Ever asked yourself the question, “What’s the click in my hip?” Firstly you need to know a little about the anatomy of the area and this is extensive!
Bones – Ilium, Ischium, Pubis, Femur
Ilium:
- Acetabulum (lunate surface, margin of acetabulum)
- Anterior inferior iliac spine
- Anterior superior iliac spine
- Ala (wing of ilium) (gluteal surface and iliac fossa))
- Iliac crest (outer lip, tuberculum, intermediate zone, inner lip)
- Gluteal lines (anterior, inferior and posterior)
- Posterior superior iliac spine
- Posterior inferior iliac spine
- Greater sciatic notch
- Body of Ilium
- Illiopubic eminence
- Arcuate line
- Auricular surface for the sacrum
- Iliac tuberosity
Ischium:
- Ischial spine
- Lesser sciatic notch
- Body of Ischium
- Ischial tuberosity
- Ramus of ischium
- Obturator foramen
- Acetabulum
- Acetabular notch
Pubis:
- Superior pubic ramus
- Pubic tubercle
- Obturator crest
- Inferior pubic ramus
- Acetabulum
- Pecten pubis (pectineal line)
- Symphyseal surface
- Obturator groove
Femur:
- Head
- Fovea
- Neck
- Intertrochanteric crest
- Intertrochanteric line
- Trochanteric fossa
- Greater trochanter
- Lesser trochanter
- Calcar Femorale
- Pectineal line
- Gluteal tuberosity
- Shaft
- Linea aspera (medial and lateral lip)
Joints of the hip
- Femoroacetabular – Synovial: spheropidal. Closed packed position: full extension, internal rotation and abduction.
- Pubic symphysis – Amphiarthrodial
- Sacroiliac – Synovial: plane
Ligaments
Hip:
- Iliofemoral – Anterior inferior iliac spine to intertrochanteric line of femur. Limits extension of hip.
- Ischiofemoral – Posterior inferior acetabulum to apex of greater tubercle. Limits internal rotation and extension of the hip.
- Pubofemoral – Obturator crest of pubic bone to blend with the capsule of hip and iliofemoral ligament. Limits hip hyperabduction.
- Ligament of head of femur – margin of acetabular notch and transverse acetabular ligament to head of femur. Carries the blood flow to supply to head of femur.
Pubic symphysis:
- Superior pubic ligament – Connects superior aspect of right and left pubic crests. Reinforces superior aspect of joint.
- Inferior pubic ligament – Connects inferior aspect of right and left pubic crests. Reinforces inferior aspect of joint.
- Posterior pubic ligament – Connects posterior aspect of right and left pubic crests. Reinforces the inferior aspect of the joint.
Sacroiliac:
- Posterior sacroiliac – iliac crest to tubercles of S1-S4. Limits movement of sacrum on iliac bones.
- Anterior sacroiliac – Anterosuperior aspect of sacrum to anterior ala of ilium. Limits movement of the sacrum on iliac bones.
- Sacrospinous – Inferior lateral border of sacrum to ischial spine. Limits gliding and rotary movement of sacrum on iliac bones.
- Sacrotuberous – Middle lateral border of sacrum to ischial tuberosity. Limits gliding and rotary movement of sacrum on iliac bones.
Muscles of the hip:
Posterior (back):
- Gluteus maximus – Posterior border of ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament to iliotibial tract of fascia lata and gluteal tuberosity of femur. Extension, external rotation and some abduction of the hip joint.
- Piriformis – Anterior aspect of sacrotuberous ligament to superior greater trochanter of femur. External rotation of extended hip, abduction of flexed hip, steady femoral head in acetabulum.
- Superior Gemellus – Ischial spine to trochanteric fossa of femur. External rotation of extended hip, abduction of flexed hip, steady femoral head in acetabulum.
- Inferior Gemellus – Ischial tuberosity to trochanteric fossa of femur. External rotation of extended hip, abduction of flexed hip, steady femoral head in acetabulum.
- Obturator internus – Internal surface of obturator membrane, border of obturator foramen to trochanteric fossa of femur. External rotation of extended hip, abduction of flexed hip, steady femoral head in acetabulum.
- Quadratus femoris – Lateral border of ischial tuberosity to quadrate tubercle of femur. Lateral rotation of hip and steadies the femoral head in the acetabulum.
- Semitendinosus – Ischial tuberosity to superomedial aspect of tibia. Hip extension, knee flexion, medial rotation of knee in knee flexion.
- Semimembranosus – Ischial tuberosity to posterior aspect of medial condyle of tibia. Hip extension, knee flexion, medial rotation of knee in knee flexion.
