What is the best treatment approach for a pregnant patient with iliopsoas bursitis?

Treatment of Iliopsoas Bursitis in Pregnancy

For a pregnant patient with iliopsoas bursitis, begin with conservative management including activity modification, physical therapy, and acetaminophen for pain control, reserving corticosteroid-anesthetic injections for refractory cases that fail initial conservative measures.

Initial Conservative Management

First-Line Approach

• Activity modification should be implemented immediately, reducing movements that exacerbate hip flexion and groin pain 1
• Physical therapy targeting the iliopsoas musculotendinous unit should be initiated as the cornerstone of treatment 1, 2
• Acetaminophen is the preferred analgesic during pregnancy, as NSAIDs should be avoided, particularly in the third trimester due to risks of premature ductus arteriosus closure 1

Duration of Conservative Trial

• A minimum 6-8 week trial of conservative management should be attempted before considering injection therapy 1, 2
• Physical therapy should focus on stretching and strengthening exercises specific to the iliopsoas complex 1

Second-Line: Injection Therapy

When to Consider Injections

• Corticosteroid-anesthetic injections into the iliopsoas bursa should be considered only when symptoms remain refractory to conservative management 1, 2
• Injections have demonstrated improvement in pain scores from a mean of 7.33 to 2.47 on the Numeric Rating Scale in non-pregnant populations 2

Injection Technique and Composition

• Target the iliopsoas bursa under ultrasound or fluoroscopic guidance for accurate placement 2
• Use a combination of local anesthetic with corticosteroid (5 of 6 studies used this combination) 2
• Ultrasound guidance is preferred during pregnancy to avoid radiation exposure 2

Safety Profile

• No complications were reported across all injection studies reviewed, suggesting a favorable safety profile 2
• However, systemic corticosteroid absorption should be considered, though local injection carries minimal fetal risk compared to systemic administration

Important Diagnostic Considerations

Rule Out Serious Pathology

• Iliopsoas abscess must be excluded in high-risk patients (history of IV drug use, immunosuppression, fever, or worsening symptoms despite treatment) 3
• Consider ultrasound imaging to assess for bursal distension and exclude abscess formation 4, 5
• MRI without gadolinium can be used if ultrasound is inconclusive, as gadolinium should be avoided during pregnancy 6

Associated Conditions

• Iliopsoas bursitis may coexist with hip osteoarthritis or other hip pathology and may not be the sole source of pain 4
• If symptoms persist despite successful bursal treatment, investigate for underlying hip joint pathology 4

Surgical Considerations

When Surgery May Be Necessary

• Approximately 28.9% of patients with iliopsoas pathology progress to surgery after failed conservative and injection therapy 2
• Arthroscopic iliopsoas lengthening or tenotomy is the most common surgical intervention (38.3% of surgical cases) 1, 2
• Do not delay urgent surgery to manage complications solely due to pregnancy if serious pathology develops 7

Timing in Pregnancy

• Elective surgical intervention should be deferred until after delivery when possible 1
• If surgery becomes necessary during pregnancy, the second trimester is the safest window for intervention

Critical Pitfalls to Avoid

• Do not use NSAIDs, particularly in the third trimester, due to fetal risks including premature closure of the ductus arteriosus 1
• Do not assume bursitis is the only pain source—always evaluate for coexisting hip pathology or serious conditions like abscess 3, 4
• Do not use gadolinium-enhanced MRI during pregnancy; use non-contrast MRI or ultrasound instead 6, 7
• Do not overlook red flags such as fever, IV drug use history, or progressive neurological symptoms that suggest abscess rather than simple bursitis 3

Monitoring and Follow-Up

• Reassess symptoms every 2-4 weeks during conservative management 1
• If injection therapy is performed, evaluate response at 2-4 weeks post-injection 2
• Maintain vigilance for worsening symptoms that could indicate progression to abscess or other serious complications 3