What is the recommended treatment for external snapping hip?

Treatment of External Snapping Hip Syndrome

The recommended treatment for external snapping hip syndrome begins with conservative management including physical therapy, activity modification, and anti-inflammatory medications, with surgical intervention reserved for cases that fail to respond to conservative measures. 1

Understanding External Snapping Hip

External snapping hip syndrome (also called lateral coxa saltans) is characterized by:

• Audible or palpable snapping on the lateral side of the hip caused by the iliotibial band slipping over the greater trochanter 2, 1
• Often seen in athletes who require increased hip range of motion 3
• May be asymptomatic in many cases, but can become painful and limiting in some individuals 1

Diagnostic Approach

• Diagnosis is primarily clinical based on history and physical examination 2
• Ultrasound can be useful to dynamically detect tendon translation during hip movement, supporting the diagnosis 1
• Standard radiographs should be obtained to evaluate the hip joint and rule out other pathologies 2

Treatment Algorithm

First-Line: Conservative Management

1. Activity modification and rest

   • Temporary avoidance of activities that provoke symptoms 1

2. Anti-inflammatory medications

   • NSAIDs at the lowest effective dose to reduce pain and inflammation 1
   • In patients with increased gastrointestinal risk, consider non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 4

3. Physical therapy

   • Stretching exercises focusing on the iliotibial band 1
   • Strengthening of hip abductors and external rotators 4
   • Physical activity should be maintained as tolerated 4

4. Patient education

   • Education about the condition and expected outcomes 4
   • Shared decision-making regarding treatment options 4

Second-Line: Interventional Approaches

• Corticosteroid injections
  • May be considered for patients with persistent symptoms despite conservative management 4
  • Ultrasound guidance can improve accuracy of injection placement 4

Third-Line: Surgical Management

For patients with persistent symptoms despite 3-6 months of conservative treatment:

• Endoscopic techniques are preferred over open procedures due to:

  • Fewer complications compared to open surgery 3
  • Lower recurrence rates 3
  • Comparable results to open procedures with less morbidity 2

• Surgical options include:

  • Endoscopic release of the iliotibial band - creating a diamond-shaped defect in the iliotibial band 2
  • Z-plasty of the iliotibial band for refractory cases 5
  • Endoscopic release of the femoral insertion of the gluteus maximus tendon 3

Outcomes and Prognosis

• Most patients respond well to conservative management 1
• Surgical outcomes are generally excellent with proper patient selection:
  • Complete resolution of snapping in most cases 2, 5
  • Return to previous level of activity in majority of patients 2
  • Rare complications including persistent pain without snapping 5

Important Considerations and Pitfalls

• Careful differentiation between external and internal snapping hip is crucial, as internal snapping involves the iliopsoas tendon and requires different management 6
• Ensure proper diagnosis before proceeding to surgery, as other hip pathologies may present with similar symptoms 5
• Physical activity should be encouraged rather than restricted completely, as it is beneficial for overall hip health 4
• Patients should be counseled about realistic expectations regarding return to activities following treatment 4