What is Psoas Syndrome?
Psoas syndrome is a rare injury to a muscle in your lower back called the iliopsoas muscle. This condition is often seen in athletes, particularly runners, dancers, and high jumpers, and usually stems from overuse or an injury. It’s often referred to as jumpers hip or dancers hip. It’s a common source of groin pain in athletes, especially those who play kick-based sports or young athletes going through a growth phase.
This condition can also be a common problem after a type of hip surgery called a total arthroscopic hip replacement. Psoas syndrome can also occur because of iliopsoas bursitis, which is the inflammation of the fluid-filled sac (bursa) that acts as a cushion between a tendon and bone, and in other conditions that affect our musculoskeletal system – our muscles and bones. Because of this, diagnosing Psoas syndrome can be difficult. When professionals speak about Psoas syndrome, they may also refer to it as iliopsoas tendinitis, internal snapping hip, or iliopsoas impingement.
Most people with this condition get better with conservative treatments such as rest, ice, and physical therapy. However, stubborn cases might need help from advanced imaging like MRI scans for diagnosis, and steroid injections or even surgery for pain relief. Therefore, doctors should always consider Psoas syndrome as a possible cause of pain at the front of the hip or in the groin, especially if patients have a history of iliopsoas injury.
What Causes Psoas Syndrome?
Psoas syndrome is often seen in athletes, but anybody can get it. It’s common in people who do a lot of running and exercises that require a lot of hip bending. Any activity where you repetitively bend your hips can lead to psoas syndrome. People with arthritis that causes inflammation or joint damage can also develop it.
Psoas syndrome can also be caused by the psoas tendon rubbing against a part of the hip bone that’s too large. After surgery, the psoas muscle can become inflamed for a variety of reasons, such as bleeding into the tendon or surgical screws sticking out.
The psoas muscle is in the lower part of your spine. It attaches to the pelvis and thigh bone. The psoas muscle mainly helps you bend your hip and rotate your leg outwards. It is attached to the sides of your lower spine. The iliac muscle, which is connected, is attached to the inside of your hip bone. Both muscles then connect to the top of your thigh bone.
In about 15% of people, the pocket of fluid (bursa) in the iliac muscle is connected to the hip joint. If you hear or feel a snapping or clunking when you move your leg from a bent to a straight position, that’s the sound of the iliac tendon moving from the inside to the outside of your hip joint. The snapping of the psoas muscle can lead to inflammation and a buildup of fluid in the iliac bursa.
Risk Factors and Frequency for Psoas Syndrome
The exact number of people affected by psoas syndrome is not certain, but we do know that some individuals are more likely to get it. These include female athletes and people with conditions like hip osteoarthritis or rheumatoid arthritis. Hip pain is pretty common in those over 60 years old, but it’s rarely because of psoas syndrome.
In terms of specific procedures, about 4.3% of patients develop iliopsoas syndrome after a total hip replacement. A study also found that 24% of people that had a total hip replacement experienced inflammation of the iliopsoas tendon.
- Psoas syndrome is more common in female athletes and those with hip osteoarthritis or rheumatoid arthritis.
- Hip pain frequently affects individuals aged 60 and over, but psoas syndrome is not usually the cause.
- Iliopsoas syndrome occurs in approximately 4.3% of patients after a total hip replacement.
- Around 24% of total hip replacement patients might experience inflammation of the iliopsoas tendon.
Signs and Symptoms of Psoas Syndrome
Individuals often complain of back pain in the lower region of the back — specifically, the lumbosacral area. This pain can sometimes spread up the lower back or down towards the sacrum, causing what feels like buttock pain, pelvic pain, or groin pain. There may also be a sensation of catching or slipping in the groin when bending the knee at a tight angle. This can suggest a labral tear or irritation from tendinopathy of the iliopsoas.
The iliopsoas muscle helps flex the hip, and people with psoas syndrome can often experience back pain while walking. This discomfort is usually associated with moving from sitting to standing or having difficulty standing straight. The patient might also complain about pain in the buttock area on the side opposite to the injury. The symptoms usually get worse with physical activity but improve when the person is resting. The resulting pain often stops at the knee.
