Arthroscopic treatment of the painful "internal" snapping hip: results of a new endoscopic technique and imaging protocol

BACKGROUND: Traditional surgical treatment for a painful snapping iliopsoas tendon has been an open lengthening of the tendon. HYPOTHESIS: An endoscopic release will alleviate painful snapping of the tendon. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Six patients with painful snapping hips who had no pain relief after magnetic resonance arthrography, which included injection of bupivacaine into the hip joint, subsequently had an ultrasound evaluation of their iliopsoas tendons and an anesthetic injection into the psoas bursa. In all 6 patients, the injection relieved their hip pain, and in 4, real-time imaging demonstrated snapping of the tendon. All hips were evaluated with the 100-point Harris hip scoring system before and at 1.5, 3, 6, and 12 months after surgery. RESULTS: Preoperative hip scores averaged 58 points. After surgery, all patients had hip flexor weakness, used crutches for 5 weeks, and had 6-week scores that averaged 62 points. The patients continued to improve, and at 6 and 12 months, their scores averaged 90 and 96 points, respectively, and none had recurrence of their snapping or pain. CONCLUSION: Ultrasound-guided anesthetic injection of the psoas bursa is useful to confirm snapping of the iliopsoas tendon as the cause of a patient's hip pain. Endoscopic release of the tendon is a safe outpatient procedure that provides effective relief of the snapping and pain.     

Surgical correction of the snapping iliopsoas tendon

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 1984 paper from 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.(ABSTRACT TRUNCATED AT 250 WORDS)     

Iliopsoas musculotendinous unit

Hip pain is a common condition with many etiologies, and the workup often includes imaging. The iliopsoas musculotendinous unit is becoming more frequently recognized as the culprit for hip pain, partially due to the increase in athletic activity in the general population as well as to the increased demand in professional sports. Iliopsoas tendon injuries are also seen in the elderly population and documented as occurring following total hip replacement. Iliopsoas diseases, often overlooked as a cause of hip pain, include tendinosis, snapping tendon, bursitis, tears, and avulsion injuries. This article reviews the normal magnetic resonance imaging and sonographic anatomy of the iliopsoas musculotendinous unit and the imaging characteristics of diseases that involve the iliopsoas musculotendinous unit. We review the causes of a snapping hip and the role of sonography in evaluating and guiding treatment of the snapping iliopsoas tendon.     

Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections

OBJECTIVE: Our objective was to review our experience performing sonography-guided iliopsoas bursal/peritendinous injections as a diagnostic and therapeutic tool in the workup and treatment of patients with hip pain. CONCLUSION: Sonography-guided iliopsoas bursal/peritendinous injections are useful in determining the cause of hip pain. They can provide relief to most patients with iliopsoas tendinosis/bursitis after hip replacement. The results of injection alone are not as successful in cases of idiopathic iliopsoas tendinosis/bursitis, but the technique can help determine which patients may benefit from a surgical tendon release.     

Extraarticular snapping hip: sonographic findings

OBJECTIVE. The aim of the study was to determine the sonographic findings of snapping hip and to correlate the findings with the presence or absence of pain. MATERIALS AND METHODS. Twenty patients with snapping hip were examined with sonography. Conventional and dynamic sonographic examinations of both hips were performed using a 5.0- or 7.0-MHz transducer. RESULTS. Conventional sonographic studies allowed identification of various structural abnormalities (tendinitis, bursitis, synovitis) and helped to document tenderness along the course of specific tendons. Dynamic sonographic studies revealed 26 cases of snapping hip. In 24 of these 26 cases, the underlying cause was clearly identified. Twenty-two snapping hips were caused by an abnormal movement of the iliopsoas tendon, and two were caused by iliotibial band friction over the greater trochanter. One patient reported a bilateral snapping sensation that could not be documented on sonography. Snapping hip was elicited by a wide variety of hip movements. Sonography established an immediate temporal correlation between the jerky tendon motion and the painful snap reported by the patient. Only 14 cases of snapping hip were painful. CONCLUSION. Conventional sonographic studies can identify signs of tendinitis, bursitis, or synovitis. Dynamic sonographic studies revealed the cause of snapping hip in most patients. Snapping hip is characterized on sonography by a sudden abnormal displacement of the snapping structure. In our study, a significant proportion of the cases of snapping hip were not painful.     

Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction

The objective of the study was to document the anatomy of the iliopsoas muscle at the level of the groin with the use of sonography. At the same time, behaviour of the muscle during external rotation-flexion and abduction was dynamically evaluated. Forty-two hips in 21 asymptomatic volunteers were studied in static and dynamic conditions. Four bundles of the iliopsoas muscle were identified in all patients. A fifth one was found in only two hips. During dynamic study, a snap was explained by the sudden release of the most medial fibres of the ilacus from an entrapment between the tendon and the superior pubic ramus in 40% of our asymptomatic hips. Anatomy of the iliopsoas muscle can be accurately depicted by sonography at the level of the groin. Snapping of the muscle is often encountered as a physiological finding.     

Surgical correction of internal coxa saltans: a 20-year consecutive study

PURPOSE: To report the complications associated with surgical correction of internal snapping hip. STUDY DESIGN: Retrospective review. METHODS: A review of 92 cases of internal coxa saltans (12 bilateral) from 1982 to 2002 was performed to identify complications following primary surgical correction. An inguinal approach was used for iliopsoas tendon fractional lengthening. The average follow-up time per patient was 5.4 years. RESULTS: A total of 40 complications occurred in 32 patients. Complications included persistent hip pain (n = 6), sensory deficit (n = 8), and hip flexor weakness persisting longer than 1 month (n = 3). Additionally, painful bursa formation (n = 1), hematoma requiring reexploration (n = 1), and superficial infection (n = 1) were noted. Some patients developed recurrent snapping after a 3-month snapping-free interval (n = 9), and some patients never had complete resolution of snapping and were considered failures (n = 11). Of these failures/recurrences, 8 patients had a second tenotomy with 4 failures. Two had a third tenotomy, with 1 failure. CONCLUSIONS: In this series, primary iliopsoas tendon lengthening in patients with internal coxa saltans was without any complication in only 60% of patients; however, overall patient satisfaction was 89%.     

Evaluation of the painful athletic hip: imaging options and imaging-guided injections

OBJECTIVE: This article reviews diagnostic imaging tests and injections that provide important information for clinical management of patients with sports-related hip pain. CONCLUSION: In the evaluation of sports-related hip symptoms, MR arthrography is often used to evaluate intraarticular pathology of the hip. The addition of short- and long-acting anesthetic agents with the MR arthrography injection adds additional information that can distinguish between symptomatic and asymptomatic imaging findings. Osseous abnormalities can be characterized with radiography, MRI, or CT. Ultrasound is important in the assessment of iliopsoas abnormalities, including tendon snapping, and to guide diagnostic anesthetic injection.     

Sonographic localization of hematomas in hemophilic patients with positive iliopsoas sign

Sonography was performed on 23 hemophilic patients presenting with positive iliopsoas sign. In 21 of these patients sonography confirmed the presence of hematomas. Comparison of the presumed clinical location and the sonographic location, however, revealed a significant discrepancy. Only seven of 15 hematomas that were clinically suspected to be in the iliopsoas muscle were confirmed by sonography at that location. Of the remaining cases, three were localized in the hip joint, one in the proximal thigh, one in the abdominal wall, and one in the iliac fossa. Hemorrhage was not found in two cases. This study indicates that sonography provides valuable information about the site of hematoma in these patients.     

The surgical treatment of internal snapping hip

BACKGROUND: Internal snapping hip is an underdiagnosed cause of hip pain that sidelines many recreational and competitive athletes. It originates from a taut iliopsoas tendon that snaps across bony prominences when the hip is extended from a flexed position. When nonoperative treatment methods fail, fractional tendon-lengthening procedures may be used. HYPOTHESIS: Surgical tendon lengthening through a true ilioinguinal approach, which has not been previously reported, will achieve good results in patients with internal snapping hip. STUDY DESIGN: Retrospective cohort study. METHODS: In 30 patients with symptoms in their anterior hip, internal snapping hip was diagnosed by history and physical examination. All patients were initially treated nonoperatively; 19 (63%) improved and did not require further intervention. Eleven patients (12 hips) whose symptoms were recalcitrant to physical therapy were offered the surgical option of iliopsoas tendon lengthening. The procedure was performed via an ilioinguinal intrapelvic approach. Patients were followed up for an average of 3 years. RESULTS: All 11 surgically treated patients (100%) had complete postoperative mitigation of their snapping hip. Nine (82%) reported excellent pain relief. Moreover, nine patients thought that they had greatly benefited from the tendon lengthening and would repeat the surgery. CONCLUSION: Although nonoperative measures are usually successful in the treatment of internal snapping hip, surgical tendon lengthening is a viable approach in cases refractory to nonoperative therapy.     

