Journal of Orthopaedic & Sports Physical Therapy 1999;29(4) :218-224

Treatment of lliopsoas Syndrome with a Hip Rotation Strengthening Program: A Retrospective Case Series C. A. M. johnston, BScH, MD David M. Lindsay, BHMS, BPh@ MScZ 1. /? Wiley, MPE, MD3

Study Design: Retrospective case series. Objective: To review the effectiveness of a homebased rehabilitation program in the treatment of iliopsoas syndrome. Background: Conservative management strategies for iliopsoas bursitis (syndrome) have not been well documented in the literature. This study relates the outcome of an exercise program (hip rotation exercises and stretching) to address clinical deficiencies observed in iliopsoas syndrome. Methods and Measures: A retrospective chart review and phone follow-up were done to determine pain and activity limitation for 9 patients (mean age, 35.6 + 12.7 years; 8 women, 1 man) before and after application of the rehabilitation program. As a group, symptoms of iliopsoas syndrome were present for a mean of 12.6 (+ 18.4) months prior to diagnosis and rehabilitation. Activity restrictions related to presenting symptoms were measured using a 4-point ordinal scale (from a score of 1 [pain and unable to do sport] to a score of 4 [pain-free, full activity]). Results: Pain and function improvement occurred in 7 of 9 (77%) patients. Five patients improved by at least 2 paidactivity levels at the time of follow-up (13.2 2 9.8 months following diagnosis); all but 2 patients were able to retum to full activity. Conclusions: This study gives preliminary evidence that a specific exercise regimen incorporating hip rotation might improve function and reduce pain for patients with iliopsoas syndrome. ) Orthop Sports Phys Ther 1 999;29:2 18-224.

Key Words: iliopsoas bursitis, iliopsoas strain, hip pain

Family Medicine Resident, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Physical Therapist, Sport Medicine Centre, Faculty of Kinesiology, The University of Calgary, Alberta,

Canada. Associate Professor, Sport Medicine Centre, Faculty of Kinesiology, The University of Calgary, Al-

berta, Canada. Send correspondence to). F? Wiley, The University of Calgary Sport Medicine Centre, 2500 University Dr. N w Calgary, AB, T2N 1 N4 Canada. E-mail: wiley@ucalgary.ca

T he iliopsoas muscle tendon junction and its bursa lies anterior to the pelvic brim and hip capsule.18

The bursa may be connected to the hip joint.6 Injury to the bursa and overlying muscle tendon junc- tion may result from traumatic or overuse etiology.I0J5 Presenting symptoms include anterior hip pain that is aggravated by activity. The condition may also be associ- ated with a deep snapping sensa- tion, which is described in the lit- erature as internal snapping hip syndrome. The snap, which has been recently documented using real-time ultrasonography? results from sudden movement of the il- iopsoas tendon over l of 3 possi- ble bony prominences: the anteri- or inferior iliac spine, the iliopec- tineal eminence, or the bony ridge on the lesser trochanter.I4 To avoid confusion about termi- nology,I0 we use the term iliopsoas syndrome in this article to define the anterior hip pain, with or without an associated snap.

Physical examination of patients with iliopsoas syndrome reveals a number of consistent findings, in- cluding tenderness in the femoral triangle, restricted hip extension

flexibility, positive snapping hip sign, and weakness on resisted hip external and internal rotation with the hip flexed to 90 degrees.I0 Radiologic investiga- tions are typically ~nremarkable,'~ although a variety of imaging techniques may detect bursal enlarge- ment '*

A recent literature review of treatment protocols for this conditionlo showed that most of the studies pertained to surgical intervention. The literature contained relatively few descriptions of conservative management strategies. Nonoperative treatment of il- iopsoas syndrome has traditionally included rest, stretching and strengthening exercises, oral anti-in- flammatory medications, and local physical therapy. Jacobson and Alleng noted that "stretching exercises involving hip extension for 6 to 8 weeks are general- ly successful in alleviating symptoms." Taylor and Clarke2' prescribed activity modification and physical therapy, involving ultrasound and assisted extension exercises, to a total of 7 symptomatic individuals. Two case reports8 identified a treatment program consisting of bed rest, diathermy to the hip region, Buck's traction, and sodium salicylate as being suc- cessful in achieving pain relief and restoring com- plete range of motion. Conservative measures pro- posed in a review article emphasized ultrasound to the femoral triangle and postisometric stretching of the iliopsoas mus~ le .~ Two reviews of ballet dancing injuries identified stretching and strengthening of particular muscles around the hip joint as essential in the treatment of iliopsoas syndrome.'J"o date, any comments made on the effectiveness of conser- vative management of this condition have been es- sentially anecdotal.

