Iliopsoas Bursitis

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Search Strategy

Databases: Pubmed
Keywords: Iliopsoas bursitis, bursitis, physiotherapy, groin pain, physical therapy

Definition/Description

For the definition of bursitis: See Bursitis
A bursitis is an inflamed bursa. The inflammation can be a result of friction from the overlying tendons. A bursa is mostly flattened and is filled with a thin layer of synovial fluid. It appears for example at a junction of a tendon on the bone. The iliopsoas bursa separates the muscle or tendon from bone and facilitates movement by reducing friction between the anterior hip capsule and the iliopsoas. [7, 3] The iliopsoas bursitis is one of the affections related to anterior hip pain.
 

Clinically Relevant Anatomy

The iliopsaos bursa is the largest bursa of the human body and is bilaterally present in 98% of adults. This bursa is bounded by the musculotendinous junction of the M. iliopsoas (anteriorly) and by the fibrous capsule of the hip (posteriorly). It extends from the inguinal ligament superiorly to the lesser trochanter inferiorly and is flanked by the femoral vessels (medially) and the femoral nerve (laterally). [2] The bursa is always collapsed, when in healthy condition. In some situations the bursa is enlarged, and contains fluid. When enlarged, it may cause a variety of symptoms such as pain, and immobility. [8, 3]

Epidemiology /Etiology

Iliopsoas bursitis is mainly caused by rheumatoid arthritis, acute trauma and overuse injury. When an acute or chronic occupational trauma incurred during sport activities, a bursitis is likely the result of multiple mini-traumas caused by vigorous hip flexion and extension. Iliopsoas bursitis is commonly seen in individuals participating in strength training, rowing, uphill running and competitive track and field.
There are a few theories concerning the origin of symptoms of iliopsoas bursitis. One of them points that when the hip is in flexion, both the iliopsoas muscle and the anterior part of the bursa move away from the hip joint. [3] If the hip is to be hyperextended suddenly, there is a great tension that stretches the muscle and the bursa. This stretching traumatizes the bursa. Another theory hypothesizes that when a flexed, abducted and externally rotated hip, with iliopsoas bursitis, is brought in an extension, it causes an interruption of the lateral to medial movement of the iliopsoas tendon. This results in a painful snapping of the tendon over the femoral head, and over the anterior hip capsule.
Inevitably, iliopsoas bursitis and tendinitis are interrelated, where inflammation of the one will result in inflammation of the other because of their close proximity. In their presentation, etiology and treatment, the two conditions are almost identical. Together it is called the iliopsoas syndrome. [3]
Patients with rheumatoid arthritis can also suffer from iliopsoas bursitis. Joint synovium is the main target of rheumatoid arthritis, but sometimes, synovial tissues of tenosynovium and bursae, are also involved. This results from the inflammatory process in the hip joint, extending in the iliopsoas bursitis. This kind of bursitis mainly affects young adults. It occurs slightly more often in women than men. [3] (Level of evidence: A1)

Characteristics/Clinical Presentation

- Pain is felt in the anteromedial aspect of the thigh.
- Pain radiated into the knee, leg and lower back.
- Tenderness in the upper quads (M. Quadriceps).
- A snapping sensation at the front of the hip.
- Pain develops during walking or specific movements like crossing the legs.
- Pain on hip flexion, resisted as well as passive.
- Pain on internal rotation or passive hyperextension.
- Stiffness or pain after a rest or in the mornings.
- Pain is worse while performing activities.
- Rest can relieve the pain.
[9]

Several joint diseases can cause distension [11]:
- Osteoarthritis
- Rheumatoid arthritis
- Avascular necrosis
- Pigmente villonodular synovitis
- Synovial chondromatosis
- Gout
- Chondrocalcinosis
- Trauma
- Lupus erythematodes
- Pyogenic infection 
[2]
- Snapping hip

Differential diagnosis of anterior hip pain by anatomical structure [11]:
- Joint
o Osteoarthritis
o Inflammatory synovitis
o Loose bodies (chondral, osteochondral, ossified, nonossified, fibrous, foreign)
o Infection (septic joint)
o Crystal-induced synovitis (gout)
o Labral tears
- Bone
o Femur
• Stress fracture
• Avascular necrosis of femoral head
• Bone tumour
• Infection
o Femoroacetabular impingement (two types: cam impingement occurs from a abnormal head junction of the femur, pincer impingement is because of over coverage of the acetabulum)
o Pelvis
• Hip fracture
• Stress fracture
• Osteitis pubis
- Muscle, tendon, bursa
o Iliopsoas bursitis and tendinitis
o Iliopsoas strain
o Retus femoris strain
o Tight iliotibial band
o Gluteus medius en minimus problems
o Capsular laxity causing instability (due to traumatic dislocation or overuse)
- Vasculature
o Aneurysm
o Arteriovenous malformation
- Pelvic mass
o Gastrointestinal causes (e.g. hernia)
o Genitourinary causes (e.g. ureteral stone)
- Nerve
o Obturator nerve entrapment
o Myalgia paraesthetica
o Referred from lumbar spine (L1, L2)

Diagnostic Procedures

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Outcome Measures

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Examination

- Tenderness to palpation can be found distal to the midpoint of the inguinal ligament in the femoral triangle
- There is a limitation in ROM according to a NIET-CAPSULAIR patron
- Exorotation is painful and has a soft EINDGEVOEL
- Flexion is lightly painful at the end of ROM
- Sometimes pain can be felt at the end of ROM when extension or adduction UITGEVOERD WORDT.
- The most painful movement is adduction with the hip in flexion.
- There’s no weakness of muscles.
- A palpable and/or audible snap can be present [3](level of evidence: A1)
[4]

Medical Management

The patient can take anti-inflammatory medications. There could be performed aspiration and corticosteroid injections of the bursa for persistent pain symptoms. [1]
If physical therapy is unsuccessful, a corticosteroid injection could be the next line of intervention.Surgery is rarely. [3]
 

Physical Therapy Management

The treatment includes stretching of the hip flexor muscles. After that a strengthening program (for hip rotators) can be followed.
Stretching exercises (involving hip extension) performed for 6 to 8 weeks alleviate the symptoms. [3] (Level of evidence: A1)
 

See more exercises on Therapy exercises for the hip

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

1. Parziale J.R., O’Donnell C.J , Sandman D.N., Iliopsoas Bursitis, Am. J. Phys.Med. Rehabil. Vol 88, No.8, August 2009
2. Van de Perre S., Vanwambeke K., Vanhoenacker F.M., De Schepper A.M., Posttraumatic iliopsoas bursitis, JBR-BTR, 2005, 88:154-155
3. Johnston C.A.M., Wiley J.P., Lindsay D.M., Wisemand D.A., Iliopsoas bursitis and tendinitis (a review), Sports Med, april 1998; 25 (4): 271 – 283 (Level of evidence: A1)
4. Ombregt L., Bisschop P., ter Veer H.J., Van de Velde T., A System of Orthopaedic Medicine. 1999.