Surgical
correction of the
snapping iliopsoas
tendon* THOMAS JACOBSON, † MD, AND WILLIAM C. ALLEN, MD From the
University of Missouri Health Sciences Center, Division of Orthopaedic Surgery, Columbia, Missouri A frequent complication has been transient or permanent sensory loss of the anterolateral thigh, yet no motor deficits have occurred. An operative approach through a cosmetic transverse inguinal incision, different from our previous approach, is described. Nearly all patients felt that they were much better because of the procedure, and only one patient stated that she would not repeat the procedure for the same problem. We feel that judicious lengthening of the painful snapping iliopsoas tendon near the brim of the pelvis can be of great benefit to symptomatic patients.
ABSTRACT
Eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this "internal" variety of snapping hip. We referred to the pathologic, painful snapping of the iliopsoas in the deep anterior groin as the "internal" snapping hip. This is in contrast to the more common and better-known "external" snapping that involves the greater trochanter and its overlying soft tissues. The results of our iliopsoas lengthening procedure are presented here.
Lengthening of the iliopsoas tendon was accomplished by step cutting of the tendinous portion of the iliopsoas. The pathoanatomy of this poorly understood symptom complex was described in a 1984 paper from
Most reports of painful snapping about the hip have dealt with snapping over the greater trochanter of either a thickened posterior border of the iliotibial band or anterior border of the gluteus maximus.1, B’~ 8~ 10,11 Less often, patients may present with persistent painful snapping in the anterior groin region associated with a variety of activities. This less common and poorly understood &dquo;internal&dquo; variety of snapping hip can present a formidable diagnostic and therapeutic challenge to the orthopaedic surgeon. Nunziata and Blumenfeld,ll in 1951, reported on three patients in whom they attributed painful hip snapping to the iliopsoas tendon snapping over the iliopectineal eminence. In 1984, our institution reported on the pathoanatomy and results of treatment in eight patients with a painful snapping iliopsoas tendon. 1’j
this institution and is reviewed here. Iliopsoas bursography demonstrated a sudden jerking movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence, synchronous with the patient’s pain and often accompanied by an audible snap. The average preoperative duration of symptoms was 2.9 years, and the average length of postoperative followup was 25 months. All patients, except one, had a marked reduction in the frequency of snapping after tendon lengthening, and 14 of 20 hips had no snapping postoperatively. Of the six patients who had recurrence of snapping, all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state. Two hips required reoperation. Postoperatively, only three patients complained of subjective weakness, and most patients were unlimited in physical activity with return to activities such as competitive football, pole vaulting, and long-distance running.
Anatomy Most patients complain of painful snapping when extending the hip from a flexed, abducted, and externally rotated position. Anatomical dissections performed here have revealed that with the hip in a neutral position, the iliopsoas tendon at the brim of the pelvis lies in the groove between the anterior inferior iliac spine laterally and the iliopectineal eminence medially. The anterior inferior iliac spine and the iliopectineal eminence are covered, respectively, by the muscular portions of the iliacus and psoas. The iliacus takes
’ Presented at the 16th annual meetmg of the AOSSM, Traverse City, June 1989 t Address correspondence and repnnt requests to Thomas Jacobson MD, University of Missoun Health Sciences Center, Division of Orthopaedic Surgery, One Hospital Drive, Columbia, MO 65212 2
Michigan,
470
471
origin from the inner table of the ilium, and the psoas originates from the lower lumbar vertebrae. The tendinous portions of each begin to form just proximal to the brim of the pelvis. At this point, the tendons become conjoined and pass through the aforementioned groove between the anterior inferior iliac spine and the iliopectineal eminence to then insert
on
the lesser trochanter. With extension of the
flexed, abducted, and externally rotated hip, the iliopsoas tendon moves from lateral to medial. The bulk of the iliopsoas tendon lies on the posterior and medial aspect of the muscle tendon unit (Fig. 1). We have observed that this major tendinous portion of the iliopsoas remains in the groove even at its far lateral and medial points of excursion (from full flexion, abduction, and external rotation to extension, adduction and internal rotation). This tendon, however, crosses over the most prominent anterior portion of the femoral head (and hip capsule) which protrudes anteriorly (Fig. 2). Our study of anatomical specimens has led us to believe that this normal lateral or medial excursion of the iliopsoas is interrupted, resulting in painful snapping of the iliopsoas over the femoral head and hip capsule. The iliopsoas bursa, which lies between the anterior capsule of the hip and the iliopsoas tendon, may become inflamed and painful with repetitive snapping. 2,6 14
Figure 1. Right hip specimen demonstrating the conjoined iliopsoas tendon (arrow head) located at the posteromedial aspect of the iliopsoas complex. Iliacus (left) retracted laterally and psoas (right) retracted medially. Sartorius has been excised. Rectus femoris (1) is seen laterally, and pectineus (2)
medially.