The painful hip: new concepts

Hip pain is a common condition, and the work-up often includes imaging. This article reviews the normal MR anatomy of the hip and the imaging findings of internal derangements, snapping hip, and femoral acetabular impingement. We will describe the role of MR arthrography in evaluating the patient with suspected labral and articular cartilage abnormalities, as well as the pitfalls in interpretation. We will review the causes of a snapping hip, and the role of sonography in evaluating and guiding treatment of the snapping iliopsoas tendon. We will also review the radiographic and MRI signs of femoroacetabular impingement (FAI), a cause of early degenerative joint disease and hip pain.     

Snapping tendon syndrome: hip tenography with fluoroscopic monitoring

The snapping tendon syndrome may be caused by abnormalities of the fascia lata, gluteus maximus muscle, or less commonly, the iliopsoas tendon. One case is reported in which fluoroscopic monitoring after computed tomography-guided injection of contrast material confirmed the diagnosis of snapping iliopsoas tendon syndrome.     

The snapping hip syndrome

The snapping hip syndrome is a symptom complex characterized by hip pain and an audible snapping of the hip with exercise typically seen in young individuals. "External" and "internal" etiologies have been described, although the "internal" etiology is poorly understood. A clinical, radiographic, and anatomical study of eight patients with this disorder, secondary to an internal etiology, was undertaken to aid in the diagnosis and surgical treatment. Iliopsoas bursography with cineradiography revealed subluxation of the iliopsoas tendon to be an apparent cause of the snapping hip. The anatomy of the hip in relationship to the iliopsoas tendon is defined with the anterior inferior iliac spine, iliopectineal eminence, and lesser trochanter assuming a significant role in the syndrome. An operative approach involving a partial release and lengthening of the iliopsoas tendon, with minimal resection of a lesser trochanteric bony ridge, if involved, is described.     

Stun gun induced myotendinous injury of the iliopsoas and gluteus minimus

We report a 57-year-old man with a complete tear of his iliopsoas tendon at the distal myotendinous junction, a near complete tear of the iliopsoas tendon at the lesser trochanter of the femur, and a high-grade tear of his gluteus minimus tendon at the greater trochanter of the femur after being struck by a stun gun in the proximal left thigh. The stun gun discharge resulted in a forced contraction of the left hip flexor muscles, which resulted in pain, weakness and difficulty with active hip flexion. Three months after the being struck with the stun gun, the patient underwent magnetic resonance imaging (MRI) of the left hip. MRI of the left hip revealed a complete tear of the left iliopsoas tendon from the lesser trochanter with 4 cm of proximal retraction and a high-grade strain of the gluteus minimus tendon at the greater trochanter. The distal iliopsoas myotendinous junction and lesser trochanter tendon insertion were surgically repaired. This case illustrates that a stun gun can cause acute rupture of the iliopsoas tendon and tear of the gluteus minimus tendon, which is well visualized on MRI.     

