hip and confirm the diagnosis 1.

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Activity Modification

   • Temporarily avoid activities that provoke snapping
   • Modify exercise routines to reduce hip flexion/extension movements that cause symptoms

2. Physical Therapy

   • Stretching exercises targeting the iliotibial band and hip external rotators
   • Strengthening of hip abductors and external rotators
   • Core stabilization exercises
   • Movement retraining to avoid positions that cause snapping

3. Pain Management

   • Regular acetaminophen (up to 4g/day) for mild-to-moderate pain 2
   • NSAIDs at lowest effective dose if acetaminophen provides inadequate relief 2
   • Avoid long-term NSAID use in patients with renal dysfunction 1

4. Corticosteroid Injections

   • Ultrasound-guided peritrochanteric or iliotibial band injections for persistent symptoms
   • Diagnostic and therapeutic tool to confirm location of pain and provide short-term relief 1

Second-Line Treatment: Surgical Management

For patients with symptoms persisting >6 months despite adequate conservative treatment:

1. Endoscopic Techniques (preferred)

   • Endoscopic iliotibial band release with or without trochanteric bursectomy 3
   • "Fan-like" technique allowing gradual, tailored release based on intraoperative findings 4
   • Benefits: Fewer complications, lower recurrence rates, and good clinical outcomes compared to open techniques 5

2. Open Surgical Techniques

   • Z-plasty of the iliotibial band 6, 7
   • Indicated when endoscopic techniques are unavailable or in complex cases
   • Can be performed under local anesthesia on an outpatient basis 7

Expected Outcomes

• Conservative treatment is successful in the majority of cases
• Surgical intervention has high success rates (>90%) for refractory cases 6
• Most patients can return to full unrestricted activities following successful treatment 6

Special Considerations

• Careful screening is necessary to rule out other hip pathologies that may mimic or coexist with external snapping hip 6
• Patient education about the condition and management options is essential for shared decision-making 1
• Physical activity and return to sport should be gradually introduced following resolution of symptoms 1
• For athletes, sport-specific rehabilitation should be incorporated into the treatment plan 1

Follow-up

• Regular assessment of treatment efficacy
• Gradual return to activities as symptoms improve
• Consider surgical options only after 4-6 months of failed conservative management

This approach prioritizes conservative management while providing clear guidance on when and how to progress to surgical intervention for optimal outcomes in terms of pain relief, function, and quality of life.