The lack of published literature dealing with iliop soas syndrome suggests that the etiology and conser- vative management strategies associated with this condition are not well understood. In view of this, the purpose of our study was to retrospectively review the effectiveness of a home-based rehabilitation p r e gram in the treatment of iliopsoas syndrome. The re- habilitation program was presented previously10 and the rationale for our program is presented below.

It has been our experience that most iliopsoas syn- drome conditions arise insidiously over time rather than through 1 specific incident. The insidious onset of symptoms suggests that overuse is a prime compo- nent of the etiology associated with this condition. We also believe that subtle dysfunction of the hip joint musculature (eg, excessive or poorly timed mus- cle contraction) may play a role. Subtle hip dysfunc- tion, when repeated over the course of hundreds of thousands of bipedal weight-bearing movements, like- ly alters the mechanical stress on the anterior hip structures, causing irritation to the iliopsoas muscle- tendon unit and impingement of the bursa. Associa- tions between muscle imbalances and pathology have previously been discussed by Sahrmann."

In our experience, clinical hip rotation weakness and hip flexor tightness was present at the initial as- sessment of patients with iliopsoas syndrome in all reviewed cases.1° We believed that these strength and flexibility deficiencies were representative of underly- ing muscle imbalance. Our rehabilitative program, the first to be discussed in the literature, attempted to correct these deficiencies through the use of spe- cific stretching, strengthening, and retraining exercis- es.

METHODS

Subject Recruitment

All patients diagnosed and treated for iliopsoas syndrome at the University of Calgary Sport Medi- cine Centre from 1993 to 1996 and who had previ- ously completed a consent form approved by the University of Calgary Medical Bioethics Committee had their charts reviewed. Our diagnostic criteria in- cluded anterior hip pain with activity (with or with- out a snap), tenderness to palpation of the femoral triangle, no evidence of hernia, and unremarkable radiologic findings.

Information from each chart included gender, age, height, weight, precipitating physical activity, dura- tion of symptoms before diagnosis, prior treatment, and outcome of radiologic investigations. Telephone interview identified activity restriction at the time of diagnosis, after treatment, and at the time of follow- up; duration of treatment; time of follow-up after treatment onset; patient benefit from the rehabilita- tion program; compliance with the treatment plan prescribed; other treatments used; time to recovery if applicable; and comments about the treatment. We also included in our analysis consenting patients who were unavailable for telephone interview but had re- ceived follow-up from the physical therapist for 3 months or longer because we felt the effects of the program would have been noticeable at that time. This decision added 1 patient to our analysis.

It is important to note that comments on compli- ance and activity restriction were prompted by the interviewer. Compliance was graded on a %point scale: (1) very compliant-exercises done essentially daily; (2) moderately compliant-exercises per- formed consistently, but not daily; (3) noncompli- ant-exercises performed at best sporadically; and each patient's response was entered as the corre- sponding number. Similarly, activity restriction relat- ed to presenting symptoms was described using a 4 point scale: (1) pain, unable to do sport; (2) pain, modified activity; (3) essentially pain-free, full activi- ty; and (4) pain-free, full activity.

J Orthop Sports Phys Ther .Volume 29. Number 4.April 1999

FIGURE 1. Internal rotation hip strengthening exercise (note patient dern- onstrating exercise in left hip).

Rehabilitation Program

The hip rotation rehabilitation program has been described previously.1° The initial strengthening com- ponent of the rehabilitation program targets both in- ternal and external rotator muscle groups. The exer- cises were performed in a sitting position using an elastic resistance strap (Figures 1 and 2). Three sets of 20 repetitions in both internal and external rota- tion directions were performed. However, if strength testing on initial examination revealed 1 direction to be particularly weak in relation to the unaffected side, we prescribed a 3 to 2 ratio in the number of sets, with the weak direction performing the greater number. Subjects experienced fatigue in the postero- lateral hip region when performing the internal rota- tion exercise and in the anteromedial hip region when performing the external rotation exercise.

The rotation strengthening exercises were per- formed daily and only on the affected side for 2 weeks before the exercises changed to incorporate a

FIGURE 2. External rotation right hip strengthening exercise.

tion with the hip in approximately 45 degrees of flexion (Figure 3).

