Snapping Hip Case Study
Jim Moretz, PhD, LMBT
Client:
Female (48) has an intermittent problem with her left hip “feeling like it pops out of joint” when she is walking. The main complication is not pain (she rates it 3 out of 10), but loss of balance and the immediate need to shift her weight to the right hip. “If not, I feel like I am going to fall.” The client does not recall an originating injury or incident. She has not noticed any causative pattern or common aggravating factors. Per week, she works three (3) twelve (12) hour shifts as a Registered Nurse in a critical care hospital unit. Occupational activities include short bursts of walking, long periods of standing, and heavy lifting/turning of patients. Recreational activities include aerobic walking, gardening, strength training, and some yoga. Until 2013, she played softball yearly, in both co-ed and women’s leagues.
Initial Assessment:
Hip Range of Motion (ROM) testing:
Lateral ROM (normal 40° to 60°)
Right - 51°
Left - 51°
Medial ROM (normal 30° to 40°)
Right - 30° LOW
Left - 20° Deficit
Client is within the normal ROM for Right and Left lateral rotation. Right medial rotation is low normal ROM. Left medial rotation is a significant deficit.
Added to the presenting symptoms, these results suggest a rather common condition called “Snapping Hip.” The investigative question in this study is how to treat snapping hip with Neuromuscular Massage Therapy.
Presently, the conservative treatments for snapping hip are anti-inflammatories, stretching, and avoiding the aggravating activities. When one’s occupation is the aggravating activity, avoidance is impossible. The only treatment for recalcitrant cases is surgery to lengthen the iliopsoas or iliotibial band. Due to the difficulty of diagnosing the actual cause of snapping hip, surgery limited to these muscles cannot have a consistently positive outcome.
Application of Neuromuscular Therapy (NMT) Treatment
Day 1
90-minute Deep Tissue massage focused on the attachment sites for the Left Coxal Adductors, TFL, and Gluteus Medius. Post-session ROM showed a 23° Left Medial Rotation
Day 2
60-minute Passive Stretching on bilateral Coxal Rotators (30 minutes each side). Client reported sore hamstrings and sitting for over six hours that day while driving and teaching. Post-session ROM test showed Right and Left Medial Rotation of 15°.
Day 3 – Day 5
No NMT sessions due to client work schedule. Client reported noticing repeatable pain pattern in left hip when it was engaged to move a patient or object from a non-ideal starting position, but no “snapping” sensation.
Day 6
120-minute Deep Tissue, Trigger Point Release, and Active Release session focused on Left Coxal Adductors, TFL, and Gluteus Medius. Post-session ROM showed a 30° Left Medial Rotation
Day 7
No NMT session
Day 8
60-minute Passive Stretching on bilateral Coxal Rotators (30 minutes each side). No Post-session ROM test.
Day 9
120-minute bilateral Myofascial Release session focused on all Lower Extremity and Coxal muscles. No Post-session ROM test.
Day 10 – Day 12
No NMT sessions due to client work schedule. Client reported no “snapping” sensation. However, a “new” pain pattern and weakness was detected in Left hip, slightly anterior to original site. Client reported a fall in which the right foot slipped out while walking down-hill. Client fell backwards and to the left, landing on left shoulder with left knee flexed and left hip abducted and laterally rotated.
Day 13
Final 120-minute Deep Tissue, Trigger Point Release, and Active Release MT session focused on Left Coxal Adductors, TFL, and Gluteus Medius.
Results:
Post-therapy Medial ROM:
Left - 33°
Right - 35°
1) Left medial rotation was normalized, although still in the low end of the range.
2) Right medial rotation was increased.
3) The proportional relationship between Left and Right medial rotation was 86% which indicates the client is now in the third stage of healing (Remodeling).
Recommendations
Further treatment to continue the NMT treatment schedule described above for an additional two weeks and consult a personal trainer to begin a strength training regimen. The progress trajectory suggests that the proportional relationship between Left and Right medial rotation could be 95% to 100% within 60 days.
Conclusions
This case study presents evidence that snapping hip resulting from a medial coxal rotation deficit combined with a significant disproportionate bilateral medial rotational relationship can be effectively resolved with alternating NMT sessions focused on 1) attachment and myofascial release, and 2) passive stretching. Attachment and Trigger Point release therapies should not be repeated within 48 hours (ideally 72 hours). Passive stretching between deep tissue modalities may be crucial to the client’s recovery and response to the more aggressive techniques. It remains unclear whether the decrease in ROM after the initial increase is to be expected, or, at least, not surprising. The initial 3° increase in the Left medial rotation is considered clinically significant.