**1. Introduction**

Snapping hip syndrome or coxa saltans is an abnormal hip condition that includes a painful popping sensation and sound with movement around the hip joint. In the general population, snapping hip can be found in about 5–10% and for most are asymptomatic. Snapping hip syndrome can be divided as intra-articular and extra-articular snapping as seen in **Table 1**.

Internal snapping hip syndrome is snapping hip caused by the iliopsoas tendon migrating over the superior pubic ramus, iliopectineal eminence, anterior hip joint, femoral head or the lesser trochanter. Multiple or bifid iliopsoas tendons can also be found during transcapsular iliopsoas release in about 17.85% of cases [1].

Signs and symptoms include pain or a popping sensation in the area near the anterior groin. The clicking or popping sensation can be reproduced by allowing the patient to perform active hip extension and/or external rotation in a flexion position of the hip (**Figure 1**). Some patients present with a positive C-sign at the painful area. The patients may have focal tenderness over the iliopsoas (anterior groin) and a positive impingement test (Flexion-Adduction-Internal Rotation test, FADIR test) either with or without concomitant femoroacetabular impingement syndrome.

The resisted straight leg raise (RSLR) test is performed by the patient flexing the hip actively at approximately 30° in full knee extension. The examiner places a hand just above the patient's knee to resist hip flexion in that position (**Figure 2**).


#### **Table 1.**

*Approach of the snapping hip syndrome that can be divided as intra-articular and extra-articular causes.*

#### **Figure 1.**

*The internal snapping test is performed by letting the patient performs active hip extension and/or external rotation from the starting flexion position of the examined hip. Positive result when the clicking or popping sensation can be reproduced.*

A positive result is when there is pain at the anterior groin or weakness in the hip flexion that represents iliopsoas problems or intra-articular pathologies [2].

The investigations include plain radiographs of the pelvis/hip that might be helpful in ruling out other causes of hip pain or detecting associated pathologies that can affect the hip joint. MRI of the affected hip could aid in ruling out others causes of hip pain or detect associated pathologies, particularly, an anterior labral lesion. Some studies showed the correlation of a 3 O'clock positioned labral tear/ injury with iliopsoas impingement by the friction of the iliopsoas tendon to the predominately, anterior portion of the labrum caused tear [3, 4]. Dynamic ultrasonography is useful to detect snapping of the iliopsoas during actual hip motion and can be conjugate with an ultrasound-guided bursal injection. In iliopsoas impingement, the pain could be improved after an iliopsoas bursal injection rather than an intra-articular injection of anesthetic agents [4].

Nowadays, total hip replacements (THR) are increasing in numbers and indications [5]. An iliopsoas impingement can be a complication of this procedure from impingement of the iliopsoas tendon with the acetabular component [6, 7] (**Figure 3**). This is noticeable in the large size of the acetabular components or in patients with dysplastic morphology of the native hip associated with under coverage of the anterior/superior acetabular rim.

Conservative management of internal snapping hip syndrome includes rest, activity modification, anti-inflammatory medications, injections of a local anesthetic combined with a corticosteroid into the involved bursa or around the tendon sheath and the stretching of the iliopsoas (**Figure 4**).

The surgical treatment consists of iliopsoas release via an open, arthroscopic or endoscopic approach with or without intra-articular procedures. In the total hip

**41**

**Figure 3.**

**Figure 2.**

*causes.*

*Arthroscopic and Endoscopic Management of the Internal Snapping Hip Syndrome*

replacement patient with obvious acetabular component malposition or prominence, acetabular cup revision maybe necessary [6]. For the arthroscopic/endoscopic iliopsoas release techniques, these can be performed using: 1. the transcapsular release (proximal arthroscopic release) via the central or peripheral compartment and 2. releasing at the lesser trochanteric level (distal endoscopic release) (**Figure 5**). In this chapter, two common iliopsoas release procedures will be presented. The contents of indications, patients positioning, arthroscopic/endoscopic portals and

*A lateral cross table radiograph of the left hip following total hip arthroplasty demonstrates the anterior overhang of the acetabular component (red circle) at about 5 mm, leading to iliopsoas impingement.*

*The resisted straight leg raise (RSLR) test is performed by allowing the patient flex to the hip actively to approximately 30° in a full knee extension, the examiner places a hand just above the patient's knee to resist hip flexion in that position. Positive result when pain or weakness represents iliopsoas pathology or intra-articular* 

*DOI: http://dx.doi.org/10.5772/intechopen.91919*

*Arthroscopic and Endoscopic Management of the Internal Snapping Hip Syndrome DOI: http://dx.doi.org/10.5772/intechopen.91919*

#### **Figure 2.**

*Essentials in Hip and Ankle*

• Ligamentum teres rupture, impingement

• Femoroacetabular impingement (FAI)

Soft tissue • Labral tears

Bone and cartilage • Chondral damage • Loose bodies • Chondromatosis

A positive result is when there is pain at the anterior groin or weakness in the hip flexion that represents iliopsoas problems or intra-articular pathologies [2]. The investigations include plain radiographs of the pelvis/hip that might be helpful in ruling out other causes of hip pain or detecting associated pathologies that can affect the hip joint. MRI of the affected hip could aid in ruling out others causes of hip pain or detect associated pathologies, particularly, an anterior labral lesion. Some studies showed the correlation of a 3 O'clock positioned labral tear/ injury with iliopsoas impingement by the friction of the iliopsoas tendon to the predominately, anterior portion of the labrum caused tear [3, 4]. Dynamic ultrasonography is useful to detect snapping of the iliopsoas during actual hip motion and can be conjugate with an ultrasound-guided bursal injection. In iliopsoas impingement, the pain could be improved after an iliopsoas bursal injection rather than an