A typical sign of this condition can be a limp or shuffling gait. On a physical examination, the doctor might find that the quadriceps and other muscles involved in lifting the leg are hypertonic or tight. Pain might also be felt when pressure is applied on the psoas’ point of insertion at the lesser trochanter. In addition to this, the patient might show a decrease in their range of leg extension. A common chronic change observed can be an exaggerated inward arch in the lower back.
- Complaints of back pain
- Pain that radiates up the lower back or down towards the sacrum
- Feeling of catching or slipping in the groin when bending the knee
- Back pain during walking or changing positions
- Pain in the buttock opposite to the side of the injury
- Symptoms worsen with activity, but improve with rest
- Tight or hypertonic hip flexor muscles
- Pain when pressure is applied to the lesser trochanter
- Decreased range of motion in leg extension
- Exaggerated arch in the lower back
Last but not least, two meaningful signs can be the Ludloff sign and snapping hip sign. The Ludloff sign is when there is pain during a specific movement, like attempting to lift the heel of the affected leg while the knee is straight. The snapping hip sign occurs when pain is experienced during another specific movement — the doctor passively extending the flexed, externally rotated, and abducted hip of the patient. If the associated pain is reproduced, there is a positive sign, suggesting a case of psoas syndrome.
Testing for Psoas Syndrome
If you’re experiencing hip pain that might be due to psoas syndrome, your doctor may need to run some tests to identify the cause. Usually, doctors don’t resort to X-rays because they typically do not show clear signs of psoas syndrome.
An ultrasound can be very useful in helping your doctor identify if your hip pain is coming from inside (intra-articular) or outside (extra-articular) your hip joint. Another test that your doctor may opt for is a lidocaine challenge test, especially if the cause of your hip pain is unclear. For this test, a numbing medicine called lidocaine is injected into the psoas tendon – a strong tendon in your hip – using the guidance of an ultrasound. If your pain decreases after the lidocaine injection, it points towards psoas tendonitis (another name for psoas syndrome).
In cases of athletes with groin pain, around 21% show signs of iliopsoas (the muscle group made up of the psoas major and iliacus muscles) damage on an MRI. So, if your pain doesn’t improve with standard treatment methods and an iliopsoas injury is suspected, your doctor might suggest an MRI. Both MRI and ultrasound often show an enlarged bursa (a small, fluid-filled sac that cushions your joints) and a thickened iliopsoas tendon.
Generally, lab tests aren’t necessary when evaluating psoas syndrome.
Treatment Options for Psoas Syndrome
The standard treatment for conditions related to the psoas muscle (a major muscle in the body that connects the lower spine to the upper thigh) often involves physical therapy. This typically focuses on activities to stretch and strengthen the spine, hip joints, and the psoas muscle itself. It’s been found that every dancer in one study responded positively to this type of treatment. By doing exercises at home centered on hip rotation, patients can reduce their pain and improve their overall ability to move around. Over-the-counter pain relievers like ibuprofen and acetaminophen can also help manage the discomfort.
For athletes experiencing groin pain possibly due to an injury to the iliopsoas tendon, getting an MRI scan might be necessary. This can help provide a detailed look at the area and give an insight into how long it might take for the athlete to return to their sport. The scan can show muscle strain, which is usually linked to a longer recovery time compared to an inflammation of the tendon (peri-tendinitis).
Other ways to treat psoas-related hip pain include osteopathic manipulative therapy, which involves a physician using their hands to move and repositioning a patient’s muscles and joints. There’s also the option of therapeutic ultrasound and steroid injections. A special type of ultrasound device can not only help detect the origin of hip pain but also act as a guide for injecting steroids, which can help treat the pain.
In cases where non-surgical treatments aren’t effective, surgery might be considered. This can involve arthroscopic tendon lengthening, a minimally invasive surgical procedure where the tendon is surgically lengthened to provide pain relief. Another surgical option available is releasing the psoas tendon from the place where it attaches to the bone. Several surgical techniques have been tried and most have similar outcomes.
