Endoscopic Treatment of Iliopsoas Tendinitis after Hip Resurfacing
Hugo Aleixo1*, Søren R Jakobsen2 and Marcus VL Oliveira3
1Department of Orthopaedic Surgery, Hospital Pedro Hispano, Portugal
2Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark
3Department of Health Technology and Biology, Federal Institute of Bahia, Brasil
Submission: September 08, 2017; Published: September 11, 2017
*Corresponding author: Hugo Aleixo, Department of Orthopaedic Surgery, Hospital Pedro Hispano, Matosinhos, Portugal,
How to cite this article: Hugo A, Søren R J, Marcus V L O. Endoscopic Treatment of Iliopsoas Tendinitis after Hip Resurfacing. Ortho & Rheum Open Access 2017; 8(3): 555740. DOI: 10.19080/OROAJ.2017.08.555740.
Introduction: Coxa saltans interna, also known as internal snapping hip, presents as groin pain associated with a catching sensation caused by the iliopsoas tendon when bringing from a position of flexed abduction to extended adduction. We describe what we consider to be the current indications for surgical lengthening or release, the pertinent physical findings, and imaging and describe a case of iliopsoas irritation after a hip resurfacing and the arthroscopic treatment performed. The results are reproducible and weakness of flexion is not expected after surgery.
Methods: We describe a case of iliopsoas tendinitis after a hip resurfacing. The pain was refractory to medical management who was submitted to an arthroscopic lengthening with success.
Results: The pain subsided after 10 weeks without any loss in hip motion. The VAS is now 9/10 and UCLA 9. No difference leg flexion or extension was noted and the patient is able to perform is daily activities without crutches.
Discussion: Iliopsoas tendinitis can be successfully managed with rest and NSAIDs in most cases. However, it is our experience that in case of need for surgical treatment, the arthroscopic management is possible with an accurate technique.
Painful snapping hips are due to external, internal, and intra-articular causes [1-3]. The external snapping hip, also the most common type of snapping hip , is the result of the iliotibial band snapping across the greater trochanter as the hip moves from flexion to extension and is evident on clinical examination. The intra-articular variety is due to labral tears, loose bodies, and articular cartilage flaps within the hip joint itself. However, the term “intra-articular snapping hip” is rarely used in current literature because a snapping mechanism is not really involved, and diagnosis of intraarticular pathology is now more accurate with other exams. The third type or internal snapping hip was first described in 1951 , which is the focus of this case-report, is the result of three possible situations: either a tendon catching at the iliopectineal eminence, or snapping across the femoral head, or flipping over the iliac muscle when the hip is brought from a flexed-abducted-externally rotated position into extension during athletic activities . This happens mostly during activities of daily living, with the associated pain .
Although there is a debate whether the tendon’s path is exactly obstructed, it is generally accepted that anatomic factors are the main cause for a tight musculotendinous unit. Whereas a painless, internal snapping hip is normal in the population in up to 10% , a painful snapping hip is due to intrinsic iliopsoas tendon pathology or is secondary to other factors, such as native or arthroplasty hip joint pathology, instability or high femoral antetorsion .
The internal snapping hip syndrome is characterized by an audible or palpable snap in the anterior area of the hip. In asymptomatic individuals, no treatment is required . Symptomatic individuals with this problem typically report a painful snapping in their hip, localized to the anterior and medial groin area . Their pain is usually exacerbated by active hip flexion and activities that require extension of the flexed, abducted, and externally rotated hip. For this reason, painful snapping iliopsoas tendons most often occur in young, physically active individuals and are common in sports that demand repeated abduction of the leg above waist level .
