Iliopsoas Tendinopathy

Lower Limb

Overview

Iliopsoas tendinopathy is an overuse injury affecting the iliopsoas tendon, characterized by inflammation, micro-tearing, or degenerative changes at the musculotendinous junction or insertion at the lesser trochanter. It commonly presents in athletes and individuals with repetitive hip flexion activities, causing anterior hip or groin pain with functional limitation. The condition results from cumulative microtrauma exceeding the tissue's capacity to repair.

Pathophysiology

The iliopsoas, comprising the iliacus and psoas major muscles, undergoes repetitive loading during hip flexion, internal rotation, and spine flexion activities. Excessive or prolonged tension creates microtrauma at the tendon, leading to inflammatory response, collagen disorganization, and potential degeneration. Tightness in the iliopsoas can restrict hip extension and increase compensatory loading on the tendon. Chronic tendinopathy involves neovascularization and failed healing with disrupted collagen architecture.

Patient Education

The iliopsoas tendon heals slowly due to limited blood supply; recovery requires activity modification, progressive loading through rehabilitation, and addressing the underlying biomechanical drivers such as hip tightness and core weakness rather than complete rest.

Typical Presentation

Site

Anterior hip, groin region, or lower abdominal area; pain may refer along the inner thigh; occasionally felt at the lesser trochanter insertion

Quality

Sharp, aching, or burning pain; may describe clicking or snapping sensation with movement

Intensity

Mild to moderate (3-7/10); often progressive if activities not modified; worse with activity, better with rest

Aggravating

Hip flexion activities (climbing stairs, running, jumping), prolonged sitting with hip flexed, hill running, resisted hip flexion, active straight leg raise, rapid direction changes

Relieving

Rest and activity modification, ice application, gentle stretching, anti-inflammatory medications, positions of hip extension and external rotation

Associated

Reduced hip extension range of motion, weakness in hip extensors and external rotators, antalgic gait, pelvic tilt dysfunction, lower back pain, compensatory movements, possible clicking or snapping at the hip

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

FABER Test (Flexion, Abduction, External Rotation)

Procedure

Patient supine. Place the foot of the tested leg on the opposite knee, then let the knee fall outwards, adding gentle overpressure on the knee while stabilising the opposite pelvis.

Positive Finding

Pain in the groin or front of the hip, or less range than on the other side.

Interpretation

A general hip provocation test. Groin pain is common with hip joint problems (labral tears, FAI, arthritis) as well as with iliopsoas problems, so a positive test does not identify the source. The figure stored here belongs to intra-articular hip problems (labral tears, FAI), not to this condition, so no figure is shown.

Sources

No accuracy study

Thomas Test

Procedure

Patient sits at the end of the plinth, then lies back hugging one knee to the chest. The other leg hangs down. Look at the hanging thigh, and repeat on the other side.

Positive Finding

The hanging thigh rises above the plinth, or passive hip extension reproduces the patient's anterior hip pain.

Interpretation

Shows hip flexor length. Pain with the stretch supports iliopsoas involvement; tightness alone is common and not diagnostic.

Sources

No accuracy study

Iliopsoas Strength Test (Modified Sit-Up or Resisted Hip Flexion)

Procedure

Patient sitting on the edge of the plinth. Ask the patient to lift the knee above 90° of hip flexion and hold against your resistance. Also test in the modified Thomas position (hip extended, hanging leg), lifting the thigh against resistance.

Positive Finding

Reproduction of the patient's own anterior hip or groin pain, or weakness.

Interpretation

Loads the iliopsoas tendon, especially in the lengthened (Thomas) position. Pain supports iliopsoas tendinopathy. The hip joint can also produce groin pain with resisted flexion; check hip rotation and FADIR.

Sources

No accuracy study

Iliopsoas Snapping Test

Procedure

Patient supine. Ask the patient to move the leg from a bent, turned-out position (flexion, abduction, external rotation) slowly back to straight, while you rest your hand over the front of the hip.

Positive Finding

A clunk or snap felt or heard at the front of the hip, often reproducing the patient's symptoms.

Interpretation

Suggests internal snapping hip, where the iliopsoas tendon flicks over the pelvis or femoral head. It often accompanies iliopsoas tendinopathy. Snapping is common and not always painful. (The Ober test is for iliotibial band tightness and does not assess the hip flexors.)

Sources

No accuracy study

Palpation of Iliopsoas Tendon (Inguinal Ligament Palpation)

Procedure

Patient supine with the hip slightly bent and turned out. Find the femoral artery pulse just below the inguinal ligament, then move just lateral to it and press gently while the patient lifts the leg slightly.

Positive Finding

Tenderness that reproduces the patient's own anterior hip pain.

Interpretation

The iliopsoas tendon lies lateral to the femoral artery (and deep to the femoral nerve), not medial to it. Tenderness supports iliopsoas tendinopathy or bursitis. Palpation here is imprecise; ultrasound can confirm.

Sources

No accuracy study

Active Straight Leg Raise

Procedure

Patient supine. Ask the patient to lift the straight leg a little off the plinth and hold, then add light resistance above the knee.

Positive Finding

Reproduction of the patient's own anterior hip or groin pain.

Interpretation

Loads the hip flexors. Pain supports iliopsoas involvement but can also come from the hip joint or, in runners, a femoral neck stress fracture. Groin pain with loading in a runner, especially with night or rest pain, needs imaging.

