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A Snappy Hip is not as Snazzy as it Sounds By Debbie Cameron

Updated: Sep 9, 2022



Throughout my career as a physiotherapist, I have been asked the question; “there is a snapping noise when I move my hip, should I be concerned?”. The quick answer is “pay more attention to your technique”. There is probably a muscle imbalance of the hip muscles and incorrect timing of a muscle contraction.

Give some thought to the muscles which are not being exercised or stretch muscles that are too tight and improve your coordination – in most instances this makes a big difference. However, it is useful, especially if you are a serious athlete, to consider more intensely why there is a snappy noise and if you may have an impingement syndrome.


An impingement syndrome is exactly as the name implies, an abutment between the top of the leg bone, the femoral head, and its socket in the pelvis. People who suffer from an impingement not only experience a snappy noise, but also report that they find movements such as getting in and out of a car, crouching, or twisting manoeuvres to cause an annoying pinch that can be painful. Athletes report that they experience an odd jab with quick movements, deep knee bend, or a pivot when the hip is fully internally rotated.


Diagnosing what is giving the sound of the snap or hip problem is tricky. This is not only something that I have witnessed but it is mentioned on the FIFA medical network site. I enjoyed this quote by a USA Orthopaedic Surgeon Dr Danyal H. Nawbi. “It is important to be able to identify primary hip pathology and be able to distinguish this from other causes of sports-related groin pain. This can be challenging and requires a comprehensive history and clinical examination. The values of the history should not be underestimated.’’


The reason that the hip joint remains a challenge to diagnose is the hip is a far more complicated joint than is often assumed. Here are some of the factors that challenge medical practitioners to come to a clear diagnosis of the snappy noise:


The shape of the bones of the hip contributes to the abutment. Amongst other deviations from the norm, there are two main misshapes that are spoken of: a ‘CAM hip’ is when the head of the femur is not round and a ‘Pincer hip’ is when there is an extra bony growth at the edge of the hip’s socket, the acetabulum. Sometimes both alterations are present. It makes sense to think that either of these bony changes to the hip that the head of the femur will not move well or fully in the hip socket or that the hip socket may be too deep for good movement of the femur.


However, this is not always the case as researcher Heerey (2021) found that the ‘CAM hip’ abnormality was evident in 63% of soccer players yet they had no pain. Whereas 71% of players with painful hips had a misshapen femoral head. Therefore, the size and prevalence of bony hip abnormality appear to be similar in football players with and without hip pain.

So, where and what alters the hip shape? Another change of the hip shape is osteoarthritis which, unfortunately, is more prevalent in people who have played competitive sports. The question of how and whether sport in childhood (the frequency and intensity of sport in younger years) influences the shape of the hip has no definitive answer yet.


Researchers are unclear as to why there are differences in the biomechanics of the hip when there is pain (Harris-Hayes 2022). Not every daily movement is affected by hip pathology either, for example, Malloy (2019) found that double leg squats were not affected, and Harris-Hayes (2022) found that the movement of stepping down was not affected. Cvetanovich (2020) found in people who had a favourable outcome from surgery on their hip that six months later there was no change in the hip biomechanics.

Other contributing structures to a snappy hip


The hip has a uniquely protective capsule, it is strong and dense. Surrounding this capsule is an extensive pattern of ligaments that also wrap around the joint and add further support to the hip joint. The capsule has three different types of collagen, including collagen type III.


There are several bursae around the hip capsule. Of interest, the iliopectineal bursa which is in the front and serves to separate the psoas and iliacus. This bursa also connects to the synovial fluid in the hip joint by a circular aperture or hole. Any change to this bursa could affect the hip through its connection to the hip’s synovial fluid.


The labarum, which is a form of cartilage that enlarges the hip socket by an estimated 25% is thought to provide a suction effect that assists to hold the femur in the socket. The presence of a ‘CAM hip’ or developmental problems with the hip predisposes the labarum to injury. Most tears happen gradually from micro-trauma however they can occur at a single event. Labral injuries are more common in athletes who play high-impact sports. The challenge for the person with a labral tear is that they often are only the sign of an underlying problem.


