Snapping Hip Syndrome ~ A Runner’s Perspective

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Psoas, Iliopsoas or Snapping hip syndrome, by any name means pain. Creaky joints and tight hips are par for the course for most consistent runners. But when things start to click or snap, you may have a more serious problem on your hands. The trickiest part of solving the problem? Diagnosing it. Iliotibial band syndrome—or IT band syndrome—gets most of the attention in the world of running-induced hip injuries. But when you feel clicking on the inside of your hip, closer to the groin area, you may be suffering from iliopsoas syndrome. 

The good news? snapping hip syndrome, also referred to as Iliopsoas syndrome, usually doesn’t require an MRI to diagnose or surgery to correct. This guide will help explain exactly which muscles are affected, which movements aggravate the injury, and what you can do to both prevent and heal it.

First of all, what is the iliopsoas?

Think of the iliopsoas tendon as your inner hip muscles, or as a hip flexor. It’s made up of two muscles:

  1. The psoas major, which connects around your spine and splits down each side to line both sides of your pelvis, attaching to each femur. Every time you lift your knee as you run, the psoas contracts. It lengthens as you swing back.

    Pelvic area on a skeleton with psoas muscle highlighted
    Wikimedia Commons –
    Anatomography
  2. The Iliacus muscle, which fills the interior side of the hip bone. This originates in the pelvis rather than the spine.

    Skeleton pelvis with iliacus muscles highlighted
    Wikimedia Commons – Anatomography

     

What is Snapping Hip Syndrome?

it occurs when the iliopsoas tendon slips over a bony ridge on the upper, interior portion of your hip called the iliopectineal eminence. You’ll feel a popping sensation in your groin area either after you move the affected leg forward and backward, move it sideways, or rotate it. (You may see these motions described in more medical-speak as hip flexion, abduction, and external rotation, respectively.) During those motions, the tendon is moving away from the bone. (In a healthy hip, this wouldn’t happen.) During the return motion back to a resting position, the tendon snaps back against the bone. That’s likely when you’ll really feel—or hear—snapping or clicking.

While iliopsoas syndrome is often referred to as snapping hip syndrome, it’s actually one of three distinct types of snapping hip:

  1. Intra-articular snapping hip: This is often the result of an acetabular labral tear or a tear in the cartilage that runs around your hip socket.
  2. Extra-articular snapping hip: This is caused by the abnormal movement of specific tendons, as opposed to a tear. Depending on which tendon is involved, it can occur in the lateral (think: external) or anterior (think: internal) portion of the hip.
    • External: This involves the iliotibial band (IT band) slipping across bone–the greater trochanter, or the eminence that juts out of the femur. In other words, this is IT band syndrome.
    • Internal: This typically involves the iliopsoas tendon slipping over the iliopectineal eminence—the ridge on the hip bone that connects the ilium (the uppermost and largest part of the hip bone) to the pubis. The iliopectineal eminence is higher and more interior than the greater trochanter involved in IT band syndrome. This internal form of extra-articular snapping hip is iliopsoas syndrome, which is what we’ll be talking about in this guide. When this particular condition is experienced without pain, it’s referred to as asymptomatic internal snapping hip.
Tendon slipping over pelvic bone, indicative of iliopsoas syndrome
Clinical Gate

Snapping Hip Syndrome Symptoms

Iliopsoas syndrome is best described as an internal hip snapping in which you feel the tendon by clicking or catching over bone. Keep in mind that it’s not always painful. It manifests itself in different ways:

female runner suffering from lower back pain
Shutterstock

Symptoms in relation to running

  • Symptoms typically involve an altered, shorter stride as pain and inflammation restrict movement.

Causes

This is usually the result of inflammation of the iliopsoas tendon or tendonitis. Therefore, the name iliopsoas tendonitis is often used interchangeably with iliopsoas syndrome. But how does the tendon become inflamed in the first place?

Overuse

In athletes, the repeated extreme movements of the hip, like the flexion motion during running, can cause inflammation of the iliopsoas tendon. But athletes other than runners are prone to iliopsoas syndrome as well:

  • Ballet dancers (lending snapping hip the common nickname ‘dancers’ hip’)
  • Soccer players
  • Weightlifters
  • Cyclists
  • Gymnasts 

Injury

Physical trauma or intramuscular injections or surgeries may mess with the functionality of the iliopsoas tendon.

