What causes twitching of the hips from side to side and how is it treated?

Twitching Hips Side to Side: Causes and Treatment

Hip twitching side to side is most commonly caused by snapping hip syndrome (coxa saltans), where tendons snap over bony prominences during hip movement, though other causes including muscle spasms, nerve irritation, and intra-articular pathology must be excluded through systematic evaluation. 1, 2, 3

Primary Causes of Hip Twitching

Snapping Hip Syndrome (Most Common)

• External snapping occurs when the iliotibial band snaps over the greater trochanter during hip flexion/extension with abduction or external rotation 1, 2
• Internal snapping results from the iliopsoas tendon subluxating over the iliopectineal eminence, anterior inferior iliac spine, or lesser trochanter during hip movement 1, 3
• Affects 90% of elite ballet dancers, with 58% experiencing associated pain 2
• Repetitive hip flexion and extension movements cause muscular tightness, leading to the tendon becoming taut and snapping over bony prominences 3

Other Differential Diagnoses to Exclude

• Femoroacetabular impingement (FAI) syndrome presents with groin pain, positive FADIR test, and cam/pincer morphology on radiographs 4
• Acetabular labral tears cause sharp catching pain with mechanical symptoms, often coexisting with FAI 4, 5
• Greater trochanteric pain syndrome includes gluteus medius tendinopathy causing lateral hip symptoms 6
• Lumbar spine pathology can refer sharp pain to the hip region and must be screened in all hip evaluations 4, 5

Diagnostic Approach

Clinical Examination

• FABER test: Move the hip from flexion, abduction, and external rotation into extension, adduction, and neutral rotation to reproduce the snapping 3
• Palpate for the snap during hip movement—clinicians can palpate 92% (46/50) of self-reported snapping hips 2
• Assess for pain location: anterior (iliopsoas), lateral (iliotibial band), or posterior (referred pain) 6
• Screen the lumbar spine in all cases to exclude referred pain 4, 5

Imaging Protocol

• First-line: AP pelvis and lateral femoral head-neck radiographs (Dunn, frog-leg, or cross-table views) to evaluate bony morphology and exclude fractures, tumors, or arthritis 4, 7, 8
• Dynamic ultrasound is the diagnostic test of choice for snapping hip, allowing real-time visualization of the snapping tendon during movement 2, 3
  • Ultrasound identified iliopsoas snapping in 59% and iliotibial band snapping in 4% of cases 2
  • Can guide diagnostic/therapeutic injections 8
• MRI without IV contrast is appropriate when radiographs are negative and intra-articular pathology (labral tear, cartilage damage) is suspected 7, 8
• Avoid bone scan, PET, or CT without contrast—these are not appropriate for this presentation 7

Treatment Algorithm

Conservative Management (First-Line)

• Rehabilitative therapy is the standard initial treatment for snapping hip syndrome 3
• Active rest with training modifications to avoid repetitive hip flexion/extension movements 3
• Over-the-counter analgesics (acetaminophen, ibuprofen) for pain control 9
• Physical therapy focusing on stretching tight tendons and strengthening weak hip musculature 3

Advanced Interventions

• Image-guided corticosteroid injection can provide both diagnostic confirmation and therapeutic benefit when conservative measures fail 7, 8
• Arthroscopic intervention with partial release and lengthening of the pathological tendon (iliopsoas or iliotibial band) is reserved for severe cases unresponsive to conservative treatment 1, 3
• Minimal resection of bony prominences (lesser trochanteric ridge) if involved in the snapping mechanism 1

Critical Pitfalls to Avoid

• Do not dismiss as benign: While snapping hip can begin as harmless popping, pain can become severe enough to limit activities and cause concomitant issues 3
• Do not miss red flags: Exclude stress fractures (night pain, inability to bear weight), tumors (constitutional symptoms), infection (fever, severe rest pain), or SCFE in adolescents/young adults 5
• Do not skip lumbar spine screening: Hip pathology can present as knee pain, and spine pathology can present as hip pain 5
• Do not rely on imaging alone: Clinical correlation is mandatory—incidental findings are common in asymptomatic individuals 4
• Do not proceed directly to advanced imaging: Plain radiographs must be obtained first to exclude serious pathology 7, 8