The surface of the capsule has connections to the tendons of the following muscles: rectus femoris, psoas, obturator externus, gluteal minimus, and a small muscle called the ‘iliocapsularis’ muscle. All of these muscles can make an impact on the hip joint through their tendon connections to the hip capsule. The proximity of the above muscles to the joint or if the muscle is tight, hip movement can interfere with, and a corresponding ‘snappy noise’ can be heard by the person. A good example of this is the psoas muscle which can shift laterally with hip flexion and medially with the extension of the hip. A snappy noise is possible because of the tendon flicking over the femoral head or iliopectineal eminence (a bump in the bone). There is strong thought that this is the greatest source of the ‘snapping noise’. However, the fault may not be with the muscle but the head of the femur sitting more forward than it should be. Gomez-Hoyo (2015) found a significant number of snapping hip pain sufferers had an abnormal position of a part on their femur, called the lesser trochanter, and that this lesser trochanter was tilted backward.


Other muscle conditions that can be the source of the problem are athletic pubalgia where there is an imbalance in the strength of the rectus abdominus compared to the hip adductors, tendinosis of the abductors such as gluteus medius and minimus, or tendinosis of the hip flexors and adductors.


People who suffer from hip pathology can develop pain at other sites of their body because of compensating for their hip inadequacy. Pain in multiple locations can make assessment confusing and difficult for the medical practitioner to find a clear diagnosis. It can be that it takes a while for the source of the problem to be found.


The tests that are used to clinically assess a hip are sensitive but not specific. Sometimes the hip is too stiff for the tests to be done. Conversely, the hip may have an incredible range of movement (people with supraphysiological motion, such as a dancer). This difference in hip range of movement, highlights Dr Nawbi’s quote that the values of the history of the person must not be underestimated.


Useful questions to ask are about how different positions affect the person’s hip pain. For example, bony impingement will typically occur during prolonged periods of sitting while hip instability will be more likely aggravated by prolonged weight bearing.


What can be done to investigate the ‘snappy’ hip?


The minimum clinical assessment that a physiotherapist should do for a person suffering from a ‘snappy’ hip is: gait analysis (look at the way the person walks), single leg control, hip range of motion, strength testing, pain provocation tests, check for a ‘give’ (unstable movement), and include a thorough palpation around the hip area.

It is important that the patient comes appropriately dressed when expecting a detailed assessment.


How can a person correct their ‘snappy hip’?


Today’s physiotherapist will partner with the person suffering from their hip. The physiotherapist will continue to clinically reason through the source of the problem that makes the ‘snappy’ noise during the assessment and following the treatment programme. Based on the current research, the findings of the assessment, and the goals of the person, the physiotherapist will comply a personalised programme of treatment for the person concerned.


The physiotherapist gives advice on required activity modification, such as modified training, and postural changes. Given that larger training loads have been shown to be associated with ‘CAM hip’ development, it is important for the physiotherapist to assist the person manage their training schedule. This is especially important with children who go through rapid periods of growth. The femoral head is only fully fused with boys aged 14 - 20 years old and girls 13 - 18 years of age.


Muscle imbalances of strength, flexibility, and coordination are worked through, and appropriate movement correction is taught. Research has shown that it is important to strengthen the hip’s external rotators, adductors, and abductors. Restore range and normalise the hip joint movement, pelvic stability, and movement (Casartelli 2018, Cvetanovich 2020, Harris-Hayes 2022, Malloy 2019 &2021)


Balance and proprioception exercises are vital for a good recovery when the hip is concerned. (Malloy (2019) showed the differences between the angles of the hip socket and thigh in single-leg squats that people suffering from a femoral impingement of their hips used). The hip and other joints may be mobilised and the muscles, including their tendons, massaged. The person can expect a home exercise programme to which they will need to commit to a certain number of exercises and a time frame for this programme. Hip loading activities especially sprinting, change of direction and kicking need to be reduced and gradually returned to as the overall condition of the hip improves.


