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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

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)
    • 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[5]
    • Approximately 14% - 30% of iliopsoas bursa communicate with the hip joint

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


Differential Diagnosis


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

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

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


References

  1. Finder JG. lliopectineal bursitis. Arch Surg 1938; 36: 519-30
  2. Johnston, Christopher AM, et al. "Iliopsoas bursitis and tendinitis." Sports Medicine 25.4 (1998): 271-283.
  3. Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports Med 1988; 6: 295-307
  4. Tom N Novacheck T. Review paper: The biomechanics of running. Gait Posture. 1998;7:77-95.
  5. 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
  6. Hucherson DC, Denman FR. Non-infectious iliopectineal bursitis. Am J Surg 1946; 72 (4): 576-9
  7. 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.
  8. Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 1990; 18 (5): 470-4
  9. 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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