This is a question I received from a young dancer that I have seen multiple times for many different injuries. Her pain and popping began in both hips when she was 13 years old. She was in the middle of a growth spurt and danced several hours a day, most days of the week. Her hip pain was starting to interfere with her dancing. She had the most pain with a grand plie which is the exact position that would irritate someone with iliopsoas tendinopathy. This condition is also known as jumpers hip, dancers hip, snapping hip syndrome, psoas syndrome, psoas tendonitis, and iliopsoas bursitis. The good news is that I know many snapping hip syndrome exercises.
What is the iliopsoas?
The iliopsoas is a group of muscles in the front of the hip. It is made up of 3 muscles: psoas major, psoas minor, and iliacus. The psoas major and minor attach to the lumbar spine (the low back) and the iliacus attaches to the inside of the pelvis. All three muscles then attach to the inside of the femur (the thigh bone) at a bony prominence called the lesser trochanter. The iliacus fuses with the psoas muscles as they pass through the pelvis in order to attach to the femur. Together the iliopsoas muscles are the main hip flexors (marching or forward kicking motion). They also assist in external rotation (rotating the hip and knee outward).
What is tendinopathy?
Before delving into the iliopsoas tendinopathy, let’s review tendons. A tendon is the connective tissue that attaches the muscle to the bone. The area where the tendon connects to the bone is more susceptible to irritation and injury because it’s limited blood supply.
Tendinopathy is a term used to encompass any issue with the tendon. This includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However, because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks.
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overload of the tendon without sufficient time to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early-stage tendinosis can heal within 6 to 10 weeks, but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis, but the term tendonitis is often used to encompass both.
What is iliopsoas tendinopathy?
Iliopsoas tendinopathy is a condition that affects the tendon that attaches the iliopsoas to the femur. There are 2 common causes of iliopsoas tendinopathy.
- Acute trauma – This would be the result of a sudden injury to the muscle or tendon.
- It could include a fracture of the area of bone where the tendon attaches (avulsion fracture). This type of injury is typically caused by a very strong contraction of the hip flexors against a stronger force that is trying to pull it in the opposite direction. For example, trying to kick a ball while someone hits the front of the thigh.
- The iliopsoas can be injured by direct trauma as well.
- Overuse injuries – This is the most common cause of iliopsoas tendinopathy. It can be caused by any activity that requires repetitive hip flexion and/or external rotation. This includes many sports and other athletic activities.
- Dancing
- Ballet
- Cycling
- Rowing
- Running on an incline
- Soccer
- Gymnastics
- Track and Field
Could it be bursitis?
The answer is yes, it could. The iliopsoas bursitis lies deep or below the iliopsoas muscle complex. However, because of the close proximity of the two, inflammation in one will lead to inflammation in the other. So, it is assumed that iliopsoas bursitis occurs with iliopsoas tendinopathy and vice versa. Luckily, the treatment is the same for both.
What are the symptoms for iliopsoas tendinopathy?
There are several symptoms associated with this condition. These include:
- Deep groin pain or pain in the front of the hip
- Pain that worsens with activity
- Pain decreases with rest
- Clicking or catching in the hip or groin
- Low back pain and/or buttock pain
Symptoms will initially present with the start of the activity and then decrease. They will then progress to constant pain during the activity that decreases with rest. Without treatment or significant rest, they will progress to pain during activity and at rest.
What are the risk factors?
There are a few risk factors for iliopsoas tendinopathy. These include:
- Adolescents – The hip flexors have decreased flexibility during growth spurts which increases the chance of injury or irritation.
- Athletes that perform repetitive hip flexion and/or external rotation are more at risk.
- It is slightly more prevalent in females.
- It is typically seen in a younger population but can also occur in older adults.
- Osteoarthritis or rheumatoid arthritis increases the risk.
Who should I see?
- Physical therapy – This would be my first stop. In fact, this will probably be the only stop you will need. Physical therapy can help decrease pain and inflammation with techniques including manual therapy and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. Your PT will also assess your training schedule and technique to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if the condition is not responding to physical therapy. Your physician can prescribe medication, give a steroid injection, or order imaging if needed.
What can I do at home?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat iliopsoas tendinopathy. Basically, stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. This might include not participating in your sport or activity for a period or time. It could also include continuing your activity but not performing certain moves or techniques that are irritating to the hip. If you are not able to participate in your activity, then you can supplement with non-irritating activities such as swimming while your tendon is healing.
- Ice – Ice can help decrease pain and swelling in the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Stretching – Stretching the iliopsoas and quadriceps muscles can help improve the pain and mobility of the hip. Begin with gentle stretching at first and then more aggressive stretching as the pain and irritation subsides. See the video below.
- Strengthening – It is important to strengthen the muscles around the hip, especially in the back of the hip and thigh. This includes your gluteal muscles and the hamstrings. It is also important to strengthen your core muscles. When the iliopsoas is tight, it moves the pelvis into an anterior pelvic tilt. This puts an arch in your low back and places the abdominal muscles on stretch. This is a suboptimal position for the abdominals and muscles of the lower back. Strengthening the core muscles after stretching the iliopsoas is very important in improving pelvic and low back posture and positioning. Using loop resistance bands can increase strength and difficulty. See the videos below.
In review
- The iliopsoas complex is made up of the psoas major, psoas minor, and the iliacus. It is the main flexor (kicking or marching motion) of the hip.
- Iliopsoas tendinopathy is an irritation of the tendon that attaches to the femur.
- It is most commonly caused by activities that require repeated hip flexion. This includes many activities such as soccer, dance, and track and field.
- It is characterized by a deep groin pain or pain in the front of the hip. The pain will increase with the irritating activity and decrease with rest.
- It commonly occurs in a younger, athletic population.
- Physical therapy is very successful in treating this condition.
- There are things that you can do.
- Relative rest
- Ice
- Stretching
- Strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Iliopsoas_Tendinopathy
https://www.ncbi.nlm.nih.gov/books/NBK551701/