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psoas muscle injury

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  • iliopsoas tendinitis
    • a rare cause of pain in the groin that has been associated with inflammatory arthritis, acute trauma, and overuse syndromes
    • been described more frequently in women than in men and tends to affect younger patients
    • hip flexors
      • comprised of your iliopsoas, tensor fasciae latae, rectus femoris and sartorius
      • although it is often regarded as a single muscle
        • the iliopsoas is comprised of 2 muscles: the psoas major and the iliacus (psoas minor - weak flexor muscle)
    • iliopsoas tendinitis and iliopsoas bursitis are closely interrelated
      • because of their close proximity inflammation of either inevitably causes inflammation of the other
      • iliopsoas tendinitis and iliopsoas bursitis are essentially identical in terms of presentation and management
      • Iliopsoas Syndrome refers to a stretch, tear or complete rupture of the iliopsoas muscle and tendon along with iliopsoas bursitis
        • rare for iliopsoas muscle-tendon to rupture completely
    • clinical features:
      • clinical presentation may include groin pain with an associated snapping sensation, a palpable mass, or a compression syndrome of the inguinal compartment secondary to enlargement of iliopsoas tendon and associated bursae
        • initially pain after onset of aggravating activity with resolution soon thereafter
        • condition may progress to pain that persists during activity but subsides with rest, and eventually to pain during activity and at rest
        • this conditoin may occur if there is an overuse phenomenon associated with repeated hip flexion or external rotation of the femur e.g. dancing
        • pain may occur with specific sports-related activities, such as running or kicking
          • there may be pain with other activities such as putting on socks and shoes
        • physical examination often reveals localized tenderness in the area of the inguinal ligament and pain with resisted hip flexion or passive hyperextension
          • examination for Ludloff sign
            • patient asked to sit on a chair with knee extended and subsequent elevation of the heel on the affected side
              • pain caused by this manoeuvre (a positive Ludloff sign) is consistent with an iliopsoas tendinitis - this is because iliopsoas is the sole hip flexor activated in this position
          • snapping hip sign or extension test may be performed
            • affected hip in a flexed, abducted, and externally rotated position (with the knee flexed) - the hip is then moved passively into extension
            • this test may cause an audible snap or palpable impulse over the inguinal region
              • if this manoeuvre is associated with pain then this is suggestive of iliopsoas tendinitis or bursitis
    • investigations:
      • CT is the imaging modality of choice for diagnosing this lesion, although ultrasonography can be useful if an enlarged bursa is present (1)
        • delay in diagnosis is common, with the time from the onset of symptoms to the diagnosis of iliopsoas tendinitis averaging 34 months (1)
    • management:
      • nonoperative treatment, including rest, nonsteroidal anti-inflammatory medications, and a stretching program, has been recommended for the treatment of this condition
        • corticosteroid/local anaesthetic injection is a nonoperative management option
        • iliopsoas muscle injury can cause lumbar lordosis and anterior pelvic tilt
          • lumbar lordosis and anterior pelvic tilt may be corrected by strengthening specific counteracting muscle groups
            • both issues may be addressed by strengthening the abdominal musculature
              • sit-ups or crunches executed with knees and hips flexed at 90° allows the iliopsoas to relax, with the effort concentrated on the rectus abdominus muscle, and preserves a neutral pelvic position
              • exercises requiring repeated hip flexion or femoral external rotation can improve iliopsoas function if resistance is low
                • exercises that satisfy this criteria include cycling with low resistance and stair climbing on a machine with the setting on the lowest resistance
      • surgical release of the iliopsoas tendon
        • procedure may be undertaken if nonoperative treatment has failed

Reference:

  • (1) Della Valle CJ et al. liopsoas tendinitis after total hip arthroplasty. The Journal of Arthroplasty 2001;16 (7): 923-926
  • (2) Noesberger B, Eichenberger AR. Overuse injuries of the hip and snapping hip syndrome. Operative Techniques in Sports Medicine 1997;5(3):138-142.

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