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Hip Popping and Pain

Popping in the hip as well as pain in the front of the hip/groin can be due to psoas tendinopathy.


What is it?

The iliopsoas tendon is a common source of hip pain and dysfunction. In addition, it contributes to a variety of lumbopelvic problems. Potential problems can range from asymptomatic snapping to painful irritation of the tendon.



The iliopsoas muscle is responsible for hip flexion and external rotation. When the muscle is excessively tight, the tendon may rub or produce a snapping sound when passing over the underlying bony landmarks.


The iliopsoas muscle can be irritated by either an acute injury or repetitive microtrauma. Acute injuries involving the hip and pelvis usually result from direct trauma or an overloaded eccentric contraction that exceeds the tendon’s capacity. Chronic injuries occur when repetitive microtrauma exceeds the body’s ability to repair itself.


This condition usually occurs with repetitive flexion on an externally rotated hip. This condition is commonly referred to as “dancer’s hip” or “jumper’s hip”, as these movements are associated with activities that predispose patients to injury. The condition is also seen in athletes who participate in resistance training, rowing, track and field, running uphill, soccer, gymnastics, and hurdling. Adolescents may be at greater risk during growth spurts due to relative inflexibility of the hip flexors.


Clinical Presentation

The symptomatic presentation of psoas tendinopathy often includes a palpable and/or audible snapping that is provoked by flexion and extension of the hip. Ongoing irritation may lead to an inflammatory response involving the tendon. Chronic irritation may lead to painful tendon degeneration and fibrosis.


Psoas tendinopathy patients complain of deep groin pain that sometimes radiates to the anterior hip or thigh. Snapping in the hip that has lasted for a long period of time can lead to weakness or an altered gait pattern from the pain. Pathology involving the psoas is often associated with a variety of lumbosacral complaints, including lower back pain and radiation of discomfort into the buttock or thigh.


Clinical observation can show signs of psoas hypertonicity, including holding the hip in slight flexion and external rotation with an anterior pelvic tilt. Palpation often demonstrates tenderness in the femoral triangle and over the psoas tendon. Psoas hypertonicity may lead to pain or limitation of passive during hip extension. Active or resistive hip flexion may trigger discomfort.


Diagnosis

Radiologic imaging of soft tissue disorders are typically unnecessary unless there are “red flags” or any suspected bony pathology. In cases where advanced imaging is indicated, MRI provides the most accurate assessment of the iliopsoas tendon.


The presence of hip pain in an adolescent warrants imaging to rule out slipped capital femoral epiphysis.


Anterior groin pain warrants evaluation of the abdomen and pelvis to rule out alternative pathology.


Management

When it comes to the treatment of tendinopathy, the use of exercise, massage therapy, acupuncture, manipulation, and mobilization. Current research shows that conservative care management of psoas tendinopathy supports the use of activity modification and relative rest with exercise.


Soft tissue manipulation and myofascial release may be appropriate to release areas of tightness or adhesions within the iliopsoas muscle. Mobilization and/or manipulation may be necessary to restore normal lumbopelvic joint mobility. Stretching and strengthening exercises should be hip flexors and rotators focused.


Symptomatic patients should be cautioned to avoid activities that involve repetitive hip flexion and to take frequent breaks from seated positions that predispose them to hip flexor shortening.


Medical management can include corticosteroid injections. Although rarely indicated, surgical management includes various tendon lengthening procedures.






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