Bifid iliopsoas tendon as a cause for internal snapping hip syndrome: A case report

Snapping hip syndrome, or coxa saltans, can result in significant clinical manifestations in patients including pain and limited mobility. A variety of both intra- and extra-articular pathologies have been implicated in snapping hip, including an anatomic variant known as the bifid iliopsoas tendon which has been briefly described in the literature. We report a case of a bifid iliopsoas tendon leading to internal snapping hip syndrome which was ultimately successfully treated with surgical release, including review of the clinical presentation, pathophysiology, and dynamic sonographic findings.     

Extraartikuläres Weichteil-Impingement des Hüftgelenks

Introduction

Conservative treatment is the gold standard for painful extra-articular snapping abnormalities of the hips caused by the psoas tendon, trochanteric bursitis and the iliotibial band. Arthroscopic tenotomy, bursectomy or tractus release are indicated if conservative management is not successful. In addition to open techniques, various arthroscopic techniques have also been described.

Therapeutic options

There are three different arthroscopic techniques described for psoas tenotomy: the extra-articular method (tenotomy at the level of the lesser trochanter), the transcapsular technique (tenotomy through the peripheral compartment) and the central technique (tenotomy at the level of the anterior rim with distracted hips). Good results have been published for all three methods. The mechanical irritation of the psoas tendon after total hip replacement is a special indication for arthroscopic tenotomy. The results are good and it is less invasive than the complicated cup replacement procedure with fewer complications. A newly described syndrome is iliopsoas impingement where an atypical tear of the labrum at the anterior rim of the acetabulum occurs. Treatment is carried out by arthroscopic refixation of the labrum and tenotomy of the psoas tendon. Open or arthroscopic procedures are recommended to perform a bursectomy or tractus release but comparative studies are currently lacking.

Conclusion

If conservative treatment of internal snapping hip syndrome and mechanical psoas irritation after total hip replacement fails, arthroscopic psoas tendon tenotomy is an effective method. Bursectomy and tractus release for extra-articular snapping hip syndrome can be carried out by open or arthroscopic procedures with similar results. The scientific evidence in other extra-articular abnormalities of the hip remains poor.     

Principles of diagnostic sonography in iliopsoas tendon pathology: A case report

This article describes the diagnostic value of musculoskeletal sonography in the management of tendon pathology and outlines a clinical example of its scope of utilization. Herein we describe the case of a 65-year-old man who sought rehabilitation services for left groin pain following a period of intense trekking and uphill walking. He presented with left hip flexor weakness and local tenderness over the left iliopsoas tendon with negative findings on neurological evaluation. Additionally, he presented with left hip capsule and hip flexor tightness with left gluteus maximus and gluteus medius weakness. The left hip capsule tightness was predominantly in the posterior fibres, with restriction of hip internal rotation. The clinical picture overall was suggestive of the presence of risk parameters for iliopsoas tendinopathy. Plain radiographs of the hip revealed mild degenerative changes with a mild pincer impingement. While his clinical and radiological picture was suggestive of degenerative and soft tissue pathology of the hip, a real-time sonographic study was useful in the quantitative confirmation of a partial tear of the left iliopsoas tendon. Additionally, a repeat sonographic study performed four weeks later, revealed a healing iliopsoas tendon seen as a decrease in the width of the hypoechoic presentation of the tear. To summarize, the value of musculoskeletal sonography as a diagnostic tool as well as the assessment of the progression of tendon healing is discussed. Sonography is safe, noninvasive, and does not use ionizing radiation. It is steadily gaining popularity in the diagnosis of tendon lesions.     

