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Iliopsoas impingement and tendinopathy

45 citationsUpdated Sep 2026

Overview

Iliopsoas impingement and tendinopathy manifest as persistent groin pain and disability, often following total hip arthroplasty or in the context of femoroacetabular impingement [1, 3]. In the athletic population, this pathology is frequently underdiagnosed, necessitating efficient examination and accurate diagnostic identification to prevent significant functional limitation [2]. Mechanical irritation of the iliopsoas tendon is a critical diagnosis to consider in post-arthroplasty patients, particularly when large-diameter metal-on-metal femoral heads create a potential failure mechanism for anterior impingement [7, 8]. Patients with symptomatic femoroacetabular impingement typically present with insidious onset of groin pain, limited hip motion, and a history of delayed or inaccurate prior diagnoses [3].

Management strategies range from conservative measures to surgical intervention. Ultrasound-guided iliopsoas bursal injections appear safe and effective for both diagnosis and treatment of tendonitis following primary total hip arthroplasty [12]. Surgical options include arthroscopic or endoscopic tenotomy, which provides good mid-term clinical outcomes and significantly alleviates anterior pain in more than 92% of cases involving acetabular component impingement [10, 14, 21]. Central transcapsular iliopsoas tendon release also demonstrates excellent clinical results [16]. For selected patients, cup revision is effective in resolving pain, with 85% of patients satisfied at last follow-up [18], and an anatomical acetabular component may prove valuable in correcting impingement in highly selected cases [4].

Surgical intervention is usually highly successful for relieving groin pain and disability resulting from anterior iliopsoas impingement after total hip arthroplasty [1]. Arthroscopic release of the iliopsoas tendon is effective in alleviating pain and persistent clicking associated with snapping hip [5]. However, surgeons should employ a high threshold when selecting patients for arthroscopic iliopsoas release in the comprehensive treatment of femoroacetabular impingement with internal snapping hip [13]. Tenotomy in patients undergoing arthroscopic surgery for femoroacetabular impingement is infrequently performed and is associated with poorer outcomes [9]. When performing an iliopsoas release from the peripheral compartment, a minimum capsulotomy of at least 10 mm or greater is recommended to ensure appropriate lengthening by sectioning one or both tendons, if two exist [19]. Arthroscopic tenotomy for refractory iliopsoas tendinopathy may be appealing due to its less invasive nature [17].

Anatomy & Pathophysiology

Bony Anatomy

The hemipelvis comprises three bones—the ilium, ischium, and pubis—which unite at the triradiate cartilage within the concave acetabulum [47]. The acetabulum is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally [53]. The iliopectineal eminence is an anterior pelvic rim prominence located at the union of the ilium and pubis [53]. The iliopsoas muscle and tendon traverse a groove between the iliopectineal eminence and the anterior inferior iliac spine (AIIS) [53].

The femoral neck-shaft angle averages 127 degrees [53]. The femoral neck is normally anteverted approximately 14 degrees in relation to the femoral condyles [53].

Muscular Anatomy

The iliopsoas muscle has a large origin along the iliac crest, iliac fossa, sacral ala, iliolumbar ligaments, and sacroiliac ligaments [55]. It also has origins along the bodies of the T12 through L4 thoracic lumbar vertebrae, the transverse processes of the first through fifth lumbar vertebrae, and the intervertebral disks [55]. The iliopsoas is one of the primary hip flexor muscles, alongside the rectus femoris and sartorius [55].

The iliopsoas tendon inserts on the lesser trochanter [55]. The iliopsoas muscle fibers run parallel to the iliopsoas tendon, and the bulk of the remaining muscle attaches directly onto the proximal femoral shaft without a tendon [40].

Pathophysiology

With hip flexion, the iliopsoas tendon lies lateral to the center of the femoral head [20]. With hip extension, the iliopsoas tendon shifts medial to the center of the femoral head [20]. In patients with developmental dysplasia of the hip, the iliopsoas tendon can be pulled tight across a capsular isthmus, contributing to narrowing of the acetabular orifice and acting as a barrier to closed reduction [52].

Soft tissue expansive lesions associated with total hip arthroplasty, such as wear debris–induced iliopsoas bursitis, can lead to extravascular compression of the femoral vein [74]. Increased joint hypermobility, quantified by the Beighton score, is associated with an increased risk of iliopsoas tendinitis developing in the postoperative period following hip arthroscopy for femoroacetabular impingement and labral pathology [15].