Iliopsoas bursography was performed by placing a 20 spinal needle over the superior medial quadrant of the
gauge
femoral head under
fluoroscopy. The needle
was
advanced
to contact the femoral head. The needle was then withdrawn 5 mm and the potential space of the iliopsoas bursa was injected with contrast medium.4,1’3 The patients were then asked to reproduce the motion of the hip that produced the
snapping while a cineradiogram was done. In several patients, this revealed a sudden lateral to medial jerking motion of the iliopsoas tendon, synchronous with the patient’s
painful snapping. Generally, this provocative maneuver was extension of the flexed, abducted, and externally rotated hip. The iliopsoas bursa was not easy to locate with a spinal needle; on several occasions, dye was injected around the tendon itself. This produced an equally reliable, if not better, diagnostic test, as the tendon itself could then be seen on the cineradiogram as the patient reproduced the snapping. MATERIALS AND METHODS
Surgical correction of the snapping iliopsoas tendon has now performed on 20 hips (18 patients) at our institution
been
(Table 1). This includes 6 cases from our original paper in 198413 and 14 additional cases since that time. Patients in this series had a minimum of 6 months of followup and an average time since surgery of 25 months. This relatively high number of cases is a result of referrals from around the country, as well as from Canada, following publication of our 1984 article. Nine females and nine males, average age, 23 years, underwent surgical correction of the snapping iliopsoas tendon. Ten right and 10 left hips were involved, the average preoperative duration of symptoms being 2.9 years. All patients
Figure 2. Right hip specimen with muscle bellies of iliacus and psoas retracted laterally (left). In neutral hip position, the tendinous portion of the iliopsoas (arrow head) is shown tented over the anterior femoral head (open arrow). Hip capsule has been excised. Rectus femoris (1 ) is again seen laterally, and pectineus (2) medially. had painful snapping in the anterior groin. For most, this occurred several times per day, with inhibition of activities of daily living or sports participation, or both. Nearly all patients could voluntarily demonstrate snapping at the preoperative examination. Preoperative activities that provoked snapping included walking, long-distance running, football, tennis, swimming, and pole vaulting. A few female patients have complained of painful hip snapping during sexual intercourse. Stretching exercises involving hip extension for 6 to 8 weeks are generally successful in alleviating symptoms. It should be noted that only a minority of patients with a
472 TABLE 1
Patients treated with
surgical correction of snappmg hip syndrome
° Not documented.
snapping hip required surgery. As previously stated, the average preoperative duration of symptoms for patients correction was 2.9 years. Treatments rendered elsewhere, before referral, included rest, ultrasound, steroid injections, and oral antiinflammatory medications. A few patients had undergone surgical procedures about the hip before referral. The records of these procedures were not available. A review of our radiographic studies of this series of patients revealed all plain radiographs of the hip to be normal. Early in our study, iliopsoas bursography was performed on several patients to demonstrate snapping of the iliopsoas tendon. Four hip arthrograms were performed early in the study, and all four were normal. Special radiographic studies are no longer used, and the diagnosis of the snapping iliopsoas is made on history and physical examination.
undergoing surgical
Operative procedure Early in our series, we performed the procedure on an inpatient basis, with an average hospital stay of 3 days. Surgery is now done on an outpatient basis with good results. We originally used a vertical incision over the anterior groin with detachment of the sartorius from the anterior superior iliac spine. We now use a more cosmetic incision that runs parallel to the inguinal crease, just distal to it. The incision is begun just medial to the palpable femoral artery pulse and is extended laterally 8 to 10 cm parallel to the inguinal crease, thus crossing the femoral artery and nerve from medial to lateral. The femoral nerve can now be seen arborizing into many branches, both motor and sensory. The lateral femoral cutaneous nerve crosses the sartorius from medial to lateral, approximately 21/a cm distal to the
superior iliac spine. Its position, however, can be quite variable, and identification of the nerve in the lateral aspect of the incision is important. The lateral femoral cutaneous nerve then pierces the fascia lata close to the intermuscular septum between the sartorius and tensor fascia lata. The deep fascia is incised starting at the medial border of the sartorius and paralleling the skin incision to just lateral to the femoral nerve, which lies just lateral to anterior
the femoral artery. Extreme care must be taken with this part of the surgical approach, as the lateral femoral cutaneous nerve may be very close to the lateral extent of the incision, and the femoral nerve, which may be arborized into many small branches, is at the medial extent of the incision. Because the iliopsoas tendon is quite deep, the deep fascia can be further opened by incising it longitudinally and distally for an inch or so along the medial border of the sartorius. With gentle medial retraction of the femoral neurovascular structures and lateral retraction of the sartorius, the iliopsoas is found just deep to a layer of loose areolar tissue. The borders of the iliopsoas are defined bluntly using a finger, and the muscle tendon unit is followed from the brim of the pelvis to its insertion on the lesser trochanter, the latter of which is quite deep in the wound. This ensures identification of the iliopsoas tendon. Snapping cannot be demonstrated at this point with the patient anesthetized. This approach exposes the iliopsoas tendon from its lateral side. The entire iliopsoas is now rotated such that its anterior border comes to face medially and its posterior border laterally. This maneuver exposes the thickest portion of the iliopsoas tendon, which, as stated previously, normally lies at the posteromedial aspect of the muscle-tendon unit. Now, under direct vision, the posteromedial tendinous portion of the iliopsoas near the brim of the pelvis is partially transected at one or more locations, with resultant lengthening of the iliopsoas unit. The anterior iliopsoas muscle belly and a portion of the medial tendon are left intact. The surgical plane is quite avascular and no drain is used. The deep fascia is closed with absorbable sutures, and a subcuticular skin closure is performed.
