Peri-articular diseases of the hip: emerging frontiers in arthroscopic and endoscopic treatments
© The Author(s) 2013
Received: 27 November 2012
Accepted: 9 July 2013
Published: 28 July 2013
The precise diagnosis of both intra and extra-capsular disease of the hip is now possible because of commonly available advanced diagnostic imaging techniques. An increasing number of reports in the orthopedic literature describe new endoscopic and arthroscopic techniques to address peri-articular pathology of the hip. The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.
Hip arthroscopy has gained considerable popularity in the past decade because of an increasing understanding of femoroacetabular impingement (FAI) . At present FAI is the most common indication for hip arthroscopy, though several other intra-articular conditions of the hip such as loose bodies, labral tears and chondral lesion are also commonly treated . Recent orthopedic literature has focused mainly on these hip conditions, but advances in diagnostic imaging techniques now allow for the precise diagnosis of extra-capsular disease of the hip, often with associated intra-capsular pathology. Furthermore, an increasing number of surgeons have recently described arthroscopic and endoscopic techniques in addressing peri-articular conditions of the hip .
The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.
Internal snapping hip syndrome and psoas tendon impingement
The internal snapping hip syndrome may be caused by the iliopsoas tendon . The snapping usually results as the hip is extended from a flexed position, usually from more than 90º of flexion. In this position the iliopsoas tendon may snap over the iliopectineal eminence or the femoral head.
Other causes of snapping should be excluded: the snap could be produced by the iliotibial band snapping over the greater trochanter, due to intra-articular pathology, such as loose bodies or labral tears . This is no longer referred to as a snapping hip because the diagnosis of intra-articular pathology is now more accurate with MRA .
Symptoms and clinical examination of external snapping syndrome will be described in the following paragraphs, and ultrasound examination can verify the snap between greater trochanter and iliopsoas.
Although the internal snapping phenomenon can’t be demonstrated directly with magnetic resonance arthrography (MRA), magnetic resonance imaging may frequently report changes within the iliopsoas tendon and bursa .
Asymptomatic internal snapping of the hip may occur in up to 10 % of the general population. It is considered within normal variance and is thus managed conservatively . The symptomatic internal snapping hip syndrome defined by pain in the groin is, however, a separate matter. Physiotherapy is the first line of treatment even in this scenario , with arthroscopic treatment reserved for those in whom symptoms persist.
The iliopsoas tendon itself may cause an impingement. Domb  described a specific pattern of hip pain associated with a labral injury at the 3 o’clock or direct anterior position with no evidence of FAI, bony abnormality, trauma, or any other known cause of labral injury. Clinical presentation is usually an anterior hip pain and pain exacerbated with active flexion, while some patients also experience a snapping sensation. Iliopsoas tenderness, a positive impingement test, and pain or apprehension with resisted straight leg raise may be apparent at physical examination. MRA may show isolated injury to the labrum at the 3 o’clock position. In some cases, this injury may be associated with an inflamed appearance of the iliopsoas tendon.
While some patients experience incomplete pain relief with intra-articular injection, many found more complete relief after a psoas injection. Arthroscopic release may be performed in patients unresponsive to corticosteroid injection.
The trans-capsular technique allows for release of the tendon via the central or peripheral compartment. The later, described by Ilizaliturri , addresses the iliopsoas tendon immediately anterior to the hip capsule in the space between the zona orbicularis and anterior labrum proximal, and anterior to the medial synovial fold. A capsulectomy is performed at this level to gain access to the iliopsoas tendon; synovial tissue from around the tendon may be debrided using a radiofrequency probe or an arthroscopic shaver.
Endoscopic release may also be performed at the lesser trochanter. A spinal needle is guided into position under image intensifier control, aiming for its tip to be located within the iliopsoas insertion. This manoeuvre may be aided by “palpating” the medial aspect of the femur with the tip of the spinal needle as it lands on the lesser trochanter. The needle may then be substituted by an arthroscopic cannula prior to the introduction of a 30° arthroscope. A second working portal is created by triangulation toward the tip of the arthroscope inside the iliopsoas bursa. The image intensifier is used to confirm correct location of the radiofrequency probe prior to iliopsoas tendon release.
