Psoas muscle injury

• iliopsoas tendinitis
  
  • a rare cause of pain in the groin that has been associated with inflammatory arthritis, acute trauma, and overuse syndromes
    • commonly seen in athletes, often runners, dancers, and high jumpers
    • usually results from overuse or trauma. It is frequently known as jumpers hip or dancers hip
    • iliopsoas tendonitis following total arthroscopic hip replacement iliopsoas syndrome can be reasonably commonplace (1,2,3)
      
      
  • been described more frequently in women than in men and tends to affect younger patients
    • female athletes are at higher risk, as well as patients with hip osteoarthritis or rheumatoid arthritis (1)
    • reported prevalence of iliopsoas syndrome postoperative following a total hip arthroplasty is 4.3% in patients (1)
      
      
  • psoas syndrome is usually a term used interchangeably with iliopsoas tendinitis, internal snapping hip, or iliopsoas impingement
  • 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:
    • X-rays of the hip are often negative in the case of psoas syndrome and often unwarranted
    • ultrasound can be helpful in diagnostic evaluation intraarticular versus extra-articular origins of hip pain
    • MRI - in 21% of athletes experiencing groin pain, iliopsoas pathology was apparent on MRI (4) In the case of patients who do not respond to conservative management for suspected iliopsoas injury, an MRI could be beneficial in the diagnosis
    • MRI and US often show enlargement of the bursa as well as thickening of the iliopsoas tendon
      
      
  • management:
    • seek expert advice
      
      
    • nonoperative treatment, including rest, nonsteroidal anti-inflammatory medications, and a stretching program, has been recommended for the treatment of this condition - exercise programs that the patient can do at home with a focus on hip rotation have demonstrated effectiveness in the reduction of pain and improvement of activity for patients in pain (1)
      
      
    • 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 interventon (1)
      • for refractory cases requiring surgery, arthroscopic lengthening of the tendon can be completed for relief, and correcting intra-articular pathology can be done
      • release of the psoas tendon from the insertion is also a possible surgical option

Notes:

• for athletes with suspected groin pain secondary to an iliopsoas tendon injury, an MRI could be warranted for an expected return to play management (1)
  • MRI changes consistent with muscle strain correlated with a significantly decreased return to play for their respective sport compared to peri-tendinitis changes seen on MRI

Reference:

• (1)

Dydyk AM, Sapra A. Psoas Syndrome. StatPearls [Internet] (accessed 21/7/2020).

• (2) Della Valle CJ et al. liopsoas tendinitis after total hip arthroplasty. The Journal of Arthroplasty 2001;16 (7): 923-926
• (3) Noesberger B, Eichenberger AR. Overuse injuries of the hip and snapping hip syndrome. Operative Techniques in Sports Medicine 1997;5(3):138-142.
• (4) Tsukada S, Niga S, Nihei T, Imamura S, Saito M, Hatanaka J. Iliopsoas Disorder in Athletes with Groin Pain: Prevalence in 638 Consecutive Patients Assessed with MRI and Clinical Results in 134 Patients with Signal Intensity Changes in the Iliopsoas. JB JS Open Access. 2018 Mar 29;3(1):e0049