*The internal snapping test is performed by letting the patient performs active hip extension and/or external rotation from the starting flexion position of the examined hip. Positive result when the clicking or popping* 

*Approach of the snapping hip syndrome that can be divided as intra-articular and extra-articular causes.*

**Intra-articular snapping Extra-articular snapping**

Anterior or internal

Lateral or external

• Iliopsoas snapping (internal snapping hip)

• Iliotibial band snapping (external snapping hip)

Nowadays, total hip replacements (THR) are increasing in numbers and indications [5]. An iliopsoas impingement can be a complication of this procedure from impingement of the iliopsoas tendon with the acetabular component [6, 7] (**Figure 3**). This is noticeable in the large size of the acetabular components or in patients with dysplastic morphology of the native hip associated with under cover-

Conservative management of internal snapping hip syndrome includes rest, activity modification, anti-inflammatory medications, injections of a local anesthetic combined with a corticosteroid into the involved bursa or around the tendon

The surgical treatment consists of iliopsoas release via an open, arthroscopic or endoscopic approach with or without intra-articular procedures. In the total hip

intra-articular injection of anesthetic agents [4].

age of the anterior/superior acetabular rim.

sheath and the stretching of the iliopsoas (**Figure 4**).

**40**

**Figure 1.**

**Table 1.**

*sensation can be reproduced.*

*The resisted straight leg raise (RSLR) test is performed by allowing the patient flex to the hip actively to approximately 30° in a full knee extension, the examiner places a hand just above the patient's knee to resist hip flexion in that position. Positive result when pain or weakness represents iliopsoas pathology or intra-articular causes.*

#### **Figure 3.**

*A lateral cross table radiograph of the left hip following total hip arthroplasty demonstrates the anterior overhang of the acetabular component (red circle) at about 5 mm, leading to iliopsoas impingement.*

replacement patient with obvious acetabular component malposition or prominence, acetabular cup revision maybe necessary [6]. For the arthroscopic/endoscopic iliopsoas release techniques, these can be performed using: 1. the transcapsular release (proximal arthroscopic release) via the central or peripheral compartment and 2. releasing at the lesser trochanteric level (distal endoscopic release) (**Figure 5**).

In this chapter, two common iliopsoas release procedures will be presented. The contents of indications, patients positioning, arthroscopic/endoscopic portals and

#### **Figure 4.**

*Demonstrate the stretching method of the right iliopsoas muscle/tendon. The affected hip is extended during controlled trunk balancing.*

#### **Figure 5.**

*Demonstration of the iliopsoas release techniques: (A) proximal arthroscopic transcapsular release via a central compartment approach; (B) proximal arthroscopic transcapsular release via a peripheral compartment approach; and (c) distal endoscopic release at the lesser trochanteric level.*

**43**

(**Figure 7**).

*Arthroscopic and Endoscopic Management of the Internal Snapping Hip Syndrome*

the details of procedures are described. The evidence-based reviews of the proce-

**2. Arthroscopic transcapsular release (proximal arthroscopic release)**

• Internal snapping hip syndrome with failed conservative treatments for more

• Conjugate with the arthroscopic procedure of the hip (such as anterior labral

The iliopsoas release could be performed using the supine or lateral decubitus position. The author's preferred patient position is supine on a traction radiolucent table (Maquet, Rastatt, Germany). Both legs and feet are well padded and wrapped with soft cotton and hung on the footplate. A large, well-padded perineal post is used to prevent complications from pudendal nerve compression. The C-arm is placed at the non-operative side and positioned horizontally to check the anteroposterior view of the affected hip. Traction is performed to check the possibility of

The peripheral compartment approach is introduced in hip flexion of 20–30° using a proximal anterolateral portal (PAL). Peripheral compartment examination and synovectomy are performed using an anterior working portal (**Figure 6**). Following the peripheral compartment work that includes synovectomy and cam resection, the central compartment is assessed under traction of the hip in a full extension position. Intra-articular examination and surgical procedures are completely performed. These include; debridement, acetabuloplasty, and labral

The arthroscopic iliopsoas tenotomy can performed by two methods: (1) central compartment approach under traction and (2) peripheral compartment approach

In a central compartment approach. After performing the intra-articular procedures, the arthroscope is retracted to the peripheral compartment to assess under traction the anterior hip capsule at approximately the 3 O'clock position of the anterior labrum. This step uses the anterolateral viewing portal and the anterior portal for the procedure. Inflammation of the anterior labrum may represent evidence of iliopsoas impingement. The iliopsoas tendon is located near the anteromedial aspect of the anterior hip capsule. The anterior capsule at this area is thin and some patients have an anterior capsular hole directly connected to the iliopsoas tendon [8]. A capsulotomy of approximately 1–2 cm is performed to the 3 O'clock position of the right hip. After capsulotomy, the synovial tissue around the iliopsoas tendon is identified and resected using an arthroscopic shaver or electrocautery. The iliopsoas tendon is identified and released until the iliacus muscle can be observed beneath the released portion of the tendon. Keeping this portion of the iliacus muscle may decrease of the risk of hip flexion weakness, postoperatively

central compartment assess and intra-articular arthroscopic work.

*DOI: http://dx.doi.org/10.5772/intechopen.91919*

dures will also be presented.

than 4–6 months.

**2.1 Indications**

repair).

**2.2 Patient position**

**2.3 Surgical technique**

with hip flexion of 20–30°.

surgery.

the details of procedures are described. The evidence-based reviews of the procedures will also be presented.