The psoas tendon may serve as an important passive and dynamic stabilizer of the hip, and release may result in a greater alteration of kinematics with high-demand activities [28]. After arthroscopic tenotomy for internal snapping hip, most patients are asymptomatic and recover flexion force with a regeneration of over 80% of the circumference of the psoas tendon [40].

Classification

Diagnostic Challenges and Presentation

Disability resulting from iliopsoas pain and dysfunction remains underdiagnosed in athletic populations, making efficient examination and accurate diagnosis essential [2]. Diagnostic accuracy is further complicated by the fact that neither physical examination findings nor ultrasound or MRI results were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected iliopsoas tendinitis [23]. The HEC test serves as an accurate diagnostic maneuver for iliopsoas tendinopathy, offering improved sensitivity and specificity compared with conventional tests [25]. Additionally, although uncommon, iliopsoas bursitis can complicate a well-functioning total hip arthroplasty with a ceramic bearing, causing significant morbidity if complicated by femoral neuropathy or venous thrombosis [35].

Anatomical and Pathological Variants

A bifid iliopsoas tendon can cause refractory internal snapping hip [19]. When performing an iliopsoas release from the peripheral compartment, an adequate capsulotomy of at least 10 mm or greater is recommended as a minimum to ensure the iliopsoas has been appropriately lengthened by sectioning one or both tendons, if two exist [19]. The position of the iliopsoas tendon relative to the femoral head is dynamic: with flexion of the hip, the tendon lies lateral to the center of the femoral head [20], whereas with extension of the hip, the tendon shifts medial to the center of the femoral head [20].

Risk Factors and Comorbidities

Increased joint hypermobility, quantified by the Beighton score, is associated with an increased risk of iliopsoas tendinitis developing in the hip arthroscopy postoperative period in patients treated for femoroacetabular impingement and labral pathology [15]. Hip joint disease and lumbar spine disease often coexist in athletes, particularly in sports where rotational velocity is a premium [20]. Athletic pubalgia can be confused with a hip joint problem because the symptoms emanate from the groin area [20]. Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity [22].

Clinical Presentation

Diagnostic Challenges and History

Hip joint disorders frequently remain undetected for protracted periods. In one study of athletes, 60% were treated for an average of 7 months before it was recognized that the joint may be the source of symptoms [20]. Coexistent pathologies complicate the history, as hip joint disease and lumbar spine disease often coexist in athletes, particularly in sports where rotational velocity is a premium, such as baseball or golf [20]. Athletic pubalgia, or "sports hernia," is another condition that often occurs in athletes and can be confused with a hip joint problem because the symptoms emanate from the groin area [20]. There is a significant prevalence of coexistent hip disorders along with athletic pubalgia [20].

Physical Examination and Special Tests

Physical examination maneuvers that isolate the iliopsoas demonstrate high sensitivity and positive predictive value for diagnosing IP tendinitis when benchmarked against responses to an imaging-guided injection [27]. These specific findings include: * Seated hip flexion (SHF) weakness * Pain with SHF * Tenderness to palpation (TTP) of the IP tendon

Dynamic ultrasound is a useful tool to detect pathological abnormalities, and diagnostic hip injections can be helpful to differentiate between the sources of pain [31].

Biomechanics and Complications

With flexion of the hip, the iliopsoas tendon lies lateral to the center of the femoral head, and with extension of the hip, the iliopsoas tendon shifts medial to the center of the femoral head [20]. Non-infective iliopsoas bursitis may occur as a complication of hip replacement, potentially as a reactive phenomenon to polyethylene wear even without direct communication with the joint [26].

Prognostic Indicators

At 5 years, young athletes with limited hip range of motion showed increased progressive degenerative changes on MRI and radiographs compared with matched controls [24].

Investigations

Clinical Examination

A thorough understanding of normal anatomy and biomechanics is necessary to identify pathology and determine the appropriate course of treatment for hip pain [37]. Clinical examination tests and imaging findings should be used to confirm a suspected clinical diagnosis of hip pain [37]. Patients with femoroacetabular impingement (FAI) will exhibit restricted hip internal rotation in 90° of flexion [39]. The impingement test (flexion, adduction, internal rotation) will elicit pain in patients with FAI, but the test is not specific for FAI [39]. Neither physical examination nor US or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected iliopsoas tendinopathy (IPT) [23].

Imaging

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip [38]. A complete hip series usually is composed of a combination of views, including an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [38]. The AP pelvis view is used to assess acetabular anatomy, including version, acetabular coverage, and femoral head sphericity [39]. Various lateral views (most commonly 45° Dunn view and frog-leg lateral) can be used to assess femoral head sphericity and head-neck offset [39]. The femoral head-neck junction morphology is often assessed using the alpha angle on radiographs [38]. Some studies have shown that radiographs, in particular the Dunn 45° view, may be more accurate for determining the alpha angle measurement than CT or MRI [38].

