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. Anatomical factors such as femoral anteversion, hip dysplasia, or altered biomechanics increase injury risk. 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

Thomas Test

Procedure

Patient supine at end of examination table with contralateral knee flexed to chest to eliminate lumbar lordosis. Observe and palpate the ipsilateral hip for flexion contracture or psoas tightness with the leg hanging off the table.

Positive Finding

Hip flexion contracture >10–15° or inability to extend the hip fully; psoas appears tight or patient reports anterior hip pain

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests iliopsoas tightness or contracture; may contribute to tendinopathy or anterior hip pain. Not specific to tendinopathy alone but indicates length restriction.

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

Procedure

Patient supine with knee bent or straight; apply resistance to anterior thigh as patient flexes hip against manual resistance. Alternatively, patient performs sit-up against resistance with hands across chest.

Positive Finding

Pain with resisted hip flexion at or above 70° flexion angle; weakness or inability to overcome resistance; pain in anterior hip/groin region

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Positive finding suggests iliopsoas muscle involvement; may indicate tendinitis or myofascial pain. Pain at higher angles favours muscle belly; lower angles may implicate musculotendinous junction.

Modified Ober Test (for Hip Flexor Tightness)

Procedure

Patient side-lying on contralateral side; ipsilateral hip flexed then extended and adducted passively. The examiner supports the leg and allows gravity to lower it towards adduction.

Positive Finding

Hip remains abducted and externally rotated; inability to cross midline or lowering leg past neutral adduction; anterior hip pain during stretch

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Indicates tightness of iliopsoas and tensor fasciae latae; may perpetuate anterior hip symptoms and contribute to compensatory loading of the tendon.

Palpation of Iliopsoas Tendon (Inguinal Ligament Palpation)

Procedure

Patient supine with hip slightly flexed and externally rotated. Palpate just medial to the femoral artery pulse, beneath the inguinal ligament at the level of the hip crease.

Positive Finding

Tenderness over the iliopsoas tendon at the inguinal ligament; pain reproducible on palpation and concordant with patient's anterior hip pain

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Direct palpation tenderness suggests inflammation of the tendon or bursa; helps confirm anterior hip pain is of iliopsoas origin. Must be differentiated from vascular or lymph node tenderness.

FABER Test (Flexion, Abduction, External Rotation)

Procedure

Patient supine; hip flexed, abducted, and externally rotated with ankle crossed over opposite knee. Examiner applies gentle overpressure or patient remains at end-range.

Positive Finding

Groin or anterior hip pain (typically indicates hip joint pathology or iliopsoas irritation); limitation of range of motion compared to contralateral side

Sensitivity / Specificity

72% (for intra-articular hip pathology) / 71% (for intra-articular hip pathology)

Reiman et al., 2013, BJSM

Interpretation

Positive result may implicate anterior hip joint structures or iliopsoas; however, more sensitive for intra-articular pathology. Used as screening test for hip pathology contributing to iliopsoas symptoms.

ASLR Test (Active Straight Leg Raise with Palpation)

Procedure

Patient supine with extended legs; palpate the iliopsoas just above the inguinal ligament while patient performs active straight leg raise to 30° and holds briefly.

Positive Finding

Palpable muscle contraction associated with pain; reproduction of anterior hip or groin pain during the lift; weakness or inability to perform test without substitution

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Assesses pain provocation during active iliopsoas contraction; helps identify if symptoms are reproduced with muscle activation, suggesting tendinopathy rather than passive stretch limitation.

⚠ 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

Region

Iliopsoas muscle and tendon

Technique

Soft Tissue

Rationale

Direct soft tissue mobilization reduces muscle tension, promotes blood flow to the inflamed tendon, and interrupts pain cycles; particularly effective for releasing trigger points in the psoas major and iliacus

Region

Hip joint and iliopsoas insertion

Technique

MET

Rationale

Muscle energy technique applied to the iliopsoas through gentle post-isometric relaxation improves flexibility and reduces tendon tension without aggressive stretching that may aggravate inflammation

Region

Lumbar spine and pelvis

Technique

Articulation

Rationale

Gentle articulation of lumbar segments and sacroiliac joint restores normal spinal and pelvic mechanics, reducing compensatory hip flexor tension and improving overall kinetic chain function

Region

Hip joint complex

Technique

Functional

Rationale

Functional technique using pain-free positioning deactivates guarding patterns around the hip, normalizes neuromuscular control, and promotes proprioceptive re-education of hip stabilizers

Region

Abdominal and pelvic organs

Technique

Lymphatic

Rationale

Gentle lymphatic drainage techniques enhance fluid clearance from the inflamed tendon region, reduce swelling, and promote tissue healing through improved tissue fluid dynamics

Region

Lumbosacral fascia and core structures

Technique

Soft Tissue

Rationale

Release of fascial restrictions in the lumbosacral region and core musculature improves force distribution, reduces compensatory iliopsoas loading, and supports functional rehabilitation

Add-On Approaches

Chinese Medicine

Acupuncture to LV3 (Taichong), ST32 (Futu), and ST34 (Liangqiu) combined with moxibustion can tonify Qi and blood, reduce inflammation, and improve circulation to the affected tendon; herbal approaches may include warming and moving formulas to address blood stasis

Chiropractic

Hip joint mobilization and manipulation to restore hip capsule mobility and normalize arthrokinematics; pelvic adjustments to correct iliac or sacroiliac dysfunction contributing to biomechanical stress on the iliopsoas

Physiotherapy

Progressive strengthening of hip extensors (gluteus maximus), external rotators, and core stabilizers; dynamic stretching; movement pattern training; sport-specific conditioning; running gait analysis and retraining

Remedial Massage

Deep tissue massage to release myofascial trigger points in psoas major, iliacus, and rectus femoris; cross-friction techniques to the tendon insertion; sustained pressure release combined with active movement to enhance tissue remodeling

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