PM R 7 (2015) 1102-1105

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Case Presentation

Atypical Coxa Saltans Due to Partial Proximal Hamstring Avulsion:

A Case Presentation Highlighting the Role for Dynamic Sonography
Luke S. Spencer-Gardner, MD, Adam M. Pourcho, DO, Jay Smith, MD,
Aaron J. Krych, MD

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.

Introduction Case Presentation

Painful snapping of the hip, or coxa saltans, can
present a diagnostic challenge for clinicians. Coxa
saltans can occur in the setting of intraarticular pa-
thology, but when an extra-articular etiology sus-
pected, it commonly occurs via 2 distinct mechanisms
[1]. Coxa saltans interna is attributed to snapping of
the iliopsoas tendon, whereas coxa saltans externa
arises from snapping of the iliotibial band over the
greater trochanter [1]. Differentiation between these
2 entities is often relatively straightforward based on
history and physical examination. Rarely, painful hip
snapping occurs that cannot be attributed to either
coxa saltans interna or externa. In this setting,
adjunctive diagnostic techniques such as dynamic
sonography become an invaluable tool to determine
the source of painful snapping. We present a case of
coxa saltans, or more accurately “snapping buttock”
following a proximal hamstring injury in which dy-
namic ultrasonography accurately identified the
source of snapping to be the conjoint tendon snapping
over the ischial tuberosity. Informed permission was
obtained from the patient allowing publication of this
case presentation.
A 47-year-old active, otherwise healthy woman was
referred for evaluation of painful, right posterolateral
hip snapping. Three months before presentation, she
had fallen forward down 4 stairs, hyperflexing her right
hip. Since that time, she had been experiencing slowly
worsening posterolateral right hip and buttock pain. At
the time of presentation, her pain was 5/10 and she
described a snapping sensation rising from a sitting
position or flexing forward in a standing position. She
denied neurological symptoms or back pain.
Physical examination demonstrated no deformity,
no trochanteric tenderness, and normal, nonpainful
passive hip range of motion. The patient was tender
to palpation over the ischial tuberosity, which repro-
duced some of her typical pain. The patient had a
normal gait and flexibility with subtle weakness (4þ/5
strength) and 5/10 pain with resisted knee flexion.
Hip provocative maneuvers were negative for groin
pain. Snapping iliopsoas provocative test results were
negative. Visible and audible lateral-posterolateral
hip snapping could be reproduced by the patient
during active hip flexion while bending over at the
waist in a standing position (Supplemental Video 1).

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The snapping appeared to occur medial to the greater
trochanter and posterior to the ischial tuberosity.
Plain radiographs demonstrated coxa profunda with
mild degenerative changes and no cam lesion. Mag-
netic resonance imaging (MRI) of the right hip
demonstrated high-grade tendinosis of the conjoint
tendon of the proximal hamstrings with partial thick-
ness tearing. Subsequently, a complete diagnostic
ultrasound of the right posterolateral buttock region
was performed. The examination included dynamic
imaging during which time the patient readily repro-
duced her snapping sensation, which localized to the
ischial tuberosity (Figure 1A-1C). Findings included
severe right proximal hamstring tendinopathy with
detachment as well as static medial subluxation of the
conjoint tendon of the biceps femoris and semite-
ndinosus from the ischial tuberosity, resulting in an
unstable proximal hamstring origin. There was a lack
of tendon retraction due to a persistent proximal
attachment of the conjoint tendon to a thickened
sacrotuberous ligament (Figure 2A and 2B). This
allowed the tendon to snap over the ischial tuberosity
during hip flexion and extension, explaining the pa-
tient’s mechanical symptoms (Supplemental Video 2).
Repeat MRI with an extended field of view confirmed
proximal hamstring tendinopathy and static medial
subluxation to the ischial tuberosity but failed to
show the dynamic nature of the injury seen on
sonography.
The patient had failed 3 months of conservative
treatment consisting of physical therapy that concen-
trated on core strength and mobility. The patient’s
pain, dysfunction, and snapping had, according to the
patient, increased over this time frame. Because of
the patient’s progressive pain and mechanical symp-
toms, she desired the option with the most predictable
outcome, and therefore surgical treatment was
discussed. The goals of surgical management were the
elimination of mechanical snapping of the conjoint
tendon over the ischial tuberosity, and the improve-
ment of the patient’s pain and function by restoration
of the normal anatomy. The surgical plan included
take-down of the attachment of the conjoint tendon
to the sacrotuberous ligament, followed by restoration
of the native anatomy of the conjoint tendon by
reattachment to the ischial tuberosity. The patient
was placed in the prone position and a 10-cm incision
was completed in the gluteal crease. Sciatic nerve
neurolysis was performed to allow safe mobilization
of the nerve away from the operative field. This pre-
vented nerve stretch injury and allowed for protection
of the nerve throughout the procedure. The proximal
hamstring origin was exposed, and intraoperative
examination confirmed conjoint tendon snapping
across the ischial tuberosity, although the amplitude
of intraoperative snapping was more subtle secondary
to patient positioning during surgery and the lack of
active muscle contraction. The proximal attachment
of the conjoint tendon onto the sacrotuberous liga-
ment was released. The anatomic footprint of the
conjoint tendon attachment on the ischial tuberosity
was debrided, and the tendon was subsequently
anatomically repaired using two 5.5-mm double-
loaded suture anchors (Figure 2C). Postrepair intra-
operative examination demonstrated resolution of the
snapping. Postoperatively the patient was placed into
a hinged knee brace locked at 60 of flexion for
3 weeks. After 3 weeks, the brace was discontinued,
with progression to weight bearing as tolerated by
6 weeks with crutches. At 12 weeks’ follow-up, the
patient was asymptomatic, with complete resolution
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.

