High Yield Topics

Iliopsoas

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Ovid: 5-Minute Sports Medicine Consult, The


Iliopsoas
Kevin E. Burroughs
Basics
  • Aching pain; can be in groin or over the anterior thigh
  • Occasionally, onset of pain is acute or subacute, with sharp lancinating or burning pain.
  • More often, it is insidious in onset, with pain exacerbated by climbing stairs, getting in/out of bed, or rising from a seated position.
Description
  • Bursitis is inflammation and secondary pain in a bursal structure.
  • It is a common cause of lower extremity pain in people of all ages and activity levels.
  • 2 types of bursae have been described, constant and adventitial. Constant bursae are formed in embryogenesis and are endothelial-lined saclike structures (eg, iliopsoas and trochanteric). Adventitial bursae form later in life through myxomatous degeneration of fibrous tissues at sites of friction (eg, a bunion).
  • The iliopsoas bursa is the largest synovial bursa in the body and is present in over 95% of adults. It averages 3 cm (width) × 6 cm (length) in size. There often is communication with the hip joint capsule (14% of adults).
  • Synonym(s): Snapping hip syndrome
  • Snapping hip syndrome is usually broken down into intraarticular and extraarticular.
  • Extraarticular is subclassified into medial (internal). which is associated with iliopsoas pathology, and lateral (external), which is associated with iliotibial band and greater trochanteric pathology.
Epidemiology
  • Bursitis is reported to account for 0.4% of all visits to primary care, but in runners the incidence may be as high as 10%.
  • In a 6-yr study of ballet dancers, 21 of 73 hip problems reported were attributed to iliopsoas bursitis/tendonitis.
  • Reported in patients of all ages, but average age is 25 yrs, with a range of 12–56 yrs.
Risk Factors
  • Rheumatoid arthritis, osteoarthritis, acute trauma, overuse, or mechanical factors (tightened hip flexors)
  • Common sports associated: Strength training, rowing, uphill running, competitive track and field, aerobics
Etiology
  • The psoas and iliacus muscles originate from the lumbar spine and the internal aspect of the pelvic brim, respectively. They converge to form the iliopsoas muscle-tendon complex and insert distally on the lesser trochanter. It is a hip flexor and external rotator.
  • The muscle-tendon complex crosses over the anterior pelvic brim and hip capsule. The iliopsoas bursa lies between the tendon and the bony pelvic brim.
  • Frictional compression of the bursa between these structures leads to an inflammatory reaction.
Commonly Associated Conditions
  • Osteoarthritis
  • Rheumatoid arthritis
  • Pigmented villonodular synovitis
  • Synovial chondromatosis
  • Infection
  • Trauma
  • Status post total hip arthroplasty
  • Avascular necrosis of the femoral head
  • Leg-length discrepancy
Diagnosis
  • Pain can be present ± snapping.
  • If pain is the predominant feature, it will be in the groin or anterior thigh.
  • Irritation of the femoral nerve can be a cause of anterior thigh pain.
  • If there is remarkable bursal swelling, a pelvic or inguinal mass may be palpated.
  • Stride may be abbreviated during gait to avoid extension.
History
  • Pain is typically achy but may be sharp and is located in the groin or anterior thigh. One must differentiate from L1 disk disease (uncommon).
  • Hip flexion and/or extension may cause pain. Stride length of gait may be shortened.
Physical Exam
  • Local tenderness to pressure beneath the midpoint of the inguinal ligament may be present.
  • The hip may be passively held in flexion, and the gait may be shortened to avoid hip extension.
  • Pain is present in the inguinal region with resisted external rotation in a seated position. Pain also should be in same location with passive hip extension or internal rotation, but there should not be a fixed limitation of motion.
  • Positive Thomas test
Diagnostic Tests & Interpretation
Imaging
  • X-rays: Anteroposterior (AP) view of the pelvis and lateral view of the affected hip may show osteoarthritis (associated cause) or other bony pathology to be considered in the differential diagnosis.
  • US: Static or conventional US is a rapid, noninvasive, cost-effective diagnostic modality that can demonstrate the fluid nature of an enlarged bursa. Dynamic US can demonstrate abnormal snapping or movement of the tendon over the anterior pelvic brim. Also can be used to guide aspiration/injection of the bursa.
  • Contrast bursography: Not often used. It will not show communication with hip joint if present, and it is difficult to interpret.
  • Arthrography: Clearly shows if there is communication of bursa with hip joint.
  • CT scan: Seldom used; can demonstrate abnormal boney pathology causing friction at the pelvic brim or a malpositioned lesser trochanter
  • MRI/MR arthrogram: MRI is a more sensitive and specific means of identifying lesions other than bursa as the source of hip pain. MR arthrography may be required to increase the sensitivity of detecting an acetabular labral tear.