- Biceps Femoris – Long head: ischial tuberosity and short head: linea aspera and lateral supracondylar line of femur to lateral aspect of head of fibula and lateral condyle of tibia. Knee flexion, hip extension and knee external rotation with the knee flexed.
Lateral (outside):
- Gluteus medius – External superior border of ilium and gluteal aponeurosis to lateral aspect of greater trochanter of femur. Hip abduction and internal rotation, maintains level pelvis in single leg stance.
- Gluteus minimus – External surface of the ilium and margin of the greater sciatic notch to anterior aspect of the greater trochanter of femur. Hip abduction and internal rotation, maintains level pelvis in single leg stance.
- Tensor fasciae latae – Anterior superior iliac spine and anterior aspect of iliac crest to iliotibial band that attaches to lateral condyle of the tibia. Hip abduction, internal rotation and flexion, aid maintaining knee extension.
Anterior (front):
- Psoas Major – Lumbar transverse processes to lesser trochanter of femur. Flexes the hip, assists with external rotation and abduction. Plays a major role in maintaining upright posture by supporting the Lumbar lordosis (inward curvature). Iliopsoas as they are both termed collectively also assists lumbar spine movement.
- Psoas minor – Lateral bodies of T12 and L1 to iliopectineal eminence and arcuate line of ilium. Flexion of pelvic on lumbar spine.
- Iliacus – Superior iliac fossa, iliac crest and ala of sacrum to lateral tendon of psoas major and distal to lesser trochanter. Flexes the hip, assists with external rotation and abduction.The psoas and Iliacus muscles are collectively termed Iliopsoas and this is best at producing inner range hip flexion (knee up near hip height, and above). In this inner range, Iliopsoas is far more mechanically effective in flexing the hip than Rectus Femoris.
- Rectus femoris – Anterior inferior iliac spine to base of patella through the patella tendon to the tibial tuberosity. Hip flexion and knee extension. When the hip is in a mid and outer range flexed position then Rectus Femoris has a far more effective lever-arm to flex the hip.
- Sartorius – Anterior superior iliac spine and notch just inferior to superomedial aspect of tibia. Flexes abducts and externally rotates the hip, flexes the knee.
- Obturator Externus – Margin of obturator foramen and obturator membrane to trochanteric fossa of femur. Hip external rotation, steadies the head of the femur in the acetabulum.
Medial (inside):
- Adductor Longus – Inferior to pubic crest to middle third of linea aspera of femur. Hip adduction.
- Adductor Brevis – Inferior ramus of pubis to pectineal line and proximal linea aspera of femur. Hip adduction and assists with hip extension.
- Adductor Magnus – Adductor part: inferior pubic ramus, ramus of ischium, hamstring part: ischial tuberosity, to adductor part: gluteal tuberosity, linea aspera, medial supracondylar line, hamstring part: adductor tubercle of femur. Hip adduction, adductor part: hip flexion, hamstring part: hip extension.
- Gracilis – Inferior ramus of pubis to superomedial aspect of tibia. Hip adduction and flexion, assists with hip internal rotation.
- Pectineus – Superior ramus of pubis to pectineal line of femur. Hip adduction and flexion, assists with hip internal rotation.
Bursae (There are as many as 20 bursae around the hip)
- Iliopectineal bursa
- Trochanteric bursa
- Iliopsoas bursa
- Gluteus medius bursa
- Ischiogluteal bursa
- Obturator externus bursa
- And more…
Connective Tissue
- Iliotibial band (ITB) – This is a connective tissue band that originates at the anterolateral iliac tubercle portion of the external lip of the iliac crest and inserts at the lateral condyle of the tibia. The ITB and its associated muscles help to extend, abduct, and laterally rotate the hip. The ITB also contributes to lateral knee stabilisation. The gluteus maximus and the tensor fasciae latae insert into the ITB.
- Labrum – This is a ring of cartilage that surrounds the acetabulum (the socket of the hip joint). It deepens the acetabulum, making it more difficult for the head of the femur to slip out of place. The Labrum increases surface area of the acetabulum by 28%, aids stability: deepening the joint by 21%, shock absorption & joint lubrication.
So back to my original question, “What’s the click in my hip?”
Basically it depends, as there a several different causes. The Snapping sensation is felt when the hip is flexed and extended. This can be audible and can be painful in some cases but for the most part it doesn’t hurt. It is categorised as either extra-articular or intra-articular, meaning inside the joint or outside the joint.
