Piriformis syndrome - muscle diagnostic tests

Snapping Hip Syndrome Snapping hip syndrome is a condition characterized by a clicking sensation and/or clicking sound that occurs in or around the hip joint when it moves. This condition has many causes. By origin they can be classified as external, internal and intra-articular. For most people, this condition is simply an annoyance, but in some cases it can lead to pain and weakness that reduces a person's ability to function.

• External cause (most common) - iliotibial tract vs greater trochanter of the femur.
• Internal cause - iliopsoas tendon vs bony protrusion of the pelvis.
• Intra-articular causes are damaged cartilage and/or loose body inside the hip joint, which can also lead to joint block.

Characteristics/Clinical Picture

In most cases, this problem is benign. However, some patients may experience pain or weakness during hip flexion and extension, which significantly reduces their functional activity and quality of life.

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In people with snapping hip syndrome due to an external cause, clicking or pain occurs gradually and is localized in the greater trochanter of the femur. This does not have to be preceded by trauma. The clinical picture is quite clear: cracks occur during flexion and extension of the hip. Sometimes patients complain of a feeling of hip dislocation. People with symptoms of a snapping hip may also have coxa vara (varus position of the femoral neck), fibrous scar tissue, a prominent greater trochanter, a small lateral pelvic dimension, and the effects of surgery for anterolateral knee instability.

The problem of hip clicking due to an internal cause also has a gradual onset and is not associated with a previous traumatic event. Such patients complain of a painful sensation that occurs in the depths of the groin area during extension and internal rotation of the hip. These movements are accompanied by clicks.

Patients with clicking due to an intra-articular cause report a sudden onset of the disease, associating it with a previous injury. The sources of clicking can be damage to the joint capsule, loose bodies deposited in the acetabulum or synovial folds, torn labrum and synovial chondromatosis).

Snapping hip

Snapping hip syndrome, as the name suggests, is a clicking sound in the thigh or hip joint that occurs during movement, often accompanied by pain. Sometimes when clicking there is not only pain, but also a feeling of springy resistance to movement, followed by a feeling of falling into emptiness. In medicine, clicking hip is also called by the Latin term coxa saltans.

Due to the origin of clicking, this syndrome is divided into three types: external, internal and intra-articular.

With the external type of the syndrome, pain and clicking occur externally, in the area of ​​the greater trochanter, are caused by friction of the iliotibial tract against this trochanter (the same causes clicking) and are often accompanied by trochanteric bursitis (trochanteritis).

The internal type of snapping hip syndrome is caused by a mechanical problem directly next to the hip joint. In the vast majority of cases, pain and clicking are caused by the iliopsoas muscle rolling over the head of the femur. The pain is triggered by high hip flexion. This type is the most common and therefore we will look at it in more detail below.

The intra-articular type of syndrome is caused by problems inside the joint, i.e. caused by changes in structures located inside the joint capsule. These may be tears of the acetabular labrum, loose intra-articular bodies (articular mice), chondromatosis or osteoarthrosis (arthrosis, coxarthrosis) of the hip joint. In addition, this type of syndrome is caused by damage to the hip joint from a strong lateral blow to the thigh, which occurs, for example, when falling on the greater trochanter of the femur. A strong collision of the head of the femur and the bottom of the acetabulum occurs, followed by death of the articular cartilage. On a magnetic resonance imaging scan, an altered signal from the femoral head, reminiscent of osteonecrosis, is visible, and sometimes a cartilage defect is visible. A history of recent trauma indicates a labral tear. Pain not directly related to injury can be caused by a rupture of the dystrophic acetabular labrum or a malformation of the hip joint, such as hip dysplasia or femoroacetabular impingement syndrome.

Hip pain can be caused not only by local causes, but also by diseases and conditions such as inguinal hernia, pinched nerves, lumbar radiculopathy, osteoperiostitis of the pubis, stress fractures of the pelvic bones or femoral neck, and instability of the hip joint. The latter is manifested by a peculiar gait disturbance: the affected leg is abducted and turned outward while walking.