Postoperative care Postoperatively, the patient is instructed in crutch use for touch weightbearing ambulation of the operated leg. We define touch weightbearing as allowing the patient to bear the approximate weight of the leg, thus minimizing muscle forces across the hip joint. Full weightbearing is allowed by 3 weeks, with gradual resumption of activity until 6 weeks postoperatively. Six weeks postoperatively, range of motion exercises and flexion strengthening are initiated. RESULTS
Followup of 20 symptomatic hips in 18 patients consisted of 14 personal interviews and 6 chart reviews (13 patients involving 14 hips by personal interview, and 5 patients involving 6 hips by chart review) (Table 2). Patients included in this study were at a minimum of 6 months post-
473
TABLE 2
Followup
on
patients treated surgically for snappmg hip syndrome
rated his outcome as the same stated, oddly enough, that he would have the operation again for his snapping hip; yet, at the same time, he felt that his scar was unsightly. Two patients stated that they were uncertain as to whether they would repeat the procedure, but both stated that they were clinically better. One patient had groin aching with weather changes, and the other patient had &dquo;slight&dquo; subjective hip weakness.
Complications Three
° Unable to contact for personal interview; chart review only. b Refused entrance into the armed forces because of history of snapping
hip.
operation, with an average time since surgery of 25 months. patients underwent the index procedure of iliopsoas lengthening as previously described, and two of the original group additionally had excision of a palpable osteophyte on the lesser trochanter. At the time, these abnormal projections of bone beyond the normal contour of the lesser trochanter were felt to possibly contribute to snapping of the iliopsoas. However, since that time, we have not encountered another lesser trochanter osteophyte. Recurrence of snapping occurred in 6 of 20 hips (Table 2). Five of the six patients who reported recurrence stated that the frequency of snapping and intensity of pain were dramatically reduced. Nearly all of the patients have been able to return to their preoperative level of activity or sports competition. These activities ranged from simple walking to college-level pole vaulting competition. We chose not to create our own subjective rating system, yet we did question patients regarding satisfaction with their postoperative result. We were able to conduct personal interviews with 13 patients (14 symptomatic hips; 1 of the 13 had bilateral procedures). Eleven of the 13 patients stated that they were definitely better as a result of their procedure, and most of these stated that they were &dquo;much better.&dquo; One patient stated that his condition was the same, and one patient
All
stated that her condition
was worse.
Ten of these 13 patients stated that they would definitely repeat the operation for the same problem, 2 were uncertain, and 1 would not repeat the operation. The patient who rated her outcome as worse, and who stated that she would not repeat the procedure, had no postoperative decrease in snapping and had a slight increase in pain. The patient who
patients reported subjective weakness of hip flexion. Only one of these had to modify his activity. Currently, objective hip flexion strength testing has not been performed. We are planning a protocol to document this data in the future by prospective study. Two patients required reoperation for recurrence. The index procedure was repeated with further iliopsoas lengthening. One patient’s condition remained unchanged and one patient reported complete resolution of symptoms. One patient reported an unsightly scar as a result of a vertical incision from our earlier technique, and one patient had a postoperative wound hematoma that resolved spontaneously. By far, the most frequent complication was periincisional loss of sensation. Ten of 20 patients reported some decrease in skin sensation. The majority of these cases involved a small infraincisional area, although two appear to have lost sensation in the lateral femoral cutaneous
nerve
distribution. This should be a very preventable complication.
DISCUSSION
Frequent and painful snapping in the deep anterior groin is a very uncommon and generally poorly understood phenomenon. History and physical examination should easily distinguish this &dquo;internal&dquo; variety from the more common and more publicized &dquo;external&dquo; variety. In 1951, Nunziata and Blumenfeldll described painful snapping of the iliopsoas tendon over the iliopectineal eminence in three patients, two of whom underwent iliopsoas lengthening with good results. Howsé attributed similar symptoms in ballet danto iliofemoral ligaments moving over the femoral head, and offered treatment options of rest or steroid injections into the anterior hip capsule. Micheli9 felt that painful anterior groin symptoms in children may be the result of stenosing tenosynovitis near the iliopsoas insertion. The iliopsoas bursa lies between the anterior hip capsule and the iliopsoas tendon, with communication between bursa and capsule in approximately 15% of cases. This communication is possibly secondary to attritional changes.2°An inflamed bursa could certainly be a cause of anterior groin pain, yet we have found little evidence of an enlarged or inflamed bursa in our patients who have undergone bursography. Additionally, the iliopsoas bursa has consistently been normal by direct inspection at the time of surgery. Iliopsoas bursography is simple to perform with fluoroscopy as described previously. In nearly all cases, when this was performed we were able to observe a sudden lateral to cers
474
medial movement of the iliopsoas tendon under fluoroscopy. This observed movement of the iliopsoas was synchronous with the patient’s painful snapping and was often accompanied by a palpable, as well as audible, component. Most likely, a similar movement occurs in normal hips. The features which distinguish symptomatic from normal hips need further study. Although snapping has been difficult to recreate intraoperatively, we feel that this absence of snapping is actually consistent with our theory of a tight iliopsoas snapping over the femoral head. With the patient anesthetized, and with relaxation of the iliopsoas, one might expect less or absent recreation of snapping.