⚠ Red Flags

  • •Acute trauma with severe pain and inability to bear weight—rule out hip joint pathology or fracture
  • •Fever with groin pain—consider septic arthritis or other infection
  • •Progressive neurological deficit—consider nerve compression or lumbar involvement
  • •Severe unremitting pain despite conservative management—evaluate for labral pathology, femoroacetabular impingement, or other intra-articular pathology
  • •Signs of compartment syndrome or acute vascular compromise—pale, cool limb with pulselessness

⚡ Yellow Flags

  • •Fear-avoidance behaviours limiting activity beyond clinical justification
  • •High pain catastrophization or persistent belief in serious pathology despite reassurance
  • •Psychological distress or mood disorders affecting recovery engagement
  • •Excessive focus on symptom monitoring or health anxiety
  • •Poor compliance with rehabilitation or unrealistic recovery expectations

Osteopathic Techniques

First-line care for iliopsoas problems is conservative: activity changes, physiotherapy, anti-inflammatories and sometimes a steroid injection. Surgery is for cases that fail. No trials of osteopathic or manual techniques for iliopsoas tendinopathy were found.

Region

Iliopsoas muscle and tendon

Technique

Soft tissue, hip and thighNo trials found

Rationale

Hands-on work to the hip and thigh muscles to ease tension and pain, given alongside exercise.

How it's done & evidence

How it's done

Hands-on kneading, stretching and sustained pressure to the muscles around the hip and thigh: the hip flexors, adductors and hamstrings, and tensor fasciae latae with the iliotibial band.

Evidence in Iliopsoas Tendinopathy

Searched 24 Oct 2026: no trials of iliopsoas soft tissue technique in iliopsoas tendinopathy.

Sources

Region

Psoas and iliacus

Technique

Muscle energy, psoasNo trials found

Rationale

Low-force, patient-powered stretch for a tight psoas and iliacus.

How it's done, cautions & evidence

How it's done

The hip is taken into extension to the barrier (prone, or supine with the leg off the table). The patient pulls the hip toward flexion for 3–5 seconds against equal resistance, relaxes, and the hip is taken further into extension. Repeat 3–5 times, then re-check.

Cautions

Do not use with a fracture in the area, an unstable pelvis or hip, recent surgery, or a patient who cannot contract on request or follow directions.

Evidence in Iliopsoas Tendinopathy

Searched 24 Oct 2026: no trials of psoas MET in iliopsoas tendinopathy.

Region

Hip joint

Technique

Articulation, hipNo trials found

Rationale

Gentle, rhythmic movement of the hip within its range to ease pain and stiffness.

How it's done, cautions & evidence

How it's done

Rhythmic, low-velocity passive movement of the hip joint within its range, with no thrust, usually with the patient supine. In hip osteoarthritis trials it was given as a course of about 9–10 sessions over 5–12 weeks.

Cautions

Side effects are usually mild and short-lived. In one hip osteoarthritis trial, 41% of the active group (manual therapy plus exercise) reported mild side effects, against 14% with sham.

Evidence in Iliopsoas Tendinopathy

Searched 24 Oct 2026: no trials of hip mobilisation in iliopsoas tendinopathy.

Region

Lumbar spine and pelvis

Technique

Articulation, lumbarNo trials found

Rationale

Gentle, rhythmic mobilisation of the lower back and pelvis to ease stiffness.

How it's done, cautions & evidence

How it's done

Rhythmic, low-velocity movement of restricted lumbar segments within their passive range, with no thrust, usually side-lying or prone. The amplitude can vary.

Cautions

Side effects reported in trials were mild and short-lived: soreness, tiredness or a flare of existing symptoms.

Evidence in Iliopsoas Tendinopathy

Searched 24 Oct 2026: no trials of lumbar or pelvic mobilisation in iliopsoas tendinopathy.

Sources

Region

Lumbosacral fascia and gluteal muscles

Technique

Soft tissue, lumbar and glutealNo trials found

Rationale

Hands-on work to the gluteal and lower back muscles to ease tension around the hip.

How it's done, cautions & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) to the lumbar paraspinals, quadratus lumborum and gluteal muscles, usually prone or side-lying.

Cautions

Only minor side effects have been reported in trials.

Evidence in Iliopsoas Tendinopathy

Searched 24 Oct 2026: no trials of lumbar and gluteal soft tissue technique in iliopsoas tendinopathy.

Sources

Rehabilitation Exercises

Supine Hip Extension (Prone Hip Flexor Stretch)

Range of MotionBeginner

Low Lunge Hip Flexor Stretch

StretchingBeginner

Kneeling Hip Flexor Stretch with Pelvic Tilt

StretchingIntermediate

Supine Gluteal Bridge

StrengtheningBeginner

Clam Shell (Hip External Rotation)

StrengtheningBeginner

Side-Lying Hip Abduction

StrengtheningBeginner

Single-Leg Hip Bridge (Progression)

StrengtheningIntermediate

Standing Hip Extension with Resistance Band

StrengtheningIntermediate

Dead Bug (Core Stabilization)

PosturalIntermediate

Quadruped Rocking (Hip Extension Control)

PosturalBeginner

Single-Leg Balance with Hip Control

BalanceIntermediate

Stationary Cycling with Proper Seat Height

CardiovascularBeginner

Referral Criteria

  • •Persistent symptoms beyond 6-8 weeks despite appropriate conservative management and activity modification
  • •Suspected labral pathology or femoroacetabular impingement—refer to orthopaedic surgeon for imaging and diagnostic injection
  • •Significant mechanical clicking or catching suggesting intra-articular pathology—refer for MRI and specialist assessment
  • •Neurological signs including radiating pain down the leg, numbness, or weakness—refer to neurologist or spinal specialist
  • •Failure to progress with rehabilitation despite good compliance—consider imaging (ultrasound or MRI) and specialist physiotherapy assessment
  • •Athlete requiring high-level performance restoration—refer to sports medicine physician or specialist sports physiotherapist
  • •Concurrent low back pain or pelvic dysfunction—consider referral to spinal specialist or pelvic health specialist