Iliopsoas Tendinopathy

Original Editor - Shejza Mino

Top Contributors - Shejza Mino, Lucinda hampton, Kim Jackson, Wendy Snyders, Rishika Babburu and Leana Louw  

Introduction

In general, the iliopsoas muscle contributes to a variety of lumbopelvis problems, and the iliopsoas tendon is a common cause of hip pain and dysfunction, ranging from asymmptomatic snapping hip syndrome to symptomatic irritation of the tendon and related bursa.

Excessive tightness of the iliopsoas muscle may cause increased friction, or result in an audible snap, when the tendon travels over the underlying bony landmarks. These landmarks include the anterior inferior iliac spine, iliopectineal eminence, bony ridge of the lesser trochanter or the anterior capsule of the femoral head, This condition is known as "asymptomatic internal snapping hip syndrome" when painless. However, when pain/dysfunction is experienced with the audible snap, there are various terms used to describe the condition including "painful internal snapping hip, internal coxa saltans, iliopsoas tendinitis, iniopsoas tendinosis, inilopsoas tendinopathy, iliopsoas bursitis, or liopsoas syndrome". Due to the close proximity of the Iliopsoas tendon and the related bursa, inflammation of one of these structures ineviable causes inflammation of the other. Therefore, the literature reports that a diagnoses of iliopsoas tendinitis and iliopsoas bursitis are synonymous, as the clinical presentation, evaluation, and management are nearly identical.

Clinically Relevant Anatomy

The iliopsoas refers to the combined iliacus and psoas muscles. The two muscles are commonly separate entities in the abdomen and merge together in the thigh.

The origin of the deep fibers of the psoas major is at the transverse process of the T12 to L5 vertebrae. The superficial fibers originate from the outer surfaces of lumbar vertebra and adjacent intervertebral discs. The origin of the iliacus muscle is in the iliac fossa of the pelvis.

The psoas major and illiacus muscles merge between L5-S2. The iliopsoas runs from the pelvis to the thigh under the inguinal ligament and the tendon travels anteriorly across the acetabulum between the anterior inferior iliac spine (laterally) and the iliopectineal eminenence (medially) to eventually attach onto the lesser trochanter of the femur. The iliopsoas bursa is located between the iliopsoas musculotendionous junction and the underlying bony pelvis. The bursa has been reported to communicate with the hip joint in ~15% of the adult population.

Nerve supply:

• The iliacus component of the iliopsoas muscle is innervated by the femoral nerve (composed of anterior rami of L2-L4)
• The psoas component of the iliopsoas muscle is innervated by direct branches of the lumbar plexus (anterior rami of L1-L3)

Vascular supply:

• Iliolumbar artery & medial femoral circumflex artery.

Function:

• Flexion & external rotation of the hip

See Psoas Major.

Epidemiology

In general, iliopsoas pathologic conditions (including tendinitis, bursitis, snapping and impingement) have been deemed to be the main cause of chronic groin pain in roughly 12-36% of athletes and in 25-30% of athletes with acute injury to the groin region

Data on the prevalence of iliopsoas tendonitis remains unknown however, it more commonly affects young adults and is mildly more prevalent in females

Etiology

Acute injury and overuse injury are the most common causes of iliopsoas tendinitis:

• Acute injury: from either eccentric contraction of the muscle or brisk flexion against an extension force. Either way, the acute injury leading to iliopsoas tendintis is not commonly due to a direct traumatic event.
• Overuse injury: may result from any activity requiring repetitive hip flexion or repetitive external rotation of the hip.

Other reported causes:

• Snapping hip sydrome (related to iliopsoas tendinitis) has been described more commonly amongst dancers who have a decreased pelvic bone width, decreased lateral hip rotation, increased abduction as well as increased strength to the lateral rotators of the hips.
• One potential cause of iliopsoas bursitis, which is closely associated to iliopsoas tendinitis, is rheumatoid arthritis.

Clinical Presentation

History

A history of insidious groin or anterior hip pain is common. Initially, pain is provoked with onset of aggravating activity, decreasing shortly after. Symptoms may progress to constant pain during activity that diminishes only with rest and lastly, to the presence of pain during activity as well as with rest. The diagnosis is usually delayed, with the average time between initial symptoms and diagnosis is estimated to be between 32-41 months.

• Patients may report pain with activities such as running or kicking. Additionally, tying shoe laces, rising from a seated position after prolonged sitting and inclined walking are some other examples activities of daily living that may provoke symptoms.
• Radicular symptoms along the anterior thigh down towards the knee may be reported.
• Commonly, an audible click or snap coming from the groin or hip area is reported. This is associated with internal snapping hip syndrome, a condition where the tendon of the iliopsoas muscle glides over the head of the femur, or over the iliopsoas bursa causing an audible snap that can usually be palpated.
• A tight iliopsoas muscle may cause symptoms over the anterior knee that resembles patellofemoral dysfunction.

Physical Examination

Observation:

• The affected hip may appear to be held in a mildly flexed and externally rotated position to decrease muscle tension.
• Tightening of the iliopsoas muscle may result in anterior pelvic tilt.
• Gait: A shortened stride length may be obvious on the affected side. Additionally, heel strike and midstance phases may reveal increased knee flexion.

Palpation:

• The iliopsoas muscultendionous junction can be palpated within the femoral triangle. Palpation of the inguinal lymph nodes in this region should be unremarkable.
• With the patient in a prone position, the insertion of the iliopsoas tendon onto the lesser troachanter can be palpated under the gluteal fold, which may reveal pain.

Functional testing:

• Resisted hip flexion at 15 degrees may produce pain
• Ludloff's sign: In a seated position with the knees extended, the patient is asked to lift the heel of the affected side off the table. Ludloff's sign is considered positive if it produces any pain.
• Snapping hip maneuver: To begin, the affected hip is positioned in a flexed, abducted and external rotated position. From this position, the hip is passively moved into extension and internal rotation. Pain provoked with this maneuver suggests iliopsoas tendinitis or bursitis.

Differential Diagnoses

• Apophysitis
• Contusion
• Femoral Acetabular Impingement (FAI)
• Avascular necrosis of the femoral head
• Stress fracture of the femoral neck
• Groin injury
• Hip tendinitis and bursitis
• Lumbosacral Disc Injuries
• Lumbosacral Radiculopathy

In addition to "internal" snapping hip, clinicians should be aware of two other potential causes for reverberation; "external" snapping hip occurs when the iliotibial band or gluteus maximus tendon passes over the greater trochanter and "intraarticular" snapping results from loose bodies, labral tears, or even recurrent dislocation

Workup

Medical Imaging

• Radiography
• Ultrasonography
• Magnetic Resonance Imaging (MRI)

Management

Physical Therapy

• Acute Phase
• Recovery Phase
• Maintenance Phase
• Return to Play

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