Genetics

  • A difference in leg length
  • Excessive lumbar curve
  • Femoroacetabular impingement (FAI) occurs when one or both of the bones that make up the hip joint have an irregular shape. Because of that shape, they don’t fit perfectly together, and the ball (the head of the femur) doesn’t have a full range of motion within the hip socket. This causes damage or irritation in other areas—potentially the iliopsoas tendon. There are two main types of FAI, which can also be simultaneous:
    1. Cam impingement: Excess bone formation on the femoral head means it isn’t round and can’t rotate properly. The resulting grinding can cause a loss of cartilage.
    2. Pincer impingement: Excess bone forms over the rim of the hip socket. As that bone hits the femoral neck, the labrum—the cushiony cartilage that runs around the hip socket—becomes pinched.
Cam and pincer impingment
Wikimedia Commons – Smith & Nephew

Risk factors

While overuse and repetition of hip movement are the biggest causes of iliopsoas syndrome in runners, other factors can increase your risk of the injury.

  • Adolescence is the primary time athletes are affected.
  • Improper warm-up and lack of sufficient stretching before a speed workout can strain the iliopsoas tendon.
  • Sitting for extended periods of time can shorten your hip flexors. The resulting tightness can restrict movement when attempting the flexion motion of the hip and thigh, aggravating the iliopsoas tendon.
  • Increasing mileage or workout intensity too quickly
  • Over-pronounced hip socket and the types of femoroacetabular impingements described above may make you biomechanically predisposed to iliopsoas syndrome.
  • Foot hyper-pronation
Ankle pronation
Wikimedia Commons – Ducky 2315

 

Diagnosis of Snapping Hip Syndrome

Prevalent in only 5 to 10 percent of the population, iliopsoas syndrome is notoriously tricky to diagnose. It can be hard for those experiencing symptoms to pinpoint the source of the snapping or the site of the pain, and it can be even more difficult for doctors to reproduce that snapping when the patient isn’t running. Unfortunately, that means diagnosis typically comes months, even years, after the onset of symptoms. Still, one method is hailed as the gold standard for identifying both iliopsoas syndrome and the other type of extra-articular snapping hip, iliotibial band (IT band) syndrome: dynamic ultrasound. This allows doctors to monitor the musculoskeletal system in real time while it’s in motion. This is typically more cost-effective than the other highly-accurate diagnostic tool, an MRI, which will show inflammation and fluid near the tendon.

Ultrasound technician examining hip joint
Shutterstock

There are several other ways to diagnose symptoms of iliopsoas syndrome using only orthopedic, clinical assessment:

  • FABER Test: Standing for Flexion, Abduction and External Rotation, FABER is performed on a patient lying supine, or on their back, with one leg straight. The knee of the test leg is bent into figure-4 position and crossed over the thigh of the straightened-out leg. After placing the test hip into the flexion, abducted and rotated position, the physician applies force against the bent knee, pressing it towards the table. If that knee cannot be lowered without pain, an iliopsoas spasm may be present. Snapping may be elicited while passively rotating the bent leg to FADIR (Flexion, Adduction Internal Rotation) position, indicative of iliopsoas syndrome. 
physical therapist administering FABER test
Flickr – Conferenceplus
  • Thomas TestA patient lies supine while holding the knee of the unaffected side to their chest to stabilize the pelvis. If the affected leg remains flat on the table, the iliopsoas is a normal length. If the thigh rises off the table, it’s shortened, signifying tightness.
Thomas test stretch
Flickr – SportCX.net
  • Milgram’s Test: While lying supine, a patient lifts both of their legs 2 to 4 inches off the table for up to 30 seconds. While this is primarily to test for back pain, the only hip muscle firing in this position is the iliopsoas. A patient with significant back or hip problems may not be able to do this.

 

Treatment of Snapping Hip Syndrome

While it’s a nagging injury, iliopsoas syndrome is relatively simple to treat. Even better: the extent to which you need to modify or scale back on your running mirrors the severity of the problem. So if your hip popping is manageable, you likely won’t have to miss out on a whole lot of training.

As you probably expected, the first course of action is rest and the avoidance of any activities that trigger your hip snapping. Almost two-thirds of iliopsoas injuries are rectified with conservative treatment like this.

Stretches for the iliopsoas

It’s important to approach these stretches cautiously and gently. Don’t get discouraged if you don’t seem to have much flexibility when you start. Try holding each stretch for 20 to 30 seconds, repeat 3 times per side.