MRI: For patients suspected of soft tissue or intra-articular pathology, MRI is the modality of choice, given its superior sensitivity and specificity [64]. Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [64]. The soft-tissue contrast of MRI is superior to other imaging modalities in assessing both intra-articular and extra-articular hip pathology [49]. MRI or magnetic resonance arthrography provides information regarding the integrity of the acetabular labrum and articular cartilage [39]. Noncontrast MRI at 3T is generally adequate for diagnosing intra-articular pathology [67]. If 3T imaging is unavailable, MRA can be considered at 1.5T for increased diagnostic accuracy [67]. Magnetic resonance arthrography (MRA) is more appropriate to determine injuries to the labrochondral structures and the ligamentum teres and identify the presence of loose bodies and synovial chondromatosis [64]. In the accurate detection and staging of articular cartilage lesions, the utility of MRA is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [64]. A dynamic radial 2D-GRE sequence can be added to standard hip MR arthrogram protocols in routine clinical practice [34]. MRI is helpful in assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [67]. Major findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [67].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [64]. Measurements of femoral head coverage and acetabular and femoral impingement can also be performed reliably using CT images [64]. Low-dose CT with three-dimensional reformats is particularly useful in surgical planning of complex or borderline deformities [39].

Ultrasonography: Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [64]. Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [49]. Ultrasonography provides dynamic assessment of structures such as tendon and nerve subluxation [68]. Dynamic ultrasound is a useful tool to detect pathological abnormalities such as groin hernias and adductor tendinopathy in patients with femoroacetabular impingement [31]. Ultrasonography is also being increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip [64]. US-CSI appears to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary THA [12]. Ultrasonography cannot image inside bone because bone cortex reflects almost all sound waves [68]. Internal joint structures are not well visualized by ultrasonography unless they are in a superficial location [68].

Other Considerations: Diagnostic hip injections can be helpful to differentiate between the sources of pain in patients with femoroacetabular impingement [31]. Findings from imaging studies should complement clinical examination findings to provide the most accurate diagnosis [37].

Treatment

Non-Operative

Conservative management constitutes a component of the treatment spectrum for symptomatic iliopsoas pathology [6]. Nonoperative treatment for iliopsoas impingement includes modification of activities, physical therapy, and oral nonsteroidal anti-inflammatory drugs [29]. Ultrasound-guided corticosteroid injections appear to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary total hip arthroplasty [12]. However, neither physical examination nor ultrasound or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected iliopsoas tendinitis [23].

Operative

Other Considerations: The psoas tendon may be an important passive and dynamic stabilizer of the hip, and release may result in a greater alteration of kinematics with high-demand activities [28]. After arthroscopic tenotomy in patients with internal snapping hip, most patients are asymptomatic and recover flexion force with a regeneration of over 80% of the circumference of the psoas tendon [40].

Revision: Revision total hip arthroplasty with acetabular implant revision is a treatment option for symptomatic iliopsoas pathology [6].

Complications

Instability: Anterior dislocation of total hip arthroplasty following iliopsoas tenotomy is a rare complication, particularly in the context of spinopelvic imbalance [17].

Other Considerations: Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for femoroacetabular impingement is infrequently performed and is associated with poorer outcomes [9].

Recovery

Other Considerations: Diagnostic delay significantly impacts the recovery trajectory for athletes with iliopsoas pathology. In one study, 60% of athletes were treated for an average of 7 months before it was recognized that the joint may be the source of symptoms [20]. Prognostic factors for return to sport are also critical; athletes who did not return to their pre-injury sport after tenotomy had a higher frequency of positive hip impingement test and inferior functional outcome compared with athletes who did return [42].

Non-Operative Management: Conservative management is a primary treatment option for symptomatic iliopsoas pathology [6].

Operative Management: Surgical intervention is usually highly successful for the relief of groin pain and disability resulting from anterior iliopsoas impingement and tendinitis [1]. Operative options for symptomatic iliopsoas pathology include iliopsoas tenotomy or fractional lengthening [6], as well as revision total hip arthroplasty with acetabular implant revision [6].