Of the patients who developed a condition known as iliopsoas tendonitis after undergoing a total hip arthroscopy (a procedure to look inside the hip joint), a quarter of them required steroid injections to manage the pain. About 12% of these patients needed another surgery or iliopsoas release, which involves cutting the muscle to relieve tension or pain.
What else can Psoas Syndrome be?
Psoas syndrome symptoms can often seem very similar to those of a herniated disc in the lower back. Other conditions with similar symptoms could be arthritis of the hip or inflammation in the hip area called femoral bursitis. Snapping hip syndrome is another condition that should be taken into account when diagnosing psoas syndrome.
There are also other non-muscle related conditions that could cause pain similar to psoas syndrome. These include conditions like prostate inflammation, appendicitis, diverticulitis, inflammation of a Fallopian tube is known as salpingitis, kidney stones, and colon cancer. A tear in the hip labrum, which is a type of cartilage found in the hip joint, also manifests with a feeling of slippage or catching in the hip, along with pain similar to psoas syndrome. This makes it hard to differentiate it from psoas syndrome based on an examination.
The psoas muscle is located near the ureter (a tube connecting the kidneys to the bladder) and the appendix. Thus, patients with a kidney stone or appendicitis often exhibit symptoms similar to those of psoas syndrome due to inflammation caused by the nearby condition.
Conditions like snapping hip syndrome, psoas syndrome, inflammation of the hip joint, hip impingement, tendon inflammation, and hip labrum disorders can have a significant overlap in symptoms. This makes diagnosis difficult.
During an examination, a weakened hip flexion (the ability to bend the hip) in an abducted hip (hip rotated outwards) can be seen in both snapping hip syndrome and psoas syndrome.
What to expect with Psoas Syndrome
Most people who are diagnosed with psoas syndrome – a condition causing lower back pain due to irritation of the psoas muscle – get better fully by following simple treatments. However, those who have undergone total hip arthroscopy – a surgical procedure where the hip joint is viewed using a small camera – may find that the pain in the psoas muscle persists after the operation. In such cases, more advanced pain relief methods may be needed.
These advanced treatments can include corticosteroid injections, which are medications injected into the body to relieve inflammation and pain. Another option might be a tendon release, a surgical procedure to relieve tension on the muscle.
Possible Complications When Diagnosed with Psoas Syndrome
People who do not get medical treatment for a condition called iliopsoas syndrome can experience ongoing pain and their athletic performance can also decrease. There is also the risk of repeatedly getting iliopsoas tendonitis, a condition that causes inflammation and pain in the tendon. In cases where a medical professional gives a patient a corticosteroid injection into the psoas tendon without using an ultrasound for guidance, it can lead to damage to the surrounding nerves and blood vessels.
Conditions and effects:
- Ongoing pain from untreated iliopsoas syndrome
- Decreased athletic performance
- Repeatedly getting iliopsoas tendonitis
- Damage to nerves and blood vessels from unguided injections.
Preventing Psoas Syndrome
Those who are involved in dance or running sports are more likely to face problems. Their treatment usually needs a team of healthcare professionals. This team often includes the family doctor, a physical therapist, and a sports medicine doc. Sometimes, even an orthopedic surgeon may have to step in if the case is tough to manage.
The treatment regimen often includes exercises that a person can do at home. These exercises work well with other simple treatments like using anti-inflammatory drugs (NSAIDs) – drugs that help reduce swelling and pain.
If these regular treatments are not enough, a special injection (of corticosteroids, a type of anti-inflammatory medication) may be used. This injection is directed using ultrasound guidance to ensure it correctly reaches the affected area. This not only helps diagnosing iliopsoas syndrome (a type of muscle and tendon inflammation) but also helps to relieve pain.
If all these methods fail to give long-lasting relief and the symptoms come back, it might be time to consider referring the patient to an orthopedic surgeon.
After hip surgery, pain because of iliopsoas tendonitis, a type of inflammation of the tendon (stringy tissue which attaches the muscle to the bone), is quite common.
