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Case Presentation
Abstract
Painful hip snapping can present as a rare sequela of proximal hamstring injury. We present a case of painful snapping of the
conjoint tendon of the semitendinosus and biceps femoris over the ischial tuberosity in the setting of a partial proximal hamstring
disruption. Dynamic ultrasonography identified the source of snapping and a persistent attachment of the conjoint tendon to the
sacrotuberous ligament, which prevented retraction and allowed subluxation of the tendons across the ischial tuberosity.
Following surgical transection of the persistent sacrotuberous ligament attachment to the conjoint tendon and tendon reat-
tachment, the patient’s symptoms resolved with full return of function.
Painful snapping of the hip, or coxa saltans, can A 47-year-old active, otherwise healthy woman was
present a diagnostic challenge for clinicians. Coxa referred for evaluation of painful, right posterolateral
saltans can occur in the setting of intraarticular pa- hip snapping. Three months before presentation, she
thology, but when an extra-articular etiology sus- had fallen forward down 4 stairs, hyperflexing her right
pected, it commonly occurs via 2 distinct mechanisms hip. Since that time, she had been experiencing slowly
[1]. Coxa saltans interna is attributed to snapping of worsening posterolateral right hip and buttock pain. At
the iliopsoas tendon, whereas coxa saltans externa the time of presentation, her pain was 5/10 and she
arises from snapping of the iliotibial band over the described a snapping sensation rising from a sitting
greater trochanter [1]. Differentiation between these position or flexing forward in a standing position. She
2 entities is often relatively straightforward based on denied neurological symptoms or back pain.
history and physical examination. Rarely, painful hip Physical examination demonstrated no deformity,
snapping occurs that cannot be attributed to either no trochanteric tenderness, and normal, nonpainful
coxa saltans interna or externa. In this setting, passive hip range of motion. The patient was tender
adjunctive diagnostic techniques such as dynamic to palpation over the ischial tuberosity, which repro-
sonography become an invaluable tool to determine duced some of her typical pain. The patient had a
the source of painful snapping. We present a case of normal gait and flexibility with subtle weakness (4þ/5
coxa saltans, or more accurately “snapping buttock” strength) and 5/10 pain with resisted knee flexion.
following a proximal hamstring injury in which dy- Hip provocative maneuvers were negative for groin
namic ultrasonography accurately identified the pain. Snapping iliopsoas provocative test results were
source of snapping to be the conjoint tendon snapping negative. Visible and audible lateral-posterolateral
over the ischial tuberosity. Informed permission was hip snapping could be reproduced by the patient
obtained from the patient allowing publication of this during active hip flexion while bending over at the
case presentation. waist in a standing position (Supplemental Video 1).
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation
http://dx.doi.org/10.1016/j.pmrj.2015.04.003
L.S. Spencer-Gardner et al. / PM R 7 (2015) 1102-1105 1103
The snapping appeared to occur medial to the greater outcome, and therefore surgical treatment was
trochanter and posterior to the ischial tuberosity. discussed. The goals of surgical management were the
Plain radiographs demonstrated coxa profunda with elimination of mechanical snapping of the conjoint
mild degenerative changes and no cam lesion. Mag- tendon over the ischial tuberosity, and the improve-
netic resonance imaging (MRI) of the right hip ment of the patient’s pain and function by restoration
demonstrated high-grade tendinosis of the conjoint of the normal anatomy. The surgical plan included
tendon of the proximal hamstrings with partial thick- take-down of the attachment of the conjoint tendon
ness tearing. Subsequently, a complete diagnostic to the sacrotuberous ligament, followed by restoration
ultrasound of the right posterolateral buttock region of the native anatomy of the conjoint tendon by
was performed. The examination included dynamic reattachment to the ischial tuberosity. The patient
imaging during which time the patient readily repro- was placed in the prone position and a 10-cm incision
duced her snapping sensation, which localized to the was completed in the gluteal crease. Sciatic nerve
ischial tuberosity (Figure 1A-1C). Findings included neurolysis was performed to allow safe mobilization
severe right proximal hamstring tendinopathy with of the nerve away from the operative field. This pre-
detachment as well as static medial subluxation of the vented nerve stretch injury and allowed for protection
conjoint tendon of the biceps femoris and semite- of the nerve throughout the procedure. The proximal
ndinosus from the ischial tuberosity, resulting in an hamstring origin was exposed, and intraoperative
unstable proximal hamstring origin. There was a lack examination confirmed conjoint tendon snapping
of tendon retraction due to a persistent proximal across the ischial tuberosity, although the amplitude
attachment of the conjoint tendon to a thickened of intraoperative snapping was more subtle secondary
sacrotuberous ligament (Figure 2A and 2B). This to patient positioning during surgery and the lack of
allowed the tendon to snap over the ischial tuberosity active muscle contraction. The proximal attachment
during hip flexion and extension, explaining the pa- of the conjoint tendon onto the sacrotuberous liga-
tient’s mechanical symptoms (Supplemental Video 2). ment was released. The anatomic footprint of the
Repeat MRI with an extended field of view confirmed conjoint tendon attachment on the ischial tuberosity
proximal hamstring tendinopathy and static medial was debrided, and the tendon was subsequently
subluxation to the ischial tuberosity but failed to anatomically repaired using two 5.5-mm double-
show the dynamic nature of the injury seen on loaded suture anchors (Figure 2C). Postrepair intra-
sonography. operative examination demonstrated resolution of the
The patient had failed 3 months of conservative snapping. Postoperatively the patient was placed into
treatment consisting of physical therapy that concen- a hinged knee brace locked at 60 of flexion for
trated on core strength and mobility. The patient’s 3 weeks. After 3 weeks, the brace was discontinued,
pain, dysfunction, and snapping had, according to the with progression to weight bearing as tolerated by
patient, increased over this time frame. Because of 6 weeks with crutches. At 12 weeks’ follow-up, the
the patient’s progressive pain and mechanical symp- patient was asymptomatic, with complete resolution
toms, she desired the option with the most predictable of her preoperative symptoms (Supplemental Video 3).
