SNAPPING HIP

1. COXA SULTANS
Dr. TARUN KUMAR BADAM
UNDER GUIDANCE OF :
PROF A. DEVADOSS
Dr. SATHISH DEVADOSS

2. COXA SULTANS
Case Report : 24yr old male patient, operated case of
shaft of femur # for which IMIL Nailing was done ,
presented for follow-up
Incidentally, Snapping of the IT band over GT was
seen , which was asymptomatic
This is External Snapping Hip or External Coxa
sultans

4. COXA SULTANS
Coxa sultans, or ‘Snapping Hip’ is characterised by an audible
snapping, usually with flexion and extension of the hip during exercise
or simply with normal daily activities.
Mostly it is asymptomatic, but some patients have pain and discomfort
Types of Coxa sultans :
(a) Extra-articular
- External
- Internal
(b) Intra-articular

5. EXTERNAL COXA SULTANS

6. EXTERNAL COXA SULTANS
Most common type of Coxa sultans or Snapping Hip
It is mainly due snapping of IT Band,Gluteus
maximus and TFL complex over Greater Trochanter
of the hip
Seen in Athletes, Ballet dancers, Soccer players

7. ANATOMY
IT BAND takes origin from iliac
crest
Proximally, gives attachment to
TFL anteriorly and Gluteus
maximus posteriorly
Distally, attached to Linea
Aspera of femur and Gerdy’s
tubercle on Antero lateral aspect
of Tibia
Complex origin and Insertion of
this structure allows it to be taut
in all ranges of motion

8. In the undersurface of IT
Band, GT is present
which is separated from
it by Trochanteric bursa

9. ETIOPATHOGENESIS
Any increase in tension in the already taut IT Band, with
repeated movements of flexion and extension
Increased friction over GT
Trochanteric bursitis and Chronic fibrosis of IT Band
Complex
Snapping of IT Band over GT
EXTERNAL COXA SULTANS

11. CAUSES OF INCREASED
TENSION IN IT BAND COMPLEX
Excessive Flexion and Extension of the hip
Femoral anteversion
Femoral retroversion
Internal tibial torsion
Excessive foot pronation

13. Other Causes
Weakness of Hip Abductors
After Total Hip Replacement
- Curved femoral stem
- Placement of femoral component is too far
medial
- Angulation in relation to long axis of the femur

14. CLINICAL FEATURES
Patients will c/o Snapping sensation over lateral aspect of
hip
Sometimes, associated with discomfort
Confirmation
- Patient should be in Left lateral or Right Lateral position
- Hip is actively flexed by the patient, and examiner
palpates over GT for the snapping
- Snapping can be blocked by applying pressure over GT

16. INVESTIGATIONS
MRI Scan of Hip: Thickening of the Posterior border
of IT Band or Anterior border of Gluteus maximus

17. INTERNAL COXA SULTANS

18. INTERNAL COXA SULTANS
It is due to Snapping of Iliopsoas musculotendinous
unit over Head of the Femur (mainly), followed by
Ilio-pectineal ridge and Lesser Trochanter
Seen mainly in Rowers

19. ANATOMY
Musculotendinous unit
of Iliopsoas passes in
the osseous groove
between AIIS and
Iliopectineal eminence

21. From it’s lateral
position when hip is in
flexion, to it’s medial
position when hip is in
extension, Iliopsoas
tendon remains in the
osseous groove
It moves back and
forth on the Head of
the femur
In Rowers, strong
Iliopsoas can cause
snapping during this
movement

22. ETIOLOGY
Tight Iliopsoas musculotendinous unit
Exostosis of Lesser Trochanter
Exostosis of Iliopectineal ridge

23. CLINICAL FEATURES
Patients will c/o Snapping sensation over anterior aspect of hip
Sometimes, associated with discomfort
Confirmation
- Patient should be in supine position
- Hip is actively flexed by the patient, and examiner palpates
over Head of the femur for the snapping
- Snapping can be blocked by applying pressure over Head
of the femur

24. INVESTIGATIONS
1. MRI SCAN OF
HIP/PELVIS
- Thick Iliopsoas
musculotendinous unit
2. Iliopsoas Bursography
- Snapping of
Iliopsoas tendon can be
seen

25. INTRA ARTICULAR COXA SULTANS

26. INTRA ARTICULAR COXA SULTANS
In this type, Snapping occurs mainly due Intra-articular
lesions like Labral tears, Loose bodies, and Synovial
Chondromatosis
Pain in the hip is more frequent complaint than
Snapping

27. ETIOPATHOGENESIS
Loose bodies can lodge in
foveal area of Acetabulum
and can lead to Snapping of
hip

29. CLINICAL FEATURES
Patients mainly give a history of trauma
Pain in the hip is the Chief complaint
Can have snapping sensation intra articulately
Quadrant test will be positive in case of Labral tears

30. INVESTIGATIONS
MRI SCAN OF HIP
- for Labral tears and Loose bodies

31. MANAGEMENT OF
COXA SULTANS

32. Majority of the patients with snapping hip are
asymptomatic and some are incidentally found. In
these patients nothing need to be done as it is
asymptomatic
Few patients will be symptomatic with minimal
discomfort without disturbing the daily routine activities
Very few have severe snapping even with daily
activities and pain during the snapping

33. CONSERVATIVE MANAGEMENT
In all symptomatic patients, initially conservative
management is done with
(a) Rest
(b) Avoiding the activities and movements which
cause snapping
(c) NSAIDS
(d) Local Hydrocortisone injection

34. STRETCHING AND
STRENGTHENING EXERCISES

36. CCT AND BFST
Cold Compression therapy ( CCT ) :
In 1st 48hrs, CCT is given which decreases
the inflammation and pain
Swelling decreases which promotes more
blood supply to the site of inflammation
Limits the cellular breakdown and tissue
damage
Limits the amount of healing by fibrosis to
occur

38. BLOOD FLOW STIMULATION
THERAPY ( BFST )
Once Inflammation and swelling decreases, BFST
increases blood flow and oxygen and nutrient supply
to the involved site
Accelerates the process of healing of soft tissue
Decreases the risk of muscle atrophy

40. SURGICAL
MANAGEMENT
EXTERNAL COXA SULTANS :
Z-plasty of the Ilio-tibial band with excision of
Trochanteric bursa

41. • Anchoring of the Ilio-tibial band to Greater trochanter
• Elipsoid resection of the tract over GT
• Resection of posterior half of the tract at the Gluteus
maximus insertion
INTERNAL COXA SULTANS:
Lengthening of the postero-lateral
tendinous portion of the iliopsoas tendon

42. INTRA-ARTICULAR COXA SULTANS:
Arthroscopically removal of loose
bodies and resection of Labral tears

43. THANK YOU