Iliopsoas Pathology Diagnosis and Management

Clinical Presentation and Diagnostic Considerations

The American College of Radiology recommends considering iliopsoas tendinitis/bursitis, snapping hip syndrome, femoroacetabular impingement syndrome, and labral pathology in the differential diagnosis of anterior groin pain along the iliopsoas, with snapping hip syndrome potentially coexisting with tendinitis 1, 2
Femoroacetabular impingement syndrome can present with anterior groin pain, but typically worsens with hip flexion activities, and labral pathology is often associated with iliopsoas symptoms 3, 1

The American College of Radiology suggests obtaining plain radiographs first to exclude osseous pathology, arthritis, or structural abnormalities, which is the recommended first-line imaging for all chronic hip pain presentations 1, 4, 5
If radiographs are negative or equivocal, MRI or ultrasound should be the next imaging modality for suspected iliopsoas pathology, with MRI being highly sensitive and specific for detecting iliopsoas bursitis, tendinitis, and associated intra-articular pathology 1, 2, 7
Ultrasound is an excellent alternative that can evaluate the iliopsoas tendon dynamically and guide therapeutic injections, and can specifically evaluate for snapping iliopsoas tendon in a noninvasive manner 1, 2, 4

The American Academy of Family Physicians recommends initial conservative measures including activity modification, physical therapy focusing on iliopsoas stretching and strengthening of hip stabilizers, and NSAIDs for pain control and anti-inflammatory effect 9
If symptoms persist after 4-6 weeks of initial conservative treatment, the American College of Radiology suggests proceeding with ultrasound-guided corticosteroid injection into the iliopsoas bursa or peritendinous region, which provides both diagnostic confirmation and therapeutic benefit 1, 2, 8

It is essential to consider referred pain from the lumbar spine and examine the spine, considering spine imaging if the hip examination is inconsistent, to avoid missing competing diagnoses that can mimic iliopsoas pathology 1, 5
A negative flexion-adduction-internal rotation test can help rule out intra-articular hip pathology, and ultrasound-guided diagnostic injection can differentiate between iliopsoas bursa and intra-articular hip joint when the pain source remains unclear 3