Kneeling Lunge

  1. Secure a padded mat and kneel on the knee of the affected side, placing the foot of the other leg about 2 feet in front of you. The bend in that forward leg should be about 90 degrees.
  2. Lean slightly forward while keeping your back straight.
  3. Raise your arms over your head.
  4. Hold, then relax.
  5. Repeat with the other leg in front.
woman in athletic gear doing kneeling lunge
Shutterstock

Warrior Pose

  1. Place one foot 3 to 4 feet in front of you, lunging forward to form a 90-degree angle with the forward knee.
  2. Rotate the back foot 45 degrees outward.
  3. Raise both arms upwards.
  4. Hold, then relax.
  5. Repeat with the other leg
Yoga warrior pose
Shutterstock

Lying static stretch

  1. Lay on your back with both feet out in front of you. Both legs should be flat on the ground.
  2. Draw one knee up to your chest, and pull gently toward you until you feel a stretch in your hip.
  3. Hold, then relax.
  4. Repeat with the other leg.
Woman lying on her back pulling one knee to her chest
Shutterstock

Passive stretch with a prop

  1. Lie face-down on the edge of a bed, sofa or table.
  2. Prop yourself up on your elbows.
  3. Place your outside foot on the floor while bending your inside leg at the knee towards you, as if you were about to kick your butt.
  4. Loop a towel, rope or band around the foot of that bent leg, pulling it up towards your head.
  5. Hold, then relax.
  6. Repeat with the other leg.

Iliopsoas massage treatment

Using myofascial release massage therapy, a therapist can apply manual pressure to myofascial tissue—tissue that wraps and connects muscles. The therapist will seek out tissue in trigger points that feel stiff, even if they’re not in the exact spot of the injury. The goal is to loosen tight tissue and muscles around the iliopsoas, allowing for a better range of motion and reduced pain.

Therapists are sometimes reluctant to do release techniques on the psoas itself since it lies deep within the abdomen and feeling around for it can be painful. Because release therapy on surrounding muscles and tissue can provide relief, that route may be taken instead.

Hip strengthening exercises

In some cases, tight hip flexors may not be the source of the problem, but rather weak hip flexors. This can lead to an unstabilized hip and spine. Several exercises can help strengthen the hip flexors.

Double-leg bridges

  1. Lie on your back with your arms at your sides, bending your knees while keeping your feet flat on the floor.
  2. Press into your heels as you raise your hips towards the ceiling, squeezing your glutes.
  3. Hold, lower and raise again, maintaining control through each movement.
  4. Repeat 8 to 10 times.
bridge stretch
Shutterstock

Single-leg bridges

  1. Follow the steps for double-leg bridges, but only keep one foot planted on the ground. Raise the lifted leg straight upwards, pointing your toes towards the ceiling.
  2. Repeat 8 to 10 times on each side.

Clamshells

  1. Lie on your side and stack your hips, bending your knees so that your feet are in line with your glutes.
  2. Keeping your feet together, raise the top knee, abducting the top leg.
  3. Repeat 8 to 10 times on each side.

line drawing of clam shell physical therapy exercise

Side Planks

  1. Turning on your side, prop your upper body up with your elbow and forearm, keeping one foot on the ground with the other foot on top of it.
  2. Hold for 15 to 30 seconds, repeating 2 to 4 times on each side.

As you build strength, you may want to attempt raising the upper stacked leg up and down while in side plank position.

Abduction lifts

  1. Lying on your side, stack your hips.
  2. Lift the top leg up 12 inches, then slowly lower it back down.
  3. Try not to let your legs touch as the top leg comes back down, and keep your top foot flexed the entire time.

Pelvic drops

This particular exercise requires some props. You’ll need a box or foam mat to stand on, at least 6 inches tall. You’ll also need a small cuff weight to wrap around your ankle.

  1. Wrap the cuff weight around your right ankle.
  2. Step onto the edge of the box or mat, balancing only on your left leg. The right leg should be hanging over the side.
  3. While doing your best to stand straight and keep your left shoulder over your left leg, dip the right hip down and back up, repeating 5 times.
  4. Place the cuff weight around your left angle and use your right leg to balance on the box, repeating the exercises on the left hip.
pelvic drop exercise
Pinterest

Side steps

  1. Loop a circular resistance band around your ankles.
  2. Standing with your legs shoulder width apart, place your hands on your hips.
  3. Take small, lateral steps, aiming for 15 to 20 steps in each direction.
  4. Repeat 2 to 4 times in each direction.

Corticosteroid injections

If screenings detect inflammation in the bursae around the iliopsoas tendon, a steroid injection can help reduce the inflammation, in turn reducing pain. This is a simple procedure. The patient remains awake and the doctor numbs the injection site with a local anesthetic. A thin needle is inserted into your bursa, delivering a mix of steroid and anesthetic.