The initial treatment consists inrest, stretching exercises, oral anti-inflammatory medications, and focal treatment including iontophoresis and ultrasound. These will resolve most iliopsoas
tendinitis . It is very important to explain the pathology to the
patient, so that he can easily cope with this treatment and avoid
recurrence of the tendinitis. It is mandatory to be certain that
a nonoperative treatment has failed before offering the surgical
release. In the setting of primary intrinsic tendon pathology and
some secondary pathologies, surgical lengthening or release
may be considered . Nevertheless, some will maintain pain,
usually being the ones with impingement across the anterior
acetabulum, irritation after hip arthroplasty or a refractory
We present a case of an active man, 54 year-old, submitted
to a left Hip Resurfacing (Birmingham Hip Resurfacing - Wright
Medical ®) in the last year; the post-operative X-ray is presented
in Figure 1. In the post-operative period, his main complaints
from osteoarthritis subsided. However, he gradually started
complaining about a medial and anterior pain when he flexed the
hip above de 70º, with no differences with internal or external
rotation. It is possible to say that the acetabular implant (Figure
1) is more anteverted comparing o the contralateral side, and
we considered this as a possible cause for the clinical iliopsoas
tendinitis. After trying the recommended initial course of rest
and NSAIDs, the pain didn’t subside. He was then indicated for
physiotherapy, with no pain relief. To confirm the source of
pain objectively, we proposed an anterior bursa injection with
ultra-sound guidance . The patient’s left iliopsoas was
injected with 5 ml of lidocaine 1% and he referred immediate
relief of pain and increase range of motion. After the initial
effect of lidocaine, pain came again. A surgical iliopsoas tendon
lengthening was needed, either open or arthroscopic. Our option
was the arthroscopic release.
We decided to propose an arthroscopic release via peripheral
compartment. As an option, and if it wasn’t possible to perform due to technical difficulties, we would perform the procedure in
an open fashion. The patient was placed in a traditional femoral
fracture table. Commercially distraction systems are also
available, according to surgeon’s preference. Special equipment
is not necessary – the same positioning devices and instruments
that are routinely used for hip arthroscopy are needed: 70º
arthroscope, arthroscopic beaver blade, nitilol guidewire, blunt
switching stick, radiofrequency device, shaver and a slotted
cannula. The decision of whether to use lateral or supine
positive is more a matter of individual training and habit of
use – the supine approach was used in this case. As in every hip
arthroscopy, it is of most importance to protect appropriately
the bony prominences. Every point of contact must be well
padded to avoid potential complications. Also, the operative hip
must maintain the possibility of having to be mobilized during
Endoscopic release can be made in essentially two ways:
approaching the hip central and peripheral compartment or
through an extra-articular release. In both, traction can or
cannot be applied . We used the antero-lateral and the
anterior portals to be able to triangulate and have direct access
to the tendon. As the patient had already been submitted to a HR
through an antero-lateral approach, the path to find the tendon
was facilitated. However, the authors recognize that it’s of
paramount importance to perform it in external rotation, so that
the lesser trochanter comes to anterior, bringing the insertion
of the muscle in a more accessible anatomy. As the tendon was
identified (Figure 2), shaver and radiofrequency devices were
used, and the lengthening was performed at the level of the
lesser trochanter . Cutting the tendon at this level preserves
40% of the musculo-tendinous unit and does not result in a
complete detachment of the iliopsoas.
The patient was discharged the day after with crutches and
permitted to do partial weight bearing . On the follow-up,
he showed loss of muscle power in flexion, which was expected.According to the literature, this happens in the first 8-10 weeks.
Approximately at 10 weeks, he no longer felt loss in ROM in
flexion, as expected as well. The pain subsided after 10 weeks
without any loss in hip motion. The VAS is now 9/10 and UCLA 9.
No difference leg flexion or extension was noted and the patient
is able to perform is daily activities without crutches.
We found the ultrasound-guided anaesthetic injection of the
psoas bursa useful to confirm snapping of the iliopsoas tendon
as the cause of a patient’s hip pain. Arthroscopic management
of iliopsoas management is a safe outpatient procedure that
provides effective relief of the snapping and pain.