SUMMARY
painful snapping felt in the deep anterior groin represents the iliopsoas tendon snapping over the femoral head and the anterior hip capsule. Our study of anatomical specimens and our observations during surgical correction for this &dquo;internal&dquo; variety of snapping hip strongly support this belief. Iliopsoas bursography and absent snapping in a relaxed tendon all support the theory of a tight iliopsoas tendon snapping over the femoral head and the anterior hip capsule. We emphasize that the vast majority of patients with a painful snapping iliopsoas do well with nonoperative treatment. The emphasis should be on stretching exercises involving hip extension. In patients who fail conservative treatment, judicious lengthening of the posteromedial tendinous portion of the iliopsoas has yielded good clinical results in the vast majority of patients. Although snapping may recur, in all but one of our patients the frequency of snapping and degree of pain involved were dramatically reduced. We feel that the
REFERENCES 1
2 3 4
5. 6
Binnie JF Snapping hip (Hanche a ressort, Schnellend Hefte). Ann Surg 58 59-66,1913 Chandler SB. The iliopsoas bursa in man Anat Rec 58. 235-240, 1934 Dickinson AM. Case reports by Dr. Arthur M Dickinson Bilateral snapping hip Am J Surg 6 97-101, 1929 Harper MC, Schaberg JE, Allen WC Primary iliopsoas bursography In the diagnosis of disorders of the hip Clin Orthop 221. 238-241, 1987 Howse AJG. Orthopaedists aid ballet. Clin Orthop 89. 52-63, 1972 Huchenson DC, Denman FR Noninfectious iliopectineal bursitis Am J Surg
72 576-579, 1946 7 Jones FW. The anatomy of snapping hip. J Orthop Surg. 1-3, 1920 8 Mayer L: Snapping hip Surg Gynecol Obstet 29. 425-428, 1919 9 Micheli LJ Overuse injuries in children’s sports The growth factor Orthop Clin North Am 14 337-360, 1983
Moreira FEG Anca a scatto (snapping hip) J Bone Joint Surg 22 506, 1940 11 Nunziata A, BlumenfeldI Cadeva a resorte A proposito de una variedad Prensa Med Argentina 38 1997-2001, 1951 12 Parsons EB The snapping hip Texas State Med J 26 361-362, 1930 13 Schaberg JE, Harper MC, Allen WC The snapping hip syndrome Am J Sports Med 12 361-365, 1984 14 Staple TW Arthrographic demonstration of iliopsoas bursa extension of the hip joint Radiology 102 515-516, 1972 10
DISCUSSION Per Renstrom, MD, Burlington, Vermont. This paper is about slipping of the iliopsoas tendon over the iliopectineal eminence, which was first described in 1951 by Nunziata and Blumenfeld and later in 1984 by the authors in a good paper where they presented the pathoanatomy. Pain and disability of a degree to justify surgery is fortunately not common with snapping hips. In spite of this, the authors have a large series-20 patients-in which they have performed surgery. Most of these patients, we have to remember, were referred to the authors. The diagnosis of this problem is based on a history of pain and snapping in the anterior groin. The authors have also used bursography as support for their diagnosis. We have experience with bursography of the Achilles tendons on both sides since 1972. Bursographies are not easy to carry out and are even more difficult to evaluate, especially in chronic conditions. Considering this and the fact that there are at least 13 permanent bursa around the hip joint region, I am impressed by the way in which the authors have used bursography in this area. They should, however, compare the bursography results with the other side so we will know better what is going on. Concerning the surgical technique used, the authors say that they have modified the technique by changing to a cosmetic transverse inguinal incision. This is a difficult surgery
through
a
keyhole. Perhaps
a
posterior approach
could be easier. I also wonder if this procedure could be done under local anesthesia, as it would then be possible to control the snapping. I understand that the authors protect the lateral femoral cutaneal nerve. I wonder somewhat, however, about the complications of transient or permanent sensory loss in the anterolateral side. This is a benign condition, but the authors state that this also is quite frequent. These considerations aside, however, the authors should be complimented. They have focused our attention on a rather unknown and uncommon problem, but they have approached it in a very candid manner.
correction of the
snapping iliopsoas
tendon* THOMAS JACOBSON, † MD, AND WILLIAM C. ALLEN, MD From the
University of Missouri Health Sciences Center, Division of Orthopaedic Surgery, Columbia, Missouri A frequent complication has been transient or permanent sensory loss of the anterolateral thigh, yet no motor deficits have occurred. An operative approach through a cosmetic transverse inguinal incision, different from our previous approach, is described. Nearly all patients felt that they were much better because of the procedure, and only one patient stated that she would not repeat the procedure for the same problem. We feel that judicious lengthening of the painful snapping iliopsoas tendon near the brim of the pelvis can be of great benefit to symptomatic patients.
