Understanding Iliopsoas Syndrome: Effective Assessment and Rehabilitation Techniques

Hip flexor pain is a common complaint among athletes who perform repetitive hip movements under load. Iliopsoas syndrome, which affects the iliopsoas muscle-tendon unit, is a frequent cause of this pain. This condition includes hip flexor strains, iliopsoas tendinopathy, and iliopsoas bursitis. It often affects runners, dancers, footballers, and martial artists. Understanding how to assess and rehabilitate this syndrome can help athletes return to their activities safely and effectively.

What Is Iliopsoas Syndrome?

Iliopsoas syndrome refers to a group of conditions involving the iliopsoas muscle and its tendon. This muscle is the primary hip flexor, responsible for lifting the thigh toward the torso. When the iliopsoas is injured or inflamed, it can cause pain in the front of the hip and groin area.

Common causes include:

• Hip flexor strains from overstretching or sudden force

• Tendinopathy due to repetitive stress and microtrauma

• Bursitis from inflammation of the iliopsoas bursa, a fluid-filled sac that reduces friction

  
  

Athletes who frequently perform hip flexion movements, such as climbing stairs, running uphill, or kicking, are at higher risk. The pain typically worsens with resisted hip flexion or passive hip extension.

Recognizing Symptoms and Signs

The hallmark symptoms of iliopsoas syndrome include:

• Anterior hip and groin pain that increases with activity

• Discomfort during resisted hip flexion or when the hip is extended passively

• Pain during activities like stair climbing, hill running, or kicking

• A snapping sensation in the hip, known as coxa saltans interna, caused by the iliopsoas tendon snapping over the iliopectineal eminence

  
  

This snapping hip often signals underlying iliopsoas problems and can be a clue during diagnosis.

How to Assess Iliopsoas Syndrome

Accurate assessment is crucial to distinguish iliopsoas syndrome from other causes of hip and groin pain such as hip joint issues, adductor muscle problems, or inguinal conditions.

Key clinical tests include:

• Resisted Straight Leg Raise Test: The patient lifts the straight leg against resistance. Pain during this test suggests iliopsoas involvement.

• Thomas Test: This evaluates hip flexor flexibility. A tight iliopsoas will limit hip extension when the opposite hip is flexed.

  
  

When clinical examination is unclear, imaging such as ultrasound can confirm tendinopathy or bursitis by showing tendon thickening or fluid accumulation.

Rehabilitation Strategies for Iliopsoas Syndrome

Rehabilitation focuses on gradually restoring hip flexor strength and flexibility while addressing any related muscle imbalances.

Progressive Loading

Start with pain-free hip flexion exercises and slowly increase the load over time. This approach helps the tendon and muscle adapt without aggravating symptoms.

Lumbopelvic Stability Training

Iliopsoas dysfunction often occurs alongside weakness in the lumbar multifidus muscle and poor control of the lumbopelvic region. Exercises that improve core stability can support hip flexor function and reduce the risk of reinjury.

A randomized trial by Hibbs et al. (2008) showed that core stability training significantly improves hip flexor performance in athletes, highlighting the importance of this component.

Manual Therapy and Pain Relief

Manual therapy techniques targeting the lumbar spine and hip joint can reduce pain and improve mobility. Soft tissue release of the iliopsoas and tensor fasciae latae (TFL) muscles, as well as dry needling, may help relieve muscle tightness and allow earlier participation in strengthening exercises.

Return to Sport

Athletes should follow a criteria-based progression to return to sport safely. This includes:

• Pain-free hip flexion and extension during activities

• Adequate hip flexor strength compared to the uninjured side

• Good control of lumbopelvic movements during dynamic tasks

  
  

When to Seek Professional Help

If you experience persistent anterior hip or groin pain that worsens with hip flexion activities, professional assessment is essential. A physiotherapist can perform detailed clinical tests and imaging if needed to confirm iliopsoas syndrome.

For those in South Kensington, Ali Momeni Pour at Physiome Kensington, Ethos Sports Centre, Imperial College London, offers expert assessment and rehabilitation for hip flexor pain and iliopsoas issues.