What is the cause and treatment for anterior groin hip pain along the iliopsoas tendon that occurs when standing and initially relieves with walking?

Anterior Groin Hip Pain Along Iliopsoas: Diagnosis and Management

This presentation is most consistent with iliopsoas tendinitis or bursitis, and you should begin with plain radiographs followed by MRI or ultrasound if radiographs are negative, then proceed with conservative management including physical therapy, NSAIDs, and consider ultrasound-guided corticosteroid injection if symptoms persist. 1

Clinical Presentation and Differential Diagnosis

The pattern of pain at the anterior groin along the iliopsoas that occurs with standing and initially improves with walking is characteristic of iliopsoas pathology, specifically tendinitis or bursitis. 2, 3 This "start-up pain" pattern reflects the biomechanical stress on the iliopsoas tendon during static hip flexion positioning that temporarily improves as the tendon warms up with activity. 3

Key diagnostic considerations include:

• Iliopsoas tendinitis/bursitis - most likely given the anatomic location and symptom pattern 2, 3
• Snapping hip syndrome (coxa saltans) - may coexist with tendinitis 1
• Femoroacetabular impingement (FAI) syndrome - can present with anterior groin pain but typically worsens with hip flexion activities 1
• Labral pathology - often associated with iliopsoas symptoms 1

Diagnostic Workup Algorithm

Step 1: Initial Imaging

Obtain plain radiographs first (AP pelvis and lateral hip views) to exclude osseous pathology, arthritis, or structural abnormalities. 1 This is the recommended first-line imaging for all chronic hip pain presentations, even though it may not directly visualize soft tissue pathology. 1

Step 2: Advanced Imaging if Radiographs Negative or Equivocal

MRI or ultrasound should be the next imaging modality for suspected iliopsoas pathology. 1

• MRI is highly sensitive and specific for detecting iliopsoas bursitis, tendinitis, and associated intra-articular pathology including labral tears and cartilage damage 1
• Ultrasound is an excellent alternative that can evaluate the iliopsoas tendon dynamically and guide therapeutic injections 1
• Real-time ultrasound can specifically evaluate for snapping iliopsoas tendon, which is noninvasive compared to fluoroscopic evaluation 1

Step 3: Diagnostic Injection

If the diagnosis remains unclear after imaging, ultrasound-guided diagnostic injection into the iliopsoas bursa or peritendinous region can confirm the pain source. 1 Pain relief following injection confirms iliopsoas pathology as the primary source. 1, 2

Treatment Algorithm

Conservative Management (First-Line)

All patients should begin with conservative treatment for 3-6 months before considering surgical intervention. 3

Initial conservative measures include:

• Activity modification - avoid provocative positions (prolonged standing, hip flexion activities) 3
• Physical therapy focusing on iliopsoas stretching and strengthening of hip stabilizers 3
• NSAIDs for pain control and anti-inflammatory effect 1, 3

Interventional Conservative Management

If symptoms persist after 4-6 weeks of initial conservative treatment, proceed with ultrasound-guided corticosteroid injection into the iliopsoas bursa or peritendinous region. 1, 4

• Ultrasound guidance is preferred over blind injection for accuracy 4
• This provides both diagnostic confirmation and therapeutic benefit 1, 5
• Can provide significant pain relief lasting weeks to months 5, 4

Surgical Management

Surgery should only be considered after failure of at least 3-6 months of comprehensive conservative management. 3

• Arthroscopic iliopsoas lengthening or release is the primary surgical option 3
• Address any concomitant intra-articular pathology (labral tears, cartilage lesions) during the same procedure 3

Critical Clinical Pitfalls

Do not miss competing diagnoses that can mimic iliopsoas pathology:

• Referred pain from the lumbar spine - always examine the spine and consider spine imaging if hip examination is inconsistent 1
• Athletic pubalgia/core muscle injury - frequently mimics intra-articular hip pathology 2
• Intra-articular hip pathology (FAI syndrome, labral tears) - often coexists with iliopsoas symptoms 1, 3
• Gynecologic or gastrointestinal sources of referred groin pain 2

A negative flexion-adduction-internal rotation test helps rule out intra-articular hip pathology, though its clinical utility is limited. 1

Ultrasound-guided diagnostic injection differentiating between iliopsoas bursa and intra-articular hip joint is essential when the pain source remains unclear, as treatment strategies differ significantly. 2