Internal snapping hip



Movement of iliopsoas tendon over femoral head / iliofemoral ridge / iliofemoral ligament


Can be seen following THA with cup impingement




Audible or palpable snap in the groin


Hip moves

- from flexed / abducted / externally rotated position

- to extended / internally rotated position




10% of the population - usually painless




Move hip

- from flexed / abducted / externally rotated position

- to extended / internally rotated position




Dynamic ultrasound




May see inflammation of labrum medially






Physical therapy


Ultrasound guided injections into iliopsoas bursa


Operative release




Arthroscopic versus open release


Khan et al Arthroscopy 2013

- systematic review of surgical options for internal snapping

- 11 studies and 248 patients

- resolution of snapping seen in 100% arthroscopic and 77% open procedures

- complications seen in 2% arthroscopic and 21% open procedures


Trans-capsular fractional lengthening (arthroscopic) versus release at lesser tuberosity (endoscopic)


Ilizaliturri et al Arthroscopy 2009

- prospective RCT of 19 patients

- no difference in outcomes


Ilizaliturri et al Arthroscopy 2014

- comparative study of 20 patients

- one recurrence in group undergoing trans-capsular fractional lengthening


Arthroscopic trans-capsular technique / fractional lengthening




Arthroscopic technique article


Vumedi video


Identify psoas tendon medially

- iliopectineal groove

- at this level the iliopsoas is half tendon and half muscle

- perform fractional lengthening

- release tendon but not muscle


Arthroscopic release at lesser tuberosity


Vumedi video


Vumedi video 2


LT psoas rel 3LT psoas rel 4


Xray psoas releaseXray psoas release 2

Use image intensifer to triangulate to lesser tuberosity


LT psoas rel 2LT psoas 1LT psoas rel 3

Psoas tendon                                             Diathermy release                              Cleared lesser tuberosity






Gouveia et al Am J Sports Med 2021

- systematic review of outcomes after arthroscopic psoas release

- 21 studies with 875 hips

- majority trans-capsular / level of labrum (93%) versus at lesser tuberosity (7%)

- 93% resolution of internal snapping

- those evaluating strength identified normal strength in 2 studies, and mild decrease in 2 studies


Maldonaldo et al AJSM 2018

- compared cohort of patients undergoing labral repair and psoas release to those undergoing labral repair only

- >350 in each group

- no difference in outcomes

- having an arthroscopic fractional lengthening of the psoas tendon did not adversely affect outcomes


Jimenez et al AJSM 2022

- compared competitive athletes undergoing FAI surgery to those undergoing FAI surgery + iliopsoase release

- 91% resolution in painful snapping

- no difference in return to sport rates (90%) between two groups





- incidence unclear

- may be decreased with trans-capsular fractional lengthening versus complete release at lesser tuberosity


Continued painful snapping

- may be less common with release at lesser tuberosity


Hip dislocation

- two case reports after psoas release

- important to perform interportal closure in those at high risk


Abdominal compartment syndrome

- associated with hip arthroscopy and trans-capsular psoas release

- allows fluid extravasation into peritoneal compartment

- consider performing after central and peripheral compartment arthroscopy