ABSTRACT
Eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this "internal" variety of snapping hip. We referred to the pathologic, painful snapping of the iliopsoas in the deep anterior groin as the "internal" snapping hip. This is in contrast to the more common and better-known "external" snapping that involves the greater trochanter and its overlying soft tissues. The results of our iliopsoas lengthening procedure are presented here.
Lengthening of the iliopsoas tendon was accomplished by step cutting of the tendinous portion of the iliopsoas. The pathoanatomy of this poorly understood symptom complex was described in a 1984 paper from
Most reports of painful snapping about the hip have dealt with snapping over the greater trochanter of either a thickened posterior border of the iliotibial band or anterior border of the gluteus maximus.1, B’~ 8~ 10,11 Less often, patients may present with persistent painful snapping in the anterior groin region associated with a variety of activities. This less common and poorly understood &dquo;internal&dquo; variety of snapping hip can present a formidable diagnostic and therapeutic challenge to the orthopaedic surgeon. Nunziata and Blumenfeld,ll in 1951, reported on three patients in whom they attributed painful hip snapping to the iliopsoas tendon snapping over the iliopectineal eminence. In 1984, our institution reported on the pathoanatomy and results of treatment in eight patients with a painful snapping iliopsoas tendon. 1’j
this institution and is reviewed here. Iliopsoas bursography demonstrated a sudden jerking movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence, synchronous with the patient’s pain and often accompanied by an audible snap. The average preoperative duration of symptoms was 2.9 years, and the average length of postoperative followup was 25 months. All patients, except one, had a marked reduction in the frequency of snapping after tendon lengthening, and 14 of 20 hips had no snapping postoperatively. Of the six patients who had recurrence of snapping, all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state. Two hips required reoperation. Postoperatively, only three patients complained of subjective weakness, and most patients were unlimited in physical activity with return to activities such as competitive football, pole vaulting, and long-distance running.
Anatomy Most patients complain of painful snapping when extending the hip from a flexed, abducted, and externally rotated position. Anatomical dissections performed here have revealed that with the hip in a neutral position, the iliopsoas tendon at the brim of the pelvis lies in the groove between the anterior inferior iliac spine laterally and the iliopectineal eminence medially. The anterior inferior iliac spine and the iliopectineal eminence are covered, respectively, by the muscular portions of the iliacus and psoas. The iliacus takes
’ Presented at the 16th annual meetmg of the AOSSM, Traverse City, June 1989 t Address correspondence and repnnt requests to Thomas Jacobson MD, University of Missoun Health Sciences Center, Division of Orthopaedic Surgery, One Hospital Drive, Columbia, MO 65212 2
Michigan,
470
471
origin from the inner table of the ilium, and the psoas originates from the lower lumbar vertebrae. The tendinous portions of each begin to form just proximal to the brim of the pelvis. At this point, the tendons become conjoined and pass through the aforementioned groove between the anterior inferior iliac spine and the iliopectineal eminence to then insert
on
the lesser trochanter. With extension of the
flexed, abducted, and externally rotated hip, the iliopsoas tendon moves from lateral to medial. The bulk of the iliopsoas tendon lies on the posterior and medial aspect of the muscle tendon unit (Fig. 1). We have observed that this major tendinous portion of the iliopsoas remains in the groove even at its far lateral and medial points of excursion (from full flexion, abduction, and external rotation to extension, adduction and internal rotation). This tendon, however, crosses over the most prominent anterior portion of the femoral head (and hip capsule) which protrudes anteriorly (Fig. 2). Our study of anatomical specimens has led us to believe that this normal lateral or medial excursion of the iliopsoas is interrupted, resulting in painful snapping of the iliopsoas over the femoral head and hip capsule. The iliopsoas bursa, which lies between the anterior capsule of the hip and the iliopsoas tendon, may become inflamed and painful with repetitive snapping. 2,6 14
Figure 1. Right hip specimen demonstrating the conjoined iliopsoas tendon (arrow head) located at the posteromedial aspect of the iliopsoas complex. Iliacus (left) retracted laterally and psoas (right) retracted medially. Sartorius has been excised. Rectus femoris (1) is seen laterally, and pectineus (2)
medially.