Key Evidence

  • [L5] Surgical intervention is usually highly successful for the relief of groin pain and disability resulting from anterior iliopsoas impingement and tendinitis. [1] (10.5435/00124635-200906000-00002)
  • [L5] Disability due to iliopsoas pain and dysfunction is underdiagnosed in the athletic population, and efficient examination and accurate diagnosis are essential. [2] (10.5435/jaaos-d-23-01166)
  • [L2] Patients with symptomatic femoroacetabular impingement typically present with insidious onset of groin pain, limited hip motion, and a significant delay in diagnosis with frequent inaccurate prior diagnoses. [3] (10.1007/s11999-008-0680-y)
  • [L4] Although our experience is limited and clinical follow-up of this patient is short, we believe that this component could prove valuable in the correction of iliopsoas impingement in highly selected patients. [4] (10.1016/j.arth.2010.12.020)
  • [L4] Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. [5] (10.1177/0363546520922551)
  • [L5] Treatment for symptomatic iliopsoas pathology includes conservative management, iliopsoas tenotomy or fractional lengthening, and revision total hip arthroplasty with acetabular implant revision. [6] (10.5435/jaaos-d-25-00476)
  • [L4] Anterior iliopsoas impingement caused by large-diameter metal-on-metal femoral heads is a potential failure mechanism resulting in persistent groin pain. [7] (10.1016/j.arth.2010.10.002)
  • [L4] Mechanical irritation and impingement of the iliopsoas tendon is an important diagnosis to be considered in persistent groin pain after total hip arthroplasty. [8] (10.1007/s00402-020-03623-z)
  • [L3] Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for FAI is infrequently performed and is associated with poorer outcomes. [9] (10.1016/j.arthro.2021.02.018)
  • [L4] Endoscopic iliopsoas tenotomy provides good mid‐term clinical outcomes in patients with iliopsoas tendinopathy following THA. [10] (10.1002/ksa.12103)
  • [L4] US-CSI appears to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary THA. [12] (10.1016/j.arth.2022.12.015)
  • [L3] Surgeons should employ a high threshold when selecting patients for this procedure in the comprehensive treatment of femoroacetabular impingement with internal snapping hip. [13] (10.1177/0363546515626173)
  • [L4] Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA. [14] (10.1016/j.arth.2019.03.030)
  • [L3] Increased joint hypermobility, quantified by the Beighton score, is associated with an increased risk of iliopsoas tendinitis developing in the hip arthroscopy postoperative period in patients treated for femoroacetabular impingement and labral pathology. [15] (10.1016/j.arthro.2022.02.015)
  • [L4] Central transcapsular iliopsoas tendon release has excellent clinical results. [16] (10.1016/j.arthro.2015.04.083)
  • [Case_report] Arthroscopic tenotomy for refractory iliopsoas tendinopathy may be appealing because of its less invasive nature. [17] (10.1186/s12891-020-03711-6)
  • [L3] Cup revision is effective in resolving the pain due to ilio-psoas impingement in selected patients, with 85% of patients satisfied at last follow-up. [18] (10.1016/j.otsr.2017.07.021)
  • [L4] Performing an adequate capsulotomy of at least 10 mm or greater made it possible to see both tendons, and we recommend this length as a minimum capsulotomy when performing an iliopsoas release from the peripheral compartment to ensure the iliopsoas has been appropriately lengthened by sectioning one or both tendons, if two exist. [19] (10.1007/s11999-010-1452-z)
  • [L5] [20] (10.1177/0363546513499136)
  • [L4] Endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. [21] (10.1016/j.otsr.2017.09.007)
  • [L5] Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity. [22] (10.1016/j.arthro.2020.09.022)
  • [L3] Neither physical examination nor US or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected IPT. [23] (10.1016/j.arthro.2020.12.184)
  • [L2] At 5 years, young athletes with limited hip range of motion showed increased progressive degenerative changes on MRI and radiographs compared with matched controls. [24] (10.1177/0363546517719460)
  • [L2] The HEC test is an accurate diagnostic maneuver for iliopsoas tendinopathy offering improved sensitivity and specificity compared with conventional tests. [25] (10.1097/corr.0000000000003520)
  • [L5] Non-infective iliopsoas bursitis may occur as a complication of hip replacement, potentially as a reactive phenomenon to polyethylene wear even without direct communication with the joint. [26] (10.1007/s00402-004-0751-9)
  • [L3] Physical examination maneuvers that isolate the iliopsoas, specifically seated hip flexion (SHF) weakness, pain with SHF, and tenderness to palpation (TTP) of the IP tendon, demonstrated high sensitivity and positive predictive value for diagnosing IP tendinitis when benchmarked against responses to an imaging-guided injection. [27] (10.1177/03635465261428681)
  • [L4] The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities. [28] (10.1016/j.arthro.2011.11.028)
  • [L4] [29] (10.1177/0363546514531037)
  • [L4] Dynamic ultrasound is a useful tool to detect such pathological abnormalities, and diagnostic hip injections can be helpful to differentiate between the sources of pain. [31] (10.1177/0363546515591259)
  • [L4] A dynamic radial 2D-GRE sequence can be added to standard hip MR arthrogram protocols in routine clinical practice. [34] (10.1016/j.arthro.2019.02.049)
  • [L5] Iliopsoas bursitis, although uncommon, can complicate a well-functioning THA with a ceramic bearing and cause significant morbidity if complicated by femoral neuropathy or venous thrombosis. [35] (10.1016/j.arth.2008.06.006)
  • [L4] [40] (10.1016/j.arthro.2013.05.002)
  • [L4] The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. [42] (10.1007/s00167-013-2738-y)
  • [L4] Soft tissue expansive lesions associated with a total hip arthroplasty can lead to vascular compression even in the absence of ominous radiographic findings. [74] (10.1016/j.arth.2006.04.002)