The relief offered by corticosteroid injections is different for everyone. For some, it may be permanent. But it is safe to have another injection every few months—up to four per year.

Surgery

Surgical intervention for iliopsoas syndrome is very rare. But if it’s deemed necessary, the purpose will be to lengthen and relax the iliopsoas tendon. Endoscopic surgery, which is minimally invasive and inserts scopes through small incisions to repair the tendon, is the preferred surgical course of action.

What about ice and NSAIDS?

These common remedies are only recommended if your official diagnosis is iliopsoas tendonitis, in which swelling is inherent, and can be treated with ice or ibuprofen. However, if you actually have iliopsoas tendinosis, a type of chronic tendinopathy, there is rarely any inflammation going on. (Skip ahead to the ‘other diagnoses’ section to learn more about these conditions.) There is damage to the tendon at a cellular level without any inflammation. So ice or pain relief medication may mask symptoms and discourage you from taking steps to actually facilitate recovery. Don’t skimp out on stretches and strengthening exercises if you decide to use either of these methods.

 

Prevention

Because iliopsoas syndrome is usually the result of overuse in athletes, it’s difficult to prevent without scaling back on your training. Plus, your bone structure could make you predisposed to it. However, you can take certain measures to lower your risk of injury, most of which have been outlined above.

male runner lunging on bridge
Shutterstock
  • Gradually increase your mileage or repetitions during interval training. Too much too soon can strain the tendon.
  • Routinely stretch your hip flexors.
  • Be vigilant and consistent with hip strengthening exercises.
  • Incorporate core strength into your training. Planks are particularly helpful to strengthen the psoas major and offer long-term relief for back pain associated with iliopsoas syndrome.
  • Avoid, if you can, sitting for long periods of time, which can shorten your hip flexors and aggravate the iliopsoas tendon. If your job requires you to spend most of your time sitting, aim to get up every hour.
  • Avoid hills (best of luck bringing this up to your coach!).

 

Other diagnoses

Because the exact site of hip popping can be hard to identify and because the psoas muscle originates so deep in the abdomen, a cursory exam may miss—or misdiagnose—iliopsoas syndrome. That being said, if you’re diagnosed with any of the following closely-related injuries, know that they can be the result of iliopsoas syndrome and that their treatment plans should correct iliopsoas syndrome as well.

Iliopsoas tendonitis

This is the most common term used interchangeably with iliopsoas syndrome. And most of the time, it’s also at the root of the cause. Tendonitis refers to inflammation, irritation and even microtears in a tendon, and usually occurs when the tendon is overloaded too suddenly. If this is your official diagnosis, ice and NSAIDs like ibuprofen can help.

Iliopsoas bursitis

While this is a separate condition from tendonitis, they often go hand in hand. Inflammation of a tendon, which occurs in tendonitis, can cause inflammation in the bursa. Never heard of a bursa? It’s a sac of fluid located where muscles and tendons slide over bone near your joints, providing cushion and lubrication. You can thank the 150+ bursae in your body for allowing you to feel virtually frictionless movement in your joints when you’re not injured. And, you guessed it, inflammation in the bursae can trigger inflammation in the tendon too, so bursitis and tendonitis can seem like a chicken-or-the-egg set of injuries. Corticosteroid injections are commonly used to treat bursitis.

scan showing bursitis
Hellerhoff

Iliopsoas tendinosis

As opposed to inflammation and microtears associated with tendonitis, tendinosis is the degeneration of a tendon’s collagen due to chronic overuse. While this is frequently regarded as the result of tendonitis that doesn’t heal, it’s actually a totally separate condition, marked by pain, burning, decreased flexibility and thickening of tissue.

False Positives

The following may cause you pain in the groin and hip area and restrict movement in a manner similar to iliopsoas syndrome. But they are very different and require different treatment.

Femoral neck stress fracture

The groin pain caused by a femoral neck stress fracture may be mistaken for a muscular injury (like iliopsoas syndrome) because it’s so rare. Only about 1% of stress fractures are femoral neck stress fractures. Symptoms are similar and pain will start to take longer and longer to go away on your runs. However, a femoral neck stress fracture probably won’t cause hip popping.

