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Iliopsoas Bursitis

To cushion the hard and soft tissues of the body, nature has laced the body with different structures. A bursa is a fluid filled sac (synovial fluid) present between the hard tissues like bones and soft tissues like muscles, tendons, and skin. Bursae are usually found in proximity to tendons. The main role of these structures is to act as a cushion and reduce friction between sliding anatomical structures. Inflammation of the bursae is termed “bursitis.” Iliopsoas bursitis is the name given to the state of inflammation of the iliopsoas bursa.

Iliopsoas bursitis hinders day-to-day activities like walking and exercise. The condition can worsen if left untreated. Symptoms of iliopsoas bursitis can range from mild discomfort to debilitating pain. It is a rare condition and usually co-occurs in patients with other co-morbidities. In a 2021 study, researchers found iliopsoas bursitis in 37 of the 544 patients analysed. These patients underwent total hip arthroplasty. With the help of CT scans, study researchers could identify heart-shaped iliopsoas bursitis. In another study, the prevalence of iliopsoas bursitis in symptomatic hip osteoarthritis patients was a mere 2.2%.

To understand the impact of iliopsoas bursitis, it is important to know the anatomy of the hips.

Structure Of Iliopsoas Muscle

The iliopsoas muscle is the strongest of the hip flexors. This hip flexor muscle consists of the iliacus and psoas muscles (psoas major). It is a member of the hip flexor muscles, including psoas minor, pectinus, etc. Other important hip flexor muscles include adductor muscles, adductor longus muscles, adductor magnus muscles, etc.

The Iliopsoas muscle is the main hip flexor. The proximal attachments of the psoas muscle allow additional movements of the lumbar spine.

Diagram of iliopsoas muscle

Iliopsoas Bursa

Also known as the iliopectinate bursa, this bursa plays a crucial role in the movement of the hip (hip flexion). This is the largest of all bursae in the hip joint. Located beneath the iliopsoas muscle (muscular-tendonous part), the bursa lies on the anterior capsule of the hip joint (front of the hip) and is positioned lateral to the common femoral neurovascular bundle. The iliopectinate bursa separates the iliopsoas muscle.

Iliopsoas Tendon

The iliopsoas tendon connects the muscle to the femur bone. The iliopsoas muscle fibers end in the iliopsoas tendon that inserts in the lesser trochanter of the femoral head. The iliopsoas tendon can get inflamed, leading to iliopsoas tendonitis.

Signs And Symptoms

It is the inflammation of the bursa that causes pain. The most common symptoms of iliopsoas bursitis include:

Hip Joint Discomfort (Hip Pain) And Groin Pain

The primary symptom of iliopsoas bursitis is hip pain. Patients suffering from iliopsoas bursitis experience pain and inflammation in the joint. The pain increases gradually, making movement difficult. The pain is most pronounced during the straightening of the leg. Climbing the stairs and even rising from a seated position can cause excruciating pain.

A significant number of patients experience pain in the groin region as well. According to a study, groin pain is a major presentation of iliopsoas disorders (bursitis and tendinopathies). Groin pain was found in 21% of analyzed athletes. Another study concluded iliopsoas bursitis is the primary cause of chronic groin pain.

Most athletes with iliopsoas disorders experience pain in the inguinal region (groin area). The pain from inflammation of the bursa can radiate from the front of the hip to the thighs or toward the knee.

Morning stiffness is usually seen in patients with autoimmune musculoskeletal disorders, but several IB patients also report morning stiffness.

Muscle Weakness And Gait Changes

Pain from iliopsoas bursitis increases in intensity over the next weeks. As a response, the patient restricts movement to avoid pain.

Over time, the muscle becomes weak, and the patient starts to limp. The iliopsoas muscle is responsible for correct posture (standing and lumbar position while sitting). With inflammation of the bursa, patients experience changes in posture.

