Patients › Hip

Iliopsoas impingement and tendinopathy

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What you're feeling¶

The pain sits at the front of your hip, deep in the groin. It often builds slowly rather than starting after one clear injury. You might notice it when you lift your knee up, bring your hip towards your chest, or stretch the leg out behind you. That is because the tendon involved slides across the front of the hip joint as it moves: it sits to one side when the hip bends and shifts to the other side when the hip straightens. Movements that take it back and forth over that spot can irritate it.

The ache tends to flare after activity, and some people feel it first thing on waking or at night. Snapping or clicking at the front of the hip can come with it. Everyday things can get harder: getting out of a car, climbing stairs, putting on socks and shoes, or getting up from a low chair. Sport that loads the hip with quick twisting, like golf or baseball, often stirs it up.

Groin pain is easy to misread. Problems in the lower back, or a strain where the muscles meet the pubic bone at the front of the pelvis (sometimes called a sports hernia), can feel much the same. These conditions often turn up together, and groin pain is sometimes blamed on the wrong cause for months before the hip is identified as the source. If you have already had a hip replacement, a tendon at the front of the hip can also become irritated where it rubs against the new joint, causing pain in much the same place.

Because several conditions can produce this same deep groin ache, a careful examination and the right scans or injections are what sort out which structure is actually causing your pain.

What's actually happening¶

The iliopsoas (say it: ill-ee-oh-soh-us) is a muscle at the front of your hip that lifts your knee towards your chest. It runs from your lower spine and the inside of your pelvis down to a bony point on your thigh bone, ending in a strong cord of tendon fibres, a bit like a rope. That rope crosses the front of the hip joint, and it slides to one side when you bend the hip and back the other way when you straighten it.

When that tendon is working normally, it glides smoothly. With iliopsoas tendinopathy, the tendon fibres themselves become irritated and worn from being loaded over and over. With impingement, the tendon is being squeezed or rubbed where it passes over the front of the hip, sometimes by the shape of the bones nearby, and sometimes by parts of a hip replacement it has to slide past. Either way, the same rope is being pinched or strained, and each bend and straighten of the hip drags it over the sore spot again. That is why lifting your knee, climbing stairs or getting out of a car flares the pain you read about above, and why the tendon can click or snap as it catches and then slips free.

The tendon is not just a passive rope, though. It also helps hold the hip steady, so a badly damaged one can leave the hip feeling less supported. The good news is that when the tendon does need surgery, the remaining fibres have a real capacity to mend: after the tendon is released, most people regain their strength and the tendon regrows much of its thickness.

Because this tendon sits deep and shares its symptoms with back problems and groin strains, it is easy for the wrong cause to be blamed. Sorting out exactly which structure is hurting is the first step, and it shapes everything that follows.

What we can do about it¶

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your hip, and arrange scans if they are needed to confirm what is causing the pain.

For a problem like this that has built up over time, we usually begin with non-operative care. The first steps are changing the activities that stir the tendon up, and physiotherapy aimed at settling the irritation and rebuilding how the hip moves and copes with load. Anti-inflammatory tablets (the same family of medicine as ibuprofen) can ease the pain while you work on it. Give this a fair run before thinking about anything further.

If those measures have not settled things, an injection can be the next step. Using ultrasound to guide the needle, we can place cortisone (a strong anti-inflammatory medicine) right around the tendon. This can help confirm that the tendon is the true source of your pain, and it can also treat the inflammation. Scans and examination alone do not reliably predict who will respond to this injection, which is one reason we use it as a test as well as a treatment. This applies whether you have your own hip or a hip replacement; the same guided injection is used for tendon irritation after a hip replacement.

Surgery comes into the conversation when a well-run course of non-operative care has not given you enough relief. The operation is a keyhole procedure (done through small cuts with a camera) that releases the tight or damaged part of the tendon so it stops catching at the front of the hip. The tendon still helps steady the hip, so we weigh that up with you carefully, and the decision to operate is one we make together. After release, most people are free of the snapping and regain their strength, and the tendon regrows over 80% of its original thickness. If your pain comes from the tendon rubbing on parts of a hip replacement, surgery on those parts is another option we can discuss. Recovery and what to expect afterwards are covered on the next page.

What to expect¶

This problem often takes a long time to be identified. Groin pain like this is frequently blamed on something else first, and many people spend months being treated for the wrong cause before the hip is recognised as the source. That delay is common, and it is not a sign that anything has gone wrong with your care so far.

Left alone, the pain tends to persist rather than settle on its own. The ache you read about above usually keeps flaring with the same movements, and it can keep you away from sport and make everyday tasks harder. Getting the right diagnosis early matters, because it points treatment in the right direction instead of at the wrong structure.

Most people do well once the cause is correctly identified and managed. For pain at the front of the hip from this tendon, surgery is usually successful at relieving the groin pain and the limits it places on what you can do. When the tendon is released with a keyhole procedure, more than 92% of people get significant relief from that deep anterior pain. If your pain comes from the tendon rubbing on parts of a hip replacement, surgery on those parts resolves the pain in most people who are selected for it, with 85% satisfied at their latest check-up.

Not every outcome is straightforward, and it is worth knowing this before you decide anything. Some people who have this tendon released during keyhole surgery for other hip problems do not get back to their pre-injury sport, and their hip function tends to be poorer afterwards. For that reason, surgery on this tendon is not offered lightly, and your surgeon will weigh up whether it truly suits your hip before recommending it.

Recovery is gradual rather than instant. The tendon regrows much of its thickness after release, and most people regain their strength, but this happens over weeks to months, not days. Set realistic goals: steady improvement in the deep groin ache, easier stairs and car trips, and a return to the activities you enjoy, at whatever pace your hip allows.

When to see someone¶

See your GP if you have had deep groin pain for more than a few weeks, especially if it keeps flaring with the same movements and has not settled with rest. Ask for a specialist review if your groin pain has already been treated as something else, like a back problem or a strain where the muscles meet the pubic bone, and it has not improved after months of that care. This delay is common: many people spend around 7 months being treated for the wrong cause before the hip is recognised as the source. Ask sooner rather than later if the pain is stopping you playing sport, or if your hip feels less supported than it used to. If you have already had a hip replacement and new pain has appeared at the front of your groin, mention that clearly, because it changes what needs checking.

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