Snapping hip syndrome (coxa saltans), internal type

The iliopsoas muscle consists of two muscles that connect only at the insertion point: the psoas major muscle and the iliacus muscle. This muscle also includes the inconstant psoas minor muscle. The iliopsoas muscle attaches to the lesser trochanter of the femur and is primarily responsible for hip flexion.

The tendon of the iliopsoas muscle is adjacent to the anterior capsule of the hip joint so that only a few millimeters separate it from the acetabulum lip (the cartilaginous ridge bordering the acetabulum). In this place there is also an iliopectineal bursa, which in every fifth person communicates with the hip joint. With snapping hip syndrome, there is inflammation of this bursa (iliopectineal bursitis).

The essence of the internal type of snapping hip is that when moving in the hip joint, the iliopsoas tendon rolls over the neck, head of the femur and acetabular labrum of the hip joint, which is accompanied by a painful click. These rolls injure the iliopsoas muscle itself and its tendon, which leads to its inflammation (tendonitis or tendovaginitis of the iliopsoas muscle). In addition, as we have already noted, in this place there is an iliopectineal bursa, which can also become inflamed during trauma (iliopectineal bursitis).

Internal type of snapping hip syndrome (coxa saltans): when the flexed, abducted and externally rotated hip (left) returns to its natural position (right), a click or push occurs in the groin, lesser trochanter or head of the femur, superior ramus of the pubis or sacrum. iliac joint.

Diagnosis

The disease begins with the appearance of unpleasant clicking in the groin, which occurs, at first rarely, and then more and more often when flexing and extending the hip. The pain is deep, dull in nature and is usually felt in the groin, or rather anywhere between the superior anterior iliac spine and the inguinal fold - most often at the level of the inferior anterior iliac spine. Instead of clicking, patients may complain of an unpleasant springy sensation in the hip joint that interferes with movement or a feeling as if the joint is sticking. Athletes often describe weakness and uncontrollability of the trailing leg during flexion. With severe tendinitis of the iliopsoas muscle, you even have to lift the sore leg with your hands when sitting in a car or lying on an examination table.

Telling your doctor about your medical history can help differentiate internal snapping hip syndrome from other causes of groin pain. The internal type of snapping hip syndrome is similar to the intra-articular type that occurs when the acetabular labrum is torn. A thorough history of the disease will help the doctor determine the true cause of clicking and pain. In particular, acetabular labral tears differ from the internal type in that they are usually associated with recent trauma or abnormalities of the pelvic and femoral bones, usually visible on radiographs. However, not everything is so simple, and there are ruptures of the degeneratively changed acetabular labrum that occur without any trauma.

To confirm the internal type of snapping hip syndrome, the doctor performs a special test: when the flexed, abducted and externally rotated hip returns to its natural position, a click occurs in the internal type. During this movement, the iliopsoas tendon is stretched, which slides along the iliopubic eminence of the pelvic bone, along the head and neck of the femur. Often pain and a clicking sensation in the groin occur with each repetition of this test. In addition to the fact that the click is felt by the patient, the doctor often hears or feels it when palpating the patient’s groin area while performing the test. Repeated performance of the test causes pain in the groin.

With a labral tear or femoroacetabular impingement syndrome (hip impingement syndrome), pain occurs from the opposite movement: flexion, adduction, and internal rotation of the freely extended hip, which brings the anterosuperior surface of the head and neck of the femur into contact with the anterosuperior part of the trochanteric labrum.

The diagnosis can also be made using dynamic ultrasound, but the accuracy of this study largely depends on the doctor performing it.

Magnetic resonance imaging may show changes in the iliopsoas muscle itself, its tendon, the iliopectineal bursa, or the anterior portion of the hip capsule. These changes are often so subtle that they can only be distinguished by comparing one hip joint to another in high-definition images taken with a powerful CT scanner. The main sign of intrinsic snapping hip syndrome on magnetic resonance imaging scans is swelling near the iliopsoas tendon.

