Coxa saltans interna is a hip syndrome resulting in the iliopsoas tendon snapping pathologically

over structures beneath it, causing a loud audible click or clunk, which may be associated with
pain. It is thought the most common involved structure it courses over is the iliopectineal
eminence (Figure 12.1); however, other intraarticular structures may be large loose bodies and
exostoses. The differential diagnosis must rule out labral tears, synovial chondromatosis, and
abnormal shapes of the femoral head from an old slipped capital femoral epiphysis or hip
dysplasia and acetabular retroversion. The iliacus and the psoas fuse to become one
musculotendinous unit as they pass in a sulcus between the anteroinferior iliac spine and the
iliopectineal eminence (Figure 12.2). The tendon courses over the anterior hip capsule as it passes
posteriorly in the iliopsoas bursa to insert onto the lesser trochanter (Figure 12.3). The tendon
assumes a lateral position on the iliopectineal eminence when the hip is in flexion, abduction, and
external rotation. As the hip is moved into extension, adduction, and internal rotation, the tendon
moves from lateral to medial; however, the musculotendinous portion remains in the groove.1
The symptomatic snapping hip is caused by the back-and-forth movement over the anterior hip
capsule and femoral head. The etiology may be a hyperextension injury to the hip capsule or
tendon itself. Other causes may be from exostoses on the acetabular rim or femoral head as well
as the lesser trochanter.2 The iliopsoas bursa may also become inflamed or hypertrophic, leading
to the condition. Of note, the iliopsoas bursa is the largest bursa in the body, measuring 7 cm long
and 4 cm in width. CLINICAL DIAGNOSIS The patient presents with a vague history of an injury that
may have felt like a groin sprain or of having done the splits. Some report a hyperextension injury
of the hip. Associated with the injury, the patient may experience the onset of popping or hip
clicking that intensifies over time to a consistent snapping sensation that may be heard by anyone
around them. The initial pain from the injury typically never resolves, and the snap hurts. Normal
walking is not painful, but pain may limit sports or dancing that involves hip flexion. With the
patient supine, the patient can reproduce the snap as he or she flexes and extends the hip. The
examiner can eliminate the snap by applying pressure over the anterior hip capsule, which
restricts the tendon’s movement. Such a maneuver is diagnostic for coxa saltans interna. IMAGING
Plain radiographs are usually normal and may be helpful to identify exostoses or a spur on the
lesser trochanter as well as dysplasia or impingement. Magnetic resonance imaging (MRI) is best
to document any thickening of the iliopsoas tendon or fluid in the bursa. Iliopsoas bursography
may demonstrate the outline of the tendon as it snaps over the hip capsule and is a dynamic test.3
Elimination of the pain by a lidocaine injection in the bursa is a positive diagnostic test. SURGICAL
TREATMENT The classic open surgical approach is through an 8- to 10-cm groin incision, protecting
the neurovascular structures and lengthening the tendon 2 cm.4,5 We have developed an
arthroscopic approach in which the iliopsoas tendon is either partially or completely released from
the lesser trochanter.

Technique The patient is positioned for the lateral approach (see Chapter 9).6,7 After the hip has
undergone a diagnostic arthroscopy, the traction is completely released. The foot is maximally
externally rotated, thus bringing the lesser trochanter to an anterior position and is viewed
orthogonal with the C-arm fluoroscope (Figure 12.4A,B). Two additional safe portals are needed:
the anteroinferior (AI) and far anteroinferior (FAI). Originally, we used the anteroinferior medial
(AIM) and AI (Figure 12.5A,B). Arthroscope Placement An intracath is directed from the AFI portal
to a point just proximal to the lesser trochanter into the iliopsoas bursa. A Nitanol wire is passed
through the intracath and the skin is anesthetized with marcaine/ epinephrine. The skin is incised
with a no. 11 blade, and the cannulated scope sheath is passed over the wire into the bursa under
fluoroscopic control. The inflow is started to distend the bursa. Instrument Placement A second AI
portal is created in the same manner and a switcher stick is placed. The iliopsoas tendon is
palpated while viewing with a 30-degree arthroscope (Figure 12.6A,B). It may be necessary to clear
bursa or muscle to view the tendon. A long cannula may aid in passing instruments or to maintain
outflow to prevent distension. The Release The iliopsoas tendon is sectioned with a radiothermal
cutter so as to coagulate bleeders as it is cut. We have used the ArthroCare devices (ArthroCare,
Sunnyvale, CA) and the Mitek VAPR (Ethicon, Someville, NJ) with good success. Starting from the
medial side of the tendon, it is sectioned working laterally (Figure 12.7A–D). Whether to do a
partial or complete release is based on clinical judgment. The goal is to lengthen the
musculotendinous unit, and a partial release accomplishes this. If there is pathology in the tendon
such as a bifid or trifid appearance (Figure 12.8) or if the lesser trochanter has a spur, a complete
release is recommended. POSTOPERATIVE TREATMENT The portals are sutured, and a thigh
dressing is applied with compression. Crutches, with partial weight bearing, are used until the
patient has good control of the hip (usually 2 to 3 weeks). Flexion exercises are begun
immediately, and strength returns in 3 to 6 weeks after a partial release and 3 to 6 months after a
complete release. Occasionally, a nonpainful mild pop may be present for 3 to 6 months. RESULTS
Since 1993 we have released 35 iliopsoas tendons for snapping hip syndrome. All were successfully
viewed and released using the arthroscopic technique. There were two complications, one with
neuropraxia of the lateral femoral cutaneous nerve and one with 4/5 flexor weakness at 6 months.
All the rest had full return of their muscle strength by 3 months. All had resolution of their snap,
and 94% had good to excellent results and pain relief. CONCLUSION Arthroscopic iliopsoas tendon
release has been described. It is a safe and effective way to treat coxa saltans interna and is
reproducible. The results are better than the results of open surgery and have fewer
complications.