Literature reports on treatments for internal snapping hip syndrome and psoas tendon impingement
Number of hips
Open release (medial approach)
31 % residual pain, 38 % recurrent snapping, 12.5 % had persistent weakness with hip flexion
Open Z plasty
19 reductions of snapping frequency, 14 no snapping, 2 required reoperation, 3 subjective weakness
Open Z plasty (iliofemoral incision)
11 had complete pain relief, no patient had detectable loss of hip flexion strength, 1 patient had a recurrence of the snapping, and 2 patients had a transient decrease in sensation over the anterolateral thigh due to injury of the lateral femoral cutaneous nerve
Open Z plasty (ilioinguinal incision)
58 % complete resolution of their hip pain, 17 % had recurrence, 25 % improved, 5 had postoperative subjective weakness. No complications related to the wound or surgical approach
Open tendon lengthening (iliofemoral incision)
12 % recurrence of snapping within 3 months and another 10 % after 3 months, 12 % had surgical incision related complications
Endoscopic release at lesser trochanter
All patients pain free, no recurrence
Endoscopic release at lesser trochanter (10) and endoscopic transcapsular (9) (randomized)
Improvements in WOMAC scores were statistically significant in both groups, and no difference was found in postoperative WOMAC results between groups. No complications were seen
Endoscopic release at lesser trochanter (athletes)
Preoperative hip scores averaged 41 and 44 points for the competitive and recreational athletes, respectively, at 12 months, 96 and 97 points, and none had recurrence of their snapping or pain
Endoscopic release at the lesser trochanter
38 points average Harris hip scores increase, no recurrence
Endoscopic release (preserving iliacus muscle) transcapsular
No complications, hip flexion strength was restored to normal within 3 months
Endoscopic release at the lesser trochanter
All the patients were relieved of their painful snapping symptoms, average WOMAC score improved from 82.5 to 91 points. The only complication seen was loss of flexion strength in all patients
Endoscopic tenotomy and either labral debridement or repair
Mean preoperative HHS, ADL HOS, and Sport HOS scores were 61.64, 73.94, and 51.63, respectively, the mean post-operative scores were 86.06, 88.21, and 72.01, respectively
Anteroinferior iliac spine impingement
Patients usually describe a “grinding sensation” in flexion and rotation of their hip and pain with athletic activity and prolonged hip flexion. Physical examination confirms pain with hip flexion, internal rotation, and adduction and limited hip flexion . Radiographs show a low AIIS, commonly due to prior traumatic avulsion .
Literature reports on treatments for anteroinferior iliac spine impingement
Number of treated hips
Resection of the hypertrophic AIIS (patient 1), 1 fixation of AIIS fragment (patient 2)
Patient 1: at 2.5 years follow-up asymptomatic and returned to his normal sporting activity. Patient 2: at 1 year follow-up pain free, able to participate actively in sport
Resection of the hypertrophic anterior inferior iliac spine
Full painless restoration of function of the hip
Average MHHS: 75.6 points pre op and 93.7 post op; average VAS 6.2 pre op and 1.1 post op
At a mean follow-up time of 14.7 months, the modified Harris hip score improved from 64.18 before surgery to 98.2 points
At 18 months follow-up returned to football, a nonarthritic hip score of 98 points, nonrestrictive heterotopic ossification
Greater trochanteric pain syndrome
Greater trochanteric pain syndrome (GTPS) has an estimated incidence of 1.8 per 1,000 persons . This syndrome includes 3 well-described entities: external coxa saltans, greater trochanteric bursitis, and gluteus medius and/or minimus tears. Although these disorders are often associated, for academic purposes they will be analyzed separately in the flollowing paragraphs .