Iliopsoas bursography was performed by placing a 20 spinal needle over the superior medial quadrant of the
gauge
femoral head under
fluoroscopy. The needle
was
advanced
to contact the femoral head. The needle was then withdrawn 5 mm and the potential space of the iliopsoas bursa was injected with contrast medium.4,1’3 The patients were then asked to reproduce the motion of the hip that produced the
snapping while a cineradiogram was done. In several patients, this revealed a sudden lateral to medial jerking motion of the iliopsoas tendon, synchronous with the patient’s
painful snapping. Generally, this provocative maneuver was extension of the flexed, abducted, and externally rotated hip. The iliopsoas bursa was not easy to locate with a spinal needle; on several occasions, dye was injected around the tendon itself. This produced an equally reliable, if not better, diagnostic test, as the tendon itself could then be seen on the cineradiogram as the patient reproduced the snapping. MATERIALS AND METHODS
Surgical correction of the snapping iliopsoas tendon has now performed on 20 hips (18 patients) at our institution
been
(Table 1). This includes 6 cases from our original paper in 198413 and 14 additional cases since that time. Patients in this series had a minimum of 6 months of followup and an average time since surgery of 25 months. This relatively high number of cases is a result of referrals from around the country, as well as from Canada, following publication of our 1984 article. Nine females and nine males, average age, 23 years, underwent surgical correction of the snapping iliopsoas tendon. Ten right and 10 left hips were involved, the average preoperative duration of symptoms being 2.9 years. All patients
Figure 2. Right hip specimen with muscle bellies of iliacus and psoas retracted laterally (left). In neutral hip position, the tendinous portion of the iliopsoas (arrow head) is shown tented over the anterior femoral head (open arrow). Hip capsule has been excised. Rectus femoris (1 ) is again seen laterally, and pectineus (2) medially. had painful snapping in the anterior groin. For most, this occurred several times per day, with inhibition of activities of daily living or sports participation, or both. Nearly all patients could voluntarily demonstrate snapping at the preoperative examination. Preoperative activities that provoked snapping included walking, long-distance running, football, tennis, swimming, and pole vaulting. A few female patients have complained of painful hip snapping during sexual intercourse. Stretching exercises involving hip extension for 6 to 8 weeks are generally successful in alleviating symptoms. It should be noted that only a minority of patients with a
472 TABLE 1
Patients treated with
surgical correction of snappmg hip syndrome
° Not documented.
snapping hip required surgery. As previously stated, the average preoperative duration of symptoms for patients correction was 2.9 years. Treatments rendered elsewhere, before referral, included rest, ultrasound, steroid injections, and oral antiinflammatory medications. A few patients had undergone surgical procedures about the hip before referral. The records of these procedures were not available. A review of our radiographic studies of this series of patients revealed all plain radiographs of the hip to be normal. Early in our study, iliopsoas bursography was performed on several patients to demonstrate snapping of the iliopsoas tendon. Four hip arthrograms were performed early in the study, and all four were normal. Special radiographic studies are no longer used, and the diagnosis of the snapping iliopsoas is made on history and physical examination.
undergoing surgical
Operative procedure Early in our series, we performed the procedure on an inpatient basis, with an average hospital stay of 3 days. Surgery is now done on an outpatient basis with good results. We originally used a vertical incision over the anterior groin with detachment of the sartorius from the anterior superior iliac spine. We now use a more cosmetic incision that runs parallel to the inguinal crease, just distal to it. The incision is begun just medial to the palpable femoral artery pulse and is extended laterally 8 to 10 cm parallel to the inguinal crease, thus crossing the femoral artery and nerve from medial to lateral. The femoral nerve can now be seen arborizing into many branches, both motor and sensory. The lateral femoral cutaneous nerve crosses the sartorius from medial to lateral, approximately 21/a cm distal to the
superior iliac spine. Its position, however, can be quite variable, and identification of the nerve in the lateral aspect of the incision is important. The lateral femoral cutaneous nerve then pierces the fascia lata close to the intermuscular septum between the sartorius and tensor fascia lata. The deep fascia is incised starting at the medial border of the sartorius and paralleling the skin incision to just lateral to the femoral nerve, which lies just lateral to anterior
the femoral artery. Extreme care must be taken with this part of the surgical approach, as the lateral femoral cutaneous nerve may be very close to the lateral extent of the incision, and the femoral nerve, which may be arborized into many small branches, is at the medial extent of the incision. Because the iliopsoas tendon is quite deep, the deep fascia can be further opened by incising it longitudinally and distally for an inch or so along the medial border of the sartorius. With gentle medial retraction of the femoral neurovascular structures and lateral retraction of the sartorius, the iliopsoas is found just deep to a layer of loose areolar tissue. The borders of the iliopsoas are defined bluntly using a finger, and the muscle tendon unit is followed from the brim of the pelvis to its insertion on the lesser trochanter, the latter of which is quite deep in the wound. This ensures identification of the iliopsoas tendon. Snapping cannot be demonstrated at this point with the patient anesthetized. This approach exposes the iliopsoas tendon from its lateral side. The entire iliopsoas is now rotated such that its anterior border comes to face medially and its posterior border laterally. This maneuver exposes the thickest portion of the iliopsoas tendon, which, as stated previously, normally lies at the posteromedial aspect of the muscle-tendon unit. Now, under direct vision, the posteromedial tendinous portion of the iliopsoas near the brim of the pelvis is partially transected at one or more locations, with resultant lengthening of the iliopsoas unit. The anterior iliopsoas muscle belly and a portion of the medial tendon are left intact. The surgical plane is quite avascular and no drain is used. The deep fascia is closed with absorbable sutures, and a subcuticular skin closure is performed.