Muscle activation patterns in snapping triceps syndrome

OBJECTIVE: To compare the muscle activation pattern in subjects with and without "snapping triceps syndrome" (dislocation of the medial head of the triceps and ulnar nerve over the medial epicondyle). DESIGN: Controlled study. SETTING: Biomechanics laboratory. PARTICIPANTS: Eight male subjects (9 elbows), with symptomatic snapping triceps and 9 male controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activation pattern of the 3 triceps heads during active elbow extension at 0 degrees , 45 degrees , 70 degrees , 90 degrees , and 115 degrees of flexion, recorded by fine-wire electromyography. RESULTS: There were no significant differences between subjects and controls in the firing pattern of the triceps heads. The medial head fired first in 6 of 9 symptomatic elbows and in 7 of 9 controls at 90 degrees of flexion, and in 6 of 9 elbows of both subjects and controls at 115 degrees of flexion, positions where snapping typically occurs. There was no significant difference between the groups as to how often the medial head fired maximally. CONCLUSIONS: This study suggests the firing pattern of the triceps heads may not contribute to the pathogenesis of this syndrome. Rather, the authors believe the anatomic position of the medial head causes it to dislocate over the medial epicondyle, often resulting in ulnar neuritis.     

Les lésions de la jonction myotendineuse du psoas-iliaque en traumatologie du sport

The psoas muscle, the main flexor of the hip joint, is highly solicited in sports activities. Sports injuries are however rarely encountered and described. We report a retrospective series of 33 cases of psoas musculotendinous tears at the point where the muscle changes direction over the iliopectineal eminence. History taking is essential to identify anterior hip pain with rapid or progressive onset. The physical examination searches for pain at hip flexion against resistance, observed in 78% of our cases, and a less sensitive sign, pain at muscle stretching. The morphology should be explored with ultrasound, which is highly contributive in the acute phase. MRI can provide complementary information if the injury is older or recurrent. If there is doubt about the diagnosis, the examination should be able to rule out other hypotheses: traumatic injury to the lower tendons, associated or not with bone detachment, abscess formation, or the more widely encountered psoas hematoma. Early management should focus on puncture aspiration of a hematoma associated with selective rest then rehabilitation over 4 to 6 weeks. Chronic and recurrent injuries may require local injections. An analysis of the sports movement should enable a specific management for each sport.     

Relationship between iliopsoas muscle thickness and hip angle during squats in different pelvic positions

[Purpose] This study aimed to investigate the relationships among the changes in iliopsoas muscle thickness, hip angle, and lower limb joint moment during squatting in different pelvic positions to help in performing hip-dominant squatting exercises. [Participants and Methods] The participants were seven healthy adult males. The measurement task consisted of squatting with 60 degrees of knee flexion in three positions: the anterior, neutral, and posterior pelvic tilt positions. The iliopsoas muscle thickness was measured in the center of the inguinal region using ultrasonography. A three-dimensional motion analysis system was used to measure the joint angles and joint moments. [Results] There were no significant differences in pelvic angles between the pelvic positions. The hip angle differences were significantly higher in the anterior and neutral pelvic tilt positions compared to those in the posterior tilt position. Only the anterior pelvic tilt position had a significantly positive correlation with iliopsoas muscle thickness and hip angle differences. [Conclusion] Squatting in the neutral or posterior pelvic tilt position was not associated with hip angle and iliopsoas muscle thickness changes, whereas squatting in an anterior pelvic tilt position was associated with changes in the iliopsoas muscle thickness and hip flexion angle. Our findings suggest that activation of the iliopsoas muscle might be necessary to promote hip-dominant squatting.Key words: Squats, Iliopsoas muscle, Pelvic position     

Sonographic Evaluation of the Distal Iliopsoas Tendon Using a New Approach

Sonography of the iliopsoas tendon plays an important role in the diagnosis and preoperative and postoperative management for the increasing number of patients under consideration for arthroscopically guided hip interventions such as iliopsoas tenotomy in a variety of conditions, including arthropathy, periarticular calcifications, and cam‐type deformities of the femoral head. The ability to visualize the iliopsoas tendon pre‐operatively can be helpful diagnostically in patients presenting with hip pain and can aid in planning surgery, while evaluating the tendon postoperatively is important in the assessment of causes of postoperative pain and other potential complications. We present a novel technique for visualizing the distal iliopsoas tendon complex in the longitudinal axis at its insertion on the lesser trochanter on sonography.     

Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain.

OBJECTIVE: We measured the surface electromyographic activities of vastus medialis obliquus and vastus lateralis in 16 subjects with patellofemoral joint pain syndrome. DESIGN: Each subject performed bilateral static knee extension exercises at 60% of his or her maximal voluntary effort under different combinations of hip rotation (30 degrees of medial rotation, neutral, 45 degrees of lateral rotation) and knee flexion (20 and 40 degrees) in a standing position. The ratio of surface-integrated electromyographic signals of vastus medialis obliquus over vastus lateralis was calculated for each of the six conditions. Because of significant interaction of hip rotation and knee flexion in the two-way analysis of variance, data were analyzed separately with paired t tests for the effect of knee positions and one-way repeated measures analysis of variance for hip positions. RESULTS: At 20 degrees of knee flexion, there was no significant difference among the three hip positions, whereas at 40 degrees of knee flexion, medial rotation of the hip resulted in significantly higher vastus medialis obliquus over vastus lateralis activity ratio than lateral rotation (P < 0.05). CONCLUSIONS: There was relatively more activation of vastus medialis obliquus than vastus lateralis at 40 degrees of semisquat with the hip medially rotated by 30 degrees. This finding has clinical implications for training the vastus medialis obliquus in patients with patellofemoral joint pain syndrome.     

MR imaging of iliopsoas musculotendinous injuries

The literature describing iliopsoas compartment injuries is based on case reports and small patient series, mostly in the orthopedic literature.Nevertheless, in recent years, there has been a growing recognition of these injuries. Because many intra-articular and extra-articular bony and soft tissue injuries in the groin may clinically mimic each other, because two or more pathologic entities may coexist, and because athletes are highly motivated to continue with their physical activity, diagnosis of iliopsoas injury is often delayed. Thus, cross-sectional imaging is highly important. MR imaging is most accurate for diagnosing nondynamic diseases of the iliopsoas compartment as well as for ruling out other abnormalities of the hip joint and surrounding structures. When a snapping hip is being investigated or corticosteroid injection is warranted, US can be of help in providing a dynamic study and by guiding the injection.     

Sonographically guided injection of anesthetic for iliopsoas tendinopathy after total hip arthroplasty

We report 2 patients who developed pain in the region of the iliopsoas tendon after undergoing total hip arthroplasty. The pain was temporarily relieved by sonographically guided injection of steroid and anesthetic and was subsequently treated by surgical release of the tendon.     

Intrinsic and imposed hamstring length influence posterior pelvic rotation during hip flexion

BACKGROUND: The contribution of posterior tilt of the pelvis (pelvic rotation) to hip flexion has been described for individuals who are standing, supine, and suspended. The effects of intrinsic and imposed hamstring length on the motion have not been investigated in a controlled manner. This study investigated the influence of intrinsic and imposed hamstring length on pelvic rotation during bilateral active hip flexion. METHODS: Intrinsic hamstring length was characterized by the maximal active straight leg raise angle. Hamstring length was imposed by immobilizing the knees in 0 degrees, 45 degrees, and 90 degrees of flexion. Pelvic and thigh segments were marked with reflective spheres. Subjects' saggital plane motion was captured using computerized motion analysis during bilateral hip flexion while both knees were immobilized in three positions. Multifactorial analysis of variance was employed to show the effect of intrinsic and imposed hamstring length on pelvic rotation. FINDINGS: Pelvic rotation occurred throughout the hip flexion range of motion. Pelvic rotation was influenced significantly by hip flexion angle, knee position, the interaction between hip flexion angle and knee position, and the interaction between hip flexion angle, knee position, and active straight leg raise angle. INTERPRETATION: Both intrinsic and imposed hamstring length influence pelvic rotation during bilateral hip flexion. These influences should be considered by clinicians who have individuals engage in hip flexion maneuvers.     