You’ll need an X-ray, MRI, or bone scan to diagnose this, and treatment depends on the location of the fracture. If it’s on the lower side of the femoral neck, you likely won’t need surgery but may be placed on crutches. If it’s on the upper side of the femoral neck, surgical screws may be required to heal the fracture.

femoral neck stress fracture
Emedicine Medscape

Labral Tear

An acetabular labral tear can certainly cause snapping hip, but not iliopsoas syndrome. The type of snapping hip caused by a tear is intra-articular snapping hip, as opposed to external extra-articular snapping hip, the official name for iliopsoas syndrome. What does this mean? Essentially, ‘intra-articular’ refers to the area within a joint. In the case of labral tears, the tissue that surrounds the acetabulum (hip socket) and protects the joint becomes worn and torn. Acetabular tears, in particular, are the most common type of labral tears in athletes, and somewhere between 22 and 55 percent of groin-pain-causing labral tears are, in fact, acetabular tears.

As you may have guessed, labral tears feel very similar to iliopsoas syndrome. The main symptom is groin pain, and they may also involve the same trademark clicking. They can even occur the same way: through constant, repetitive hip motions. Often times, though, labral tears will be the result of a femoroacetabular impingement (FAI), a condition in which your hip bones don’t fit together quite right. Recovery is also different from that of iliopsoas syndrome, requiring arthroscopic surgery if physical therapy and rest don’t relieve pain.

Unfortunately, labral tears of all kinds often go undiagnosed for a long period of time since pain starts dully, and the potential for other injuries will be explored first. To diagnose an acetabular labral tear, your physician may start with an anterior hip impingement test. While lying on your back, you’ll flex your hip and knee 90 degrees. Your doctor will rotate the hip inward while applying force as it adducts. A positive test will cause pain in your groin area. From there, an MRI or MRA (magnetic resonance arthrography) can confirm the tear.

IT band syndrome

The biggest difference between IT band syndrome and iliopsoas syndrome? The first is extremely common among runners. The second is not.

Anatomically speaking, there are also major differences. IT band syndrome occurs in the lateral, or outside portion of the hip, while iliopsoas syndrome occurs in the anterior, or inside portion. So this type of hip snapping feels different; it doesn’t originate in your groin area; it originates by what you traditionally think of as your hip bone as the iliotibial (IT) band slips back and forth over the top of your femur.

While snapping occurs in the hip area, pain is more likely to occur on the outside of your knee. That’s because the IT band runs all the way down your outer thigh, from your iliac crest (the outermost part of your hip) to your lateral knee, and constantly rubs against the outer part of the knee called the lateral femoral epicondyle.

While IT band syndrome is also an overuse injury marked by tightness, the motion that aggravates it is anything that causes the leg to turn inward repeatedly, as opposed to hip flexion. It can be triggered by running on uneven surfaces, wearing worn shoes, downhill running, even too many lefts turn on the track.

Just as is the case for iliopsoas syndrome, rest is the most effective treatment for IT band syndrome. Massage can also be particularly helpful to break up any scar tissue that has formed along the muscle.

Conclusion

If you think you’re suffering from iliopsoas syndrome, it’s safe to assume you’ve been training pretty hard. After all, this injury is the result of extreme, repetitive hip motions unique to athletes like runners and dancers. With this in mind, it’s understandable that rest is the last remedy you want to be prescribed. But in this case, it’s overwhelmingly the most effective one.

Remember, your iliopsoas tendon, or a hip flexor right around your groin area is probably inflamed from the repetitive flexion movement of your hip. As a result, it’s not functioning correctly as you raise and lower your leg. Instead of smoothly facilitating this motion, it’s catching on the interior portion of your hip bone (the iliopectineal eminence), causing a hip pop that you can feel, hear, or feel and hear. Rest is the best treatment for that inflammation.

To prevent this from happening again, you’ll want to focus not only on keeping your hip flexors stretched and warmed up prior to athletic activity, but also strong. There are many different hip strengthening exercises you can do on your own at home or in a gym without the help of a physical therapist. This is a nagging injury, so sticking to your recovery routine is extremely important. But iliopsoas syndrome will probably not sideline you completely.

 

Sources used while conducting our research

Each of the sources consulted for this guide cite medical professionals, were published in a medical journal or were disseminated by a university. Still, it is intended to be used as exactly that—a guide. We want to arm you with all the information you need to learn about your body, how it functions, what may be causing an injury and how that injury manifests itself. But for an accurate medical diagnosis and a proper treatment plan, we encourage you to talk to your doctor or another medical professional. The sooner you accurately identify the problem, the sooner you can start treating it. Then you’ll be back to running pain-free.

 

 

 

 

Sources

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  11. Mayo Clinic Staff, Bursitis, Mayo Clinic, Aug 20, 2014
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