What is the recommended treatment for iliopsoas syndrome using a hip rotation strengthening program?

Treatment of Iliopsoas Syndrome with Hip Rotation Strengthening Program

A hip rotation strengthening program combined with stretching exercises is strongly recommended as an effective treatment for iliopsoas syndrome, with evidence showing improvement in function and pain reduction in 77% of patients.1

Understanding Iliopsoas Syndrome

Iliopsoas syndrome involves dysfunction of the iliopsoas muscle group, which consists of the iliacus, psoas major, and psoas minor muscles. As the primary hip flexor, this muscle group connects the spine to the lower limbs and is crucial for daily activities and sports performance.2

Common symptoms include:

• Anterior hip or groin pain
• Weakness with resisted hip flexion in abduction
• Symptomatic clicking or snapping with hip movement
• Pain during activities requiring hip flexion

Treatment Algorithm

1. Initial Conservative Management

• Relative rest: Avoid activities that exacerbate pain while maintaining moderate activity to prevent muscle atrophy3
• NSAIDs: For pain management and reducing inflammation
• Cryotherapy: Apply ice to the affected area for 10 minutes to reduce pain and inflammation3

2. Hip Rotation Strengthening Program

The core of treatment should focus on a specific exercise regimen incorporating hip rotation exercises:

Progressive Exercise Protocol (based on EMG activation levels):4, 1

1. Begin with lower activation exercises (30-40% MVIC):

   • Closed kinetic chain exercises
   • Trunk movements with fixed lower extremity

2. Progress to moderate activation exercises (40-60% MVIC):

   • Mid-range active straight leg raise (ASLR) around 45° of hip flexion
   • Lifting straight trunk while in hip flexed position

3. Advance to high activation exercises (>60% MVIC):

   • Active straight leg raise in ranges around 60° of hip flexion
   • Supine hip flexion exercises
   • Leg lifts

3. Stretching Component

• Iliopsoas stretching in prone or modified lunge positions
• Hip flexor stretches
• Pelvic mobilization techniques5

4. Advanced Rehabilitation

• Progress from closed to open kinetic chain exercises
• Add external loads as tolerance improves4
• Incorporate dynamic exercises with progression over time6

Evidence for Effectiveness

A retrospective case series showed that a specific exercise regimen incorporating hip rotation improved function and reduced pain in 77% of patients with iliopsoas syndrome. Five out of nine patients improved by at least 2 pain/activity levels, and all but two patients were able to return to full activity after following this program.1

The European League Against Rheumatism (EULAR) recommends progressive strength training involving major muscle groups at least 2 days/week at a level of moderate to vigorous intensity (60-80% of one repetition maximum) for 8-12 repetitions.6

Special Considerations

For Dancers and Athletes

Dancers have a high incidence of iliopsoas syndrome (9.2% in females, 3.2% in males), with student dancers having the highest incidence (14%). Conservative treatment including NSAIDs, activity modification, and physical therapy specific to the iliopsoas has shown excellent results, with no patients requiring corticosteroid injections or surgical intervention in a study of 49 dancers.5

For Post-Surgical Cases

In cases of persistent groin pain after total hip arthroplasty and iliopsoas tenotomy, a combination of joint mobilization and exercise has been effective for improving range of motion, reducing groin pain, and enhancing function.7

When to Consider Additional Interventions

If conservative treatment fails after 3-6 months:

• Corticosteroid injections: Using 40-80 mg of methylprednisolone or equivalent mixed with 2-3 mL of 1-2% lidocaine, preferably under ultrasound guidance3
• Surgical intervention: Consider endoscopic approach for less invasive option with quicker recovery3

Monitoring Progress

Evaluate improvement using:

• Pain levels during hip flexion (Numeric Pain Rating Scale)
• Functional improvement (Lower Extremity Functional Scale)
• Range of motion and strength assessments
• Return to previous activity levels

The American College of Rheumatology and EULAR guidelines strongly recommend that all patients with hip-related conditions be enrolled in an exercise program commensurate with their ability to perform these activities, with no preference for aquatic versus land-based exercises.6