Magnetic resonance imaging (cross-section). Signs of internal snapping hip: an inflamed and thickened iliopsoas tendon (blue arrow), swelling near the tendon (red arrow indicates clearing). 1 - edges of the acetabulum (bone), 2 - cartilaginous acetabulum lip (dark triangle at the edge of the acetabulum), 3 - head of the femur, 4 - neck of the femur. Thickening of the iliopsoas tendon is often detected in comparison with a tomogram of the opposite joint

Treatment

Conservative treatment. It is based on the exclusion of pain-provoking movements, especially high (more than 90°) hip flexion, and taking non-steroidal anti-inflammatory drugs (ibuprofen, diclofenac, etc.). Stretching exercises for the iliopsoas muscle and physiotherapeutic procedures, in particular cryotherapy and electrical stimulation, also help .

Glucocorticoid injections into the iliopsoas tendon sheath are sometimes used to relieve symptoms. Injections are carried out under ultrasound or fluoroscopy control. The recommended mixture contains hydrocortisone or diprospan, lidocaine and/or bupivacaine. The injection is performed under local anesthesia with a lumbar puncture needle. The needle is inserted into the sheath of the iliopsoas muscle tendon, to the iliopsoas bursa underlying the tendon. If the injection has only a partial or temporary effect, it is repeated.

Surgery. Surgical treatment is resorted to in those rare cases when conservative methods do not give the expected results. The goal of surgery is to relieve tension on the iliopsoas tendon, which rubs against the pelvis and hip bone during hip flexion and extension, while maintaining hip flexor strength.

Suggested procedures include open tenotomy of the iliopsoas muscle at its insertion on the lesser trochanter (which permanently reduces hip flexion strength and is therefore not recommended for athletes), open iliopsoas muscle transfer to the more proximal, superior femur, and arthroscopic iliopsoas muscle transfer. - psoas muscle through anterior access to the hip joint.

Complications

Glucocorticoid injections do not appear to increase the risk of iliopsoas tendon rupture, unlike injections for inflammation of other tendons (eg, Achilles tenopathy). After the injection, a temporary exacerbation of symptoms is possible (for 1-2 days). If, despite the injection, symptoms persist, it is necessary to exclude other, primarily intra-articular causes of groin pain combined with mechanical symptoms. For this purpose, magnetic resonance arthrography is performed.

During surgery, it is important not to touch the femoral nerve. Having isolated the iliopsoas muscle, you need to make sure that it responds to electrical stimulation of the nerve, and only then cross the tendon. The lateral cutaneous nerve of the thigh lies within the operative field, so after surgery, numbness of the anterior surface of the thigh is possible, about which the patient must be warned. Weakness in hip flexion is also expected, gradually improving during rehabilitation. When the iliopsoas tendon is cut off from the lesser trochanter, weakness can persist for a long time, so other surgical techniques are preferable for athletes.

Forecast

After starting conservative treatment: avoiding pain-provoking movements, taking non-steroidal anti-inflammatory drugs and physical therapy, improvement usually occurs quickly, and after 1-4 weeks even athletes can resume training. If rapid improvement does not occur, an injection of glucocorticoids is indicated, after which after 1-2 weeks, in most cases, the pain and clicking goes away.

It is difficult to completely prevent the internal type of snapping hip syndrome, but recognizing it at an early stage and eliminating the movements that provoke it (in particular, high hip flexion, which is considered the main cause of this syndrome) can reduce the severity and reduce the duration of the disease. In addition, stretching the hip flexor muscles during warm-up before exercise can be of some benefit.

Materials used in preparation:

Dobbs MB et al: Surgical correction of the snapping iliopsoas tendon in adolescents. J Bone Joint Surg Am 2002;84-A(3):420.

