What is Iliopsoas Tendinopathy/Bursitis?

The iliopsoas tendon, which runs in front of the hip joint, is a vital tendon. It connects two of the most important hip flexor muscles (responsible for raising your knee during activities such as putting your socks on). Repetitive motions, such as jogging, can harm this tendon, and it can also be bothersome following a total hip replacement. When a tendon is inflamed, the healing process is hampered, and the tendon thickens. A tendonopathy is the medical term for this condition. The iliopsoas tendon is occasionally injured, but a tiny fluid-filled sac (bursa) develops inflamed instead. Bursitis is the medical term for this condition. A bursitis can be quite painful and appear with symptoms that are similar to those of a tendonopathy, or even occur at the same time.

If your iliopsoas tendonitis or bursitis isn’t improving or growing worse, an ultrasound-guided steroid injection can help. We would recommend physiotherapy after the injection to prevent the discomfort from recurring, restore full hip movement and strength, and get you back to full function.

What are the symptoms of Iliopsoas Tendinopathy/Bursitis?

The following are the signs and symptoms of Iliopsoas tendinopathy/bursitis:

  • A throbbing discomfort in the front of your hip (in the crease of your hip).
  • When flexing your hip, you may experience a clicking or clunking sensation or sound (lifting your knee up).
  • Sharp pain when sitting or standing, especially after sitting for a long time.
  • Walking, running, and sports, especially those requiring kicking and jumping, might cause pain.
  • A sense of weakness in the hips.

What are some additional conditions that are similar to Iliopsoas Tendinopathy/Bursitis?

  1. Femoroacetabular impingement
  2. Greater trochanteric pain syndrome
  3. Hip osteoarthritis
  4. Osteitis pubis 

Iliopsoas Tendinopathy/bursitis vs Great trochanteric pain syndrome:

Illiopsoas tendinopathy/bursitis and greater trochanteric pain syndrome are both caused by tendinopathy or bursitis and can affect persons of any age. Both diseases can also become inflamed as a result of exercise or general movement. The location of symptoms, on the other hand, is highly diverse. Iliopsoas tendonitis/bursitis affects the front of the hip/groin, as opposed to greater trochanteric pain syndrome, which affects the outside of the hip.

Anatomy of the hip flexors:

The iliopsoas tendon connects the two main hip flexor muscles, the psoas and the iliacus (see below). All of the lumbar spine vertebrae’s anterior (front) aspects give rise to the psoas muscle. It starts as a tendon in front of the hip joint and ends on the femur’s lesser tuberosity (a tiny bony protuberance on the upper inside surface of the femur) (long bone of the thigh). The iliacus starts on the inside of the ilium (pelvis bone) and joins the psoas tendon in front of the hip joint to form the iliopsoas tendon, which attaches to the smaller tuberosity.

The iliopsoas muscle has two purposes

  • It helps to provide stability between the lumbar spine segments and is a crucial deep core stabiliser for the lower back and hips.
  • It offers stability and is involved in moving your knee up towards your chest (hip flexion). Because it goes through the front of the hip joint, it is prone to injury and is a typical source of pain.

Patients with iliopsoas (hip flexor) disease typically fall into one of two categories. These are the following:

Runners – this is linked to the iliopsoas tendon moving along the front of the hip repeatedly during action like running. Inflammation of the tendon and the bursa (a tiny sac around the tendon) is possible. Poor biomechanics and tissue overload (‘doing too much too fast’) can exacerbate this condition, which can be caused by both muscle weakness and stiffness in the hip musculature.

The iliopsoas tendon and bursa can become swollen and/or irritated (described in more detail below) as it travels over the metal implant in individuals who have had a total hip replacement (see below). According to reports, this occurs in 4.3 percent of total hip replacement patients (Nunley et al., 2009).

How does the iliopsoas major tendon and bursa become injured?