Extra-articular:
- Lateral extra articular – This is the most common type and occurs when the iliotibial band, tensor fascia lata, or gluteus medius tendon slides back and forth across the greater trochanter. This actually is a normal thing but when the connective tissue thickens and tightens it catches with motion. The Trochanteric bursa can become inflamed, causing a painful external snapping hip syndrome and Trochanteric bursitis.
- Medial extra-articular – This is less common, the iliopsoas tendon catches on the anterior inferior iliac spine (AIIS), the lesser trochanter, or the iliopectineal ridge during hip extension. This can result in excessive friction and may eventually cause pain from muscle trauma, bursitis, or inflammation in the area.
Intra-articular:
- Because the iliopsoas or hip flexor crosses directly over the anterior suprior labrum of the hip, an intra-articular hip derangement (i.e. labral tears, hip impingement, loose bodies) can lead to an effusion that subsequently produces internal snapping hip symptoms. Interestingly 80% of labral tears of the hip present with an audible or palpable click and this is reiterated here: A clicking hip is strongly associated with acetabular labral tears of the hip joint (Cleland & Koppenhaver 2015).
Who gets these problems?
Gymnasts, cyclists, dancers and track athletes commonly get this due to repetitive hip flexion movements within their sport. In Ballet dancers hip injuries are about 10% of orthopaedic complaints & ‘snapping hip’ syndrome is 45% of these (Reid et al 1988). Snapping hip syndrome most often occurs in persons who are 15 to 40 years old and is more common in females.
What are the contributing factors to getting a clicky hip?
Extra-articular snapping hip syndrome is caused by tightness in the iliotibial band (ITB), weakness in the hip abductors and external rotators, poor core stability and/or faulty foot biomechanics. Some people believe leg length inequality can be a factor too but remember in normal people, 96.7% were found to have a difference in leg length (O’Brien et al 2010). Also there is no evidence of an association between leg-length inequality & greater trochanteric pain syndrome according to Segal et al (2008). However if the difference is big enough then it could be significant.
With the Intra-articular type the pain tends to be more intense as it is indicative of such injuries as a torn acetabular labrum, recurrent hip subluxations, ligamentum teres tears, loose bodies, articular cartilage damage, or synovial chondromatosis (cartilage formations in the synovial membrane of the joint).
How do you diagnose it?
- Intra-articular – Many of these pathologies will be easily seen on X-ray or MRI scanning but Acetabular labral tears are more difficult to see: Only 3 out of 55 were found on MRI (Fitzgerald 1995).
- Extra-articular – MRI & ultrasound can show tendinopathy or bursitis. Iliopsoas bursography & dynamic ultrasound can highlight subluxation of the tendon.
- FABER test for medial (Iliopsoas or rectus femoris related).
- Obers test for lateral (ITB related).
- Another good test for lateral extra-articular is done in side lying on unaffected side with pillow under the hip, flex and extend the hip and palpate over greater trochanter for click (Brignall et al 1991).
- Static hip extension flexibility (Thomas test) does not appear to be reflective of functional dynamic movements (Schache et al 2000).
So how do you treat it?
Well it depends on the type. Extra articular is easier to treat but intra-articular may be difficult and may require surgery in some cases depending on the particular issue. Obviously the key is to get to the root cause so potentially you need to correct biomechanical abnormalities, stretch tightened muscles, and strengthen weak muscles. Most patients respond well to conservative management: This generally involves avoidance of activities which cause a click, non-steroidal anti-inflammatory drugs & physiotherapy.
- Eccentric strengthening exercises showed the greatest value in decreasing pain & increasing function in tendinopathy (Andres et al 2008).
- Myofascial release of the tensor fascia latae, gluteus medius, gluteus maximus & adductor musculature with stabilisation & strengthening had the best effect on external snapping hip syndrome (Spina 2007).
- Stretching of any shortened structures may alleviate the symptoms.
Injection:
- Corticosteroid injections are usually administered to the iliopsoas or trochanteric bursa. These effects are temporary and usually only last weeks to months unless the root cause is corrected. However, they cause weakening of the connective tissue.
Surgery:
Surgical treatment may be needed if pharmacological or physiotherapy are ineffective or abnormal structures are found that need surgical repair.
- Medial extra-articular – Lengthening of the iliopsoas tendon. Resection of the bony prominence of the lesser trochanter. Complete release of the iliopsoas tendon. Surgical lengthening of the iliopsoas tendon has an 85% success rate (Jacobson & Allen 1990).
- Lateral extra-articular – Z-plasty of the iliotibial band. Resection of the posterior half of the iliotibial band. Elliptical resection of a portion of the iliotibial band.
- Intra-articular – Correction of intra-articular pathologies so the type of surgery will depend.
If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.
DISCLAIMER:
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.
