Treatment of Full Thickness Iliopsoas Tendon Tear
Begin with conservative management for all full-thickness iliopsoas tendon tears, reserving surgical repair for cases that fail 3-6 months of non-operative treatment or present with significant functional impairment. 1
Initial Conservative Management (First-Line Treatment)
The standard approach for iliopsoas tendon pathology, including full-thickness tears, prioritizes non-operative treatment 1:
- Activity modification: Eliminate aggravating movements, particularly hip flexion against resistance and activities requiring deep hip flexion 1
- Physical therapy: Focus on gentle range of motion initially, progressing to strengthening of surrounding hip musculature once acute symptoms resolve 1
- NSAIDs: Use for pain control and inflammation management 1
- Corticosteroid injections: Consider for symptomatic relief, though evidence for efficacy is limited; may provide temporary benefit in select cases 1
Duration of conservative trial: Continue for 3-6 months before considering surgical intervention 1
Indications for Surgical Treatment
Proceed to surgery when 1:
- Conservative management fails after 3-6 months
- Significant functional limitations persist despite appropriate non-operative treatment
- Patient experiences persistent pain limiting activities of daily living or athletic performance
Surgical Technique Options
Arthroscopic lengthening or release of the iliopsoas musculotendinous unit is the preferred surgical approach, with similar outcomes reported across different release locations 1:
- Central compartment release: Performed at the level of the anterior hip joint/labrum 1
- Peripheral compartment release: Performed in the peripheral compartment 1
- Lesser trochanter release: Performed at the tendon insertion site 1
Critical Surgical Considerations
Be aware that 71.7% of patients have multiple distinct iliopsoas tendons (64.2% have two tendons, 7.5% have three tendons), requiring complete release of all tendinous structures for successful treatment 2. The psoas major tendon is consistently the most medial structure, with the primary iliacus tendon located immediately lateral, and when present, an accessory iliacus tendon positioned lateral to the primary iliacus tendon 2.
Concomitant Pathology
Always address intra-articular hip pathology during surgical treatment, as iliopsoas impingement commonly causes labral tears at the 3-o'clock position 3, 1. MR arthrography findings suggestive of iliopsoas-related labral injury include isolated labral tears at the 3-o'clock position 3.
Expected Outcomes
Tendon healing after surgical release or repair demonstrates restoration of continuity with altered biomechanical properties 4. Following iliopsoas tenotomy, tendons re-adhere and heal as more rigid, thinner structures compared to intact tendons, while maintaining functional integrity 4.
Common Pitfalls to Avoid
- Incomplete release: Failure to identify and release all tendinous components (remember 72% have ≥2 tendons) leads to persistent symptoms 2
- Premature surgical intervention: Operating before adequate conservative trial (minimum 3-6 months) 1
- Ignoring concomitant intra-articular pathology: Failing to address associated labral tears or other hip joint abnormalities during surgery 1