Iliopsoas tendinitis

Iliopsoas tendinitis – briefly explained

Iliopsoas tendinitis is an irritation, inflammation or degenerative change (tendinopathy) of the hip flexor tendon. It often arises from repeated overload, unfavorable movement patterns or muscular imbalances. Those affected usually feel stabbing or pulling pain deep in the groin, often intensified when lifting the leg, walking quickly or doing sports. It is not uncommon for there to be accompanying irritation of the adjacent bursa (iliopsoas bursitis) or a mechanical snapping at the front of the hip (coxa saltans interna).

• Main symptom: Groin pain when flexing the hip, starting pain after rest
• Commonly affected: runners, football, dance, fitness, hockey
• Accompanying possible: iliopsoas bursitis, internal hip snapping (iliopsoas snapping)

Anatomy and function of the iliopsoas

The iliopsoas muscle consists of two parts: the psoas major muscle (originating in the lumbar spine) and the iliacus muscle (originating in the pelvic blade). Both unite to form a strong tendon that runs over the front of the hip joint and attaches to the trochanter of the femur (minor trochanter). Between the tendon and the bone/joint capsule there are gliding tissue and bursa that enable low-friction sliding.

• Primary function: vigorous hip flexion (e.g. climbing stairs, sprinting)
• Secondary: Stabilization of the pelvis and lumbar spine while walking
• Mechanical hotspot: tendon-bone transition (insertion) with high tensile stress

When repeatedly overloaded, the tendon reacts with microtrauma, remodeling processes and increased pain sensitivity. This is less a “classic inflammation” and more a tendinopathy with disturbed tissue homeostasis. Accordingly, the therapy aims at load control, gradual increase in load and optimization of biomechanics.

Typical symptoms

• Deep groin pain, sometimes radiating to the front inner thigh
• Pain when actively flexing the hip (lifting the leg), sprinting, changing direction
• Start-up pain after sitting for a long time, morning stiffness
• Discomfort when climbing stairs, walking uphill or getting into the car
• Tenderness in the groin, painful stretching of the hip flexors
• Sometimes a noticeable or audible “snapping” at the front of the hip (Coxa saltans interna)
• Often tolerable at rest, significantly increased under higher loads

In clinical examination, the pain can be reliably provoked by resistance to hip flexion, when lifting the leg straight, or by specific stretching tests. A precise distinction from other causes of groin pain is important because therapeutic approaches vary.

Causes and risk factors

The focus is usually on overloading or incorrect loading. Common triggers are training errors (increasing volume/intensity too quickly), monotonous stress without regeneration or technical deficits. Muscular imbalances also play a role: a relatively dominant hip flexor with weaker gluteal muscles (gluteus medius/minimus) or insufficient trunk stability increases the strain on the tendons.

• Sports with repetitive hip flexion: running, soccer, dance, hockey, CrossFit
• Rapid increases in training, inadequate recovery, little variance
• Weakness of hip abductors and core muscles, limited hip extension
• Pelvic statics, leg length differences or foot misalignments
• Hip joint morphology (e.g. femoroacetabular impingement) as a contributing factor
• After surgery on the hip joint, irritation can occur
• Rare factors: systemic inflammation, metabolic disorder; Drug-induced tendon problems (fluoroquinolones) are generally possible, but rare in the hip

Not every tendon change visible on imaging causes pain. What is crucial is the interaction between tissue condition, stress and pain processing. That's why anamnesis and functional diagnostics are just as important as imaging.

Diagnostics in our practice

We start with a targeted anamnesis: duration of pain, stress profile, training history, previous treatments and accompanying symptoms. The physical examination includes assessment of gait, pelvic stability, hip abductor strength, range of motion, and iliopsoas pain provocation testing.

• Palpation: tenderness deep in the groin, possibly thickened tendon
• Resistance testing: painful hip flexion against resistance
• Stretch tests: shortened/hypersensitive hip flexors
• Function: Single-legged pelvic stability, step-down test, running/jumping pattern

Sonography (ultrasound) shows tendon structure, sliding behavior and bursa. It is dynamic, radiation-free and is ideal for assessing progress. An MRI is considered if unclear findings, resistance to therapy or differential diagnoses (e.g. labral lesion, stress reaction) need to be clarified. In selected cases, sonographically guided test infiltration of the bursa/tendon sheath can provide diagnostic information.

What else do you have to think about? Differential diagnoses

• Adductor tendinopathy (pain more in the pubic bone/adductor insertion)
• Hamstring tendinopathy on the ischium (posterior thigh root)
• Trochanteric tendinosis / trochanteric syndrome (pain tends to be on the side)
• Gluteus medius/minimus tendinopathy (lateral hip, abductor weakness)
• Iliopsoas snapping (Coxa saltans interna) with mechanical snapping sensation
• Hip osteoarthritis, femoroacetabular impingement, labral lesion
• Inguinal hernia, urological/gynecological causes, rare: stress fracture

The correct classification determines the therapy. For example, lateral hip pain (trochanteric syndrome, gluteal tendons) benefits from a different training focus than anterior iliopsoas tendinopathy.

