September 5th, 2020
Ever noticed your hip click when you get up to stand? Even louder perhaps when you’re doing some abdominal or hip flexor strengthening in a deadbug or straddle position? Then this blog is for you!
Recently I saw someone’s clicking hip get completely dismissed by a non-health care professional as perfectly normal and they were told it was just something they needed to get used to. Whilst I bit my tongue but to say it frustrated me is an UNDERSTATEMENT 😂. (side note: please do not give out medical advice if you are not a health care professional!)
So I’ve written this blog as a way to finally address what is normal and not so normal when it comes to clicking in a hip. And strangely enough, I’m going to start this blog by writing the conclusion.
And whilst you could technically stop reading the blog after reading the conclusion because TLDR, you won’t, or more specifically you shouldn’t. Why? Because today’s blog is not just about the answer to the question ‘is it normal for hips to click?’. This blog is actually about understanding what we can do to help. Cue the 80’s journey music… now. Here we go:
Conclusion
Whilst the hip flexor and glutes/ITB are common causes of clicking, snapping or popping sounds around the hip, there are about 10 + more structures of greater concern that also can cause this sound. Whilst most clicking hips are pain-free and don’t cause us any issue other than a mild uncomfortable sensation, I would suggest they should still be assessed by a healthcare professional to at least rule out serious pathology and corrected if possible by strengthening and/or release.
Some of these causes are associated with anatomical variations from person to person, ligament laxity or even pathology, but most important to note is a higher number of them are caused by muscle strength or even recruitment strategies that can all be addressed. All painful clicks should be attended to by a physiotherapist immediately.
So there you have it! The answer is clicking hips should not be ignored, but instead assessed by a healthcare professional to ensure no underlying pathology is causing it first. Now buckle up for the journey to understand why…
The Clicking Hip
Known as the Snapping Hip Syndrome (SHS), this condition is a fairly big umbrella term that is characterised by a snapping sensation, an audible ‘click’ or a pop in the hip joint whilst it moves through range of motion. SHS can be further classified into extra-articular (outside the joint) or intra-articular (inside the joint) causes which we will explore below. For most people the sound is an annoyance whilst in others it can significantly interfere with their function and may even cause pain.
Aetiology
This condition is thought to be prevalent in 10% of the general population, with majority being in females dancers/gymnasts (aerialists included), and it has been associated with acetabular dysplasia in infants (shallow hip sockets).
Common Causes
The common causes of this issue can be divided into two main categories: external and internal causes. External factors are more commonly the cause of this condition, with their onset occurring from reduced strength, muscle recruitment asymmetries and overuse of activities that involve repetitive hip flexion and extension (1).
This is by no means a fully extensive list, but the most common causes of a clicking hip are the following:
Extra-articular
the psoas or iliopsoas tendon (also known as internal snapping hip)
the rectus femoris proximal tendons (also known as internal snapping hip)
the iliotibial band
the gluteus maximus
ischiofemoral impingement
a subluxing or torn proximal hamstring tendon
Intra-articular
a chondral/cartilage flap
a labral tear
a loose body or fragment
Joint synovitis (lumps in the joint lining)
Synovial folds or plicae (natural folds in the joint lining)
Joint cavitation
As you can see, there are quite a few. And unless you are able to determine whether it’s an internal or external issue first, you won’t be able to deal with the issue at hand. Let’s delve into each of these causes a little bit more…
Extra-articular causes of Snapping Hip
Anterior Snapping Hip – Iliopsoas, psoas and/or rectus femoris tendon
One of the most common and less serious causes of a snapping hip, it is believed that one of the psoas, iliosoas or rectus femoris tendons snap over the pelvic brim or femoral head as a leg moves through range.
In the past, this clicking has been attributed to tightness in the hip flexor muscle and previously people have attempted to stretch or release this tightness. However, these theories remain unfounded. In fact, this type of clicking commonly occurs from weakness in these local muscles or even from sacroiliac joint dysfunction (pelvis) loading up the hip flexor tendon. Very few pole dancers have overactive psoas tendons. So stop unnecessarily stretching or massaging out your hip flexors! Instead maybe try some tailored strengthening.
Lateral Snapping Hip – Gluteus maximus and/or ITB
The second most common source of hip snapping is the ITB/glute maximus tendon snapping around the outside of the hip (greater trochanter). This frequently occurs when the abductors of the hip are loaded with activities such as climbing stairs or squatting. In some cases, a patient may even report their hip is ‘dislocating’ or ‘popping out’. Naturally neither of these are occurring, it just provides this super unpleasant sensation that should be addressed asap by a physiotherapist.
Posterior Snapping Hip (Snapping bottom) – Proximal hamstring tendon
Yes, snapping bottom syndrome is a thing! Although seriously uncommon and is associated with a proximal hamstring tendinopathy which we have previously covered here or even a partial tear of the hamstring (2). This snapping commonly occurs in a forward fold position or with external rotation and flexion of the hip.
