This is an uncommon cause of pain in the hip and groin. It has been associated with inflammatory arthritis, acute trauma, and overuse syndromes, women are more commonly affected than men and it tends to affect younger patients
Psoas bursa Iliopsoas tendon and muscle
These are comprised of the iliopsoas and tensor fasciae lata. Although it is often regarded as a single muscle, the iliopsoas is comprised of 2 muscles: the psoas major and the iliacus (psoas minor - weak flexor). They insert via a common tendon into the lesser trochanter. The rectus femoris and sartorius are the other flexors of the hip.
Iliopsoas tendinitis and iliopsoas bursitis are closely inter-related because of their close proximity. Inflammation of either inevitably causes inflammation of the other. Iliopsoas tendinitis and iliopsoas bursitis are essentially identical in terms of presentation and management.
This refers to inflammation, partial tear or complete rupture of the iliopsoas muscle and tendon along with iliopsoas bursitis. It is rare for the iliopsoas muscle-tendon to rupture completely.
Presentation may include groin pain with an associated snapping sensation, a palpable mass, or a compression syndrome of the inguinal compartment secondary to enlargement of iliopsoas tendon and associated bursae.
Symptoms include pain, after onset of aggravating activity, with resolution soon after ending the activity. The condition may progress to pain that persists during activity but subsides some time after with rest. Eventually it progresses to pain during activity and at rest. This condition may occur if there is an overuse phenomenon associated with repeated hip flexion or external rotation of the femur e.g. in professional dancing. Pain may occur with specific sports-related activities, such as running or kicking as in football. There may be pain with other simple activities, such as putting on socks and shoes in the severe cases.
This often reveals localised tenderness in the area of the inguinal ligament, and pain with resisted hip flexion or passive hyperextension.
The patient is asked to sit with knees extended and subsequent elevation of the heel on the affected side. Pain caused by this manoeuvre (a positive Ludloff sign) is consistent with an iliopsoas tendinitis. This is because iliopsoas is the sole hip flexor activated in this position. The affected hip in a flexed, abducted, and externally rotated position (with the knee flexed) - the hip is then moved passively into extension. This test may cause an audible snap or palpable impulse over the inguinal region. If this manoeuvre is associated with pain then this is suggestive of iliopsoas tendinitis or bursitis.
MRI scan is the imaging modality of choice for diagnosing this problem, although ultra sonography can be useful if an enlarged bursa is present.
There is usually a delay in diagnosis of psoas tendonitis, with the time from the onset of symptoms to the diagnosis of iliopsoas tendinitis. This can be as long as 3 to 5 years from initial onset of symptoms.
Non-operative treatment, including rest, non steroidal anti-inflammatory medications, and a stretching exercise programme, has been recommended for the treatment of this condition. Corticosteroid/local anaesthetic injection is a non-operative management option that may be required if the exercises have no effect.
Iliopsoas muscle injury can cause lumbar lordosis and anterior pelvic tilt. These can be corrected by strengthening the abdominal musculature, sit-ups or crunches executed with knees and hips flexed at 90°. These allow the iliopsoas to relax, with the effort concentrated on the rectus abdominus muscle.
Surgical release of the iliopsoas tendon procedure may be undertaken if non-operative treatment has failed. This can be performed as an open procedure or arthroscopically as Mr Aslam Mohammed prefers to do.
and examination of the peripheral compartment of the hip joint is undertaken and the iliopsoas tendon can be located and partially released to take off the tension and stop the catching and reduce the symptoms. The release can be done at the level of the head neck junction or at its insertion into the lesser trochanter.
Iliopsoas tendon exposed at hip arthroscopy of the peripheral compartment*