External snapping of the hip
Literature reports on treatments for external snapping of the hip, trochanteric bursa inflammation and gluteus medius diseases
Number of hips
Results and complications
Open Z plasty
All patients had complete resolution of the snapping hip, 1 returned to full unrestricted activities but no residual snapping
Open vertical incision and multiple transverse cuts
14 asymptomatic patients after release (2 hips needed a second release)
Open Z plasty
Good results, 3 had problems due to scar sensitivity
Open cross cut and inverted flap suture
30 % successful results, 30 % had a recurrence of symptoms and over 60 % continued to experience pain
Open longitudinal release of the iliotibial band combined with excision of the trochanteric bursa
The mean difference between the pre- and postoperative Merle d’Aubigné and Postel scores was 11.7 points; 6 excellent results, 5 good and 1 poor. One screw removal for pain, one surgically drained hematoma
Endoscopic diamond shape defect
1 residual nonpainful snapping, 10 excellent results
Endoscopic bursectomies and in 4 coxa saltans suture of the iliotibial tract to the greater trochanter
32.5 points was the average Japanese orthopedic association score improvement; VAS improved from 7.2 to 3.8 points. Four patients developed hematoma
VAS improved from 7.2 to 3.1, mean Harris hip scores improved from 51 to 77 points, one seroma and one subsequent open bursectomy
60 (only for 22 patients)
24 good or excellent results without complications, 2 recurrences, 1 unsatisfied
Immediate symptomatic improvement, returned to competitive basketball with occasional aching in his right hip
Endoscopic bursectomy and concomitant iliotibial band release under local anesthesia
All excellent results, no recurrence
Endoscopic excision of gluteus medius/minimus calcifications
Symptom-free without limitation of any activity, normal abduction strength
Endoscopic repair of gluteus medius/minimus tears
10 complete resolution of pain; no adverse complications. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal
Open suture of torn abductors with soft-tissue anchors in the greater trochanter
4 re-ruptures, 1 deep infection. In the remaining 11 patients there were statistically significant improvements in VAS and Oxford hip score
Trochanteric bursa inflammation
Inflammation of the trochanteric bursa is the most common cause of pain over the lateral aspect of the hip . Symptoms may be aggravated by pressure over the area, weight bearing, and resisted external rotation in supine (with hip flexed to 90°) and prone (with hip extended) positions.
The first line of treatment is conservative, with appropriate anti-inflammatory therapy and lifestyle modification . Corticosteroid injections have been commonly utilized in the presence of failed conservative treatment. Bursitis often responds favorably to conservative management . When the bursitis is refractory to conservative treatment and to corticosteroid injection, surgical bursectomy should be considered .
Gluteus medius diseases
When GTPS is caused by a gluteus medius tendinopathy, the majority of patients describe lateral-sided hip pain of insidious onset that is aggravated with weight bearing and resisted hip abduction . Patients can often point to an exact point of pain that often occurs some centimeters proximal to the tip of greater trochanter. Good quality MRI is necessary to discriminate gluteal tears and trochanteric bursitis . Once again, physiotherapy is the first line of treatment. When this fails, surgical treatment via various open  and more recently described endoscopic techniques is an option. Two endoscopic repair techniques of the gluteus tendon are described in the literature [39–44].
Voos et al. , describes a technique to repair gluteus tendon tears via the peritrochanteric compartment utilizing an anterior portal and a distal posterior portal.
Domb  described another endoscopic technique of approaching the tendon through a longitudinal split in line with its fibers, in order to visualize and treat intra-substance tears without affecting the integrity and strength of the tendon itself. He describes the use of posterolateral and distal peritrochanteric portals. This technique results in a side-to-side repair of the longitudinal tendon split while firmly approximating the tendon to the footprint on the lateral facet.
As shown in Table 3, both techniques showed a good efficacy. According to our view, Domb’s procedure  appears more challenging for the surgeon and aims to better preserve the tendon, which may be helpful in younger and more active patients. Studies with a larger cohort are necessary to give an evidence-based conclusion for the efficacy of these endoscopic techniques.
Piriformis syndrome results from sciatic nerve entrapment by the piriformis muscle . It manifests as buttock pain and radicular-like pain associated with hip flexion movements with combined internal or external rotation. Piriformis syndrome often occurs after blunt trauma to the buttock with resultant hematoma formation and subsequent scarring between the sciatic nerve and external rotators . Clinical tests such as Lasègue, Pace and Friberg sign are commonly positive and useful in the diagnosis of sciatic nerve entrapment.