This involves the hamstring tendon snapping over the ischial tuberosity (insertion at the pelvis).
Ischiofemoral Impingement
A very uncommon cause of clicking, Ischiofemoral impingement occurs when the muscles that sit between the pelvis and the inside of the hip bone become irritated/compressed. This condition is not always accompanied by a click, but is most noticeable when it does occur with a large walking stride. So this theory can be tested out by taking larger or smaller steps. Management of this condition is out of the scope of today’s blog, but is just another type of clicking to be mindful of!
Ok, so as you’re probably starting to see there are a few more causing to a snapping hip than just the hip flexor. Let’s take a quick look into the internal causes now…
Intra-articular causes of Snapping Hip
Hip joint pathology – Chondral flaps, cartilage tears or synovitis
This right here is the reason why you should not ignore a clicking hip. It’s very common for dancers particularly to have multiple tears or even loose fragments in the joint. I won’t get too in depth with the background of this, but these issues are frequently associated with femoroacetablular impingement (FAI) (hip impingement) and in many people FAI is asymptomatic. But in some it can be quite painful and a cause of many issues. If this condition is the underlying cause of the clicking, it requires physiotherapy management and tailored strengthening from the start. At no point should this clicking be ignored.
Synovial Folds/Plicae
Not commonly recognised as a cause of clicking, movement of the hip bone in the socket against the folds in the joint capsule can cause a deep clunking sensation. This usually occurs with large movements such as side lunging. When this occurs randomly it’s of no major concern or consequence, however repetitive deep clunking of the joint and joint-related pain is a concern that requires immediate medical attention.
Joint Cavitation
Like any synovial joint in our body (fingers, neck etc), clicking or popping sounds in the joint can be generated from a sudden release of built up of gas in the joint over time known as a cavitation. This is the sound commonly heard during manipulation-based treatment. Hypermobile joints frequently experience this cause of click and is thought to be due to secondary ligament laxity or reduced labral seal. Hypermobile joints clicking frequently require physiotherapy management.
Management
Alrighty, you’ve got a clicking hip, how do you fix it? Well as you can tell from above, the first thing to do is to see a Physiotherapist to determine what the underlying cause is and whether there is any concerning underlying pathology. If your clicking hip is determined to be of a non-hip flexor related cause then a Physiotherapist should work with you to tailor a specific rehabilitation program.
However if they have determined the cause of clicking to be hip flexor related without any underlying pathology, then you can attempt to address this issue yourself or with the assistance of your stellar Physiotherapist. Here’s some suggestions on what you can do to help:
Strengthen
Whilst it is considered ‘normal' for clicking of the hip flexor muscles to occur, in some it may be a sign of some deeper muscular imbalances that require addressing. These weaknesses may also be linked to something else such as the reason why you are finding it difficult to stabilise yourself in certain tricks such as your balance V/Ayesha etc. The hip, pelvis, abdomen and lower back muscles intimately rely on each other to stabilise in these pole tricks. Whilst we don’t require perfect muscular symmetry, we do require strength and proximal stability of each of these muscles. So get your physio to determine which muscles of yours are weaker and target them with some specific strengthening. And when these strength deficits are
correctly addressed you may start to notice that you’re able to get further into your hip flexion/extension range of movement before the clicking occurs. And that Ayesha you were once finding so difficult you may not find as challenging anymore.
Release
Contrary to the belief, you actually don’t want to release iliopsoas (hip flexor) in this case. Instead I encourage releasing all of the other muscles around it such as the mid to distal quad, groins & glutes. This can help to reduce the amount of load through the hip flexors and improve your ability to strengthen the other muscles around the abdomen.
Take home messages
Clicking or snapping hips should not be ignored
Get your hips assessed by a physiotherapist that has experience in pole or dancer based injuries to determine the underlying cause
Get a tailored program to address any underlying pathology and to improve your click
Do not stretch or massage the clicking muscles/areas but instead release the areas surrounding
Building strength takes time but long-term outcomes will be favourable if you follow the correct rehabilitation process
Wanting tailored guidance and rehabilitation for your clicking hips?
Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'.
Until next time, train safe.
The Pole Physio
x Disclaimer: This information and these exercises are not tailored to you as an individual and do not constitute as medical advice. If you have medical or injury concerns, then please individually consult with a medical professional.
References
Via AG, Fioruzzi A, Randelli F. Diagnosis and Management of Snapping Hip Syndrome: A Comprehensive Review of Literature. Rheumatology (Sunnyvale). 2017;7(228):2161-1149.
Scillia, A., Choo, A., Milman, E., McInerney, V. and Festa, A., 2011. Snapping of the Proximal Hamstring Origin: A Rare Cause of Coxa Saltans. The Journal of Bone and Joint Surgery-American Volume, 93(21), pp.e125(1)-e125(3).