Iliopsoas Pathology from Prolonged Driving
The pain is most likely originating from iliopsoas tendinitis or bursitis, which commonly presents as tightness and pain over the iliac crest and hip region after prolonged hip flexion activities like driving. 1
Primary Differential Diagnosis
The clinical presentation of pain and tightness over the left iliac crest and hip region after prolonged driving strongly suggests iliopsoas pathology as the primary source. 1 The prolonged hip flexion position during driving is a classic provocative mechanism for iliopsoas tendinitis or bursitis. 1
Additional considerations in the differential include:
- Greater trochanteric pain syndrome (lateral hip pain, though this patient's pain is more anterior/iliac crest region) 2
- Snapping hip syndrome (which can coexist with iliopsoas tendinitis) 1
- Referred pain from lumbar spine pathology (must be excluded, especially given the iliac crest location) 1
Diagnostic Workup Algorithm
Step 1: Plain Radiographs
Obtain AP pelvis and frog-leg lateral hip radiographs first to exclude osseous pathology, arthritis, or structural abnormalities. 3, 1 This is the recommended first-line imaging for all chronic hip pain presentations. 3
Step 2: Advanced Imaging if Radiographs Negative
If radiographs are negative or equivocal, proceed with either:
- MRI hip without IV contrast (highly sensitive and specific for iliopsoas bursitis, tendinitis, and associated intra-articular pathology) 3, 1
- Ultrasound (excellent alternative that can evaluate the iliopsoas tendon dynamically and guide therapeutic injections) 3, 1
Step 3: Spine Evaluation
Examine the lumbar spine and consider spine imaging if hip examination findings are inconsistent with iliopsoas pathology, as referred pain from lumbar pathology can mimic this presentation. 1 This is a critical pitfall to avoid.
Physical Examination Findings to Assess
Look for:
- Point tenderness along the iliopsoas muscle/tendon (anterior hip/groin region extending to iliac crest) 1
- Pain with resisted hip flexion (classic for iliopsoas pathology) 1
- Negative flexion-adduction-internal rotation test (helps rule out intra-articular hip pathology) 1
- Assess for greater trochanteric tenderness (posterolateral to greater trochanter if trochanteric pain syndrome) 2
Treatment Algorithm
Initial Conservative Management (4-6 weeks)
- Activity modification (avoid prolonged sitting/driving positions) 1
- Physical therapy focusing on iliopsoas stretching and strengthening of hip stabilizers 1
- NSAIDs for pain control and anti-inflammatory effect 1
If Symptoms Persist After 4-6 Weeks
Proceed with ultrasound-guided corticosteroid injection into the iliopsoas bursa or peritendinous region, which provides both diagnostic confirmation and therapeutic benefit. 1
Special Considerations for This Patient
Given this patient's hypertension and diabetes, ensure:
- Blood pressure control (target <130/80 mmHg per diabetes guidelines) 3
- Glycemic control optimization (as poor control increases risk of complications) 3
- Cardiovascular risk factor modification including physical activity (at least 150 minutes of moderate-intensity aerobic activity per week distributed over at least 3 days) 3
These comorbidities increase cardiovascular and peripheral vascular disease risk 4, 5, 6, though they do not directly cause the acute iliopsoas pain from prolonged driving. However, peripheral arterial disease should be considered if pulses are diminished, though the acute onset after driving and location make this less likely. 3
Critical Pitfall to Avoid
Do not assume this is simply "hip arthritis" without proper imaging workup. 3 The specific mechanism (prolonged driving causing hip flexion) and location (iliac crest/anterior hip) point toward soft tissue pathology rather than intra-articular disease. 1 Additionally, always examine and consider the lumbar spine as a competing diagnosis, as referred pain can present identically. 1