Gait changes arise due to joint stiffness and pain. The affected leg has evidently shortened stride length. According to a study, iliopsoas pathologies after hip arthroplasty can lead to groin pain and consequent gait changes.

Psoas syndrome that occurs secondary to iliopsoas bursitis leads to a shuffling gait. Clinical studies conclude that many patients with the condition move with a limp. Thus patients need a walking cane for locomoting.

Systemic Symptoms

Bursa inflammation does not present with any systemic symptoms. However, if the bursa ruptures and gets infected, you may experience pain with fever/chills. You should never ignore if the hip skin turns red or if you have warm skin.

Causes And Risk Factors

Bursitis of the hip joint falls under the umbrella term, i.e., iliopsoas syndrome. Different conditions can lead to the development of this chronic pain syndrome of the inner hip. As hip flexors are involved, pain is felt on the outside or on the front of the hip.

The main reason for developing this condition is repetitive stress to the hip joint. It can also develop due to overuse of the joint. Thus, it can also be termed an overuse injury. Individuals involved in repetitive activities of the hips can develop bursitis. This includes swimmers, runners, and dancers.

Conditions of chronic inflammation, such as arthritis, can predispose you to develop iliopsoas bursitis. Rheumatoid arthritis (an autoimmune joint disease) and osteoarthritis (degenerative disease of the joints) patients are at a greater risk.

Tight hip flexor muscles increase your propensity to develop iliopsoas bursitis. This is because individuals with tight hip flexor muscles have increased pressure in the bursae. This increased pressure amps up the amount of friction between the bursa.

The snapping syndrome can lead to iliopsoas bursitis. The syndrome is characterized by an unavoidable snapping sensation and audible popping in the hip joint while moving. Research suggests that snapping syndrome can lead to bursitis.

Diagnosis

Physical Examination And Imaging

After a complete medical history of radiating hip pain, your doctor will perform a physical exam of the hip joint. The physical exam involves applying pressure on the bursa and noting the symptoms.

Diagnostic imaging is ultimately important for an accurate diagnosis. X-rays and Magnetic Resonance Imaging (MRI) scans are generally advised to image the bursa and the neighbouring tissues. Your doctor may also require a bone scan and hip ultrasound to rule out bone abnormalities.

Differential Diagnosis Of Iliopsoas Bursitis

As the diagnosis of iliopsoas bursitis depends on patient history, there are multiple diseases with similar symptoms. Following diseases fall under the differential diagnosis of IB:

Iliopsoas Tendonitis- The iliopsoas tendon lies very close to the bursa. Inflammation of the tendon has similar symptoms.

Trochanteric Bursitis– Trochanteric bursa is the other important bursa of the hip. The trochanteric bursa and the iliopsoas make the major hip bursae. It can become irritated and inflamed to present features similar to IB.

Other conditions that fall in the DD of IB include:

  • Snapping hip
  • iliopsoas tendonitis
  • Arthritis (rheumatoid/osteoarthritis)
  • Intraperitoneal hernias
  • Iliac/Femoral Vessel Aneurysms

Treatment Of Iliopsoas Bursitis

The treatment of iliopsoas bursitis depends on multiple strategies. The main aim of the treatment is to soothe the inflamed iliopsoas bursa and relieve the pain of the patient. Doctors prefer starting with simple home strategies to improve the condition. Initial treatment is aimed at reducing pain without intervention. Conservative treatment for iliopsoas bursitis includes:

Rest- Physical stress aggravates the condition. Taking rest from work allows your bursa to heal. Bursae and tendons take some time to repair. Thus, you should be patient during the healing time.

Medications And Oral Steroids- Anti-inflammatory medications (NSAIDs and steroids) manage symptoms well. Over-the-counter painkillers relieve pain and cut down swelling. Oral steroids also help reduce pain, but a corticosteroid injection is the need of the hour for quick relief. instantly.

