Original Article| Volume 31, ISSUE 10, P1991-1995, October 2015

Internal Snapping Hip Syndrome: Incidence of Multiple-Tendon Existence and Outcome After Endoscopic Transcapsular Release


      To report the frequency of presentation of bifid or multiple iliopsoas tendons in patients who underwent endoscopic release for internal snapping hip syndrome (ISHS) and to compare both groups.


      A consecutive series of patients with ISHS were treated with endoscopic transcapsular release of the iliopsoas tendon at the central compartment and prospectively followed up. The inclusion criteria were patients with a diagnosis of ISHS with failure of conservative treatment. During the procedure, the presence of a bifid tendon was intentionally looked for. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at last follow-up. Four patients presented with a bifid tendon and one patient had 3 tendons. At a minimum of 12 months' follow-up, the presence of snapping recurrence was evaluated and the WOMAC scores were compared between both groups.


      Among 279 hip arthroscopies, 28 patients underwent central transcapsular iliopsoas tendon release. The mean age was 29.25 years (range, 16 to 65 years; 6 left and 22 right hips). Group 1 included 5 patients with multiple tendons; the remaining patients formed group 2 (n = 23). None of the patients presented with ISHS recurrence. The mean WOMAC score in group 1 was 39 points (95% confidence interval [CI], 26.2 to 55.4 points) preoperatively and 73.6 points (95% CI, 68.4 to 79.6 points) at last follow-up. In group 2 the mean WOMAC score was 47.21 points (95% CI, 44.4 to 58.2 points) preoperatively and 77.91 points (95% CI, 67.8 to 83.4 points) at last follow-up. We identified a bifid tendon retrospectively on magnetic resonance arthrograms in 3 of the 5 cases that were found to have multiple tendons during surgery. None of these were recognized before the procedures.


      In this series the surgeon intentionally looked for multiple tendons, which were found in 17.85% of the cases. Clinical results in patients with single- and multiple-tendon snapping seem to be similarly adequate. However, the possibility of a type II error should be considered given the small number of patients.

      Level of Evidence

      Level IV.
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        • Allen W.C.
        • Cope R.
        Coxa saltans: The snapping hip revisited.
        J Am Acad Orthop Surg. 1995; 3: 303-308
        • Anderson S.A.
        • Keene J.S.
        Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes.
        Am J Sports Med. 2008; 36: 2363-2371
        • Byrd J.W.
        Evaluation and management of the snapping iliopsoas tendon.
        Instr Course Lect. 2006; 55: 347-355
        • Deslandes M.
        • Guillin R.
        • Cardinal E.
        • Hobden R.
        • Bureau N.J.
        The snapping iliopsoas tendon: New mechanisms using dynamic sonography.
        AJR Am J Roentgenol. 2008; 190: 576-581
        • Gruen G.S.
        • Scioscia T.N.
        • Lowenstein J.E.
        The surgical treatment of internal snapping hip.
        Am J Sports Med. 2002; 30: 607-613
        • Shu B.
        • Safran M.R.
        Bifid iliopsoas tendon causing refractory internal snapping hip.
        Clin Orthop Relat Res. 2011; 469: 289-293
        • Ilizaliturri Jr., V.M.
        • Camacho-Galindo J.
        Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon.
        Sports Med Arthrosc. 2010; 18: 120-127
        • Ilizaliturri Jr., V.M.
        • Buganza-Tepole M.
        • Olivos-Meza A.
        • Acuna M.
        • Acosta-Rodríguez E.
        Central compartment release versus lesser trochanter release of the iliopsoas tendon for the treatment of internal snapping hip: A comparative study.
        Arthroscopy. 2014; 30: 790-795
        • Glick J.M.
        • Sampson T.G.
        • Gordon R.B.
        • Behr J.T.
        • Schmidt E.
        Hip arthroscopy by the lateral approach.
        Arthroscopy. 1987; 3: 4-12
        • Ilizaliturri V.M.
        • Villalobos F.E.
        • Chaidez P.A.
        • Valero F.S.
        • Aguilera J.M.
        Internal snapping hip syndrome: Treatment by endoscopic release of the iliopsoas tendon.
        Arthroscopy. 2005; 21: 1375-1380
        • Byrd J.W.T.
        Snapping hip.
        Oper Tech Sports Med. 2005; 13: 46-54
        • Crompton T.
        • Lloyd C.
        • Kokkinakis M.
        • Norman-Taylor F.
        The prevalence of bifid iliopsoas tendon on MRI in children.
        J Child Orthop. 2014; 8: 333-336
        • Khan M.
        • Adamich J.
        • Simunovic N.
        • et al.
        Surgical management of internal snapping hip syndrome: A systematic review evaluating open and arthroscopic approaches.
        Arthroscopy. 2013; 29: 942-948