Hip Labrum Q&A: Troubleshooting Painful and Frustrating Clicking Psoas

Hip Labrum Q&A – Troubleshooting Painful and Frustrating Clicking Psoas

Question from Amy:

I’m feeling frustrated. I noticed a little bit of snapping in my groin since surgery, depending on how I move. It’s some of the same snapping I had before surgery. I know it’s not the joint because it’s a different feel. Not the thud pop the joint makes. It feels like something in the groin is rolling over bone. PT said it felt like snapping hip syndrome to her. Is this a common experience pre-or post-surgery? I notice the more inflamed my muscles are the worse/more frequent/more painful the snapping is.

Surgery included:

• Right hip pain
• Synovectomy (central and peripheral)
• Labral repair
• Chondroplasty of acetabulum
• Femoroplasty
• Ligamentum teres debridement

Answer:

Hi Amy, snapping hip phenomenon is not an uncommon occurrence. In fact, I find that it is very common in those, especially women, with hip pain. I

haven’t read this in the literature, but in my experience, I believe that many folks who have psoas issues related to hip labral tears likely also have concomitant internal snapping hip. The “VIP” (very important point) here is psoas snapping is not yet definitively correlated to hip labral tears in the literature, but psoas compression has been implicated in increasing risk for anterior hip labral tears and paralabral cysts (see Figure 1).  A small retrospective study by Cascio and King in 2013 found evidence of psoas impingement as the main causative factor in hip labral tears. Read the study abstract

 Internal Snapping Hip – The iliacus or psoas tendon can strike the superior pubic ramus/iliopectineal eminence, anterior hip joint, or lesser trochanter (see Figure 2). 

Testing for Internal Snapping Hip – A provocative test for snapping hip is not exclusive to a single mechanism or movement; however, in many cases I have found the most reliable provocative test to be a modified Thomas test, where the patient moves the leg (on his/her own) from hip flexion to FABER (flexion/abduction/external rotation) down toward hip extension with a combination of adduction and internal rotation. A positive test is one that elicits the symptom (e.g. clicking, popping, or snapping, not necessarily associated with pain), oftentimes between 30-45 degrees of dynamic hip flexion. Additionally, snapping hip can sometimes be confirmed via ultrasound; however, the technology is not widely available for this use and may not be covered under insurance. 

Figure 2. Photo sourced from: Lewis CL. Extra-articular Snapping Hip: A Literature Review. Sports Health. 2010 May; 2(3): 186–190.

Overall, the fact that the psoas snaps is not anything to be too concerned in and of itself – UNLESS it is directly associated with pain or impairment. Unfortunately, for many hip patients, this occurrence is painful and frustrating.

The bottom line is internal snapping hip (psoas) can be very common with anterior labral tears. The most important point from a clinical management perspective is to figure out WHICH tendon it is – (it usually is the psoas in many cases).

In addition to differentially diagnosing which tendon or soft tissue is snapping, your therapist needs to consider the following:

• If is it the psoas, which side of the psoas is it? Major or minor? Lateral or medial?
• If it is scar tissue, where is it and what is it associated with? AIIS is a osteplasty is commonly performed with extra-articular hip impingement, for example, although more rare, and it could implicate the muscles which attach to the AIIS and the immediate area, including the sartorious, tensor fascia, lata, and/or the rectus femoris. Read my blog post here about New Discoveries in Hip Impingement
  

  Figure 3. Image: The Arthroscopy Association of North America

• What functional activities does the snapping interfere with, cause discomfort with, or prevent? E.g. – Test both unloaded and loaded hip flexion and abduction, which is typically provocative for anterior internal snapping hip.
• Consider strength or neuromuscular patterning deficits which would cause faulty form or force closure in the hip joint and pelvic area.
• Is the snapping coming from the rectus femoris instead of the psoas? This is possible, especially if there is still active healing and tissue remodeling happening, as would be in the first year post-surgical (see Figure 3).
• Consider if the pain associated with the psoas snapping could be mapped to correlate with the menstrual cycle, specifically during ovulation or the late luteal phase (see figure 4) .
• Is the pain also associated with deep hip rotator dysfunction, especially from the obturator internus (see Figure 5).
• Does the pain result in diminished respiratory diaphragm, transversus abdominis or pelvic diaphragm function? (See my test for this, the TATD Breath)
  

  Figure 4. Menstrual Cycle and Hormonal Correlates

Since you are having pain and impairment with the snapping – I would say it’s time to evaluate scar tissue related to extra-articular impingement that could involve the immediate tissue structures such as the sartorius or rectus femoris in particular, peripheral tissues (which can be tethered to anything from the psoas to the gluteus medius) or visceral tissues (fascia of the iliacus/small intestine or mesenteric root, or iliocecal valve). It is also crucial to consider involvement of the hip scope scars themselves. Address any immobility in the scars and distal from them and then recheck the snapping hip discomfort by repeating the functional activities that previously caused them. Then you’ll know whether or not scar tissue was a culprit (indeed it is almost every time).

Tips:

• Keep in mind the points I have mentioned is where I may start as a PT when caring for my patient(s).
  

  Figure 5. Hip External Rotators, often called “deep hip rotators”. Note the obturator internus, which can often be implicated in hip labral tear rehab and recovery.

• You’ll need a PT who has had advanced training in fascia and/or visceral work and can apply it to hip scopes.

Hope this helps!

Amy: Thank you for replying. I didn’t realize I posted here and I’m glad I did! The snapping is very painful. Just as painful as it was pre surgery. I am 2 weeks post op today.

Ginger: You are VERY early post-op Amy, and typically snapping happens with active ROM – which means, are you moving too early? Most protocols really want no hip flexor engagement for the first 2-3 weeks, plus observance of hip precautions.

Amy: It happens during passive flexion either at PT or when my husband brings me to 90* per my protocol. Doesn’t happen every single time. Was frequent today. Also happened when I leaned left to reach something from a sitting position (right hip operation). I am 20lbs weight baring on right leg with crutches. I do not lift my leg independently yet. I am in a CPM 8 hours per night and still in bolster boots when laying. I rest most of the day and also wearing a hip brace.

Ginger: Yes, your protocol is very typical. It sounds like you are following it well, that is wonderful. You are so early out – that a snapping (likely the psoas) could indeed be aggravating the immediate area – due to local inflammation, most likely, since it is still very early. Scar formation will be important to manage well during this time – make sure your PT addresses that during this acute phase of rehab. Also, make sure you aren’t inadvertently firing your psoas when you transfer or reach for things. Now is really the time to let it rest and calm down – it’s been aggravated for some time now, depending on how long ago you tore the labrum.

Hope this helps!

Sources

1. Henning PT. The running athlete: Stress fractures, osteitis pubis, and snapping hips. Sports Health. 2014;6(2):122-127.
2. Lewis CL. Extra-articular Snapping Hip: A Literature Review. Sports Health. 2010 May; 2(3): 186–190.
3. Brignall CG, Stainsby GD. The snapping hip, treatment by Z-plasty. J Bone Joint Surg Br 1991;73:253-254