How is soft tissue clicking movement over the greater trochanter diagnosed?

Diagnosis of Soft Tissue Clicking Movement Over the Greater Trochanter

Soft tissue clicking movement over the greater trochanter is primarily diagnosed through clinical examination and confirmed with imaging studies, with ultrasound and MRI being the most effective diagnostic modalities.

Clinical Evaluation

• The physical examination may reveal a stable "clicking" hip, characterized by a hip with no laxity but with a "click" elicited during examination 1
• Palpation over the greater trochanter with the patient in side-lying position can elicit tenderness and reproduce the clicking sensation 2
• Differentiation between a stable clicking hip and an unstable hip is important, as unstable hips may indicate ligamentous or capsular laxity 1

Imaging Evaluation

Initial Imaging

• Radiographs should be obtained first in most cases to rule out bony abnormalities and assess for other causes of hip pain 1, 3
• Radiographs showing >2 mm surface irregularities of the greater trochanter have been associated with abductor tendon abnormalities, though with limited specificity (25.7%) 1
• Radiographic findings alone are insufficient for diagnosing soft tissue clicking, as they have limited sensitivity for soft tissue pathology 4

Advanced Imaging

• MRI is the preferred imaging modality for evaluating soft tissue clicking over the greater trochanter when radiographs are negative or nondiagnostic 1, 3, 5
• MRI can comprehensively assess peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 1, 3
• MRI can detect abnormalities in both symptomatic and asymptomatic hips, revealing structural damage in gluteal tendons and muscles 5
• Ultrasound is effective for detecting trochanteric bursitis and tendon abnormalities, and has the advantage of being dynamic to visualize the clicking movement in real-time 3, 6
• Ultrasound can identify tendinopathy, partial tears, and complete tears/avulsion of the gluteus medius tendon 1

Diagnostic Procedures

• Diagnostic injection with local anesthetic into the trochanteric bursa can provide both diagnostic confirmation and therapeutic benefit 3
• If clicking is associated with snapping hip syndrome (coxa sultans), real-time ultrasound during movement can evaluate the snapping iliopsoas tendon 1
• Fluoroscopic motion studies (with or without contrast) can be useful to evaluate periarticular conditions such as snapping iliopsoas tendon 1

Common Underlying Causes

• Gluteus medius or minimus tendinopathy or tears are more common causes of greater trochanteric pain with clicking than trochanteric bursitis 6
• Of patients with greater trochanteric pain, studies show that only 20.2% have true bursitis, while 49.9% have gluteus tendinosis 6
• Snapping iliopsoas tendon over the femoral head or iliopectineal eminence can cause clicking sensations 1
• Iliotibial band abnormalities are present in approximately 28.5% of patients with greater trochanteric pain 6

Diagnostic Pitfalls

• Differentiating between trochanteric bursitis and gluteus medius/minimus tendinosis can be challenging, and these conditions frequently coexist 3
• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 1
• The sensitivity and specificity of clinical examination depend on the expertise of the evaluator 1