Effect of pelvic-femoral position on vertebral separation produced by lumbar traction.

The purpose of this study was to determine the relationship between hip position and the amount of vertebral separation produced by intermittent lumbar traction. Ten subjects received intermittent lumbar traction at a force of 31.8 kg (70 lb) for 15 minutes in each of three positions of hip flexion (supine): 0 degrees, 45 degrees, and 90 degrees. Vertebral separation was measured on lateral roentgenograms by outlining and marking the vertebral bodies and measuring interspaces with fine-point calipers. Except for the T12-L1 interspace, traction produced greater posterior interspace separation as the angle of hip flexion increased from 0 to 90 degrees. These differences were statistically significant at interspaces L4-5 and L5-S1. We found no systematic changes in anterior interspace distance. To produce maximal posterior vertebral interspace separation, pelvic traction should be applied with the hip flexed 90 degrees.     

A rat model of hip joint contracture induced by mono-articular hip joint immobilization

BackgroundTo elucidate the formation process and therapeutic targets of hip flexion contracture, we developed a rat model of hip flexion contracture induced by hip mono-articular immobilization.MethodsKirschner wires inserted into the femur and hip bone were anchored at the hip in a flexed position in the immobilization groups and unanchored in the sham groups for up to four weeks. Age-matched untreated rats were used as controls. Hip extension range of motion (RoM) was measured at three different extension moments (7.5, 15, and 22.5 N•mm) in each successive myotomy step as follows: before myotomy, after sequential myotomy of the tensor fascia lata, quadriceps muscle, iliopsoas muscle, and after myotomy of all residual muscles (the gluteus medius and adductor muscles). Histological analysis of the hip joint was also performed.FindingsAfter four weeks of immobilization, the RoM before myotomy at 22.5 N•mm was significantly decreased by 29° compared with controls, and this value was unaltered in the sham group. Analyses following serial myotomy suggested that the structures responsible for myogenic contracture were the tensor fascia lata, iliopsoas, gluteus medius, and adductor muscles because the RoMs were increased by these myotomies. Unexpectedly, arthrogenic contracture was not detected at moments other than at 7.5 N•mm, even after four weeks of immobilization. Histological analysis confirmed that pathological changes were not apparent in the anterior capsule of the hip joint.InterpretationThe present findings suggest that myogenic contracture may be an important therapeutic target for immobilization-induced hip flexion contracture.     

Dynamic sonography of external snapping hip syndrome.

OBJECTIVE: To evaluate the dynamic sonographic findings of external snapping hip syndrome. METHODS: Five patients with 7 cases of painful external snapping hip (3 male and 2 female; age range, 14-32 years; mean, 19 years) were examined with sonography. Two patients had bilateral snapping. Dynamic sonographic examinations of hips were performed with a linear 5- to 12-MHz transducer during hip motion. RESULTS: Dynamic sonographic studies of the affected hip revealed causes of the external snapping hip in all cases. It was elicited by an abnormal jerky movement of the iliotibial band overlying the greater trochanter in 5 of 7 cases and of the gluteus maximus muscle in 2 cases. The iliotibial band over the greater trochanter was hypoechoic in 3 of the 5 cases and thickened in 1 case. Dynamic sonography showed good correlations between the jerky movements of the iliotibial band and the gluteus maximus muscle and the painful snapping reported by the patients. CONCLUSIONS: Dynamic sonography was helpful in the diagnosis of external snapping hip syndrome; it showed real-time images of sudden abnormal displacement of the iliotibial band or the gluteus maximus muscle overlying the greater trochanter as a painful snap during hip motion.     

