What is the treatment for iliopectineal (ipso lateral) bursitis?

Treatment of Iliopectineal (Iliopsoas) Bursitis

Conservative management with NSAIDs, activity modification, physical therapy focusing on hip rotation strengthening, and corticosteroid injection under ultrasound guidance should be the first-line treatment approach for iliopectineal bursitis, with surgical excision reserved only for cases that fail 3-6 months of comprehensive conservative therapy. 1, 2

Initial Conservative Treatment (First 3-6 Months)

Pharmacologic Management

• NSAIDs are FDA-approved and recommended as first-line therapy for bursitis, providing both pain relief and anti-inflammatory effects 3
• Naproxen dosing for acute bursitis: 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial daily dose not exceeding 1250 mg 3
• The American Academy of Family Physicians supports NSAIDs as primary pharmacologic treatment for lower extremity bursitis 1, 4

Activity Modification and Physical Therapy

• Activity modification to reduce repetitive loading is essential, combined with relative rest while allowing pain-free activities 1, 2
• Hip rotation strengthening exercises are specifically effective for iliopsoas syndrome, with 77% of patients showing improvement in pain and function 5
• Eccentric strengthening of hip flexor and rotator muscles should be incorporated into the rehabilitation program 1, 5
• Stretching of the iliopsoas muscle complex is recommended as part of comprehensive physical therapy 2, 5

Diagnostic Imaging When Indicated

• Plain radiographs should be obtained first to rule out underlying hip pathology such as osteoarthritis, avascular necrosis, or other bony abnormalities that may be contributing to the bursitis 6, 1, 7
• Ultrasound is highly effective for detecting iliopsoas bursitis and can guide therapeutic interventions 6, 1, 2
• MRI provides comprehensive assessment of peritrochanteric and iliopsoas structures and can identify communication between the bursa and hip joint cavity, which is present in most symptomatic cases 6, 1, 7

Second-Line Treatment for Persistent Symptoms

Corticosteroid Injection

• Ultrasound-guided corticosteroid injection into the iliopsoas bursa provides both diagnostic confirmation and therapeutic benefit 6, 1, 2
• Peribursal injections are preferred over intrabursal injections to minimize potential complications 1
• Injections are more effective than NSAIDs alone for acute phase pain relief, though they don't alter long-term outcomes 6, 1

Important Clinical Caveat

Iliopectineal bursitis frequently communicates with the hip joint cavity (found in 5 of 6 cases in one series) and is commonly associated with underlying hip pathology including chronic synovitis, avascular necrosis, rheumatoid arthritis, or infectious arthritis 7, 8. This communication is a critical radiographic finding that distinguishes it from other inguinal masses and indicates the need to address underlying joint disease 7.

Surgical Management

Indications for Surgery

• Surgical excision or resection of the bursa should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 2
• Surgery is indicated when conservative measures fail and symptoms significantly impair function 2, 7

Surgical Approach

• Arthroscopic lengthening of the iliopsoas musculotendinous unit with treatment of concomitant intra-articular pathology is the preferred surgical technique 2
• Tendon release can be performed in the central compartment, peripheral compartment, or at the lesser trochanter with similar outcomes 2
• When underlying hip joint disease is present (osteoarthritis, avascular necrosis), comprehensive surgical treatment must address both the bursa and the joint pathology through total hip arthroplasty, femoral head revitalization, or resection as appropriate 7
• Surgical excision requires meticulous dissection due to proximity to femoral vessels and nerves 8

Critical Differential Diagnosis Considerations

When evaluating a painful inguinal/groin mass, iliopectineal bursitis must be differentiated from 7, 8:

• Inguinal or femoral hernia
• Abscess or lymphocele
• Femoral artery pseudoaneurysm
• Lymphadenopathy
• Soft tissue tumor

The finding of communication between the bursa and hip joint cavity on CT or MRI is the key radiographic feature for differential diagnosis 7.

Common Pitfalls to Avoid

• Do not overlook underlying hip joint pathology (chronic synovitis, avascular necrosis, inflammatory arthritis) as these are frequently the etiopathogenetic factors driving iliopectineal bursitis 7
• Avoid intratendinous or intrabursal corticosteroid injections as peribursal placement is safer and equally effective 1
• Do not proceed to surgery without adequate trial of conservative therapy (minimum 3-6 months) unless there are compelling indications 1, 2
• Be aware that patients on chronic steroid therapy are at higher risk for developing iliopectineal bursitis secondary to avascular necrosis 7