Endoscopic Technique for Iliotibial Band and Gluteus Maximus Tendon Lengthening in the Treatment of External Snapping Hip Syndrome

Abstract

External snapping hip affects approximately 5% to 10% of the population. Surgical intervention, typically via endoscopic or open iliotibial band release, is generally reserved for recalcitrant cases. This article describes a step‐by‐step guide to the endoscopic treatment of persistent external snapping hip. The technique may be performed in isolation to address external snapping hip or in conjunction with procedures for intra‐articular pathology, such as femoroacetabular impingement and labral tears. It involves releasing the iliotibial band and the gluteus maximus tendon at its femoral attachment, with the goal of minimizing recurrence and achieving sustained pain relief.

External snapping hip (ESH) affects approximately 5% to 10% of the population. ¹ ESH is caused by the iliotibial band (ITB) snapping over the greater trochanter, typically due to thickening of the posterior ITB and a thigh attachment of the gluteus maximus to the femur anchoring the ITB closer to the greater trochanter. ² , ³ Although often asymptomatic in its early stages, repetitive snapping can lead to irritation of the trochanteric bursa, resulting in inflammation and lateral hip pain. ⁴ , ⁵

Conservative management is typically the first‐line treatment for ESH and includes physical therapy, stretching, and targeted corticosteroid injections. ³ , ⁴ Traditionally, surgical interventions such as endoscopic or open release of the ITB are reserved for recalcitrant cases. ⁶ , ⁷ , ⁸ , ⁹ Both approaches have shown favorable patient‐reported outcomes, with low complication and recurrence rates. ⁵ , ¹⁰ , ¹¹ , ¹²

We present a step‐by‐step guide to the endoscopic treatment of recalcitrant ESH. This approach can be performed in isolation to address ESH or in conjunction with procedures for intra‐articular pathology, such as femoroacetabular impingement (FAI) and labral tears. It involves releasing the ITB and addressing the gluteus maximus tendon at its femoral attachment, aiming to minimize recurrence and provide sustained pain relief.

SURGICAL TECHNIQUE

A detailed description of the endoscopic ITB and gluteus maximus tendon release technique is provided in Video 1.

VIDEO 1.

Download video file ^{(75MB, mov)}

Endoscopic technique for iliotibial band and gluteus maximus tendon lengthening in the treatment of external snapping hip syndrome. The video shows a left hip in supine positioning on a postless traction table, portal establishment, and safe cannula placement through the distal anterolateral accessory portal under fluoroscopic guidance. A 70° arthroscope is used for visualizing the peritrochanteric space, and a partial trochanteric bursectomy is performed to enhance visualization and identify key landmarks. The iliotibial band is then released in an L‐shaped pattern at the vastus ridge using a radiofrequency wand. Video content can be viewed at https://doi.org/10.1002/atn2.70136.

Step‐by‐Step Surgical Technique

The patient is positioned supine on a traction table; however, traction is not required for this technique. The operative leg is mobilized into 20°‐30° of abduction.

If performed in isolation, the visualization portal is established under fluoroscopic guidance, located approximately 2 cm anterior and 2 cm distal to the greater trochanter. A second (working) portal is then created under direct visualization, positioned 3 cm lateral and 3 cm posterior to the visualization portal (Figure 1A).

FIGURE 1.

(A) Portal placement depicted in left hip for isolated cases of ESH. (B) Portal placement depicted in left hip for ESH cases concomitant with hip arthroscopy. (AL, anterolateral portal; DALA, distal anterolateral portal; ESH, external snapping hip; GT, greater trochanter.)

If the procedure is performed following hip arthroscopy, the distal anterolateral accessory portal may be used for visualization, and the anterolateral portal as the working portal (Figure 1B). Fluoroscopic guidance is recommended to ensure accurate orientation (Figure 2).

FIGURE 2.

Intraoperative anteroposterior (AP) fluoroscopic image of the left hip demonstrating cannula placement (solid black arrow) through the distal anterolateral accessory (DALA) portal. The cannula is advanced just inferior to the greater trochanter, providing safe entry into the peritrochanteric space.

Once in the peritrochanteric space, a partial trochanteric bursectomy is performed to improve visualization and facilitate identification of the femoral insertion of the gluteus maximus tendon, as well as the anterior and posterior borders of the ITB (Figures 3, 4).

FIGURE 3.

Intraoperative view of the left hip through distal anterolateral accessory (DALA) portal, viewing the anterior border of the iliotibial band (white arrow) and posterior border of the iliotibial band (black arrow).

FIGURE 4.

Intraoperative view of the left hip through distal anterolateral accessory (DALA) portal, viewing gluteus maximus tendon insertion.

The release is then performed using a radiofrequency wand at the level of the vastus ridge, following an “L”‐shaped pattern (Figure 5). The release begins with a transverse incision from the anterior border of the ITB extending posteriorly. Upon reaching the posterior border, the incision is turned distally to create a longitudinal cut, continuing until the gluteus maximus tendon insertion is fully released (Figures 6, 7).

FIGURE 5.

Intraoperative view of the left hip through distal anterolateral accessory (DALA) portal, viewing “L” shaped release of the iliotibial band on the gluteus maximus tendon attachment (transparent dual arrow).

FIGURE 6.