Gruen GS et al: The surgical treatment of internal snapping hip. Am J Sports Med 2002;30(4):607.

Wahl CJ et al: Internal coxa saltans (snapping hip) as a result of overtraining: a report of 3 cases in professional athletes with a review of causes and the role of ultrasound in early diagnosis and management. Am J Sports Med 2004;32(5):1302.

Byrd JW: Lateral impact injury. A source of occult hip pathology. Clin Sports Med 2001;20(4):801.

Kelly BT et al: Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med 2003;31(6):1020.

Seldes RM et al: Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop 2001;Feb(382):232.

Survey

The examination of a patient with snapping hip syndrome should include an analysis of the patient's symptoms: prevalence, location, time of onset, duration of disease, pain and disability, impact on activity. Brignall and Stainsby found that the average duration of symptoms in these patients was 2 years and 2 months. In general, the patient himself can easily indicate where his problem is. A visual analogue scale (VAS) can also be used to measure pain intensity.

Diagnostics

Next comes an examination of the body. In this case, the doctor always examines both sides equally, even if coxalgia in this case manifests itself only on one side.

The doctor evaluates the patient’s gait and pays attention to possible lameness. It checks whether the axis of the legs is straight or whether the patient has X-shaped or O-shaped legs. In addition, the doctor checks whether the pelvis is level and whether the legs are the same length.

The next step is to feel and tap the groin area and the area around the trochanter of the femur on the outside of the pelvis. He pays attention to symptoms of inflammation, such as local redness, hyperthermia and swelling. These symptoms may indicate inflammation of the bursa (bursitis) as the cause of coxalgia.

A mobility test is very important when determining the cause of pain in the hip joint. Using various tests, the doctor checks how much mobility the hip joints have, whether the hip is freely abducted to the side, and whether it can be rotated inward or outward.

Blood tests

Blood tests are also very helpful in determining the cause of coxalgia. For example, erythrocyte sedimentation rate (ESR) is an important parameter for recognizing inflammatory and rheumatic causes of coxalgia. In the case of diseases caused by wear and tear, the ESR, on the contrary, increases slightly or does not increase at all. The number of white blood cells (leukocytes) is also informative. Leukocytosis is present in nonspecific arthritis, as well as osteomyelitis or bacterial inflammation of the hip joints.

Visualization methods

An X-ray examination of the pelvis serves, first of all, to detect possible symptoms of arthrosis as the cause of pain in the hip joints. An even more detailed picture is obtained using computed tomography (CT). She can better understand the severity of joint destruction (for example, in the case of necrosis of the femoral head).

Ultrasound examination of the hip joint can identify, for example, inflammation of the bursa, intra-articular effusion and inflammation of the synovium (synovitis) as the cause of hip pain . Changes in the muscles and ligaments in the hip joint can be clearly visible on ultrasound.

Magnetic resonance imaging (MRI) is good for diagnosing inflammatory soft part changes and the early stages of osteonecrosis or stress fracture.

If the basis for coxalgia is inflammation or swelling in the joint area, this is determined using a radioisotope study (joint scintigraphy).

Treatment

As mentioned earlier, most cases of snapping hip syndrome are asymptomatic and do not require intervention. However, in some cases characterized by pain and/or limitation of physical activity, therapeutic measures may be required.

Conservative treatment

This is the first and most preferred treatment approach, which includes methods commonly used to treat common forms of tendinopathies: rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid or lidocaine injections, physical therapy.

Surgical intervention

Recommended only in extreme cases when conservative treatment has not helped. The main goal is to lengthen and relax tight tendons/ligaments and eliminate the pathologies that are most commonly associated with snapping hip syndrome. Currently, there is some disagreement about what type of surgical treatment to prefer based on the existing classification. However, researchers agree that when surgery is necessary, arthroscopic surgery provides better results and fewer complications than the traditional open method.

Coxalgia. What to do?

