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Hip Flexor Tendonitis

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Other Names

  • Iliopsoas Tendinopathy
  • Iliopsoas Bursitis
  • Iliopectineal Bursitis
  • Medial Snapping Hip Syndrome
  • Iliopsoas Strain
  • Iliopsoas Impingement

Background

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Hip Flexor Tendonitis

History

  • Discussed in the literature as early as 1938[1]

Epidemiology

  • Prevalence study in ballet dancers
    • Of 73 athletes with hip pain, 16 were diagnosed with anteromedial snapping hip, 5 with iliopsoas bursitis[2]
  • Time from symptom onset to diagnosis ranges from 32.9 to 41.4 months

Demographics

  • More common in women than men
  • Average age is 25.4 (range 12 to 56)[3]

Introduction

Illustration of the Iliopsoas[4]
Transverse view of sartorius, tensor fasciae latae, rectus femoris, and iliopsoas a short distance below anterior inferior iliac spine, crossing anterior to the femoral head.[5]

General

  • Occurs Due to repetitive hip flexion and external rotation
  • Can be acute or chronic, can be difficult to diagnosis clinically
  • Treatment is generally non-surgical with good outcomes

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[6]
  • 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)
    • Although joints are classically involved in RA, tynosynovium and bursa may be affected
    • Associated with RA affecting the Hip Joint, less commonly in isolation of the bursa[7]
    • Approximately 14% - 30% of iliopsoas bursa communicate with the hip joint

Anatomy of 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 Conditions

Risk Factors

Sports

  • Dancing
  • Ballet
  • Resistance training
  • Cycling
  • Rowing
  • Running (particularly uphill)
  • Track and field, especially hurdling
  • Soccer
  • Gymnastics

Other

Differential Diagnosis

Differential Diagnosis Hip Pain

Clinical Features

Clinical demonstration of a normal thomas test[8]

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: Physical Exam Hip

  • 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[9]
  • There may be weak resisted external rotation
  • Pain with resisted hip flexion
  • Pain with exaggerated passive hip extension

Special Tests

Evaluation

Large fluid filled mass adjacent to the psoas tendon and arising from the joint anteriorly is typical of a distended iliopsoas bursa[10]
CT exam performed without contrast medium. Axial plane shows the voluminous fluid relaxation of the right iliopsoas bursa (circle)[11]

Radiographs

  • Standard Hip Radiographs
    • Screening tool, typically normal
  • Can consider arthrography, bursography
    • These have fallen out of favor for MRI

Ultrasound

  • May demonstrate
    • Well defined, thin-walled fluid collection along the iliopsoas tendon[12]
  • 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

  • Clinical utility is not well defined

Classification

  • N/A

Management

Nonoperative

  • Relative rest
  • Physical Therapy
    • Emphasis on eccentric exercises
    • Stretching involving hip extension for 6-8 weeks in alleviating symptoms[13]
  • Pharmacotherapy

Procedures

Operative

  • Indications
    • Unknown
  • Technique
    • Tenotomy
    • Tendon lengthening

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Proposed Rehabilitation Protocol[14]

  • 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/Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Needs to be updated

Complications

  • Inability to return to sport

See Also

Internal

External

References

  1. ↑ Finder JG. lliopectineal bursitis. Arch Surg 1938; 36: 519-30
  2. ↑ Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports Med 1988; 6: 295-307
  3. ↑ Johnston, Christopher AM, et al. "Iliopsoas bursitis and tendinitis." Sports Medicine 25.4 (1998): 271-283.
  4. ↑ Image courtesy of kenhub.com
  5. ↑ Loukas, Marios, et al. Gray's Anatomy Review E-Book: Gray's Anatomy Review E-Book. Elsevier Health Sciences, 2021.
  6. ↑ Tom N Novacheck T. Review paper: The biomechanics of running. Gait Posture. 1998;7:77-95.
  7. ↑ 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
  8. ↑ Peeler, J., and Judy E. Anderson. "Reliability of the Thomas test for assessing range of motion about the hip." Physical Therapy
  9. ↑ Hucherson DC, Denman FR. Non-infectious iliopectineal bursitis. Am J Surg 1946; 72 (4): 576-9
  10. ↑ Case courtesy of Chris O'Donnell, Radiopaedia.org, rID: 16356
  11. ↑ Corvino, Antonio, et al. "Iliopsoas bursitis: the role of diagnostic imaging in detection, differential diagnosis and treatment." Radiology Case Reports 15.11 (2020): 2149-2152.
  12. ↑ 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.
  13. ↑ Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 1990; 18 (5): 470-4
  14. ↑ 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:
26 June 2025 18:26:43
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