ARE YOUR HIPS SNAPPING MORE THAN YOUR FINGERS?

What is Snapping Hip Syndrome?

Snapping hip occurs when a muscle, tendon, or ligament rolls over a bony prominence in the hip. Snapping hip can occur in different areas of the hip:

• Front. Snapping at the front of the hip can involve the hip flexor muscle rolling over the front of the hip bone, or the hip ligaments rolling over the thigh bone or tissues of the hip joint.
• Side. This condition involves the ITB (iliotibial band) rolling over the outer thigh bone or the big muscle on the back of the hip (gluteus maximus) sliding over the outer thigh bone.
• Back. This condition involves one of the hamstring muscles rolling over the bottom of the hip bone.

Snapping hip can occur when the hip muscles are excessively used and become fatigued, tight, and/or swollen.

Athletic activities like track and field, soccer, horseback riding, cycling, gymnastics, and dance can trigger the condition. It can also occur during everyday activities that require repeated forceful movement of the legs.

How Does it Feel?

Snapping hip causes a snapping sensation and sound that can be felt in the front, the side, or the back of the hip. Often, the snapping can be pain-free. If it causes pain, the pain usually ceases when the leg movement causing the snapping is stopped. In athletes and dancers, the snapping can be accompanied by weakness and may diminish performance.

The snapping is most commonly felt when kicking the leg forward or to the side, when bringing the leg behind the body, when rising from a chair, or when rotating the body or the leg.

Often, walking and running in a straight line are snap-free and pain-free, although in some people these activities are limited by the pain of the structure that is snapping.

Signs and Symptoms

With snapping hip, you may have:

• Snapping or popping in the front, side, or back of hip when lifting, lowering, or swinging the leg
• Weakness in the leg when trying to lift it forward or sideways
• Tightness in the front or back of the hip
• Swelling in the front or side of the hip
• Difficulty performing daily activities such as rising from a chair and walking

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will ask you:

• How you injured your hip and if you heard a pop when you suffered the injury
• If you feel snapping, popping, or pain
• Where you feel the snapping or pain
• If you experienced a direct hit to the leg
• If you saw swelling in the first 2 to 3 hours following the injury
• If you experience pain when lifting your leg forward or backward, walking, changing directions while walking or running, or when lifting the knee
• If you participate in any repetitive, forceful, or plyometric (quick explosive jumping) sport activities.

Your physical therapist also will perform special tests to help determine whether you have a snapping hip, such as:

• Asking you to lift your leg quickly
• Asking you to push against the physical therapist’s hand when he or she tries to push your leg outward, backward, and forward (muscle strength test)
• Gently feeling the muscle to determine the specific location of the injury (palpation)

Your therapist may use additional tests to assess possible damage to other parts of your body, such as your hip joint or lower back.

To provide a definitive diagnosis, your therapist may collaborate with a physician or other health care provider. The physician may order further tests—such as an x-ray or magnetic resonance imaging (MRI)—to confirm the diagnosis and also to rule out other potential damage. However, these tests are not commonly needed for snapping hip syndrome.

How Can a Physical Therapist Help?

Your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should perform at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may advise you to:

• Rest the injured hip by avoiding walking or any activity that causes pain. In rare cases, crutches may be recommended to reduce further strain on the muscles when walking.
• Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
• Consult with another health care provider for further services such as medication or diagnostic tests.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electricity, taping, exercises, and special hands-on techniques that move muscles and joints (manual therapy).

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with movements of the leg and hip joint that the therapist gently performs, and progress to active exercises and stretches. Treatment for snapping hip often involves manual therapy techniques called trigger point release and soft tissue mobilization, as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your injury at each stage of recovery, and your physical therapist will choose and teach you the appropriate exercises that will restore your strength, power, and agility. These may be performed using free weights, stretchy bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For snapping hip syndrome, muscles of the hip and core are often targeted by the strength exercises.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport, as well as design your plan of care to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work retraining activities. Athletes will be taught sport-specific techniques and drills to help achieve sport-specific goals.

Prevent Future Re-injury

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core (abdomen) to help prevent future injury. These may include strength and flexibility exercises for the hip, thigh, and core muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of snapping hip syndrome. If it is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Snapping hip syndrome can be prevented by:

• Warming up before starting a sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including those for the muscles on the front, side, and back of the hip.
• Gradually increasing the intensity of an activity or sport. Avoid pushing too hard, too fast, too soon.
• Following a consistent strength and flexibility exercise program to maintain good physical conditioning, even in a sport’s off-season.
• Wearing shoes that are in good condition and fit well.

ADHESIVE CAPSULITIS

Often called a stiff or “frozen shoulder,” adhesive capsulitis occurs in about 2% to 5% of the general population. It affects women more than men and typically occurs in people who are over the age of 45. Of the people who have had adhesive capsulitis in one shoulder, 20% to 30% will get it in the other shoulder.

What is Frozen Shoulder (Adhesive Capsulitis)?

