Anterior - groin - iliopsoas

Normally insidious onset suggesting an over use component. Pain thought to originate form the bursa (the largest in the body), muscle belly, musculo-tendinous junction or tendon itself (Johnston 1998). Linked with co-existing pathologies making differential diagnosis difficult.

Pain normally felt anterior groin, proximal thigh and lower abdomen. Some patients may experience snapping hip syndrome (often this sign is asymptomatic).

Has been linked to a higher incident of low back pain. Tyler et al (2014) suggests that 45% all dancers with iliopsoas groin pain had lumbar spine symptoms.

Aggravating Factors: Running especially fast long strides, sudden changes in speed and direction, active flexion activities e.g. Stair climbing, sitting in low chairs.

Prevalence

Little is known about prevalence but reported high incidence in runners (Holmich, 2007).

No published research was found into the reliability and validity of the commonly used tests mentioned below. Very limited reliability studies into Thomas test mainly demonstrate poor reliability (Peeler and Anderson, 2004). There is no standardisation with regards to how to perform these tests.

For a test to be positive it should reproduce the patient's reported pain.  Weir et al (2015) recommended using:

• Pain on resisted hip flexion AND/ OR
• Pain on stretching hip flexors

Other tests

Active Hip Flexion

Test in standing and high sitting. Note quality and control of lumbo-pelvic area.

Thomas Test or modified version +/- resistance (Video Link)

Patient sits at end of plinth. Gently patient falls back into lying position with contra-lateral knee flexed. Allow ipsilateral leg to fall into extension without allowing lumbar spine extension.  Does not exclusively test iliopsoas. Aim is to produce passive compression with hip in extension. Are anterior structures long or short?

With resistance applied by therapist in this position generates an isometric compression load across the front of the hip. If pain is produced/ increased this may indicate iliopsoas involvement +/- intra articular pathology.

Anterior hip ‘snapping’ test (Video Link)

Slight variations of this test exist including whether it is passive or actively assisted by the patient.

Start position- hip flexion/ slight add moving into abduction /and ER with finishing position in neutral. The examiner can feel for snap or patient reports snapping sensation as iliopsoas moves over the pelvic rim.

Palpation

Locate femoral pulse, move slightly superior and lateral to identify inferior border pubic rami (Remember generally tender so comparison to other side necessary).

Hip Joint screening tests

Many different tests are available to assess the hip joint. These are a few of the most commonly used tests:

• Hip flexion - looking for limitation and/ or pain
• Hip internal rotation - looking for limitations and/or pain
• Impingement test (Video Link)
  
  Flex hip to 90° then adduct and internally rotate thigh. A positive test produces groin pain.
• FABER (Video Link)
  
  The hip is placed in flexion, abduction, and external rotation (a figure 4).The examiner applies a posterior directed force against the medial knee of the bent leg towards the table top. A positive test occurs when groin pain or buttock pain is produced.

Often unremarkable (Johnston et al, 1998).  MRI often used to confirm/ exclude intra-articular pathology (high sensitivity / poor specificity).  Can be difficult due to co-existing pathologies.

• Optimise pain management
• Minimise tendon compression. Avoid unnecessary hip extension e.g. reduce stride length and ‘snapping’ activities
• Optimise muscle function + tendon loading
  • Postural re-education regarding aggravating positions
  • All advice and treatment should not ‘flare’ symptoms, look for 24 hour response
  • Load modification
  • Muscle re-training (isometrics → functional exercise)

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment, based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Exercise Prescription

Very limited research carried out for this specific condition. Only one retrospective case series has been published (Johnston et al, 1998).

Commonly suggested treatment approaches:

• Isometrics if very sore +/- weak)
• Improve hip flexor strength (consider concentric and eccentric)
• May need to incorporate exercises for other muscles around lumbo-pelvic region including glut min and med. (Johnston et al, 1998)
• Hip flexor stretching only indicated if iliopsoas found to be short on muscle length testing
• Progress as symptoms allow
• Generally 3 – 4 months to see significant improvement

Non evidence based strategies

Physiotherapy interventions commonly used in treatment of musculoskeletal conditions:

• Relative rest
• Hot/cold
• Electrotherapy
• Transverse friction massage
• Manual therapy

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

• Discuss with senior member of staff
• Consider referral to Orthopaedics for imaging or steroid injection under ultrasound guidance
• Surgery is rare

Holmich, P. 2007. Long standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients . British Journal of Sports Medicine; 41:247-52 Link Here (link correct as of 30/10/2015). NHS Scotland Athens username and password may be required.

Johnston, C.A, Wiley, J.P., Lindsay, D.M. and Wiseman, D.A. 1998. Iliopsoas Bursitis and tendonitis: A review. Sports Medicine 25(4) 271-283 Link Here (link correct as of 30/10/2015). NHS Scotland Athens username and password may be required.

Peeler, J. and Anderson, J.E. 2007. Reliability of the Thomas test for assessing range of motion about the hip for assessing range of motion about the hip: Physical Therapy in Sport: 8(1): 14-21 Link Here (link correct as of 30/10/2015). NHS Scotland Athens username and password may be required.

Tyler, T.F., Fukunaga, T. And Gellert, J. 2014. Rehabilitation of soft tissue injuries of the hip and pelvis. International Journal of Sports Physical Therapy, 9(6): 785-797 Link Here (link correct as of 30/10/2015). NHS Scotland Athens username and password may be required.

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A.G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., Tyler, T., Verrall, G., de Vos, R.J., Vuckovic, Z. and Holmich, P. 2015. Doha agreement meeting on terminology and definitions of groin pain in athletes. British Journal of Sports Medicine 49 (12): 768-774 Link Here (link correct as of 30/10/2015). NHS Scotland Athens username and password may be required.

Musculoskeletal (MSK) Physiotherapy - NHSGGC - hip self help and information

NHS Inform - Hip Problems