Literature reports on treatments for piriformis syndrome
Number of hips
Results and complications
Open excision of post-traumatic adhesions
Eleven excellent and four good results, one seroma and one infected hematoma
Open nerve decompression
68.8 % patients showed 50 % or greater improvement; mean improvement was 68 %
Open nerve decompression (3 cm incision, transgluteal approach)
Excellent outcome in 58.5 %, good outcome in 22.6 %, limited benefit in 13.2 %, no benefit in 3.8 %, and worsened symptoms in 1.9 %
Endoscopic nerve decompression, piriformis tendon release or by hamstring tendon scarring
The mean postoperative MHHS increased to 78.0 and VAS score decreased to 2.4. The mean postoperative MHHS increased to 78.0 and VAS score decreased to 2.4
Endoscopic release of the piriformis muscle under local anesthesia
Good results in all patients
Endoscopic incision, drainage of benign cystic lesion on the sciatic nerve and release of the piriformis tendon
Good result, no recurrence
Hamstring avulsion and tendinopathy
Surgical repair is indicated for patients in their youth, in athletes and those who have sustained acute complete tear of all three tendons with more than 2 cm retraction. Chronic tendinopathy on the other hand is commonly treated conservatively . Surgical debridement of scar may be indicated in cases where conservative treatment has failed. Open surgical techniques [56–59] for hamstring avulsions and tendinopathy are described in the literature, and recently Guanche described an endoscopic technique . Endoscopic treatment is performed in the prone position through three portals. The first two portals are created 2 cm medial and lateral to the ischial tuberosity. The lateral portal is first used for a 30° arthroscope. The tip and medial aspect of the ischium are delineated, then the lateral aspect is exposed with the use of radiofrequency. With the lateral aspect identified, the dissection continues anteriorly and laterally towards the sciatic nerve. A careful release of soft tissue is performed to cautiously mobilize the nerve and avoid inadvertent injury. The tendinous origin is then inspected for any obvious tearing. A more inferior portal may then be created approximately 4 cm distal to the tip of the ischium and equidistant from the medial and lateral portals. This portal is employed either for insertion of suture anchors or suture management.
Literature reports on treatments for hamstring avulsion and tendinopathy
Number of hips
18 patients acute hamstring avulsion, 7 patients chronic tears
92 % minimal or no pain, 96 % estimated their functional recovery to be greater than 75 % of the uninvolved limb, and 88 % felt their strength was greater than 75 % of the uninvolved limb. Subjects who were isokinetically tested more than 1 year after surgery averaged 98 % strength compared to the uninvolved limb
21 patients acute hamstring avulsion, 5 patients chronic tears
76 % percent of their patients returned to sports.Overall, 96 % of athletes reported good leg control, and 80 % of athletes were pain free
At an average of 37 months 90 excellent results, 10 were good, 5 were moderate, and 7 were poor. Six of 7 poor results were in patients treated >3 months post injury
47 complete retracted tears, 16 complete and minimally retracted tears, 7 incomplete tears, 1 severe muscle-tendon rupture, 1 ischial tuberosity avulsion
At 2 years postoperatively 84 % strength. 80 % of patients returned to their previous sporting activities. There were statistically inferior hamstring strength and endurance results in patients with chronic retracted tears when compared to the remaining patients
Acute hamstring avulsion (3 patients), partial hamstring avulsion (9 patients), ischial bursitis (3 patients)
One patient (with preoperative refractory ischial bursitis) had recurrent ischial pain, 2 patients complained of numbness over the posterior thigh with resolution of their symptoms by 6 weeks postoperatively
Open surgery has been utilized for many years to address various extra-capsular pathologies of the hip. Endoscopic techniques have since evolved to treat internal snapping hip syndrome, iliopsoas impingement, AIIS impingement, external snapping hip syndrome, trochanteric bursitis, gluteus medius tears, piriformis syndrome and proximal hamstring diseases. Although the current evidence for these endoscopic techniques is limited to single case series, published results are encouraging. Excellent results are not reported in all patients with either open, arthroscopic or endoscopic procedures. There is consensus about the importance of accurate patient selection to achieve the best results. Further randomized studies would be necessary to justify the choice of arthroscopic or endoscopic procedures, perhaps based on comparability of success rates, complication rates and attendant advantages of day-case surgery.
Conflict of interest
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