Iliopsoas Tendinitis Treatment & Management

Rehabilitation Program

Physical Therapy

The primary objective of the acute rehabilitation phase is to alleviate pain, spasm, and swelling. A secondary issue, if necessary, is to return the patient to activities of daily living (eg, walking unassisted). A combination of medication, ice, rest, and gentle stretching assists these goals in coming to fruition. A pack of crushed ice in a damp cloth-covered ice bag applied for 20 minutes every 1-2 hours also can provide the patient with relief of pain, spasm, and inflammation.

In addition to relative rest (avoidance of activities that stress the iliopsoas muscle), a gentle stretching regimen can assist in reduction of spasm in the iliopsoas complex. Note that stretching must not immediately follow icing, when the sensitivity to pain is lessened, because a potential to overstretch exists. A gentle stretch for the iliopsoas muscle is demonstrated in the image below. Hold the stretch for a count of 20 seconds, relax for 30 seconds, and repeat the stretch 5 times. Caution patients to not hold their breath while maintaining a pain-free stretch.

If a normal gait is not present at the time of diagnosis, the patient needs to begin ambulation exercises with the assistance of crutches, gradually moving to partial weight bearing, progressing to full weight bearing, and, finally, walking without an antalgic gait and without assistance. The patient can practice walking in front of a full-length mirror to ensure that ambulatory rhythm and techniques are correct.

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.

Rehabilitation Program

Physical Therapy

The purpose of this rehabilitation phase is to return the patient to normal ROM, strength, endurance, and activity specific to the patient’s sport. Normal ROM can be accomplished by sustaining normal gait mechanics, maintaining a stretching regimen, and practicing good warm-up and cool-down techniques with exercise.

Stretching exercises that facilitate full ROM for the iliopsoas complex are demonstrated in the images below.

In addition to stretching for ROM, certain stretches can allow an anteriorly over-rotated pelvis to return to a more anatomical position. Stretching the rectus femoris (see the image below) promotes a neutral pelvic position and diminishes strain or spasm of the iliopsoas muscles. Instruct patients to hold the stretch as instructed in the Acute Phase of physical therapy.

In addition to stretching for return of normal pelvic alignment, strengthening the hamstrings provides a posterior force on the pelvic girdle and combats the stress of the iliopsoas pull on the anterior pelvis (see the images below). Iliopsoas muscle injury can cause lumbar lordosis and anterior pelvic tilt, both of which can be corrected by strengthening specific counteracting muscle groups.

Strengthening the abdominal musculature by performing sit-ups addresses both issues. Sit-ups performed by hooking ankles under an object or having them held fast can aggravate the lumbar lordosis and iliopsoas strain. Sit-ups or crunches executed with knees and hips flexed at 90° allows the iliopsoas to relax, with the effort concentrated on the rectus abdominis muscle, and preserves a neutral pelvic position (see the first image below). Exercises that strengthen the gluteus maximus also augment the ideal pelvic status (see the second image below).

Begin all strengthening exercises at a weight that the patient can comfortably lift or with an elastic band resistive device with which the patient controls the tension. Exercises should be pain-free and performed daily in 4 sets of 10-15 repetitions. As the weight becomes easier to lift, increase the resistance.

Endurance is gained through movement with low resistance over time. Exercises requiring repeated hip flexion or femoral external rotation can improve iliopsoas function if resistance is low. Examples of these exercises are cycling with low resistance, stair climbing on a machine with the setting on the lowest resistance, or walking. The workout should not produce pain but could fatigue the iliopsoas muscle. Use caution so that the musculature has time to recuperate prior to the next bout of endurance training. As the muscle recovers, endurance exercises can be performed daily, and resistance gradually can be increased with time of activity.

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.^{[1, 2]}

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.^[3] Hoskins et al reviewed their experience with surgical correction by iliopsoas tendon fractional lengthening in 92 cases.^[4] 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.^[5] 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.^[5] 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.^[5]

Dobbs et al reported outcomes for surgical fractional lengthening of the iliopsoas tendon in adolescents (mean age 15 y).^[6] 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,^[7] and in a small study, Anderson and Keene evaluated whether athletes can return to full participation in their sport following arthroscopic iliopsoas tendon release.^[8] 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.^[8]

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.^[8] 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).

Rehabilitation Program

Physical Therapy

The goal of the maintenance phase of rehabilitation for iliopsoas injury is to challenge the muscles involved to continue to perform their work. Stretching the iliopsoas and rectus femoris must continue (see the images below), and strengthening should be increased to meet the demands of the recovered iliopsoas and perform at an optimal level.

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 depicted in the images below.

The images below depict 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.

The advanced move of the lunge (see the image below) 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.

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.