Figure 1. T2 axial magnetic resonance imaging (MRI) of the right posterior hip with correlative sonographic images. (A) T2 axial MRI of the right
posterior hip (Note: Image has been flipped horizontally 180 to correlate with sonographic images). The conjoint tendon (dotted circle) is located
deep to the gluteus maximus (GM) and demonstrates high-grade tendinopathy. Because of its detachment from the ischial tuberosity (IT), it
statically medially subluxated from its typically posterolateral location. The sciatic nerve (*) lies in close proximity to the detached conjoined
tendon, posterior to the quadratus femoris muscle (Q). The dotted rhomboid represents the sonographic field of view for images B and C.
(B) Sonographic short-axis view of the posterior hip is shown, obtained with a 9-4eMHz curvilinear probe. As seen on MRI, there is high-grade
tendinopathy of the conjoint tendon (dotted circle), manifest as thickening and heterogenous hypoechogenicity (ie, darker than normal). The
abnormal, medially subluxated resting position of the tendon just posterior to the IT is more apparent on ultrasound compared to the MRI. (C) After
hip flexion, the conjoint tendon (dotted circle) has subluxated laterally to the IT, displacing the sciatic nerve (*) laterally (L). Dynamic sonographic
evaluation is demonstrated in Supplementary Video 2.
1104 Atypical Coxa Saltans and Dynamic Sonography
Figure 2. Cadaveric gross anatomy of the posterior hip with artificial recreation of the represented injury and postoperative radiographs.
(A) Unembaled cadaveric model of the posterior hip with the superficial layers removed and the gluteus maximus retracted to view the underlying
anatomy. The sacrotuberous ligament (open arrow) can be seen with its intimate relationship to the conjoint tendon (solid arrow) and hamstring
muscle (HS). The sciatic nerve (*) can be found as it emerges from deep to the piriformis muscle (P), running just lateral to the ischial tuberosity
(IT). The oblique head of the adductor magnus muscle (AM), myotendinous junction, and tendon (arrowhead) can be seen attaching to the medial
ischial tuberosity. (B) In an attempt to recreate the injury experienced by the patient in this case presentation, the conjoint tendon (solid arrow)
has been completely detached from the IT and reflected laterally, displacing the sciatic nerve (*). The semimembranosus tendon (SM), adductor
magnus tendon (arrowhead), and sacrotuberous ligament (open arrow) were left intact as was seen clinically on advanced imaging and surgically in
the presented patient. (C) Anterioreposterior view of the pelvis after right conjoint tendon repair using two 5.5-mm double-loaded suture anchors
placed in the anatomic footprint on the posterolateral aspect of the ischial tuberosity.
Disclosure
L.S.S.-G. Department of Orthopaedics, Sports Medicine Center, Mayo Clinic, A.J.K. Department of Orthopaedics, Sports Medicine Center, Mayo Clinic, W14
Rochester, MN Mayo Building, 200 1st St, SW, Rochester, MN 55905. Address correspondence to:
Disclosures: nothing to disclose A.J.K.; e-mail: krych.Aaron@mayo.edu
Disclosures: nothing to disclose
A.M.P. Department of Physical Medicine and Rehabilitation, Swedish Medical
Submitted for publication October 18, 2014; accepted April 3, 2015.
Group, Seattle WA
Disclosures: nothing to disclose