Throughout the recovery programme, the physiotherapist will check on how the person is managing through scheduled appointments. The physiotherapist will assess how the person is coping with the suggested changes and if the prescribed exercise are done correctly, frequently and when the person can move onto the next stage up until the hip is ready for return to competitive sport.


There may be psychological or physical barriers to implementing the advice and the exercise programme given. The physiotherapist can consider them and adjust the programme where necessary or just encourage the person that the body takes time to heal and for normal function to return. Over time as symptoms settle, the physiotherapist may or may not come to a conclusion as to the source of the sappy noise. And there can be healing without the source ever identified.


Should a person have hip surgery?


Casartelli (2019) and Monn (2022) found that there is a good outcome for the return of the hip to normal function when physiotherapy included hip abductors strengthening, pelvic alignment, stability, and movement were corrected. Monn’s follow-up was at 4.6 years post-conservative management only. However, when there is a severe hip bone abnormality, the results were not favourable.

Should the physiotherapist see that despite the person’s best efforts, the required improvement is not happening, three months have passed since the start of therapy, the physiotherapist will refer the person to a specialist. A specialist will ask about the offending movements, and all the symptoms, conduct a clinical examination to find clinical signs and send the person for imaging. From this, if it is concluded that there is premature contact between the proximal femur and the acetabulum, the specialist may recommend surgery.


General comments


For those suffering from a snapping hip, I have written this article to illustrate that there are many causes of a “snappy’ hip. It appears that most Google searched articles give a quick and superficial response as to how to recognise that they may have an abnormal hip, followed by a few easy steps to correct it. This is most definitely not the case. And the conditions that I have written here are by no means an exhaustive list- this article would be too long if all were included.


Research has shown a good response when an appropriate investigation is done which is match the right treatment pathway. There is nothing in the research articles that hints at a quick approach. Correct assessment and treatment will take time. I think that the result of a normally functioning hip is worth it but that is for the reader to decide.


References

Casartelli, NC, et al, (2019) ‘Exercise therapy for the management of femoroacetabular impingement syndrome: preliminary results of clinical responsiveness.’ Arthritis Care Research, 71(8):1074-1083.


Cvetanovich, GL, et al, (2020) ‘Squat and gait biomechanics 6 months following hip arthroscopy for femoroacetabular impingement syndrome.’ J Hip Preserv Surg. 18;7(1):27-37.


FIFA Medical Network (2022). ‘The Hip.’ Available at:


Accessed 30/08/2022


Gomez-Hoyos, et al, (2015) ‘Is there a relationship between psoas impingement and increased trochanteric retroversion?’ J Hip Preservation Surgery. 2(2):164-169


Griffin, DR, et al,(2018) ‘Hip arthroscope versus best conservative care for the treatment of femoroacetabular impingement synfdrome (UK FASHIoN):a mulitcentre randomised controlled trial.’ The Lancet June 2018 391(10136):225-2235



Heerey, J, (2021) ‘The Size and Prevalence of Bony Hip Morphology Do Not Differ Between Football Players With and Without Hip and/or Groin Pain: Findings From the FORCe Cohort.’ J Ortho & Sports Phys Ther. 51(3):115-125


Malloy, P, et al, (2019). ‘Hip Biomechanics During a Single-Leg Squat: 5 Key Differences Between People With Femoroacetabular Impingement Syndrome and Those Without Hip Pain. J Ortho & Sports Physical Therapy.’ Vol 49(12): 908-916


Malloy, P, et al, (2021) ‘Impaired Lower Extremity Biomechanics, Hip External Rotation Muscle Weakness, and Proximal Femoral Morphology Predict Impaired Single-Leg Squat Performance in People With FAI Syndrome.’ Am J Sports Med . 49(11):2984-2993.



Newcomb, et al, (2018). ‘Effects of a hip brace on biomechanics and pain in people with femoroacetabular impingement.’ J Sci Med Sport. 21(2):111-116.


Zarzycki, R, et al, (2022). ‘Application of the 4-Element Movement System Model to Sports Physical Therapy Practice and Education.’ Int J Sports Phys Ther. 17(1): 18–26.



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