Postoperative care Postoperatively, the patient is instructed in crutch use for touch weightbearing ambulation of the operated leg. We define touch weightbearing as allowing the patient to bear the approximate weight of the leg, thus minimizing muscle forces across the hip joint. Full weightbearing is allowed by 3 weeks, with gradual resumption of activity until 6 weeks postoperatively. Six weeks postoperatively, range of motion exercises and flexion strengthening are initiated. RESULTS
Followup of 20 symptomatic hips in 18 patients consisted of 14 personal interviews and 6 chart reviews (13 patients involving 14 hips by personal interview, and 5 patients involving 6 hips by chart review) (Table 2). Patients included in this study were at a minimum of 6 months post-
473
TABLE 2
Followup
on
patients treated surgically for snappmg hip syndrome
rated his outcome as the same stated, oddly enough, that he would have the operation again for his snapping hip; yet, at the same time, he felt that his scar was unsightly. Two patients stated that they were uncertain as to whether they would repeat the procedure, but both stated that they were clinically better. One patient had groin aching with weather changes, and the other patient had &dquo;slight&dquo; subjective hip weakness.
Complications Three
° Unable to contact for personal interview; chart review only. b Refused entrance into the armed forces because of history of snapping
hip.
operation, with an average time since surgery of 25 months. patients underwent the index procedure of iliopsoas lengthening as previously described, and two of the original group additionally had excision of a palpable osteophyte on the lesser trochanter. At the time, these abnormal projections of bone beyond the normal contour of the lesser trochanter were felt to possibly contribute to snapping of the iliopsoas. However, since that time, we have not encountered another lesser trochanter osteophyte. Recurrence of snapping occurred in 6 of 20 hips (Table 2). Five of the six patients who reported recurrence stated that the frequency of snapping and intensity of pain were dramatically reduced. Nearly all of the patients have been able to return to their preoperative level of activity or sports competition. These activities ranged from simple walking to college-level pole vaulting competition. We chose not to create our own subjective rating system, yet we did question patients regarding satisfaction with their postoperative result. We were able to conduct personal interviews with 13 patients (14 symptomatic hips; 1 of the 13 had bilateral procedures). Eleven of the 13 patients stated that they were definitely better as a result of their procedure, and most of these stated that they were &dquo;much better.&dquo; One patient stated that his condition was the same, and one patient
All
stated that her condition
was worse.
Ten of these 13 patients stated that they would definitely repeat the operation for the same problem, 2 were uncertain, and 1 would not repeat the operation. The patient who rated her outcome as worse, and who stated that she would not repeat the procedure, had no postoperative decrease in snapping and had a slight increase in pain. The patient who
patients reported subjective weakness of hip flexion. Only one of these had to modify his activity. Currently, objective hip flexion strength testing has not been performed. We are planning a protocol to document this data in the future by prospective study. Two patients required reoperation for recurrence. The index procedure was repeated with further iliopsoas lengthening. One patient’s condition remained unchanged and one patient reported complete resolution of symptoms. One patient reported an unsightly scar as a result of a vertical incision from our earlier technique, and one patient had a postoperative wound hematoma that resolved spontaneously. By far, the most frequent complication was periincisional loss of sensation. Ten of 20 patients reported some decrease in skin sensation. The majority of these cases involved a small infraincisional area, although two appear to have lost sensation in the lateral femoral cutaneous
nerve
distribution. This should be a very preventable complication.
DISCUSSION
Frequent and painful snapping in the deep anterior groin is a very uncommon and generally poorly understood phenomenon. History and physical examination should easily distinguish this &dquo;internal&dquo; variety from the more common and more publicized &dquo;external&dquo; variety. In 1951, Nunziata and Blumenfeldll described painful snapping of the iliopsoas tendon over the iliopectineal eminence in three patients, two of whom underwent iliopsoas lengthening with good results. Howsé attributed similar symptoms in ballet danto iliofemoral ligaments moving over the femoral head, and offered treatment options of rest or steroid injections into the anterior hip capsule. Micheli9 felt that painful anterior groin symptoms in children may be the result of stenosing tenosynovitis near the iliopsoas insertion. The iliopsoas bursa lies between the anterior hip capsule and the iliopsoas tendon, with communication between bursa and capsule in approximately 15% of cases. This communication is possibly secondary to attritional changes.2°An inflamed bursa could certainly be a cause of anterior groin pain, yet we have found little evidence of an enlarged or inflamed bursa in our patients who have undergone bursography. Additionally, the iliopsoas bursa has consistently been normal by direct inspection at the time of surgery. Iliopsoas bursography is simple to perform with fluoroscopy as described previously. In nearly all cases, when this was performed we were able to observe a sudden lateral to cers
474
medial movement of the iliopsoas tendon under fluoroscopy. This observed movement of the iliopsoas was synchronous with the patient’s painful snapping and was often accompanied by a palpable, as well as audible, component. Most likely, a similar movement occurs in normal hips. The features which distinguish symptomatic from normal hips need further study. Although snapping has been difficult to recreate intraoperatively, we feel that this absence of snapping is actually consistent with our theory of a tight iliopsoas snapping over the femoral head. With the patient anesthetized, and with relaxation of the iliopsoas, one might expect less or absent recreation of snapping.
