Iliopsoas Tendinitis Clinical Presentation

Patients often present with complaints of an insidious onset of anterior hip or groin pain. As in other cases of tendinitis, initially the patient may note pain after onset of aggravating activity with resolution soon thereafter. This condition may progress to pain that persists during activity but subsides with rest, and eventually to pain during activity and at rest. The average time from initial onset of symptoms to diagnosis has been noted to range from 32-41 months.

• At presentation, patients may note pain with specific sports-related activities, such as jogging, running, or kicking. Pain with simple activities, such as putting on socks and shoes, rising from a seated position with the hips flexed for some time, walking up stairs or inclines, or brisk walking may be reported.
• Pain may radiate down the anterior thigh toward the knee.
• Reports of an audible snap or click in the hip or groin commonly are reported and associated with internal snapping hip syndrome.
• Patients may report anterior knee pain consistent with patellar tendinitis or patellofemoral dysfunction, which may be the result of a tight iliopsoas muscle.

Physical examination should focus on complete examination of the abdomen, hip, and groin. In females, a complete pelvic examination also should be considered.

• Inspection

  • The hip may be held in slight flexion and external rotation to ease tension on the musculotendinous unit.
  • Gait may demonstrate a shortened stride length on the affected side and increased knee flexion in the heel strike and midstance phases.
• Palpation

  • An anterior pelvic tilt may be appreciated due to subsequent tightening of the iliopsoas muscle.
  • Direct deep palpation to the area of the femoral triangle, which is bordered superiorly by the ilioinguinal ligament, medially by the adductor longus muscle, and laterally by the sartorius muscle, results in direct palpation of the iliopsoas musculotendinous junction.
  • Tenderness over the iliopsoas tendon's insertion may be noted by palpating the lesser trochanter under the gluteal fold with the patient lying in a prone position.
• Functional testing

  • Functional testing includes resisted hip flexion at 15° with palpation of the psoas muscle below the lateral half of the inguinal ligament.
  • The patient also may be asked to sit with knees extended and subsequent elevation of the heel on the affected side. Pain caused by this maneuver (a positive Ludloff sign) is consistent with an iliopsoas tendinitis because the iliopsoas is the sole hip flexor activated in this position.
  • The snapping hip sign or extension test also may be performed. Start with the affected hip in a flexed, abducted, and externally rotated position (knee is flexed for ease of testing), and passively move the hip into extension. This may result in an audible snap or palpable impulse over the inguinal region. Pain associated with this maneuver is highly suggestive of iliopsoas tendinitis or bursitis.

The 2 most common causes of iliopsoas tendinitis are acute injury and overuse injury. The acute injury often involves eccentric contraction of the iliopsoas muscle or rapid flexion against extension force/resistance but may less commonly result from direct trauma. The overuse phenomenon may occur in any activity resulting in repeated hip flexion or external rotation of the femur.

• Among dancers, a narrow bi-iliac width, greater abduction, decreased lateral rotation, and greater strength in the lateral rotators have been described more commonly with snapping hip syndrome, which is related to iliopsoas tendinitis.
• Rheumatoid arthritis may be a cause of iliopsoas bursitis.