Rev. bras. ortop. vol.49 número5

rev bras ortop.2014;49(5):532–534

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Technical

Note

Proposal

for

a

new

clinical

test

for

diagnosing

lateral

hip

snapping

夽

,

夽夽

Henrique

Antonio

Berwanger

de

Amorim

Cabrita

_,

_Henrique

_Melo

_de

_Campos

_Gurgel

,

Ricardo

Marques

_,

_Leandro

_Emilio

_Nascimento

_Santos

_,

_José

_Ricardo

_Negreiros

_Vicente

_,

Marcos

de

Camargo

Leonhardt

_,

_Leandro

_Ejnisman

_,

_Alberto

_Tesconi

_Croci

a_{InstitutodeOrtopediaeTraumatologia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,}

Brazil

b_{InstitutoVita,SãoPaulo,SP,Brazil}

c_{HospitalFelícioRocho,BeloHorizonte,MG,Brazil}

d_{FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil}

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Articlehistory:

Received2September2013 Accepted2September2013 Availableonline27August2014

Keywords: Hip Hipinjuries Arthralgia

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Lateralhipsnappingisanosologicalentitythatisoftenunknowntomanyorthopedistsand eventosomehipsurgeryspecialists.Itcomprisespalpableand/oraudiblesnappingonthe lateralfaceofthehipthatissometimespainful,causedbymuscle-tendonfrictiononthe greatertrochanterduringflexionandextensionofthecoxofemoraljoint.Inthefollowing, wedescribeanewtestfordiagnosinglateralhipsnapping,whichiseminentlyclinical.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Proposta

de

um

novo

teste

clínico

para

o

diagnóstico

do

ressalto

lateral

do

quadril

Palavras-chave: Quadril

Lesõesdoquadril Artralgia

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Oressaltolateraldoquadriléumaentidadenosológicamuitasvezesdesconhecidapela maioriadosortopedistaseatémesmoporalgunsespecialistasemcirurgiadoquadril. Trata-sedapresenc¸adeumestalidopalpávele/ouaudívelnafacelateraldoquadril,porvezes doloroso,causadopeloatritomusculotendíneosobreograndetrocanterduranteaflexão eaextensãodaarticulac¸ãocoxofemoral.Descreveremosaseguir umnovotesteparao diagnósticodoressaltolateraldoquadril,queéeminentementeclínico.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

Pleasecitethisarticleas:deAmorimCabritaHAB,deCamposGurgelHM,MarquesR,SantosLEN,VicenteJRN,deCamargoLeonhardt Metal.Propostadeumnovotesteclínicoparaodiagnósticodoressaltolateraldoquadril.RevBrasOrtop.2014;49(5):532–4.

夽夽

WorkdevelopedintheDepartmentofOrthopedicsandTraumatology,HospitaldasClínicas,MedicalSchool,UniversidadedeSão PauloandattheVitaInstitute.

∗ _{Correspondingauthor.}

E-mail:drgurgel@usp.br(H.M.d.C.Gurgel). http://dx.doi.org/10.1016/j.rboe.2014.08.004

rev bras ortop.2014;49(5):532–534

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Introduction

Itmaybedifficulttoevaluatepatientswithhippaingiventhat thereare vast numbers ofdifferential diagnoses,including intra-articularandextra-articularpathologicalconditionsand painrelatingtopelvicandvertebralpathologicalconditions.

Advancesinimagingexaminations, particularregarding magneticresonanceimaging,andknowledgecomingfromthe evolutionofsurgicalproceduressuchasarthroscopyhaveled togreater comprehensionofthefunctional anatomyofthe hip,whichincludesdiseasesofsofttissuessuchasmuscles andtendons.1

Thegreatertrochantericpainsyndromewasdefined orig-inallyas“painfulpalpationabovethegreatertrochanter”and itincludestrochantericbursitis,tendinopathyofthegluteus mediusand minimus muscles and lateral hip snapping. It hasgreater prevalenceamongwomen thanamongmen.1,2 It isrelatively common and affects 10–25% ofthe general population,1 _{but only a small percentage presents lateral} snapping.

