Treatment of Iliopsoas Bursitis
The treatment of iliopsoas bursitis should begin with conservative measures including relative rest, NSAIDs, stretching exercises, and cryotherapy, with corticosteroid injections recommended if initial conservative treatment fails. 1
Initial Conservative Management
First-Line Approaches
- Relative Rest: Avoid activities that exacerbate pain while maintaining moderate activity to prevent muscle atrophy
- NSAIDs: Naproxen 500mg twice daily is recommended for acute bursitis 2
- For elderly patients or those with renal/hepatic impairment, consider lower doses
- Initial total daily dose should not exceed 1250mg, with subsequent daily doses not exceeding 1000mg
- Cryotherapy: Apply ice through a wet towel for 10 minutes to reduce pain and inflammation
- Stretching and Strengthening Exercises: Essential for long-term treatment and prevention of recurrence
Physical Therapy Interventions
- Hip Rotation Strengthening Program: Has shown effectiveness with 77% of patients experiencing pain and functional improvement 3
- Eccentric Strengthening Exercises: Particularly for the hip abductors
- Deep Transverse Friction Massage: Can help reduce pain
Diagnostic Evaluation
Imaging
- Radiographs: Should be the first imaging test to evaluate bony structures 4, 1
- MRI without contrast: Recommended when radiographs are negative or equivocal 1
- Best for assessing peritrochanteric structures, including iliopsoas muscle and tendon
- Ultrasound: Useful for detecting associated bursitis and tendinopathy 1, 5
- Helps differentiate iliopsoas bursitis from other inguinal masses such as lymphadenopathy, hernias, and tumors
Advanced Interventions
Corticosteroid Injections
- Indicated when conservative measures fail to provide relief 1
- Technique:
- 40-80mg of methylprednisolone or equivalent mixed with 2-3mL of 1-2% lidocaine
- Ultrasound guidance recommended for accurate needle placement
- 22-25 gauge needle, 1.5-inch (3.8cm) length (2-inch/5cm for obese patients)
- Injection at 90° angle for optimal medication delivery
Surgical Management
- Consider after 3-6 months of failed conservative treatment 1
- Endoscopic Approach: Less invasive option with quicker recovery
- May include arthroscopic lengthening of the musculotendinous unit 6
- Post-operative protocol includes crutches for 4-6 weeks and progressive rehabilitation
- Open Decompression: For severe cases when endoscopic approach isn't feasible
Special Considerations
Associated Conditions
- Iliopsoas bursitis may coexist with hip osteoarthritis or other pathological conditions 7
- When associated with other conditions, bursitis may not be the only source of pain
- In cases where symptoms persist despite resolution of bursitis, consider underlying hip pathology that may require additional treatment 7
Differential Diagnosis
- Differentiate from other causes of groin/hip pain:
- Gluteus medius tendinopathy
- Hip osteoarthritis
- Inguinal hernias
- Lymphadenopathy
- Tumors
Treatment Pitfalls
- Treating only the bursitis when an underlying hip condition exists may lead to incomplete resolution of symptoms
- Failure to use image guidance for injections may result in inaccurate medication delivery and poor outcomes
- Inadequate physical therapy focusing only on pain relief without addressing muscle imbalances may lead to recurrence
By following this structured approach to treating iliopsoas bursitis, clinicians can effectively manage symptoms and improve patient outcomes while addressing both the inflammatory condition and any underlying contributing factors.