What is the first-line treatment for iliopsoas tendinopathy?

First-Line Treatment for Iliopsoas Tendinopathy

Begin with conservative management consisting of activity modification, physical therapy with eccentric strengthening exercises, and NSAIDs for pain relief. 1

Initial Conservative Approach

The foundation of treatment prioritizes non-invasive interventions that address the underlying degenerative tendon pathology:

Activity Modification and Rest

• Implement relative rest by reducing activities that cause repetitive hip flexion loading, but avoid complete immobilization which leads to muscle atrophy and deconditioning 2
• For athletes and manual laborers, modify technique to minimize repetitive stresses on the iliopsoas tendon 3

Physical Therapy Protocol

• Initiate eccentric strengthening exercises as the cornerstone of rehabilitation, as they have proven beneficial in reversing degenerative changes, reducing symptoms, and increasing strength in tendinopathies 2, 4
• The eccentric-biased approach specifically targets the iliopsoas as a major decelerator of the hip during running and functional activities 4
• Implement deep transverse friction massage to reduce pain 2
• Include supportive kinetic chain exercises to address biomechanical contributors 4

Pharmacologic Pain Management

• Prescribe NSAIDs for short-term pain relief, recognizing they provide symptomatic relief but do not alter long-term outcomes or affect the degenerative process 2
• Consider topical NSAIDs as a preferred alternative for localized tendinosis, as they provide similar pain relief with fewer systemic side effects 2
• Paracetamol up to 4g/day can be used as an oral analgesic first choice due to its favorable safety profile 2
• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief 2

Clinical Context and Evidence Quality

The recommendation for conservative management as first-line treatment is supported by both guideline-level evidence 3, 2 and high-quality research 1. A 2016 review in Clinics in Sports Medicine explicitly states that "first-line treatment for iliopsoas disorders is typically conservative" 1. This aligns with the broader tendinopathy management principles established by the American Academy of Family Physicians, which emphasize relative rest and eccentric exercises as the foundation 2.

Important Distinction: Tendinosis vs. Tendinitis

• The underlying pathology is degenerative tendinopathy (tendinosis) rather than acute inflammation (tendinitis), a critical distinction that affects treatment approach 2
• This explains why anti-inflammatory treatments provide only symptomatic relief without altering the degenerative process 2

Expected Timeline and Progression

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 2, 5
• Progressive tendon loading should be implemented as symptoms improve, with gradual return to activity 4

When to Consider Advanced Interventions

If conservative management fails after an appropriate trial:

Corticosteroid Injections (Second-Line)

• Ultrasound-guided iliopsoas peritendinous corticosteroid injection can be considered for patients whose symptoms are refractory to conservative management 6, 7
• These injections provide better acute pain relief compared to oral NSAIDs but do not alter long-term outcomes 2
• A 2019 prospective study demonstrated improved outcomes in all Hip Disability and Osteoarthritis Outcome Score subcategories at 6 weeks post-injection 6
• Use with caution as corticosteroids may inhibit healing and reduce tensile strength 2

Surgical Referral (Last Resort)

• Surgery is reserved for carefully selected patients who have failed 3-6 months of appropriate conservative therapy 2, 5, 1
• Following injections, 28.9% of patients progress to surgery, with psoas tenotomy being the most common procedure 7
• Surgical techniques include arthroscopic lengthening of the musculotendinous unit with treatment of concomitant intra-articular abnormality 1

Common Pitfalls to Avoid

• Never completely immobilize the hip, as this accelerates muscular atrophy and deconditioning 2
• Do not rely solely on NSAIDs or corticosteroids, as they do not address the underlying degenerative pathology 2
• Avoid premature surgical referral before completing an adequate 3-6 month trial of conservative therapy 2, 5
• If symptoms persist beyond 6 months despite well-managed conservative therapy, surgical consultation is warranted 2