Adhesive capsulitis is the stiffening of the shoulder due to scar tissue, which results in painful movement and loss of motion. The actual cause of adhesive capsulitis is a matter for debate. Some believe it is caused by inflammation, such as when the lining of a joint becomes inflamed (synovitis), or by autoimmune reactions, where the body launches an "attack" against its own substances and tissues. Other possible causes include:

• Reactions after an injury or surgery
• Pain from other conditions—such as arthritis, a rotator cuff tear, bursitis, or tendinitis—that has caused you to stop moving your shoulder
• Immobilization of your arm, such as in a sling, after surgery or fracture

Often, however, there is no known reason why adhesive capsulitis starts.

How Does it Feel?

Most people with adhesive capsulitis have worsening pain and then a loss of range of movement. Adhesive capsulitis can be broken down into 4 stages, and your physical therapist can help determine what stage you are in:

Stage 1 - "Pre-Freezing"

During this stage, it may be difficult to identify your problem as adhesive capsulitis. You've had symptoms for 1 to 3 months, and they're getting worse. There is pain with active movement and passive motion (movements that a physical therapist does for you). The shoulder usually aches when you're not using it, but pain increases and becomes "sharp" with movement. You'll have a mild reduction in motion during this period, and you'll protect the shoulder by using it less. The movement loss is most noticeable in "external rotation" (this is when you rotate your arm away from your body), but you might start to lose motion when you raise your arm (called "flexion and abduction")or reach behind your back (called "internal rotation"). You'll have pain during the day and at night.

Stage 2 – "Freezing"

By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). The shoulder still has some range of movement, but this is limited by both pain and stiffness.

Stage 3 – "Frozen"

Your symptoms have persisted for 9 to 14 months, and you have greatly decreased range of shoulder movement. During the early part of this stage, there is still a substantial amount of pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it.

Stage 4 – "Thawing"

You've had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at night. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate.

How Is It Diagnosed?

Often, physical therapists don't see patients with adhesive capsulitis until well into the freezing phase or early in the frozen phase. Your physical therapist will perform a thorough evaluation, including an extensive health history, to rule out other diagnoses. Your therapist will look for a specific pattern in your decreased range of motion; it's called a "capsular pattern" and is typical with adhesive capsulitis. In addition, your therapist will consider other conditions you might have—such as diabetes, thyroid disorders, and autoimmune disorders—that are associated with adhesive capsulitis.

How Can a Physical Therapist Help?

Your physical therapist's overall goal is to restore your movement so that you can perform your activities and life roles. Once the evaluation process has identified the stage of your condition, your therapist will create an exercise program tailored to your needs. Exercise has been found to be most effective for those who are in stage 2 or higher.

Stages 1 and 2

Your physical therapist will help you maintain as much range of motion as possible and will help reduce the pain. Your therapist may use a combination of stretching and manual therapy techniques to increase your range of motion. The therapist also may decide to use treatments such as heat and ice to help relax the muscles prior to other forms of treatment. The therapist will give you a home exercise program designed to help reduce the loss of motion.

Stage 3

The focus of treatment will be on the return of motion, with your therapist using more aggressive stretching and manual therapy techniques. You may begin some strengthening exercises as well, and your home exercise program will change to include these exercises.

Stage 4

In the final stage, your therapist will focus on the return of "normal" shoulder body mechanics and your return to normal, everyday, pain-free activities. The therapist will continue to use stretching, strength training, and a variety of manual therapy techniques.

Sometimes, conservative care cannot reduce the pain. If this happens to you, your physical therapist may refer you for an injection of anti-inflammatory and pain-relieving medication into the joint space. Research has shown that although these injections don’t provide longer-term benefit for range of motion and don’t shorten the duration of the condition, they do offer short-term benefit in reducing pain.

Can this Injury or Condition be Prevented?

The cause of adhesive capsulitis is debatable, with no definitive cause, so there is no known method of prevention. The onset is usually gradual, with the disease process needing to "run its course."

Real Life Experiences

Cheryl L. is 47-year-old woman whose physical therapist has diagnosed her with adhesive capsulitis. She has no history of trauma and reports a slow onset of pain that increased over the past 6 months. She says that it significantly affects her sleep.

Her pain is accompanied by a loss of range of movement that has now progressed to the point where she can’t lift her arm to shoulder level. Her therapist provides heat treatments to relax her muscles and designs a home exercise program to help stall the loss of motion. He monitors Cheryl periodically, encouraging her to continue with the home exercises despite the pain. Treatment in the physical therapy clinic consists of stretches performed by the therapist, who also mobilizes the joint to help maintain its current range of motion. At this stage, the therapist focuses the manual therapy not on increasing range of motion but on mobilizing the joint to reduce pain and reduce the amount of range of motion that is lost.

When Cheryl progresses into stage 3 ("frozen"), her visits to the physical therapist are increased. The therapist uses stretching and manual therapy techniques to improve her range of motion. After 4 weeks of treatment, Cheryl reports minimal pain, and her range of motion is beginning to increase rapidly. Her therapy is reduced to weekly visits and then to twice monthly visits. Fourteen months after the onset of her condition, her range of motion returns to normal, and her pain has stopped. Cheryl's progress is rapid, and the therapist credits this to her full participation in her exercise program.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have frozen shoulder, or adhesive capsulitis. You may want to consider:

• A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with frozen shoulder.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.