The side-lying abduction/external rotation exer- cise was performed daily for a 2-week time frame. Three sets of 20 repetitions were completed on the injured side, while 2 sets of 20 repetitions were per- formed on the unaffected side. The initial internal and external rotation exercises in sitting positions continued during this stage, but only at a frequency of 2 to 3 times per week.

more functional position of the hip joint (iei the hip was exercised closer to the neutral position). The strengthening exercise performed at this stage in- volved a side-lying abduction/external rotation mo- FIGURE 3. Side-lying abduction right hip strengthening exercise.

220 J Orthop Sports Phys Ther .Volume 29. Number 4.April 1999

TABLE 1. Characteristics of study patients diagnosed with iliopsoas syn- drome.'

Age Height Weight Patient Gender (v) (m) (ke)

1 F 36 172.7 63.6 2 F 58 167.6 61.3 3 F 50 167.6 54.5 4 F 23 167.6 61.3 5 F 42 157.5 52.3 6 F 31 171.5 50.9 7 F 18 165.1 51.8 8 F 32 162.6 59.1 9 M 30 177.8 72.7 Mean 35.6 167.8 58.6 SD 12.7 5.9 7.1

F = female; M = male; SD = standard deviation.

untary contraction should not change the cadence or way they walked and that they should retrain both the affected and unaffected sides. Because voluntarily contracting the gluteal muscles in this manner for a prolonged period can irritate the hip, patients were instructed to limit this voluntary contraction to a maximum of 10 to 15 steps at a time, 2 to 3 times per day.

Evaluation of the Effectiveness of the Rehabilitation Program and Data Analysis

FIGURE 4. Weightbearing right hip strengthening exercise.

The final progression of the strengthening pro- gram occurred at the 1-month stage. The exercise in- volved the individual standing against a wall, weight- bearing on the affected side and performing a series of mini-squats while maintaining external rotation of this hip so the knee remained over the lateral por- tion of the weightbearing foot (Figure 4). Three sets of 20 repetitions on the affected side and 2 sets of 20 on the uninjured side were performed 2 to 3 times per week. For each exercise, proper technique is imperative to avoid muscle substitution.

Daily stretching was also a very important compo- nent of the conservative management program. The main stretches prescribed targeted the hip flexor, quadriceps, and lateral hip/piriformis and hamstring muscles. Patients were instructed to perform twice as many stretches on the affected side compared to the normal side and to repeat them as often as possible throughout the day. The stretching program contin- ued at least as long as the pain persisted.

Throughout the duration of the stretching and strengthening program, gluteal muscle reeducation also took place. This reeducation involved voluntari- ly tightening the gluteal muscles of the stance leg during the mid to late portion of the stance phase of the gait cycle. Patients were instructed that this vol-

The success of the rehabilitation program was as- sessed by comparing the change of activity restriction from prior to the diagnosis of iliopsoas syndrome to that after treatment and at the time of followup. This was done for the group as a whole and on an individual basis.

Descriptive statistics were performed on subject de- mographic data and on data collected by telephone survey for the duration of symptoms and treatment and the time of follow-up after onset of therapy, as well as for activity restriction levels and compliance.

RESULTS

Each patient in the study received 3 therapy visits. These visits occurred at the start of the program, at 2 weeks, and at 4 weeks.

A total of 18 patients were identified as having il- iopsoas syndrome. Of these, 12 had given consent to be contacted for research purposes. Of these 12, 8 were contacted and 1 individual's progress was as- sessed by chart review. Eight women and 1 man were assessed. Patient characteristics are identified in Ta- ble 1. None of the patients recalled having received hip rotational exercise training previously.

Table 2 identifies the physical activity associated with the onset of the symptoms of iliopsoas syn- drome and any treatments that were attempted prior

J Orthop Sports Phys Ther*Volume 29.Number 4.April 1999 221

TABLE 2. Patient details regarding activity at the onset of symptoms and treatment prior to their diagnosis with i l i o p s syndrome.

Symptom Duration* Patient Activity at Onset of Symptoms Prior Treatment (m~n)

Running Running upstairs Cycling

Baseball Post-arthroscopy Running on treadmill Highland dancing Fall while rollerblading Running

Orthotics, physical therapy Chiropractor, physical therapy Chiropractor, massage therapy,

physical therapy, rest Rest Physical therapy Rest Chiropractor Rest Athletic therapist, rest

Duration of symptoms in months prior to diagnosis and start of treatment at the clinic.

to diagnosis at the Sport Medicine Centre. Of the 9 hip problems, overuse was responsible for generating symptoms in 7 cases, and 2 were the result of trau- ma.

