Understanding and Treating Iliopsoas Syndrome in the Dancer Population

By Dr. Kathleen Darley, PT, DPT

It has been shown that over 90% of dancers at some point complain of clicking and snapping of the hips. Snapping is often audible and occurs as a muscle or tendon passes over a bony structure during movement. Coxa saltans, Latin for “dancer’s” or “jumpers,” hip can be classified as either external, internal and intra-articular. As a physical therapist, working with this population, it is important to understand the anatomy, how to diagnose and treat a painful snapping hip, and when further imaging is required.

Anatomy Review of Snapping Hip

External snapping is more common in the general population. Ilotibial band or gluteus maximus tightness and snapping occurs as these tendons roll across the greater trochanter of the femur. Internal type of snapping hip is attributed to movement of the iliopsoas tendon over the anterior capsule of the femoral head, the iliopectineal eminence (located along the pelvic border along the front of the hip), or lesser trochanter of the femur. The iliopsoas tendon inserts at the lesser trochanter of the femur and is key in ballet technique because of its ability to lift and externally rotate the thigh. With the hip in extension, adduction, and internal rotation, the iliopsoas tendon remains medial to the center of the femoral head in the groove between the iliopectineal eminence and the AIIS. As the hip flexes, abducts and externally rotates (such as in passé or developpe), the ilipsoas tendon moves over the anterior femoral head and capsule to become lateral to the center of the femoral head, creating a snapping or clicking sound. Additionally, dancers attempting to achieve more turnout assume a hyperlordotic pelvis posture, causing the femoral head to become more anterior and the iliopsoas tendon to snap over it. Internal snapping hip is the most frequent type of snapping hip among ballet dancers due to the amount of emphasis placed on external rotation. Repetitive flexion of an externally rotated hip often results in painless internal coxa saltans. However, if there is accompanying pain or weakness it is referred to as iliopsoas syndrome. Examination will show a positive Iliopsoas Syndrome Test, which can be determined by weakness with, or without pain, during resisted hip flexion in an externally rotated position. Intrarticular causes of a snapping hip may include loose bodies, synovial chondromatosis, and labral tears.

Distinguishing Between Iliopsoas Syndrome and Labral Tears

Distinguishing iliopsoas syndrome versus an intrarticular cause, such as a labral tear, is important as they present similarly. Studies have shown that the FDAIR test used to identify labral tears, consisting of hip flexion, adduction, and internal rotation have positive test results in approx 50% of patients diagnosed with iliopsoas syndrome. However, with resolution of iliopsoas syndrome patients after 12 weeks of physical therapy treatment, patients resolved their FDAIR test, avoiding the need for advanced imaging to for a labral tear.

This is important as a recent study, by Register et al., identified labral tears by MRI in 69% of an asymptomatic population. Furthermore, another study found that 43% of patients with labral tears, indicated for hip arthroscopy, were eventually diaganosed with extra- articular sources of their pain. The question is when to refer a patient for advanced imaging when symptoms of iliopsoas syndrome do not resolve? A recommended treatment algorithm by a Laible et al., based on these studies and physical therapy treatment on dancers, uses the following guidelines:

A. If a patient has snapping hip with pain and/ or weakness and a positive FDAIR and negative iliopsoas test refer for an MRI.

B. If a patient has snapping hip with pain and/ or weakness and a positive FDAIR and positive iliopsoas test allow 12 weeks of a conservative physical therapy program. Then after 12 weeks if the iliopsoas test and FDAIR is still positive refer then for an MRI.

Recommended Physical Therapy Treatment for Iliopsoas Syndrome

Literature suggests that 12 week physical therapy program can successfully resolve iliopsoas syndrome. Physical therapy specifically focused on strengthening hip and core musculature, ilioposas lengthening, ilioposas progressive strengthening, decreasing hyperlordotic postures, pelvic mobilization, long axis hip distraction, posterior femoral glides, and specific dance modification (limiting passe developpe and grand battement for a period of at least 4-6 weeks) has been shown to have high success rates among dancers.

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Medicine (Philadelphia, Pa.), 2001. 16(4): p. 609.

2. Kadel, N.J., Foot and Ankle Injuries in Dance. Physical Medicine And

Rehabilitation Clinics Of North America, 2006. 17: p. 813-826.

3. Van Dijk, C.N., et al., Degenerative joint disease in female ballet dancers. The

American Journal Of Sports Medicine, 1995. 23(3): p. 295-300.

4. Laible, et al. Iliopsoas Syndrome in Dancers. The Orthopaedic Journal of Sports Medicine. 2015. 1(3): p. 2-6.

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Kathleen Darley Understanding and Treating Iliopsoas Syndrome in the Dancer Population