Discussion been reported previously [5-7]. In each case, partial

This case presentation highlights the uncommon
condition of painful external snapping hip due to prox-
imal hamstring instability, and the role of dynamic
diagnostic sonography in evaluating painful hip snap-
ping. In this case, static imaging failed to show the
dynamic nature of the injury, which was easily demon-
strated with sonography.
The conjoint tendon of the semitendinosus and biceps
femoris originates from the ischial tuberosity in an oval-
shaped area that measures on average 2.7  0.5 cm from
proximal to distal and 1.8  0.2 cm from medial to lateral
[2]. The origin of the semimembranosus lies lateral to
that of the conjoint tendon in a crescent-shaped area
measuring on average 3.1  0.3 cm from proximal to
distal and 1.1  0.5 cm from medial to lateral [2]. In a
subset of the population, robust connections occur be-
tween the sacrotuberous ligament (STL) and the conjoint
tendon [3]. Bierry et al reviewed the anatomy of the STL
and its relationship to the proximal hamstring tendons in
normal and injured states on MRI [4]. The authors noted
that the STL can remain in continuity with the conjoint
tendon in the setting of high-grade partial tearing from
the ischial tuberosity. Furthermore, they noted signifi-
cantly less retraction of the ruptured hamstring tendons
when the STL remained in continuity with the conjoint
tendon [4]. In this setting, the proximal hamstrings,
although detached from the insertion on the ischial tu-
berosity, remain in close proximity to the tuberosity and
can subluxate, resulting in coxa saltans. Painful snapping
of the hamstring, or “snapping bottom syndrome,” has
rupture of the proximal hamstrings tendons caused
painful snapping resulting from medial to lateral and
lateral to medial subluxation of the tendons over the
ischial tuberosity. Surgical release of the proximal
hamstring tendon led to resolution of the patient’s
symptoms in each case. In our opinion, restoration of the
native anatomy is preferred. Our case presentation is the
first to report the successful treatment of this condition
with restoration of the native anatomy via reattachment
of the proximal hamstrings. Without reattachment,
hamstring strength of 62%-66% of the uninjured side can
be expected, based on data extrapolated from a series of
patients who did not undergo surgical repair of complete
proximal hamstring disruption [8].
Conclusion
When a patient presents with atypical painful snap-
ping of the hip, we recommend a thorough diagnostic
evaluation, including dynamic sonography when neces-
sary for definitive diagnosis. When a partial disruption of
the proximal hamstrings causes painful subluxation of
the tendon mass over the ischial tuberosity, we
recommend restoration of the native anatomy with
proximal hamstring reattachment.
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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

J.S. Department of Physical Medicine & Rehabilitation, Sports Medicine Center,

Mayo Clinic, Rochester, MN
Disclosures outside this publication: consultancy, Tenex Health (money to author
and institution); employment, Tenex Health; payment for lectures including
service on speakers bureaus, Gulf Coast Ultrasound Institute; patents, Tenex
Health (money to author and institution); royalties, Tenex Health (money to
author and institution); stock/stock options, Tenex Health (money to author and
institution)