Snapping hip syndrome (SHS), also known as coxa saltans, is common among athletes and the general population. The most common mechanism of injury is when the hip muscles become fatigued and swollen from overuse. SHS is typically the result of overactive/tight muscles in combination with other muscles which are underactive/weak. Most cases are painless which does not call for immediate treatment. However, this can increase the likelihood of joint damage while the snapping sensation can become painful and unpleasant over time.
Let’s guide you through how we resolve snapping hip syndrome here at Breathe using our Roadmap to Recovery:
Step 1. Pain Reduction
Step 2. Activation
Step 3. Movement
Step 4: Strengthening / Sports Performance
Pain reduction
To manage and reduce symptoms, it is important to understand these four concepts:
what causes the click? (internal vs external vs intra-articular causes)
stretches/mobility exercises
hands-on treatment
movement strategies
Internal Snapping Hip
The internal snapping hip is due to the iliopsoas tendon ‘snapping’ over the lower pelvic bony structures (e.g. the iliopectineal eminence). When the hip moves into flexion, the iliopsoas tendon lies lateral (outside) of the femoral head making a ‘snapping’ sensation. Internal SHS is most commonly caused by repetitive hip flexion (bending forward at the hip) and external rotation (hip rotating outwards). Athletes who also have tight hip flexors or imbalances in their abdominal, pelvic or hip muscles are more at risk of developing this type of SHS.
External Snapping Hip (most common)
External snapping hip is due to the iliotibial band (or the anterior fibers of the gluteus maximus) ‘snapping’ over the greater trochanter of the femur. This is most commonly due to an overactive and tight iliotibial band from repetitively climbing stairs or running. When the hip moves into extension (straightening of the hip), the iliopsoas shifts medial to the centre of the femoral head and creates the ‘snapping’ sensation.
Intra-articular Snapping Hip (least common)
Intra-articular snapping hip can have many causes but is most commonly due to trauma rather than an overuse injury. It can be the result of the iliofemoral ligaments sliding over the head of the femur, a labral tear, chondral defect or intra-articular loose bodies. Pain is most reproduced with movements of the hip from a flexed, abducted and externally rotated to a neutral position.
Physiotherapy management starts with accurate diagnosis of the type of snapping hip syndrome you are presenting with. Sufficient modification of the aggravating activity will allow for the recovery process to begin. These modifications include reducing the intensity/frequency of training sessions and using ice and anti-inflammatory medication (NSAIDs) to manage swelling.
SHS can be managed conservatively through a program which focuses on gradually building load in combination with specific education. Physiotherapy will aim to assist in the correction of underlying biomechanical overloading factors such as reduced mobility, muscle imbalances etc. Therefore, a combination of hands-on treatment with the above activity modification and mobility exercises such as iliotibial band and iliopsoas stretching works well during the initial injury stages. Treatments such as deep tissue techniques and trigger point release of the iliopsoas or the gluteus medius can enhance recovery outcomes.
Activation
On completion of the pain reduction phase, the muscles around your hip will be ready to start activating to build their load capacity. Early muscle activation exercises should focus on activating the abdominals and muscles around the hip due to these commonly being underactive or weak in SHS. Focusing on the correct muscle activation will also decrease the overactivity of the iliotibial band iliopsoas and therefore reduce the snapping sensation.
The following exercises will focus on the management of internal and external snapping hip syndrome. Intra-articular snapping hip syndrome is best addressed through seeking advice from multiple health professionals to ensure the best outcomes due to the medical complexities of this injury.
Example exercises can include:
Standing neutral spine + bracing the core
Place your fingers on your belly button then move out 6-7 cm. Take a deep breath in and then push fingers away by activating the obliques.
3x5 reps with 5 second holds
Isometric hip flexion
Place your leg in the position just before you normally feel the snap sensation. Next, push down onto your knee as hard as you can without letting the leg drop.
10x 5 sec holds
Glute activation with band
Pre-tension the band then push into the resistance band with your foot while straightening and lowering your leg. Only go to the range where you normally experience snapping.
3x20 reps
Movement
The movement stage allows us to progress the movement patterns from previous stages. Once the correct muscles are activating and your pain has reduced, we can focus on increasing the load through the muscles. Some great movements for you to practice are:
Standing hip flexion: Find a neutral spine and engage your core while flexing one hip. This will target the muscles that flex your hip (iliopsoas).
Single leg glute bridge: This exercise focuses on strengthening all the gluteal muscles whilst lengthening the hip flexors.
Floor-sliding Mountain climbers: Contract your abdominals to hold a neutral spine whilst alternating pulling your knees to your chest.
Strengthening / Sports Performance
To avoid the recurrence of SHS in the future, it is important to continue weekly strength and conditioning sessions. These sessions should aim to continually progress your strength and mobility through exercising focusing on abdominal and hip muscle strength. Programs that incorporate these muscle groups along with other muscle groups of the kinetic chain will have the most success in enhancing performance and reducing further injury. Once you have the movement patterns down, try adding some weight or resistance bands to the above exercises!
As you can see, snapping hip syndrome varies from person to person. So we recommend you consult a physiotherapist in relation to your specific injury.
Reference:
Andres, B. M., & Murrell, G. A. (2008). Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research, 466(7), 1539–1554. https://doi.org/10.1007/s11999-008-0260-1
Sugrañes, J., Jackson, G. R., Warrier, A. A., Allahabadi, S., & Chahla, J. (2023). Snapping Hip Syndrome: Pathoanatomy, Diagnosis, Nonoperative Therapy, and Current Concepts in Operative Management. JBJS Reviews, 11(6).