Diagnostic and therapeutic ankle tenography: outcomes and complications

OBJECTIVE: The purpose of our study was to evaluate tenography complications and outcomes in a large series. MATERIALS AND METHODS: Of 144 tenograms obtained consecutively from May 5, 1995, to March 17, 1997, 111 were located for at least a 6-month follow-up; 65 were posterior tibial, 39 peroneal, two anterior tibial, three flexor digitorum longus, and two flexor hallucis longus tenograms. Tenography was performed fluoroscopically with contrast material and anesthetic followed by steroid placement into tendon sheaths. RESULTS: Of 65 patients undergoing posterior tibial tenography, 31 (48%) had complete or near-complete symptom resolution; 17 (26%) had no relief. Seventeen patients (26%) had initial relief with the subsequent return of pain to the pretenography level. Of 39 patients undergoing peroneal tenography, 18 (46%) had complete or near-complete symptom resolution; 10 (26%) had no and 11 (28%) had initial relief with subsequent pretenography pain return. Of three patients undergoing flexor digitorum longus tenography, one had complete, one had no, and one had initial relief with complete pretenography pain return. One of two patients who underwent flexor hallucis longus tenography had no relief; the other had initial relief with complete pain return. Two patients who underwent anterior tibial tenography had complete pain relief. We found no correlation between degree of tenosynovitis shown radiographically and therapeutic improvement with anesthetic and steroid injection. Tenography complications included one posterior tibial tendon rupture (0.89%) and 14 patients with skin discoloration at the tendon sheath injection site. CONCLUSION: Forty-seven percent of surgical candidates whose condition was refractory to conservative therapy had complete or near-complete prolonged symptom relief after tenography. In appropriate patients, tenography is excellent therapy for tenosynovitis. Certain precautions make complications rare.     

Imaging features of iliopsoas bursitis

The aim of this study was firstly to describe the spectrum of imaging findings seen in iliopsoas bursitis, and secondly to compare cross-sectional imaging techniques in the demonstration of the extent, size and appearance of the iliopsoas bursitis as referenced by surgery. Imaging studies of 18 patients (13 women, 5 men; mean age 53 years) with surgically proven iliopsoas bursitis were reviewed. All patients received conventional radiographs of the pelvis and hip, US and MR imaging of the hip. The CT was performed in 5 of the 18 patients. Ultrasound, CT and MR all demonstrated enlarged iliopsoas bursae. The bursal wall was thin and well defined in 83% and thickened in 17% of all cases. The two cases with septations on US were not seen by CT and MRI. A communication between the bursa and the hip joint was seen, and surgically verified, in all 18 patients by MR imaging, whereas US and CT failed to demonstrate it in 44 and 40% of the cases, respectively. Hip joint effusion was seen and verified by surgery in 16 patients by MRI, whereas CT (4 of 5) and US ( n=12) underestimated the number. The overall size of the bursa corresponded best between MRI and surgery, whereas CT and US tended to underestimate the size. Contrast enhancement of the bursal wall was seen in all cases. The imaging characteristics of iliopsoas bursitis are a well-defined, thin-walled cystic mass with a communication to the hip joint and peripheral contrast enhancement. The most accurate way to assess iliopsoas bursitis is with MR imaging; thus, it should be used for accurate therapy planning and follow-up studies. In order to initially prove an iliopsoas bursitis, US is the most cost-effective, easy-to-perform and fast alternative.     

Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain

OBJECTIVE: Epidural corticosteroid injections have been used extensively to treat lower back pain, but the relative effectiveness of one corticosteroid versus another has never been reported in a large patient series. We retrospectively reviewed 597 patients who had epidural corticosteroid injections to determine any difference in Kenalog or Celestone efficacy. MATERIALS AND METHODS: We reviewed charts and self-reported pain score evaluations of 597 patients who received either Kenalog or Celestone Soluspan as an epidural injection for the treatment of lower back pain from 1997 to 2002 at our university hospital and affiliated Veterans Affairs hospital. Kenalog was used for the initial 2 years and Celestone was used for the next 3 years. Fluoroscopic guidance was used to confirm epidural location, and each patient was injected with a mixture of 5 mL of 0.5% preservative-free lidocaine and 2 mL of either Kenalog 40 mg/mL (triamcinolone acetonide injectable suspension) or Celestone Soluspan 6 mg/mL (betamethasone sodium phosphate and betamethasone acetate injectable suspension). Each patient was given a standardized pain evaluation sheet that used an 11-point scale for initial pain severity. Scoring of pain compared with baseline during the following 14 days was based on a 5-point scale of pain improvement or worsening. RESULTS: On days 0-3 after the procedure, no statistical significance in improvement of lower back and buttock pain was seen between groups. On day 7, 59% of Celestone recipients and 73% of Kenalog recipients showed improvement in lower back pain (p = 0.002, Pearson's chi-square test), and 58% of Celestone recipients and 75% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). On day 14, 54% of Celestone recipients and 71% of Kenalog recipients showed improvement in lower back pain (p < 0.001), and 54% of Celestone recipients and 71% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). CONCLUSION: The epidural injection of Celestone Soluspan and Kenalog reduced lower back and radicular pain in more than half the patients, although Kenalog reduced pain in a significantly larger number of patients than Celestone Soluspan at 1 and 2 weeks after injection.     