How hip pain is treated depends on the diagnosis. A couple of examples:

• Therapy for coxarthrosis primarily involves lifestyle changes. In case of obesity, weight loss, various aids for daily use (cane, aids for putting on shoes and socks, etc.) and more movement with reduced stress on the joints, such as cycling or swimming, are recommended.
• This provides mobility and reduces pain in the hip joints. The exercises, as demonstrated by the physical therapist to the patient, must be performed at home regularly. Additionally, conservative treatment procedures are used, such as kinesitherapy, heat therapy and electrotherapy.
• In advanced stages of coxarthrosis, medications (such as anti-inflammatory drugs) are used. If these measures do not help enough against limited mobility and pain in the hip joints, the patient must have an artificial hip joint installed.
• If coxalgia is caused by inflammation of the synovial bursa in the hip joint, glucocorticoid injections (Cortisone) can be administered. You can also try shock wave therapy. In rare cases, the affected bursa is removed surgically.
• Inflammation of the hip joint (coxitis) is treated depending on the pathogen.
• For septic coxitis, along with immobilization and antibiotics, surgical opening and washing of the joint is recommended. In this case, infected tissue is removed. It is also possible to install an artificial hip joint.
• Hip replacement is also necessary for rheumatoid coxitis, if other treatment procedures (medicines, physiotherapy, etc.) cannot eliminate pain in the hip joint and mobility is severely limited because of this. The mode of action for activated arthrosis of the hip joints is similar.
• Hip pain from coxitis fugax can most often be relieved within a few days with bed rest and the painkiller paracetamol. As long as pain in the leg and hip joint from the groin side persists, the sick child must be exempted from physical education classes at school.

Physical therapy

Compared to the body of literature regarding surgical treatment, there is insufficient evidence for specific interventions targeting the conservative management of patients with snapping hip syndrome and/or tendinitis of the involved structures. Given that this condition is classified as a syndrome, the physiotherapist must be prepared to detect several abnormalities, each of which requires individual consideration, i.e. The results of the examination of each patient determine the treatment tactics.

Because the mechanism of injury and surgical focus involve excessive shortening of the iliopsoas tendon and iliotibial tract, patients may benefit from stretching of the iliotibial tract and anterior femoral structures (various studies, level of evidence: 5, 2B, 2A).

Andres et al. conducted a systematic review of tendinitis treatments and determined that eccentric exercise was superior in reducing pain and increasing function compared with other physical therapy interventions (Evidence Level 2A).

A case study has also been published that demonstrates complete pain relief in cases of snapping hip syndrome. Myofascial release of the tensor fascia lata, gluteus medius and maximus, and hip adductors was performed, as well as a program to strengthen the hip abductors (level of evidence: 4).

A systematic Cochrane review found no benefit of transverse friction massage compared with other treatments (level of evidence: 1A).

It is important that the patient is trained to avoid movements that cause pain and/or clicking. Once pain and discomfort have been eliminated and an increase in the range of motion of the hip joint has been achieved, it is important to teach the patient how to move correctly. This helps prevent symptoms from recurring in the future.

Location of the lesion

The human musculoskeletal system is anatomically very complex and includes not only the spine, bones or joints, but also ligaments, tendons, and muscles. The normal functioning of the lower or upper extremities directly depends on the health of the soft tissues. When the muscle tissue surrounding the synovial bursa or its tendons is injured or inflamed, in the absence of the necessary therapy, the pathological process spreads to the articular structures, subsequently leading to more serious illnesses and consequences. Therefore, if you experience non-physiological sounds when moving your leg, it is important to undergo an examination and find out the root cause of the problem. It is difficult to determine it accurately on your own. The characteristic sounds and feeling of wedging are observed in various parts of the leg above the knee, where tendons and muscles slide along different protrusions of the femur. Depending on the location of this defect, the doctor prescribes diagnostic tests, makes a diagnosis and outlines a further treatment plan.