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Hip Flexor Tendonitis
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Contents
Other Names
- Iliopsoas Tendinopathy
- Iliopsoas Bursitis
- Iliopectineal Bursitis
- Medial snapping hip syndrome
- Iliopsoas strain
Background
- This page discusses tendinopathy of the hip flexor muscles
History
- Discussed in the literature as early as 1938[1]
Epidemiology
- More common in women than men
- Average age is 25.4 (range 12 to 56)[2]
- Prevalence study in ballet dancers
- Of 73 athletes with hip pain, 16 were diagnosed with anteromedial snapping hip, 5 with iliopsoas bursitis[3]
- Time from symptom onset to diagnosis ranges from 32.9 to 41.4 months
Pathophysiology
- See: Tendinopathies (Main), Bursopathies (Main)
- General
- Due to repetitive hip flexion and external rotation
- Bursitis vs tendinitis
- Note that iliopsoas bursitis and iliopsoas tendinitis are discrete entities
- However, interrelated and inflammation of one leads to inflammation of the other
- Clinically, they present the same and thus are indistinguishable
- Biomechanics
- During stance phase when running, the hip is extending[4]
- The iliopsoas contracts eccentrically, decelerating the hip
- Gains potential energy as it elongates
- Energy is then released during swing phase as the ipsilateral limb comes forward
Etiology
- Acute trauma
- Less common
- Overuse injury
- Likely due to repetitive hip trauma as the result of flexion and extension
- May be in part due to sudden hyperetextension of a flexed hip, stretching the iliopsoas muscle and bursa
- Another hypothesis is a flexed, abducted and externally rotated hip causes the muscle and bursa to snap over the femoral head and joint capsule
- Enlarged bursa more commonly seen in individuals with hip related symptoms and not overuse injuries
- The tendon may also rub against the pubic iliopectineal eminence
- Rheumatoid Arthritis (RA)
Pathoanatomy
- Iliopsoas
- Composed of Iliac, Psoas Major and Psoas Minor
- Function is primarily hip flexion, to a lesser degree external rotation
- Mscle passes anterior to the pelvic brim and hip capsule in a groove between the anterior inferior iliac spine laterally and iliopectineal eminence medially
- Iliopsoas Bursa sits inferior to these muscles and above the joint capsule of the Hip Joint
Associated Pathology
Risk Factors
- Sports
- Dancing
- Ballet
- Resistance training
- Cycling
- Rowing
- Running (particularly uphill)
- Track and field, especially hurdling
- Soccer
- Gymnastics
- History of Total Hip Replacement
- Rheumatoid Arthritis
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Pain may be insidious or acute
- Located on anterior hip but sometimes less focal or at deep to the groin
- Often worse during exercise and immediately following
- Initially pain free at rest, may develop pain even at rest
- May or may not have a snapping sensation, which is more common in athletic population
- Often worse with sitting for a long period of time, walking up stairs, jogging, running and kicking
- The pain may radiate down the thigh towards the knee
- Physical Exam
- An inguinal mass suggests an enlarged bursa, usually in more chronic presentations
- Tenderness to palpation distal to the inguinal ligament, lateral to the femoral triangle, medial to Sartorius is considered pathognomonic[6]
- There may be weak resisted external rotation
- Pain with resisted hip flexion
- Pain with exaggerated passive hip extension
- Special Tests
- Thomas Test: Ipsilateral limb is flexed to chest, contralateral limb is brought into extension
- Modified Thomas Test: Same as thomas test, except contralateral limb allowed to hang off table
- Snapping Hip Sign: extension of their flexed, abducted and externally rotated hip (needs to be updated)
- Pelvifemoral Angle: measure angle of pelvis to hip flexor
- Elys Test: prone, passively flex knee to buttocks
- Rectus Femoris Contracture Test: knee to chest, observe contralateral limb
- Prone Hip Extension Test: prone, extend affected hip, measure horizontal thigh angle
Evaluation
Radiographs
- Standard Hip Radiographs
- Screening tool, typically normal
- Can consider arthrography, bursography although these have fallen out of favor for MRI
Ultrasound
- May demonstrate
- Well defined, thin-walled fluid collection along the iliopsoas tendon[7]
- Can be used guide a needle for diagnostic or therapeutic purposes
- Target is just inferior to the iliopsoas muscle-tendon junction
MRI
- Findings
- Distended bursa
- Peritendinous fluid
- Can demonstrate communication between bursa and hip joint
CT
Classification
- N/A
Management
Prognosis
Nonoperative
- Relative rest
- Physical Therapy
- Emphasis on eccentric exercises
- Stretching involving hip extension for 6-8 weeks in alleviating symptoms[8]
- Pharmacotherapy
- Corticosteroid Injection
Operative
- Indications
- Technique
- Tenotomy
- Tendon lengthening
Rehab and Return to Play
Rehabilitation
Proposed Rehabilitation Protocol[9]
- Phase 1
- Weeks 1-4: load management, eccentric exercise
- Discontinue running
- Hip stretching, eccentric hip flexion
- Lumbo-pelvic and core exercises, lunges, squats
- Phase 2
- Weeks 5-8: introduce loading, cross training
- Begin walking program if pain free
- Perform deep water running
- Continue phase 1 protocol
- Phase 3
- Re-introduce running with walk-run interval program
- Continue deep water running, sideways hills
Return to Play
- Needs to be updated
Complications
- Inability to return to sport
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Finder JG. lliopectineal bursitis. Arch Surg 1938; 36: 519-30
- ↑ Johnston, Christopher AM, et al. "Iliopsoas bursitis and tendinitis." Sports Medicine 25.4 (1998): 271-283.
- ↑ Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports Med 1988; 6: 295-307
- ↑ Tom N Novacheck T. Review paper: The biomechanics of running. Gait Posture. 1998;7:77-95.
- ↑ Toohey AK, LaSalle TL, Martinez S, et al. Iliopsoas bursitis: clinical features, radiographic findings, and disease associations. Semin Arthritis Rheum 1990; 20 (1): 41-7
- ↑ Hucherson DC, Denman FR. Non-infectious iliopectineal bursitis. Am J Surg 1946; 72 (4): 576-9
- ↑ Lungu E, Michaud J, Bureau NJ. US Assessment of Sports-related Hip Injuries. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (3): 867-889.
- ↑ Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 1990; 18 (5): 470-4
- ↑ Rauseo C. THE REHABILITATION OF A RUNNER WITH ILIOPSOAS TENDINOPATHY USING AN ECCENTRIC-BIASED EXERCISE-A CASE REPORT. Int J Sports Phys Ther. 2017;12(7):1150-1162. doi:10.26603/ijspt20171150
Created by:
John Kiel on 5 July 2019 08:35:24
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Last edited:
5 October 2022 13:06:44
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