See Also

References

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[2] The Iliopsoas: Anatomy, Clinical Evaluation, and Its Role in Hip Pain in the Athlete: A Scoping Review. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01166

[3] Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0680-y

[4] Use of an Anatomical Acetabular Component for Treatment of Iliopsoas Impingement. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.12.020

[5] Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Postoperative Outcomes. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520922551

[6] Iliopsoas Tendonitis and Impingement After Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00476

[7] Failure of Larger-Diameter Metal-on-Metal Total Hip Arthroplasty Resulting from Anterior Iliopsoas Impingement. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.10.002

[8] Results after arthroscopic treatment of iliopsoas impingement after total hip arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03623-z

[9] Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated with Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.02.018

[10] Satisfactory mid‐term clinical outcomes of endoscopic tenotomy for iliopsoas tendinopathy following total hip arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12103

[12] Ultrasound-Guided Iliopsoas Bursal Injections for Management of Iliopsoas Bursitis After Total Hip Arthroplasty. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2022.12.015

[13] The Functional and Structural Outcomes of Arthroscopic Iliopsoas Release. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515626173

[14] Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.03.030

[15] Joint Hypermobility Is Associated With Increased Risk of Postoperative Iliopsoas Tendinitis After Hip Arthroscopy for Femoroacetabular Impingement. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.02.015

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[17] Anterior dislocation of THA after Iliopsoas tenotomy in spinopelvic imbalance: a rare case report. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03711-6

[18] Outcomes of cup revision for ilio-psoas impingement after total hip arthroplasty: Retrospective study of 46 patients. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.07.021

[19] Case Report: Bifid Iliopsoas Tendon Causing Refractory Internal Snapping Hip. Clinical Orthopaedics & Related Research. 2011. DOI: 10.1007/s11999-010-1452-z

[20] Femoroacetabular Impingement in Athletes. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513499136

[21] Endoscopic or arthroscopic iliopsoas tenotomy for iliopsoas impingement following total hip replacement. A prospective multicenter 64-case series. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.09.007

[22] Athletic Pubalgia (Sports Hernia): Presentation and Treatment. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.09.022

[23] The Limited Reliability of Physical Examination and Imaging for Diagnosis of Iliopsoas Tendinitis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2020.12.184

[24] Cam Deformities and Limited Hip Range of Motion Are Associated With Early Osteoarthritic Changes in Adolescent Athletes: A Prospective Matched Cohort Study. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517719460

[25] Evaluation of Clinical Tests to Diagnose Iliopsoas Tendinopathy. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003520

[26] Iliopsoas bursitis following total hip replacement. Archives of Orthopaedic and Trauma Surgery. 2004. DOI: 10.1007/s00402-004-0751-9

[27] Can a Clinician Accurately Diagnose Iliopsoas Tendinitis on a Physical Examination?. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261428681

[28] Clinical Outcomes After Arthroscopic Psoas Lengthening: The Effect of Femoral Version. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.11.028

[29] Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514531037

[31] Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515591259

[34] Real‐Time Assessment of Femoroacetabular Motion Using Radial Gradient Echo Magnetic Resonance Arthrography at 3 Tesla in Routine Clinical Practice: A Pilot Study. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.02.049

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[42] Can hip impingement be mistaken for tendon pain in the groin? A long‐term follow‐up of tenotomy for groin pain in athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2738-y

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[74] Extravascular Compression of the Femoral Vein Due to Wear Debris–Induced Iliopsoas Bursitis. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.04.002

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.