Lateralhipsnapping,alsoknownassnappingorclacking ofthe iliotibialband (ITB), occursthroughfriction between the posterior edge of the ITB or anterior edge of the glu-teus maximus muscle and the lateral face of the greater trochanter duringhip movements, particularly flexion and extension.1,3–5 _{When thehip isextended,the ITBis} poste-riortothegreatertrochanter.Asthehipisthenflexed,the ITBpassesbythegreatertrochantertoreachamoreanterior position.Althoughthispassageisphysiologicalandbenign, snappingmayoccurincasesoflateraltensionandthis some-timesbecomesaninflammatoryandpainfulconditionthat irradiates tothe lateral face of the thigh or tothe ipsilat-eralglutealregion.6_{Patientswithsymptomaticsnappingare} generallyyoungandphysicallyactive.1_{Thesnappingmaybe} voluntaryorinvoluntary7_{andpalpableand/oraudible.}8

Becauseofthefewstudiesthathavebeenpublishedonthis topic,thediagnosisofsnappingisoftennotmadeand ade-quatetreatmentisimpaired.History-takinggenerallyshows thatthepatientsareactive,withanontraumaticlong-lasting conditionthatshowsprogressivesymptomsof“discomfort” aroundthegreatertrochanter.Underphysicalexamination, patientsmaybeabletoreproducethesnappingunaided,or theorthopedistmayfinditthroughhipextensionand flex-ionmaneuvers,withthepatientinhorizontalorlateraldorsal decubitus.TheObertest maybepositiveand indicate ten-sionintheITB,andTrendelenburggaitmaybefound,thus indicatinggluteallesions.4

Snapping needstobedifferentiated from intra-articular causesofclacking ofthehip, suchasfreebodies, synovial osteochondromatosisandlesionsoftheacetabularlabrum.9,10 Simple radiographs of the coxofemoral joint are generally normalandthisresulthelpstoruleoutfreebodies. Examina-tionslikestaticultrasoundandmagneticresonanceimaging mayshow localinflammatoryprocesses, and these exami-nationshelptocorroboratethediagnosisoflateralsnapping and are also important for discarding other likely causes of clacking hips. Dynamic ultrasound is the best method for making imaging diagnoses of snapping, although it is examiner-dependent.11

Thetreatmentforpainfulsnappingcanbeconservative, throughchangingtheactivitiesthatcauseit,administrationof oralanalgesicsandanti-inflammatorydrugs,stretching exer-cisesfortheiliotibialtractand,ifnecessary,localinfiltration withcorticoidsandanesthetic,whichdiminishesthe inflam-mationoftheiliotibialtractandthehipbursas.

Inaminorityofthesecases,ifconservativetreatmentfails, surgery becomes necessary.1 _{This generally involves} zeta-plastywithstretchingorresectionofpartoftheITB,andit can be done bymeans of open techniques8 _{or endoscopic} techniques.3,4

Althoughthemechanismthatcausessnappinghasbeen welldescribedintheliterature,noclinicaltesthasyetbeen describedfordiagnosisthis,tothebestofourknowledge.

Theaimofthisstudywastodescribeasimpleclinicaltest withthecapacitytoidentifylateralsnappingofthehip.

Description

of

the

clinical

test

Thepatientshouldbepositionedinhorizontaldorsal decu-bitus on an examination bed, with the lower limbs fully extended. Theexaminer stands contralaterallytothe limb that is to be tested, in order to carry out the maneuvers (Fig.1).

Fig.1–Examinerpositionedonthesidecontralateraltothe limbthatistobeexamined.

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Fig.3–Internalrotationofthehipwiththehipflexedat 15◦_{andadductedat45}◦_{.Atthismoment,thesnappingcan}

beseenwhenthetestispositive.

Fig.4–Externalrotationofthehipwiththehipflexedat 15◦_{andadductedat45}◦_{.Atthismoment,thesnappingcan}

beseenwhenthetestispositive.

Thelimbthatisnotgoingtobeexaminedisthenmoved offthebedandislefthanging,withthekneeflexedat90◦_.The

lowerlimbthatistobeexaminedshouldbepositionedwith thekneeextendedandwiththehipflexedat15◦_andadducted

at45◦_{(Figs.2and3).}

Theexaminer placesweight onthe anterosuperior iliac spinewithonehandandthusstabilizesthepelvis.Withthe other,heholdsthelowerlimbunderexaminationbytheankle and makesinternal and external hip rotation movements (Figs.3and4).

Whenthelimbispositiveforsnapping,thisisnotedonthe lateralfaceofthehip.Thesnappingisoftenvisible,palpable andevenaudible,anditmayormaynotbepainful.

Final

remarks

Althoughlateralsnappingofthehipisrareandgenerally pain-less,itshouldformpartofthedifferentialdiagnosisforpainful hipsyndrome.

Webelievethatthetestdescribedabovemayhelp orthope-diststorecognizelateralsnappingofthehip,althoughfurther studieswouldbenecessaryinordertoconfirmitsvalidityand reproducibility.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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