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Differential Diagnosis
  • Inguinal mass present: Lymphadenopathy, malignant tumor, hernia, vascular malformation, hematoma
  • Pain or paresthesia present: L1 disk disease, meralgia paresthetica, hip arthritis, stress fracture of the hip, acetabulum labral tear, proximal rectus femoris avulsion fracture at the anteroinferior iliac spine in an adolescent
Treatment
  • In mild cases, relative rest, NSAIDs, and heat or other physical therapy modalities
  • If there is a palpable mass or remarkable enlargement of the bursa by imaging or CT scan, US-guided aspiration and instillation of a steroid preparation may be indicated.
Additional Treatment
General Measures
  • 2 basic premises: Reduce pain and inflammation and rehabilitation and prevention of reinjury
  • Treatment depends on the severity and nature of the underlying cause.
Additional Therapies
  • Stretching of the hip flexors including iliopsoas and quadriceps
  • Strengthening of same and of hip rotators (internal and external)
  • Modification of any underlying mechanical abnormality (ie, correcting leg-length discrepancy)
Surgery/Other Procedures
  • Typically only as a last resort after several attempts at conservative measures
  • May be necessary if bony pathology causes the bursal irritation
  • Partial surgical release or lengthening of the distal tendinous portion has demonstrated good outcomes.
  • Mild hip weakness and loss of sensation in the lateral femoral cutaneous nerve distribution have occurred following surgical release.
Ongoing Care
Patient Education
  • A study by Johnston and colleagues showed that a home-based exercise program lead to the majority of individuals being pain-free or essentially pain-free.
  • The program included:
    • Exercises performed in a seated position with an elastic resistance strap. 3 sets of 20 repetitions of both internal and external rotation of the hip were performed. These were performed daily for 2 wks.
    • The patient continued these exercises, but with the hip in less flexion, and now only 2–3 days per week. The patient added a side-lying abduction/external rotation with the hip at 45 degrees of flexion. These again were performed daily for 2 wks.
    • At 1 mo, an additional exercise of a 1-legged minisquat on the affected side was added. 3 sets of 20, 2 to 3 times per week.
    • Daily stretching targeting the hip flexor, quadriceps, and lateral hip/piriformis and hamstring muscles was performed.
Prognosis
Good prognosis with reduction of inflammation, appropriate rehabilitation, and proper attention to alteration of mechanical issues
Additional Reading
Adler RS, Buly R, Ambrose R, et al. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005;185:940–943.
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996;53:2317–2324.
Flanagan FL, Sant S, Coughlan RJ, et al. Symptomatic enlarged iliopsoas bursae in the presence of a normal plain hip radiograph. Br J Rheumatol. 1995;34:365–369.
Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series. J Orthop Sports Phys Ther. 1999;29:218–224.
Johnston CA, Wiley JP, Lindsay DM, et al. Iliopsoas bursitis and tendinitis. A review. Sports Med. 1998;25:271–283.
Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009;17:337–344.
Pelsser V, Cardinal E, Hobden R, et al. Extraarticular snapping hip: sonographic findings. AJR Am J Roentgenol. 2001;176:67–73.
Penkava RR. Iliopsoas bursitis demonstrated by computed tomography. AJR Am J Roentgenol. 1980;135:175–176.
Schon L, Zuckerman JD. Hip pain in the elderly: evaluation and diagnosis. Geriatrics. 1988;43:48–62.
Taylor GR, Clarke NM. Surgical release of the ‘snapping iliopsoas tendon’. J Bone Joint Surg Br. 1995;77:881–883.
Toohey AK, LaSalle TL, Martinez S, et al. Iliopsoas bursitis: clinical features, radiographic findings, and disease associations. Semin Arthritis Rheum. 1990;20:41–47.
Codes
ICD9
726.5 Enthesopathy of hip region


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