Effects of glenohumeral rotations and translations on supraspinatus tendon morphology

OBJECTIVE: The purpose of this study was to evaluate the effects of glenohumeral rotations and humeral head translations on supraspinatus tendon morphology. DESIGN: A convenience sample of cadaver shoulders was used to measure supraspinatus tendon shape and dimensions from MRI images. BACKGROUND: Epidemiological evidence has indicated that shoulder elevation and external rotation may be risk factors for rotator cuff tendon pathology, but little is known about how these postures affect tendon morphology. METHODS: Measurements of supraspinatus tendon morphology were made from three-dimensional reconstructions based on T2-weighted fast spin-echo magnetic resonance images. Seven cadaver arms were imaged at neutral, 45 degrees external and 45 degrees internal rotations at 0 degrees, 30 degrees, and 60 degrees of glenohumeral abduction. Measurements of the anterior, middle, and posterior portions of the tendon were made using ANALYZE software. RESULTS: The supraspinatus tendon was twisted at the muscle-tendon junction of the middle and posterior portions in 45 degrees external and 45 degrees internal axial rotations of the humerus, especially over 30 degrees of abduction. Abduction over 30 degrees shortened the entire supraspinatus tendon. External and internal rotation motions elongated the anterior and posterior portions, respectively. CONCLUSIONS: Arm posture affects morphology of the supraspinatus tendon. RELEVANCE: The results support the epidemiologic evidence linking external rotation and abduction to supraspinatus tendon disorders.     

Removal of the lateral or medial third of patellar tendon alters the patellofemoral contact pressure and area: an in vitro experimental study in dogs

OBJECTIVES: To compare patellofemoral contact pressure and areas after immediate removal of the lateral, central, or medial third of patellar tendon. DESIGN: In vitro experiment in 12 dogs. BACKGROUND: Alteration of the vector sum of the quadriceps muscle contraction after removal of partial patellar tendon might result in changes of patellar tracking in the trochlea. METHODS: Patellofemoral contact pressure and areas were recorded using Fuji pressure-sensitive film at 45 degrees, 60 degrees, and 90 degrees of knee flexion under an isometric quadriceps force of 100% body weight. The patellofemoral contact imprint from the intact knees were obtained as control, and the lateral (n=4), central (n=4), and medial (n=4) third of the patellar tendon were subsequently removed and the patellofemoral contact imprint was recorded. RESULTS: The patellofemoral contact area was found to increase with increasing knee flexion angles. No change in patellofemoral contact pressure and areas was found after removal of the central third patellar tendon. However, after removal of either lateral or medial third of patellar tendon, the patellofemoral contact was rotated with increasing knee flexion angles. This was due to the altered vector sum of the quadriceps force, resulting in significantly decreased patellofemoral contact areas and simultaneously a significantly increased contact pressure, characterized with concentration of patellofemoral contact pressure on both lateral and medial facets of the patellofemoral joint. CONCLUSIONS: The results suggest that removal of the central third of patellar tendon may not alter the patellofemoral contact pressure and areas as compared with removal of either lateral or medial third of patellar tendon that may result in an altered postoperative tracking mechanism of the patellofemoral joint immediately after operation. RELEVANCE: Findings of this in vitro animal study supports the use of central third of patellar tendon as autograft for anterior cruciate ligament reconstruction. However, further experimental studies are needed to investigate how the postoperative healing of the host patellar tendon will influence the findings obtained from this in vitro study.     

Screw penetration of the iliopsoas muscle causing late-onset pain after total hip arthroplasty: A case report

BACKGROUNDPostoperative pain following total hip arthroplasty (THA) may occur in a few patients but may pose a significant challenge to surgeons if the etiology is not identified. Herein, we report the case of a patient who developed late-onset pain following THA due to screw penetration of the iliopsoas tendon.CASE SUMMARYWe report the case of a 77-year-old man who developed inguinal pain 7 years after THA. While the symptoms resembled that of iliopsoas impingement by the acetabular cup, the pain resolved only when the supplementary acetabular screw protruding through the ilium was decompressed. Decompression was performed using the pararectus approach. The patient was able to ambulate pain-free immediately after surgery.CONCLUSIONA protruded screw through the ilium may penetrate the iliopsoas muscle, causing pain following THA. Pain may resolve with the decompression of the protruded screw.     