SUMMARY
painful snapping felt in the deep anterior groin represents the iliopsoas tendon snapping over the femoral head and the anterior hip capsule. Our study of anatomical specimens and our observations during surgical correction for this &dquo;internal&dquo; variety of snapping hip strongly support this belief. Iliopsoas bursography and absent snapping in a relaxed tendon all support the theory of a tight iliopsoas tendon snapping over the femoral head and the anterior hip capsule. We emphasize that the vast majority of patients with a painful snapping iliopsoas do well with nonoperative treatment. The emphasis should be on stretching exercises involving hip extension. In patients who fail conservative treatment, judicious lengthening of the posteromedial tendinous portion of the iliopsoas has yielded good clinical results in the vast majority of patients. Although snapping may recur, in all but one of our patients the frequency of snapping and degree of pain involved were dramatically reduced. We feel that the
REFERENCES 1
2 3 4
5. 6
Binnie JF Snapping hip (Hanche a ressort, Schnellend Hefte). Ann Surg 58 59-66,1913 Chandler SB. The iliopsoas bursa in man Anat Rec 58. 235-240, 1934 Dickinson AM. Case reports by Dr. Arthur M Dickinson Bilateral snapping hip Am J Surg 6 97-101, 1929 Harper MC, Schaberg JE, Allen WC Primary iliopsoas bursography In the diagnosis of disorders of the hip Clin Orthop 221. 238-241, 1987 Howse AJG. Orthopaedists aid ballet. Clin Orthop 89. 52-63, 1972 Huchenson DC, Denman FR Noninfectious iliopectineal bursitis Am J Surg
72 576-579, 1946 7 Jones FW. The anatomy of snapping hip. J Orthop Surg. 1-3, 1920 8 Mayer L: Snapping hip Surg Gynecol Obstet 29. 425-428, 1919 9 Micheli LJ Overuse injuries in children’s sports The growth factor Orthop Clin North Am 14 337-360, 1983
Moreira FEG Anca a scatto (snapping hip) J Bone Joint Surg 22 506, 1940 11 Nunziata A, BlumenfeldI Cadeva a resorte A proposito de una variedad Prensa Med Argentina 38 1997-2001, 1951 12 Parsons EB The snapping hip Texas State Med J 26 361-362, 1930 13 Schaberg JE, Harper MC, Allen WC The snapping hip syndrome Am J Sports Med 12 361-365, 1984 14 Staple TW Arthrographic demonstration of iliopsoas bursa extension of the hip joint Radiology 102 515-516, 1972 10
DISCUSSION Per Renstrom, MD, Burlington, Vermont. This paper is about slipping of the iliopsoas tendon over the iliopectineal eminence, which was first described in 1951 by Nunziata and Blumenfeld and later in 1984 by the authors in a good paper where they presented the pathoanatomy. Pain and disability of a degree to justify surgery is fortunately not common with snapping hips. In spite of this, the authors have a large series-20 patients-in which they have performed surgery. Most of these patients, we have to remember, were referred to the authors. The diagnosis of this problem is based on a history of pain and snapping in the anterior groin. The authors have also used bursography as support for their diagnosis. We have experience with bursography of the Achilles tendons on both sides since 1972. Bursographies are not easy to carry out and are even more difficult to evaluate, especially in chronic conditions. Considering this and the fact that there are at least 13 permanent bursa around the hip joint region, I am impressed by the way in which the authors have used bursography in this area. They should, however, compare the bursography results with the other side so we will know better what is going on. Concerning the surgical technique used, the authors say that they have modified the technique by changing to a cosmetic transverse inguinal incision. This is a difficult surgery
through
a
keyhole. Perhaps
a
posterior approach
could be easier. I also wonder if this procedure could be done under local anesthesia, as it would then be possible to control the snapping. I understand that the authors protect the lateral femoral cutaneal nerve. I wonder somewhat, however, about the complications of transient or permanent sensory loss in the anterolateral side. This is a benign condition, but the authors state that this also is quite frequent. These considerations aside, however, the authors should be complimented. They have focused our attention on a rather unknown and uncommon problem, but they have approached it in a very candid manner.
