Iliopectineal Bursitis: Symptoms and Treatment
Clinical Presentation
Iliopectineal bursitis typically presents as a tender, palpable mass in the groin or hip region, accompanied by anterior hip pain that worsens with hip extension, abduction, and internal rotation. 1, 2
Key Symptoms to Identify:
- Tender swelling in the inguinal/groin region (most common presenting feature) 1, 3
- Anterior hip pain aggravated by specific hip movements (extension, abduction, internal rotation) 2
- Pulsating mass in rare cases when adjacent to vascular structures 1
- Lower extremity edema when the enlarged bursa compresses the external iliac or common femoral vein 4
- Radiation of pain along the femoral nerve distribution 3
- Dysuria or dysmenorrhea if the bursa extends into the pelvis 3
- Asymptomatic presentation is possible, discovered incidentally on imaging 1
Associated Conditions:
Iliopectineal bursitis is strongly associated with chronic hip synovitis from underlying joint pathology 1:
- Rheumatoid arthritis (especially with steroid use) 1, 5
- Avascular necrosis of the femoral head (often steroid-induced) 1
- Infectious arthritis (salmonella, tularemia) 1
- Osteoarthritis 3
Diagnostic Approach
High-frequency ultrasound (10 MHz or higher) is the first-line imaging modality for diagnosing iliopectineal bursitis, as it can visualize the fluid-filled bursa lateral to the femoral vessels and assess for communication with the hip joint. 6
Imaging Algorithm:
- Ultrasound examination - Shows liquid mass lateral to femoral vessels 3, 6
- MRI or CT scan - Confirms diagnosis, defines bursa dimensions, demonstrates communication with hip joint cavity (present in 5 of 6 cases in one series), and shows extension into retroperitoneum when large 1, 6
- Aspiration with contrast injection - Reveals clear fluid with possible synovial cells and defines bursa dimensions 3
Critical Diagnostic Finding:
Communication between the bursa and hip joint cavity on CT or MRI is a key radiographic factor for differential diagnosis and suggests underlying hip joint pathology. 1
Treatment Strategy
Conservative management with NSAIDs and rest should be attempted first, as iliopectineal bursitis responds well to non-surgical treatment in most cases. 2
Step 1: Conservative Management (First-Line)
- Naproxen 500 mg twice daily for acute bursitis 7
- Rest and activity modification 2
- Systemic corticosteroids (prednisone 25 mg/day) for refractory cases, particularly in rheumatoid arthritis patients 5
- One case report showed complete resolution of inguinal mass and pain after one month 5
Step 2: Aspiration/Drainage
- Ultrasound-guided bursa drainage for large, symptomatic collections 1, 6
- Consider when conservative management fails after 4-6 weeks 1
Step 3: Surgical Intervention
Surgery is reserved for cases that fail conservative treatment and should address both the bursa and underlying hip joint pathology. 1
- Failure of conservative management
- Recurrent symptomatic bursitis
- Vascular or nerve compression symptoms 4, 3
- Underlying hip joint disease requiring intervention 1
Surgical approach must include 1:
- Bursa excision or resection 1, 3
- Treatment of underlying hip pathology (total hip arthroplasty for severe arthritis, femoral head revitalization for avascular necrosis, or Girdlestone procedure for severe infection) 1
Critical Pitfalls to Avoid
- Never assume isolated bursitis - Always investigate for underlying hip joint disease (chronic synovitis, avascular necrosis, arthritis), as this drives treatment strategy 1
- Do not perform bursa excision alone - Surgical treatment must address the underlying hip pathology to prevent recurrence 1
- Consider differential diagnoses - Abscess, cyst, hernia, pseudoaneurysm, lymphocele must be excluded 1, 3
- Lack of communication with hip joint is favorable - When the bursa does not communicate with the hip joint cavity, prognosis is better and steroid therapy more likely to succeed 5
- Avoid surgery in rheumatoid arthritis patients initially - Systemic steroid therapy should always be attempted first 5