Healing process and prognosis

Most iliopsoas tendinopathies respond well to conservative measures. What is crucial is load reduction in the acute phase and a structured build-up of load. The first improvements are often noticeable within 2-4 weeks; stable results require 6-12 weeks depending on the initial situation, or longer in chronic cases.

• Positive factors: early adaptation of training, consistent exercise, sleep/nutrition
• Delaying factors: continued overload, severe imbalances, unclear accompanying factors
• Goal: pain-adapted return to sport and everyday life without recurrence

Conservative therapy: our step-by-step plan

It is important to control according to symptoms rather than according to a rigid schedule. A good sign: Stress is acceptable during this time and the symptoms calm down within 24 hours. If pain lasts longer or increases, the strain is temporarily reduced.

Exercises: a possible basic program

The following exercises are examples and should be adapted to your symptoms. Start with low intensity, pay attention to clean technique and increase slowly. Mild muscular tension is ok, stabbing groin pain is not.

• Isometric hip flexion while sitting: Press knee against hand (5x20-30 seconds per side).
• Marching bridge: Keep your pelvis stable, alternately lifting your heel (3×8–12 slowly).
• Lateral step-down: Control of pelvic stability (3×8–10 per side).
• Hip flexor stretch in a half-kneeling position: Raise your pelvis, hold for 30-45 seconds (3 sets).
• Side plank variations for gluteus medius: 3×20–40 seconds.
• Later: eccentric hip flexion with mini band, running ABC with short stride length.

Progression: initially stable, low pain in everyday life, then brisk walking, cycling, then running intervals with breaks. Sport-specific drills come last. An individual plan from our physio partners speeds up your return.

Targeted interventions: when and why?

If relevant symptoms persist after consistent conservative therapy for several weeks, additional measures can be considered. The goal is to reduce pain to enable active training - not to replace exercise treatment.

• Ultrasound-targeted infiltration of the iliopsoas bursa/tendon sheath: local anesthetic, if necessary low-dose corticosteroid. Benefit: short-term pain relief. Risks: Tendon irritation/weakening, therefore indication cautious and limited.
• PRP (autologous blood): Possible for chronic tendinopathy if standard measures have been exhausted. Evidence specifically for the iliopsoas is limited; Benefits, risks and costs are discussed transparently.
• Shock wave therapy (ESWT): Partially helpful for tendinopathies, but limited research on the iliopsoas. Use after individual testing.
• Taping/Neuromodulation: can provide symptomatic support, but does not replace training.

We openly discuss the opportunities and limitations of the procedures. Reliable expectation management protects against disappointment and supports sustainable therapeutic success.

Surgery – in rare cases

Surgical therapy (arthroscopic/endoscopic tenotomy or release of the iliopsoas) is only considered in rare, treatment-resistant cases - for example in cases of severe internal hip snapping or mechanical conflict situations that persist despite extensive conservative measures.

• Indication: ≥ 3–6 months of structured conservative therapy without sufficient improvement, clear correlation between findings and symptoms.
• Goals: Reduction of mechanical friction, reduction of pain.
• Risks: temporary weakness in hip flexion, persistent discomfort possible, general surgical risks.

Even after the operation, a structured rehabilitation program with load building, strength and coordination remains central to the result.

Prevention: how to protect the hip flexors

• Control your load cleverly: do not exceed a 10-15% increase per week.
• Train glute and core strength regularly; Maintain hip extension.
• Check your running technique: shorter stride length, higher stride frequency.
• Sufficient rest, sleep and a balanced diet.
• Warm up before exercise, cool down afterwards.
• Take early warning signals seriously and temporarily adapt training.

Everyday tips for iliopsoas complaints

• Avoid sitting for long periods of time with your hips strongly bent; Stretch your hips regularly.
• Walk stairs slowly and with shorter stride lengths.
• When working in the office: adjust the seat height and keep your hips open.
• Light stretching after getting up and after activities.
• Keep a pain diary: Which activities provoke, what helps?

When should you seek medical advice?

• Sudden shooting groin pain with loss of function (accident/event).
• Fever, redness, severe swelling or pain at night when resting.
• Numbness, weakness, radiating below the knee.
• Persistent symptoms despite 2-4 weeks of adjustment and basic exercises.
• Uncertainty about diagnosis or return to sport.

A prompt examination will clarify the cause and prevent incorrect loading. In Hamburg we would be happy to be your contact for a well-founded, conservative treatment strategy.

Your treatment in Hamburg

In our orthopedic practice at Dorotheenstraße 48, 22301 Hamburg, we combine thorough diagnostics with a clear, step-by-step therapy concept. Our focus is on conservative measures: individual exercise programs, load control, technique coaching and – when appropriate – targeted, gentle interventions under ultrasound control.

We take the time to understand your goals – whether they are pain-free in everyday life, running safely or returning to sport. Surgical options are only discussed if there is a clear indication and after conservative options have been exhausted.