Accessibility of extra-articular pathologies of iliopsoas tendon and bursitis of greater trochanter in hip arthroscopy

Purpose

Different pathologies leading to psoas tendon pain and chronic bursitis of the greater trochanter are well known. The purpose of the study was to underline the accessibility of the psoas tendon at lesser trochanter, reproduce the results and measure the distances to anatomical landmarks.

Methods

Twelve hips of six human cadavers underwent hip arthroscopy. The accessibility of the iliopsoas tendon at the lesser trochanter and the bursa at the greater trochanter was documented with the camera. In addition to the usual access portals, alternative ventral ports were analysed concerning accessibility of the lesser trochanter. Afterwards, arthroscopy needles were placed along the extra-articular portals followed by dissection. The distances of the portals in relation to important anatomical landmarks were analysed.

Results

The accessibility to the iliopsoas tendon at the lesser trochanter and to the bursa at the greater trochanter throughout the conventional portals was reproducible. Sufficient distances to the important anatomical landmarks could be shown. The mean distance of the distal ventro-lateral and the wide distal ventro-lateral portal to the nervous cutaneous femoris lateralis was 26.8 ± 5.4 mm and 32.2 ± 3.9 mm. The mean distance from the more ventral located portals to the nervous arteria and vena femoralis was 28.3 ± 2.1 mm.

Conclusion

This is the first study known to us that describes in detail the accessibility of the extra-articular structures underlined by anatomical preparation. In addition, it was demonstrated that a more ventrally located portal had sufficient distance to the important neurovascular structures of the ventral femur and can also be used in addendum if necessary.     

Diagnostic and Therapeutic Foot and Ankle Injections

For patients with disabling foot or ankle pain, medical or surgical treatment decisions can be difficult to make when multiple joints show changes of osteoarthritis or if the patient's pain clinically is related to a joint or tendon that is normal by other imaging studies. For these patients, injection of anesthetic, steroid, or both, into joints or tendon sheaths of the foot and ankle provides important diagnostic information and therapeutic relief. Diagnostic injections may show that the joints noted by other imaging studies have osteoarthritis that are not responsible for a patient's pain or that a normal joint is responsible. When multiple joints show changes of arthritis, anesthetic injections can help decide which and how many joints could benefit from surgical arthrodesis. Relief of pain after anesthetic joint injection correlates well with postoperative pain relief subsequent to arthrodesis. This article discusses the indications and the contraindications for performing diagnostic and therapeutic joint injections, and also presents the techniques for performing these studies.     

MRI and gross anatomy of the iliopsoas tendon complex

Objective The objective was to explain the anatomic basis of a longitudinal cleft of increased signal in the iliopsoas tendon seen on hip MR arthrograms. Materials and methods A prospective review of 20 MR hip arthrograms was performed using standard and fat-suppressed T1-weighted images to establish whether or not the cleft was composed of fatty tissue and to define the anatomy of the iliopsoas tendon complex. Three cadaver dissections of the hip region were then performed for anatomic correlation. Results Fourteen out of 20 MR hip arthrograms demonstrated a longitudinal cleft of increased T1 signal adjacent to the iliopsoas tendon, which suppressed on frequency selective fat-suppressed images, indicating fatty composition. Gross anatomic correlation demonstrated this fatty cleft to represent a fascial plane adjacent to the iliopsoas tendon, in one case separating the iliopsoas tendon medially from a thin intramuscular tendon within the lateral portion of the iliacus muscle. Also noted was a direct muscular insertion of the lateral portion of the iliacus muscle onto the anterior portion of the proximal femoral diaphysis in all 3 cadavers. Conclusion The anatomy of the iliopsoas tendon complex is more complicated than typically illustrated and includes the iliopsoas tendon itself attaching to the lesser trochanter, the lateral portion of the iliacus muscle attaching directly upon the anterior portion of the proximal femoral diaphysis, and a thin intramuscular tendon within this lateral iliacus muscle that is separated from the iliopsoas tendon by a cleft of fatty fascia that accounts for the MRI findings of a cleft of increased T1 signal.