The most common cause of liopsoas tendinopathy/bursitis is misuse. The iliopsoas tendon can get impinged as it travels through the front of the hip joint (pinched). An inflammatory reaction occurs when the tendon is compressed or pinched repeatedly. Tendinitis is the inflammation of a tendon. Tendinitis is normally a self-limiting condition that goes away after a few weeks of rest. The iliopsoas tendon grows weaker when it is subjected to many bouts of tendinitis with insufficient healing. The tendon thickens and gets impaired as a result of a maladapted healing process. Tendinopathy is the medical term for this condition. It’s not uncommon to have’snapping’ or clicking in the front of the hip when you have this illness. The ‘clicking’ can be painful at times, but it it can be asymptomatic sometimes.
A bursa is a tiny sac or cushion that surrounds the iliopsoas tendon at the level of the hip joint. Synovial fluid is a naturally produced lubricant found in bursa. Over 150 bursae can be discovered at ‘anatomical friction hotspots’ throughout the body. During movement, these protective structures are exactly built to allow smooth gliding between structures. The bursa can develop inflamed if it is subjected to repetitive movements (such as running) or trauma (in this example, total hip surgery). Bursitis is the inflammation of the bursa. Iliopsoas bursitis is a very uncommon condition that might be linked to a hip joint disease such as osteoarthritis. As a result, it’s vital to do a thorough and precise assessment of the hip.

How do you know if you have iliopsoas Tendinopathy/Bursitis?

Both iliopsoas tendinopathy and bursitis can be very painful and impede your daily activities. The following are some of the most common symptoms of iliopsoas tendinopathy/bursitis:

  • Agony in the anterior part of the hip, as in a deep painful pain.
  • During hip flexion (lifting the knee to the chest) and/or hip extension, a ‘clunking’ or ‘clicking’ feeling deep within the hip is frequently felt.
  • Standing from a seated position causes pain.
  • Pain that occurs during or after a long period of sitting
  • Walking and exercise, particularly running, cause pain.
  • The muscles surrounding the hip and thigh have a feeling of weakness.

It is critical to have an accurate diagnosis prior to seeking therapy for your symptoms so that the appropriate treatment may be prescribed. As a result, it is critical to seek professional assistance.
A combination of clinical physical examination and diagnostic ultrasound imaging is required to diagnose iliopsoas tendinopathy/bursitis.
A clinical physical assessment can be performed by one of our highly skilled clinicians at Joint Injections and often entails the following:

  • An in-depth conversation about your condition’s history. Direct queries frequently include how your pain began, what aggravates it, and what relieves it. In order to rule out systemic causes of pain, such as rheumatoid arthritis, you will be asked questions about your general medical status. If your doctor suspects a systemic cause for your symptoms, blood tests may be ordered to aid in diagnosis.
  • Range of motion of the hip joint.
  • Strengthening of the hip muscles
  • Lower limb flexibility is important.
  • The hip and lower back are palpated (felt).
  • Squatting technique, as well as walking and running assessments, are all part of the functional testing (if you are a runner).

    The clinician might construct a working hypothesis using the clinical evaluation method. It can also check for biomechanical insufficiencies that could be worsening your discomfort and/or the underlying cause.

The diagnosis of iliopsoas tendinopathy/bursitis cannot be made solely on the basis of clinical examination. Diagnostic imaging is essential for a definitive diagnosis.

Other causes of hip pain that may be misdiagnosed as iliopsoas tendinopathy/bursitis or happening concurrently with a tendon condition can be distinguished using diagnostic imaging.

  • Hip osteoarthritis is a type of arthritis that affects the hip joint.
  • Hip acetabular impingement femoral acetabular impingement femoral acetabular impingement (FIA). The ball and socket joint of the hip develops a tiny bony protrusion in FIA, which is a common disease. A pincer lesion is a bony prominence on the acetabulum (hip socket) while a cam lesion is a bony prominence on the neck of the femur. It can affect up to 30% of the population. The bony protrusion snags during movement, causing an impingement within the joint.
  • Hip tears should be labelled. The labrum is a fibrocartilaginous ring that surrounds the hip socket in a crescent form (acetabulum). The depth of the socket is increased by this construction, which improves the joint’s stability. It can be torn as a result of an injury or as a result of femoral acetabular impingement (FAI) or hip osteoarthritis.
  • Greater trochanteric pain syndrome is a condition that causes pain in the greater trochanteric (GTPS). This is caused by gluteus tendinopathy and/or an accompanying bursitis, and causes pain on the exterior of the hip (known as trochanteric bursitis).
  • X-ray:

Iliopsoas tendinopathy and bursitis cannot be diagnosed with an X-ray. X-ray imaging (as seen above) is a highly effective diagnostic tool for detecting bone and joint disorders, and it is frequently requested to check for osteoarthritis. This gold standard imaging technology has been around for decades and can diagnose joint pathology as well as assess the severity of the condition. If your doctor suspects osteoarthritis in your hip joint, he or she may order an x-ray.

