One of the common causes of pain in the front of the hip is iliopsoas tendinitis and bursitis.
Iliopsoas tendinitis occurs when the iliopsoas tendon—the main tendon responsible for hip flexion—becomes inflamed due to repetitive stress.
Bursitis, on the other hand, develops when the bursa located next to this tendon (a fluid-filled sac that reduces friction) becomes irritated and inflamed.
These conditions are frequently seen in athletes and active individuals, especially those involved in sports or activities that require repetitive hip flexion such as running, soccer, and dancing.
In addition, iliopsoas bursitis and tendinitis may also develop after total hip replacement surgery, particularly if the acetabular component is positioned with anterior overhang, leading to mechanical irritation of the tendon.
Pain is usually felt in the groin area and may radiate down the thigh or toward the knee.
While physical examination plays a key role in diagnosis, ultrasound and MRI imaging provide valuable confirmation.
Treatment most often begins with non-surgical (conservative) options.
What Are the Iliopsoas Muscle and Bursa?
The iliopsoas muscle is formed by the combination of two muscles: the psoas major and the iliacus.
It originates from the lumbar spine and inner surface of the pelvis, passes through the groin, and attaches to the lesser trochanter of the femur.
It is the strongest hip flexor muscle, responsible for lifting the leg forward.
In front of the iliopsoas tendon and on the inner side of the hip joint lies the iliopsoas bursa.
This small fluid-filled sac acts like a cushion to minimize friction between the tendon and surrounding bone surfaces.
When subjected to overuse, trauma, or mechanical irritation (including after hip replacement surgery), the bursa may become inflamed, leading to bursitis.
Symptoms of Iliopsoas Tendinitis and Bursitis
The most common symptom of iliopsoas tendinitis and bursitis is pain in the groin area.
This pain may radiate to the front of the thigh or even down to the knee.
Symptoms often worsen during movements that require lifting the leg forward, such as climbing stairs, getting out of a car, or standing up from a seated position.
Typical symptoms include:
- Groin pain: Usually felt as a deep, anterior ache.
- Pain aggravated by activity: Especially noticeable in sports that demand repetitive hip flexion such as running, soccer, and dancing.
- Difficulty climbing stairs: Pain becomes sharper when lifting the leg upward.
- Tenderness: Discomfort when pressing on the groin area.
- Catching or snapping sensation: More commonly felt when bursitis is present.
- Groin pain after hip replacement: In cases where the acetabular component of a total hip replacement places pressure on the iliopsoas tendon, severe pain may occur during forward bending or sitting.
Causes of Iliopsoas Tendinitis and Bursitis
Inflammation of the iliopsoas tendon or bursa can develop from several mechanisms, most often related to overuse or mechanical irritation.
Main causes include:
- Repetitive stress: Running, soccer, dancing, or other activities that demand frequent hip flexion.
- Overuse injuries: Long-term exercise, sudden increases in training intensity, or poor training techniques.
- Trauma: Direct injuries to the groin or sudden forceful movements.
- Muscle imbalances: Weakness or imbalance in surrounding hip muscles.
- Post-hip replacement impingement: Anterior overhang of the acetabular component after total hip replacement may cause the iliopsoas tendon to rub against the implant.
- Structural hip abnormalities: Conditions such as hip dysplasia or femoroacetabular impingement (FAI).
Diagnosis of Iliopsoas Tendinitis and Bursitis
Accurate diagnosis is essential, as groin pain can also be caused by other conditions such as hip labral tears, femoroacetabular impingement (FAI), or even non-musculoskeletal disorders.
Diagnostic methods include:
- Physical examination: A physician evaluates tenderness in the groin area. Pain that worsens with hip flexion—particularly during resisted hip flexion—suggests an iliopsoas-related issue.
- Imaging techniques:
- Ultrasound: Useful for both diagnosis and guiding injections.
- MRI: Can reveal inflammation of the tendon and bursa as well as associated intra-articular pathologies.
- CT scan: Often used to assess the position of the acetabular component after hip replacement surgery.
- Diagnostic injection: An ultrasound-guided cortisone injection of local anesthetic into the iliopsoas bursa can help confirm the source of pain.
Treatment of Iliopsoas Tendinitis and Bursitis
The first step in treating iliopsoas tendinitis and bursitis is always non-surgical (conservative) management. Most patients respond well to these methods without the need for surgery.
Non-Surgical Treatments
- Rest and activity modification: Temporarily limiting exercises or activities that worsen pain.
- Physical therapy and exercise: Customized programs designed to strengthen the surrounding hip muscles and improve flexibility.
- Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) help reduce pain and inflammation.
- Ice therapy: Applying ice packs, particularly in the acute phase, can help relieve pain.
- Injection therapies:
- Cortisone injections can quickly reduce inflammation in the bursa.
- PRP (platelet-rich plasma) and exosome injections may be considered to promote healing and tissue regeneration.
Surgical Treatments
If non-surgical treatments fail to provide relief, surgery may be recommended.
- Arthroscopic iliopsoas release (tenotomy): The portion of the tendon causing mechanical friction is released, reducing irritation. This option is often preferred in cases related to overuse or trauma.
- Hip replacement revision surgery: When iliopsoas impingement develops after a total hip replacement due to anterior overhang or malposition of the acetabular component, simple tendon release may not be enough. In such cases, revision surgery with proper repositioning of the acetabular component may be required.
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