Clinical Orthopaedics and Related Research®

, Volume 469, Issue 1, pp 289–293

Case Report: Bifid Iliopsoas Tendon Causing Refractory Internal Snapping Hip

Case Report

Abstract

Background

Treatment of painful internal snapping hip (coxa saltans) via arthroscopic lengthening or release of the iliopsoas tendon is becoming preferred over open techniques because of the benefits of minimal dissection, the ability to address concomitant intraarticular disorders, and a low complication rate. Persistent snapping after release is uncommon, especially when performed arthroscopically. Reported causes include incomplete release, intraarticular disorders, and incorrect diagnosis. Anatomic variants are not discussed in the orthopaedic literature.

Case Description

We report a case of an 18-year-old softball player with internal snapping hip treated with arthroscopic iliopsoas release in the peripheral compartment. Postoperatively, the athlete continued to have painful snapping. Repeat arthroscopy with a larger capsulotomy revealed a bifid iliopsoas tendon causing refractory internal snapping hip, which resolved after revision arthroscopic release.

Literature Review

Bifid iliopsoas tendon as a cause of persistent snapping of the hip has not been reported in the orthopaedic literature. Prior sonographic and anatomic studies suggest the bifid iliopsoas tendon exists but is uncommon.

Purpose and Clinical Relevance

Recognition that a bifid iliopsoas tendon may be the source of painful internal snapping hip is important to prevent clinical failure of surgical management of the internal snapping hip. The differential diagnosis of failed iliopsoas lengthening surgery should include the consideration of an incompletely lengthened tendon attributable to bifid iliopsoas tendon anatomy. Prevention of this complication includes making a large enough capsulotomy to identify the tendon and to ensure it is not bifid.

References

  1. 1.
    Allen WC, Cope R. Coxa saltans: the snapping hip revisited. J Am Acad Orthop Surg. 1995;3:303–308.PubMedGoogle Scholar
  2. 2.
    Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. Am J Sports Med. 2008;36:2363–2371.CrossRefPubMedGoogle Scholar
  3. 3.
    Byrd JW. Evaluation and management of the snapping iliopsoas tendon. Instr Course Lect. 2006;55:347–355.PubMedGoogle Scholar
  4. 4.
    Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. 2008;190:576–581.CrossRefPubMedGoogle Scholar
  5. 5.
    Flanum ME, Keene JS, Blankenbaker DG, Desmet AA. Arthroscopic treatment of the painful “internal” snapping hip: results of a new endoscopic technique and imaging protocol. Am J Sports Med. 2007;35:770–779.CrossRefPubMedGoogle Scholar
  6. 6.
    Fredensborg N. The CE angle of normal hips. Acta Orthop Scand. 1976;47:403–405.CrossRefPubMedGoogle Scholar
  7. 7.
    Guillin R, Cardinal E, Bureau NJ. Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction. Eur Radiol. 2009;19:995–1001.CrossRefPubMedGoogle Scholar
  8. 8.
    Gruen GS, Scioscia TN, Lowenstein JE. The surgical treatment of internal snapping hip. Am J Sports Med. 2002;30:607–613.PubMedGoogle Scholar
  9. 9.
    Hoskins JS, Burd TA, Allen WC. Surgical correction of internal coxa saltans: a 20-year consecutive study. Am J Sports Med. 2004;32:998–1001.CrossRefPubMedGoogle Scholar
  10. 10.
    Ilizaliturri VM Jr, Chaidez C, Villegas P, Briseno A, Camacho-Galindo J. Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome. Arthroscopy. 2009;25:159–163.CrossRefPubMedGoogle Scholar
  11. 11.
    Ilizaliturri VM Jr, Villalobos FE Jr, Chaidez PA, Valero FS, Aguilera JM. Internal snapping hip syndrome: treatment by endoscopic release of the iliopsoas tendon. Arthroscopy. 2005;21:1375–1380.CrossRefPubMedGoogle Scholar
  12. 12.
    Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med. 1990;18:470–474.CrossRefPubMedGoogle Scholar
  13. 13.
    Jamali AA, Mladenov K, Meyer DC, Martinez A, Beck M, Ganz R, Leunig M. Anteroposterior pelvic radiographs to assess acetabular retroversion: high validity of the “cross-over-sign.” J Orthop Res. 2007;25:758–765.CrossRefPubMedGoogle Scholar
  14. 14.
    Jelev L, Shivarov V, Surchev L. Bilateral variations of the psoas major and the iliacus muscles and presence of an undescribed variant muscle—accessory iliopsoas muscle. Ann Anat. 2005;187:281–286.CrossRefPubMedGoogle Scholar
  15. 15.
    Lyons JC, Peterson LF. The snapping iliopsoas tendon. Mayo Clin Proc. 1984;59:327–329.PubMedGoogle Scholar
  16. 16.
    Omeroglu H, Biçimoglu A, Aguş H, Tümer Y. Measurement of center-edge angle in developmental dysplasia of the hip: a comparison of two methods in patients under 20 years of age. Skeletal Radiol. 2002;31:25–29.CrossRefPubMedGoogle Scholar
  17. 17.
    Reynolds D, Lucas J. Klaue K. Retroversion of the acetabulum: a cause of hip pain. J Bone Joint Surg Br. 1999;81:281–288.CrossRefPubMedGoogle Scholar
  18. 18.
    Schaberg JE, Harper MC, Allen WC. The snapping hip syndrome. Am J Sports Med. 1984;12:361–365.CrossRefPubMedGoogle Scholar
  19. 19.
    Shah A, Busconi B. Hip, pelvis, and thigh. In: DeLee JC, Drez D Jr, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine. Ed 3. Philadelphia, PA: Saunders; 2009. www.mdconsult.com.laneproxy.stanford.edu/book/player/linkTo?isbn=978-1-4160-3143-7&eid=4-u1.0-B978-1-4160-3143-7..00021-X--s0115&type=bookPage&lpState=open&lpTab=contentsTab&from=toc.Google Scholar
  20. 20.
    Tatu L, Parratte B, Vuillier F, Diop M, Monnier G. Descriptive anatomy of the femoral portion of the iliopsoas muscle: anatomical basis of anterior snapping of the hip. Surg Radiol Anat. 2001;23:371–374.CrossRefPubMedGoogle Scholar
  21. 21.
    Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy. 2006;22:907e1–4.Google Scholar
  22. 22.
    Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint: with special reference to the complication of osteo-arthritis. Acta Chir Scand. 1939;83(suppl 58):1–135.Google Scholar
  23. 23.
    Winston P, Awan R, Cassidy JD, Bleakney RK. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118–126.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryStanford UniversityRedwood CityUSA

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