Magnetic Resonance Imaging

MRI imaging may detect joint and soft tissue abnormalities, and it’s frequently used to diagnose iliopsoas tendinopathy/bursitis, femoral acetabular impingement (FAI), and labral tears. An MRI can take anywhere from 30 minutes to an hour, and it requires you to lie perfectly still inside a metal tube. The MRI scanner captures numerous images of your hip from front to back. These slices produce a 3D representation of your hip structure that is extremely detailed.

Diagnostic Ultrasound Imaging

Every session at Joint Injections includes a diagnostic ultrasound, which is provided free of charge. The use of diagnostic musculoskeletal ultrasound imaging to identify tendon and bursal disease around the hip is particularly useful. The only imaging technique that allows us to analyse anatomical structures as you move is diagnostic ultrasonography. This is referred to as a dynamic ultrasound scan. This is a great way to check for hip ‘clicking’ and ‘clunking.’

It is thus a highly effective imaging tool for evaluating both iliopsoas tendinopathy and bursitis during movement in order to assess for discomfort and clicking associated with this pathology (Garala et al., 2014). Balus and colleagues (Balus et al., 2014). Our clinicians are both physiotherapists and musculoskeletal sonographers at the same time.Your clinician will conduct a complete clinical assessment as well as a diagnostic scan during your initial evaluation.

How do we treat Iliopsoas Tendinopathy/Bursitis?

The vast majority of patients benefit greatly from conservative care. The core of your treatment for iliopsoas tendinopathy/bursitis is physiotherapy. Physiotherapy frequently entails:

  • Stretching and strengthening exercises for the hip muscles as part of a personalised progressive rehabilitation programme.
  • Advice on how to modify your activities to lessen the aggravating elements in your hip.
  • Re-education in biomechanics. This could involve instructing you on proper squatting or lunging technique.
  • Soft tissue release techniques are sometimes used to relieve discomfort and improve flexibility around the hip. You may also be taught how to use a foam roller to perform self-massage.


What if conservative management does not work?

If conservative management has failed to alleviate your symptoms and you are still in pain, injectable therapy may be the best option for you.

Patients with psoas tendinopathy/bursitis are usually divided into two groups: those who need an injection and those who don’t.

    • Repetitive rubbing of the iliopsoas tendon and bursa over the front of the hip causes pain and symptoms in runners, triathletes, and ironmen.
    • Following a total hip replacement, patients may develop iliopsoas tendinopathy and/or bursitis.This is caused by the bursa and tendon rubbing against the new metals. Injection therapy can be quite effective for patients with these symptoms. Prior to administering an injection, your surgeon will discuss injectable therapy with you in detail.

Injection therapy is not a treatment in and of itself. It gives you a pain-free ‘window of opportunity’ to effectively rehabilitate your hip. Joint Injections recommends starting a course of physiotherapy within two weeks of receiving an injection to obtain the optimum outcomes.Injection therapy is a fantastic way to reduce pain and inflammation, and it’s especially useful if you have one or more of the following conditions:

    • Pain keeps you awake at night or prevents you from sleeping.
    • You are unable to do daily chores or sports/leisure activities due to pain.
    • You are unable to complete a physiotherapy rehabilitation programme due to pain.

Because of the depth of the iliopsoas tendon and bursa, as well as the close proximity of the leg’s arteries, veins, and nerves, an ultrasound-guided injection is required. Ultrasound-guided injections have been shown to deliver medication to the target area with great accuracy. Real-time ultrasound imaging is used to guide the needle tip directly to the source of the symptoms during this procedure. Post-injection difficulties can be reduced thanks to this highly precise approach. Ultrasound-guided injections are more effective and have fewer problems than Landmark-guided injections, according to research.

Ultrasound-guided steroid injection

For prolonged discomfort associated with iliopsoas tendinopathy/bursitis, ultrasound-guided corticosteroid injection is an effective therapy option (Garala et al., 2014 and Nunlet et al., 2009). A little dose of corticosteroid (a potent anti-inflammatory medicine commonly used in injectable therapy) is coupled with a short-acting local anaesthesia during this guided approach. The scholarly consensus is that after having an ultrasound-guided corticosteroid injection, a meaningful reduction in pain takes 10 to 12 weeks on average. This window of opportunity will allow you to get the most out of your treatment.

Every clinician at Joint Injections is a fully qualified musculoskeletal sonographer and an independent prescriber. Your session will involve a complete and thorough diagnosis, as well as a diagnostic ultrasound scan and an ultrasound-guided injection if necessary.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all hand and wrist disorders, including Iliopsoas Tendinopathy/Bursitis. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.