eMedicine Specialties > Sports Medicine > Lower Limb
Iliopsoas Tendinitis: Treatment & Medication
Updated: Aug 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Medical Issues/Complications
The average time from onset of symptoms to diagnosis typically ranges from months to years; therefore, most patients may present in the subacute or chronic phases of the condition. Despite this, medical treatment during the acute phase consists of relative rest and avoidance of activities that cause pain. Rarely, crutches may be necessary if sufficient pain is associated with ambulation or activities of daily living. The application of ice for 20 minutes every 1-2 hours for the first 1-3 days is recommended in addition to a short course (eg, 5-14 d) of nonsteroidal anti-inflammatory drugs (NSAIDs) in order to potentially limit inflammation and assist with analgesia.
Recovery Phase
Rehabilitation Program
Physical Therapy
Recreational Therapy
As tolerance to activity increases, the patient can begin easy resistance cycling, walking, and jogging (without terrain). In the recovery phase, the patient intends to gradually return to sport-specific activities, leading to full pain-free participation.
Medical Issues/Complications
Intermittent episodes of pain may be experienced as the patient slowly starts to return to the activities of daily living and progresses in the strengthening program. At these times, short courses of analgesics may be required, in addition to activity modification.
Surgical Intervention
Surgical intervention is not commonly used for iliopsoas tendinitis; however, it is considered for those patients in whom typically prolonged nonsurgical management and a lidocaine injection trial fail.
The 2 surgical techniques that have been described are (1) complete release of the iliopsoas tendon and (2) partial release by transection of the posteromedial aspect of the iliopsoas tendon. Each approach has produced generally good results in terms of pain relief, with little documentation of significant residual weakness. Gruen et al reported 73% of patients returned to previous athletic activities, with 45% also returning to their previous level of athletic participation following surgery.7 Hoskins et al reviewed their experience with surgical correction by iliopsoas tendon fractional lengthening in 92 cases.8 Complications were noted in one third of patients and mostly included persistent hip pain, sensory deficits, and hip flexor weakness.
Ilizaliturri et al conducted a randomized study of the short-term results of 2 different techniques of endoscopic iliopsoas tendon release for the treatment of internal iliopsoas tendinitis.20 One group of patients (n = 10 [5 men, 2 women]; average age, 29.5 y) underwent endoscopic iliopsoas tendon release at the lesser trochanter; the second group (n = 9 [1 man, 8 women and 1 male]; average age, 32.6 y) underwent endoscopic transcapsular psoas release from the peripheral compartment. Both groups received hip arthroscopy of the central and peripheral compartments, and any associated injuries were identified and treated arthroscopically.20 Both groups received the same postoperative physical therapy as well as 400 mg of celecoxib daily for 21 days after surgery. There were no complications.
The investigators found statistical improvement in Western Ontario MacMaster (WOMAC) scores for both groups, but there was no difference in postoperative WOMAC results between the groups. Ilizaliturri et al concluded that iliopsoas tendon release at the level of the lesser trochanter or at the level of the hip joint using a transcapsular technique is effective and reproducible.20
Dobbs et al reported outcomes for surgical fractional lengthening of the iliopsoas tendon in adolescents (mean age 15 y).3 At 4-year mean follow-up, all patients had returned to their preoperative level of activity without subjective weakness.
Byrd et al described releasing the iliopsoas tendon arthroscopically,1 and in a small study, Anderson and Keene evaluated whether athletes can return to full participation in their sport following arthroscopic iliopsoas tendon release.21 A total of fifteen athletes (2 college, 3 high school, 10 recreational) with painful snapping hips that did not have pain relief following anesthetic magnetic resonance arthrography received an ultrasonographic evaluation of their iliopsoas tendon and an anesthetic injection into the psoas bursa. All 15 patients had pain relief and were followed up with Byrd's 100-point hip scoring system at 1.5, 3, 6,and 12 months after surgery.21
Postsurgery, the groups used crutches for 4 weeks, and had markedly improved 6-week, 6-month, and 12-month scores; none of the patients had recurrence of their hip snapping or pain, and all 15 athletes had full return to play in their sport at an average of 9 months after surgery.21 Anderson and Keefe concluded that a return to college, high school, and recreational sports can be expected after arthroscopic release of the iliopsoas tendon.
Consultations
Peritendinous injections generally are performed by either an interventional radiologist or orthopedic surgeon. For physicians unfamiliar with diagnosis and management of iliopsoas tendinitis/bursitis, a referral to primary care sports medicine, orthopedic surgery, or physiatry is appropriate.
Other Treatment (Injection, manipulation, etc.)