Ultrasound-guided bursa injections- A local anaesthetic is often mixed with a corticosteroid injection to relieve pain. Per a 2022 study, a selective steroid with anaesthetic injection into the iliopsoas bursa under ultrasound guidance provides adequate pain relief.

Physical Therapy And Strengthening Exercises

An experienced therapist can flush out pain and inflammation from your body. Hip bursitis is common in players, so physical therapy for bursitis is frequently a part of sports medicine (sports physical therapy). Visiting a physical therapist can improve the blood flow to your knee and hip muscles. This improved blood flow aids in removing the inflammatory cells from the site.

Strengthening exercises of the hip rotators play an important role in preventing the recurrence of the painful disorder. Your physical therapist will teach you to stretch and stretch the hip flexor muscles and associated tendons.

Surgery

In most cases, the condition is completely resolved with simple steps like rest, strengthening exercises, and physiotherapy. Surgery is rarely indicated. Surgical removal of a part of the synovial membrane (synovectomy) is reserved for refractory bursitis and severe symptoms of iliopsoas syndrome. The orthopaedic surgeon may opt for extensive surgical procedures like capsulectomy (surgical removal of hip capsule) or bursectomy (removal of bursa)).

Iliopsoas tendon release surgery is often selected to manage IB symptoms in athletes and players. The surgical option effectively alleviated snapping hip symptoms among athletes with IB.

How To Prevent Iliopsoas Bursitis

The best way to prevent the occurrence and recurrence of IB is to strengthen your hip muscles. The underlying weakness of the hip rotation muscle is the major contributor to soft tissue disorder. Isokinetic evaluations and manual muscle tests have highlighted the link between muscle weakness and bursa inflammation.

Athletes with snapping hips must do exercises for internal and external hip rotators. Strengthening your gluteal muscles, buttocks, hamstrings, and buttocks can also keep diseases at bay.

Retraining of gait is also a crucial step for prevention because weak gluteal muscles increase muscle imbalances and decrease hip stability leading to further complications.

Frequently Asked Questions

What does iliopsoas bursitis feel like?

Iliopsoas bursitis presents as pain felt on the front of the hip, which aggravates on climbing stairs, exercising, standing up, and extending the leg. The hip pain is often accompanied by groin pain. The pain may radiate from the hips to the thighs and knees. The discomfort gradually increases (over weeks) and leads to muscle stiffness and weakness. Patients also experience posture and gait abnormalities.

How do you treat iliopsoas bursitis?

It is simple to treat the condition. Most patients get pain relief by taking ample rest, taking painkiller medications, and getting physical therapy sessions. Ultrasound-guided corticosteroid injections into the affected joint provide quick relief. Surgical procedures like synovectomy and bursectomy are reserved for severe refractory cases only.

Will iliopsoas bursitis go away?

Yes, in the majority of cases, iliopsoas bursitis heals with minimum care. The damaged and inflamed bursa has the capacity to heal on its own, but that requires time and patience. Physical stress can aggravate the condition. So, to ensure natural healing, you need to avoid irritation of the iliopsoas structures by taking rest.

How long does it take for the iliopsoas bursa to heal?

Rest and gentle stretching of the hip flexors can get you back on track. If you follow the strengthening exercises of the hip rotators, you can start noticing evident pain relief after 6 to 8 weeks.

What is iliopsoas bursitis?

Iliopsoas bursitis is a hip pain condition characterized by inflammation of the iliopsoas bursa present in the hip joint. The inflammation of the bursa (fluid-filled sacs) is common in swimmers, runners, and athletes. It presents as hip and groin pain with gait/posture changes. It is caused by repetitive stress to the hips and is termed an overuse injury.

What aggravates hip bursitis?

Physical stress to the affected leg and knee is the main aggravating factor of the disease. Activities like running, rowing, and swimming irritate the tendons and bursae, leading to further inflammation and swelling. Thus, if you want to get rid of the movement-limiting disorder, take sufficient rest and painkiller medications.

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