Ressaut distal du biceps fémoral : à propos de 2 cas et revue de la littérature

Snapping of the biceps femoris over the fibular head is an uncommon condition. Reported causes include an anomalous insertionof the tendon, trauma at the insertion site of the tendon, and an abnormality of the fibular head. This article reports two cases of a painful snapping biceps femoris tendon. Medical management resulted in a complete resolution of symtoms.     

Changes in geometry of the finger flexor tendons in the carpal tunnel with wrist posture and tendon load: an MRI study on normal wrists.

OBJECTIVES: (1) To develop a methodology to determine the trajectories of the digital flexor tendons using MRI. (2) To examine changes in tendon trajectories due to wrist posture, with and without pinch force. (3) To calculate the radius of curvature of the flexor tendons and note implications for contact forces on the median nerve. (4) To assess the use of Landsmeer's models at the wrist. DESIGN: Finger flexor tendon centroids were digitized from magnetic resonance images of the carpal tunnel and the tendon paths were determined analytically. Radii of curvature were calculated from the tendon paths. BACKGROUND: Landsmeer's models of joint-tendon interaction (Landsmeer, 1961) have been used to determine moment arms and radius of curvature of the tendon paths about articulations. An explanation for a biomechanical cause of work-related carpal tunnel syndrome originated from these models. METHODS: Three healthy male participants had their right wrist scanned while splinted in four wrist postures (flexed to 20 degrees, 45 degrees, neutral, extended to 20 degrees ) with and without maintaining a 10 N pinch grip. 20-24 cross-sectional images were used for each condition. RESULTS: Volar movement of the tendons was seen with wrist flexion and the opposite was true with extension. Tendon intersection angles were calculated between the tendon as it entered the carpal tunnel and as it exited the tunnel and were 50-65% of the wrist angle (R(2)=0.81-0.96). The radius of curvature was smallest (mean=82-127 mm) with an active pinch grip with the wrist splinted at 45 degrees of flexion (mean actual wrist angle 37 degrees ). CONCLUSIONS: The radius of flexor tendon curvature is not constant as previously assumed and is larger than previous estimates. The addition of tendon force with the wrist flexed acts to reduce the radius of curvature which further increases the contact stress on the median nerve and other wrist structures. The use of MRI to determine the tendon paths has provided new insight into the relationships between the finger flexor tendons and other structures at the wrist. RELEVANCE: These findings provide data for biomechanical models of the carpal tunnel and predict the possible pathophysiology of work-related carpal tunnel syndrome.     

The use of a tissue expander to enlarge a graft for surgical treatment of a pressure ulcer in a quadriplegic. Case report

This case reports the use of a tissue expander to facilitate the surgical closure of a decubitus ulcer in a spinal cord injured quadriplegic. The patient is a 42-year-old man with chronic nonhealing of a right ischial pressure ulcer. It had required a flap rotation and partial ischiectomy in the remote past that had been problem-free for many years. The patient subsequently required the placement of a new flap, but insufficient tissue was available to close the wound with the hip in 90 degrees of flexion. Closing the wound with the hip in extension merely led to breakdown when the hip was put in the 90 degrees of flexion required for the sitting position. The problem was solved by using a tissue expander to increase the available soft tissue. A tissue expander was inserted and gradually expanded over a period of weeks by injecting it with fluid. It was then removed, and the expanded tissue that had grown over it allowed closure of the wound without tension on the tissues with the hip in flexion. The patient subsequently returned to the sitting position and his work as a computer programmer. Tissue expanders are commonly used in breast reconstruction, but have found many other uses in plastic surgery over the last decade. It is felt that tissue expansion techniques should not be the primary surgery treatment of decubitus ulcers, but can be used in difficult cases like this one to provide additional tissue.