A peritendinous corticosteroid injection may be performed under ultrasonographic guidance with a combination of a local anesthetic (eg, 1% lidocaine) and a corticosteroid (eg, betamethasone, triamcinolone).
Maintenance Phase
Rehabilitation Program
Physical Therapy
External rotation strengthening with elastic band resistive device.
Iliopsoas stretch.
Iliopsoas stretch in external rotation.
Rectus femoris stretch.
Exercises moving away from those depicted in the Recovery Phase can be initiated in a gym, although the same results can occur by gradually increasing resistance to the exercises in Media Files 5-8.
Iliopsoas strengthening with cuff weight.
Hip flexion (straight-leg raising) strengthening with cuff weight.
External rotation strengthening with cuff weight.
External rotation strengthening with elastic band resistive device.
Refer to Media Files 11-13 for demonstrations of advanced strengthening exercises for the iliopsoas and hamstrings. These pain-free exercises should gradually progress in resistance by increasing either the repetitions or weight every third or fourth workout, as tolerated.
Four-way hip marching (standing hip flexion).
Prone hamstring curls.
Seated hamstring curls.
The advanced move of the lunge (see Media File 14) allows for many muscles (ie, iliopsoas, hamstrings, gluteus maximus, groin) to work together to return strength and balance to the athlete. Lunges are intended to be slow gentle exercises, with fluid movement as the back knee lowers toward the ground. This position is held for 5-7 seconds prior to returning to a more upright position to end the exercise.
Lunges.
Recreational Therapy
Recreational activities that facilitate the recovered iliopsoas muscle to maintain its strength and function include rollerblading, cycling, dancing, skating, horseback riding (especially English riding), and rowing. Other sports, such as soccer, competitive cycling, running, and gymnastics, all have a high demand of hip flexion combined with trunk flexion, which shortens the iliopsoas and can cause stress when the body demands hip flexion independent of trunk flexion. Maintaining a stretching and strengthening program is crucial and the patient should consider cross-training for lower extremity sports that allow for a more upright trunk.
Medication
The drugs of choice for treatment of iliopsoas tendonitis and most other tendinopathies are NSAIDs. This class of drugs provides good analgesia and possible anti-inflammatory properties.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
This class of drugs has analgesic and antipyretic activities and possibly also anti-inflammatory activities. Their mechanism of action is not known, but they may inhibit COX activity and prostaglandin synthesis. Other mechanisms may also exist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for mild to moderate pain. May inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis. Ibuprofen is a low-cost medication.
Adult
600-800 mg PO q6-8h; not to exceed 3.2 g/d
Pediatric
10-20 mg/kg/d PO divided bid/tid
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; may inhibit inflammatory reactions and pain by decreasing activity of COX, which is responsible for prostaglandin synthesis. May demonstrate superior analgesic properties compared to ibuprofen.
Adult
250-500 mg PO bid
Pediatric
<2 years: Not recommended
>2 years: 2.5-5 mg/kg/dose PO bid
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Cyclooxygenase-2 (COX-2) Inhibitors
Cox-2 inhibitors operate as non-steroidal anti-inflammatory drugs with the potential for less fatal GI bleeding due to ulceration and possibly enhanced analgesic properties. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient. Provides good analgesia with potential for less GI toxicity.
Adult
100 mg PO bid or 200 mg PO qd
Pediatric
<18 years: Not recommended
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity, or sulfonamide allergy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Not recommended for patients with severe renal disease; discontinue if liver disease develops; monitor for GI ulcer/bleed in patients otherwise at high risk for GI ulcer; edema; heart failure
Analgesics
Useful for patients in whom NSAIDs are contraindicated. Analgesics are potentially useful for patients who require a more prolonged use of analgesics.
Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
650-1000 mg PO q6-8h; not to exceed 4 g/d
Pediatric
15 mg/kg/dose PO q6h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Hepatotoxicity possible in individuals with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
More on Iliopsoas Tendinitis |
| Overview: Iliopsoas Tendinitis |
| Differential Diagnoses & Workup: Iliopsoas Tendinitis |
 Treatment & Medication: Iliopsoas Tendinitis |
| Follow-up: Iliopsoas Tendinitis |
| Multimedia: Iliopsoas Tendinitis |
| References |
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References
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Ilizaliturri VM Jr, Chaidez C, Villegas P, Briseno A, Camacho-Galindo J. Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome. Arthroscopy. Feb 2009;25(2):159-63. [Medline].
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Further Reading
Keywords
iliopsoas tendinitis, iliopsoas bursitis, iliopsoas syndrome, internal snapping hip syndrome, inflammation of the tendon, anterior hip pain, groin pain, rheumatoid arthritis