Intraoperative view of the left hip through distal anterolateral accessory (DALA) portal, viewing iliotibial band (black arrow) release starting from the anterior border towards the posterior border.

FIGURE 7.

Intraoperative view of the left hip through distal anterolateral accessory (DALA) portal, viewing gluteus maximus tendon release.

IRB Approval

This study was approved by the Institutional Review Board (IRB). (IRB ID: 20242189).

DISCUSSION

Surgical treatment for ESH in the hip preservation literature has shown favorable outcomes, both when performed in isolation and when combined with hip arthroscopy. ⁵ , ¹² , ¹³ , ¹⁴ , ¹⁵ A recent trend has emerged favoring minimally invasive techniques due to their improved results. For example, Pierce et al. conducted a systematic review of patients with isolated, painful ESH who failed conservative management and subsequently underwent surgical intervention. ⁷ The review included 7 studies with a mean follow‐up of 39 months, comprising 46 patients treated endoscopically and 67 treated with open surgery. The authors reported excellent outcomes, with a recurrence rate of 7% (8 patients: 6 open, 2 endoscopic), and only 1 patient requiring revision surgery to further address the gluteus maximus tendon attachment.

Furthermore, Randelli et al. recently reviewed the literature comparing surgical options for ESH, including open and endoscopic techniques. ¹⁰ They found that endoscopic approaches were associated with favorable clinical outcomes, lower recurrence rates, and fewer complications compared to open procedures.

In cases of painful ESH concomitant with FAI, Zhang et al. examined 23 hips treated with ITB release as part of comprehensive arthroscopic management for both FAI and ESH. ¹⁶ Their technique involved a transverse ITB release without addressing the gluteus maximus tendon attachment. These patients were propensity matched to a control group of FAI patients without ESH. Both groups achieved significant and comparable improvements in the modified Harris Hip Score, International Hip Outcome Tool, and Visual Analog Scale scores, with no significant differences in abduction strength, complication rates, or revision rates at 24‐month follow‐up.

The present study describes a stepwise endoscopic approach for treating ESH, involving release of both the ITB and the gluteus maximus tendon attachment to the femur using an “L”‐shaped configuration. This technique is designed to minimize recurrence and provide sustained pain relief and can be effectively performed either in isolation or in combination with hip arthroscopy for addressing concomitant intra‐articular pathology. Advantages and surgical considerations are summarized in Tables 1 and 2.

TABLE 1.

Advantages and Disadvantages

Advantages	Disadvantages
Easy access in both isolated cases and following hip arthroscopy	Potential ITB weakness
Minimally invasive approach	Incomplete symptom relief if release is insufficient
Restore pain‐free range of motion

ITB, iliotibial band.

TABLE 2.

Surgical Pearls and Pitfalls

Pearls	Pitfalls
Begin by marking the trajectory to the trochanteric ridge under fluoroscopy to avoid iatrogenic damage	Careful bursectomy to avoid damage to the abductors
Slight abduction assures an easier mobilization of the ITB	Start proximal and anterior to ensure a complete release of the ITB
An adequate trochanteric bursectomy facilitates visualization

ITB, iliotibial band.

DISCLOSURES

The authors (R.Q‐J., A.H.K‐R., E.S., B.G.D.) declare the following financial interests/personal relationships which may be considered as potential competing interests: R.Q‐J. reports receiving travel reimbursement from Arthrex, Stryker, and Zimmer Biomet. A.H.K‐R. reports receiving travel reimbursement from Arthrex, Stryker, and Zimmer Biomet. E.S. reports a relationship with Arcuro Medical that includes: consulting or advisory. B.G.D. reports a relationship with Arthrex that includes: consulting or advisory, speaking and lecture fees, royalties, research funding, and travel reimbursement; reports a relationship with Smith & Nephew that includes: research support; reports a relationship with DJO, LLC that includes: royalties; reports a relationship with Medacta USA that includes: royalties; reports a relationship with Stryker that includes: consulting or advisory, research funding, and nonfinancial support; reports a relationship with Smith & Nephew that includes: nonfinancial support; reports a relationship with Bioventus LLC that includes: nonfinancial support; reports a relationship with Heraeus Medical, LLC that includes: nonfinancial support; reports a relationship with Lightbody Medical Technologies that includes: nonfinancial support; reports a relationship with Oak Med that includes: nonfinancial support; reports a relationship with DePuy Synthes Sales that includes: nonfinancial support; reports a relationship with Shalby Advanced Technologies that includes: nonfinancial support; has patent #8920497 with royalties paid from Arthrex; has patent #2612625 with royalties paid from Orthomerica and DJO Global; has patent #RE47811 with royalties paid from Arthrex; has patent #0338177 with royalties paid from Orthomerica; he is a Board Member of American Hip Institute Research Foundation, AANA Learning Center Committee, the Journal of Hip Preservation Surgery, the Journal of Arthroscopy, AOSSM Research Committee, ISHA Hip Preservation Society; and has had ownership interests in the American Hip Institute and affiliates. The other authors (T.S., I.A.W.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Quesada‐Jimenez Roger, Syed Talha, Wallace Isabella A., Kahana‐Rojkind Ady H., Sugarman Etan, Domb Benjamin G.. Arthrosc Tech. 2026; 15:e70136. 10.1002/atn2.70136