Information regarding patient ability to perform activities prior to diagnosis, after treatment, and at follow-up as well as the time frames involved and compliance with the rehabilitation home program, are presented in Table 3. As a group, symptoms of iliopsoas syndrome were present for 12.6 5 18.4 months prior to diagnosis at the Sport Medicine Centre, and rehabilitation started within 1 week of diagnosis. At the completion of the rehabilitation program, 7 of 9 (77%) subjects reported decreased activity restriction, 5 (55%) improved by at least 2 ac- tivity levels, and 2 (22%) reported a 1-level improve- ment. At the time of follow-up, all but 2 subjects were able to return to full activity. Patient follow-up occurred at approximately 13.2 2 9.0 months from the initial diagnosis of iliopsoas syndrome. Overall, patients were moderately compliant in performing their rehabilitation home program (Table 3).

When the patients were asked if they benefited

from the physical therapy home program, 7 an- swered yes, and 1 replied no. For 1 patient this ques- tion was not applicable because the follow-up was done by chart review. When asked about the exercise effectiveness, 3 patients felt the strengthening exer- cises using the elastic were most beneficial, 2 stated that the stretching and strengthening exercises were most effective in combination, and 2 patients felt that the stretches were the most useful. The 1 indi- vidual who indicated no benefit was received stated that all the exercises caused hip pain and the quadri- ceps stretch was especially painful.

The patients were also asked about functional ben- efits derived from the physical therapy home pro- gram. Using the 4point activity restriction scale, 2 patients (patients 2 and 4) showed no change in ac- tivity level after completion of treatment. Of these 2 patients, only 1 (patient 4) had improved at the time of follow-up. Only 1 patient (patient 3) had im- proved by 1 point on the activity restriction scale af- ter using the rehabilitation home program and no change was noticed at the time of follow-up. Three patients (patients 1,7, and 8) experienced improve-

TABLE 3. Patient details regarding outcome of treatment.

Duration of Time of Follow-up Symptoms Prior Duration of after Onset of

to Diagnosis Activity Restriction Treatment Activity Restriction Treatment Current Activity Compliance with Patient (mod Prior to Diagnosis* (mod after Treatment* (mod Restriction* Home Program

1 # 9 1 3 3 3 N/A N/A 2 16 2 3 2 14 2 1 3 10 2 45 3 4 3 2 4 6 2 1 2 9 3 3 5 4 1 0.5 2 13 4 311 6 1 1 6 4 12 4 2 7 60 2 3 4 10 4 2 8 5 1 8 3 32 4 1 9 2 1 1 4 22 4 2 Mean 12.6 1.4 3.3 3 13.2 3.5 2 SD 18.4 2.3 9.0

Graded on a scale of 1 to 4: l-pain, unable to do sport; 2-pain, modified activity; 3-essentially pain free, full activity; 4--pain free, full activity. t Graded on a scale of 1 to 3: 1-very compliant; 2--moderately compliant; 3--noncompliant. t Chart review, unavailable for telephone follow-up. 5 Ongoing treatment at time of follow-up. 11 Noncompliant because physical therapy program caused pain.

J Orthop Sports Phys Ther-Volume 29.Number 4.April 1999

ment of at least 2 points following adherence to the home program. Two patients (patients 5 and 9), af- ter being unable to do sport, had regained full activi-

ty- Patients stated that strengthening, and more fre-

quently, stretching exercises continued to be used af- ter treatment had ended. Concurrent treatments were used by the noncompliant patient (insole pro- vided by podiatrist) and in the other case (chiroprac- tic, massage therapy, and yoga) as a continuing part of her normal health care.

DISCUSSION

This study retrospectively reviewed the effective- ness of a rehabilitation program in treating iliopsoas syndrome. From this study, it appears the rehabilita- tion program contributed to reduction of the activity restriction imposed on patients by iliopsoas syn- drome.

The 9 persons described in this study vary in terms of male to female ratio (1:s) and average age (35.6 years) from the other 9 patients diagnosed with iliop soas syndrome not in the study (4 male:5 female and 30.4 years) and also from those documented in pri- mary data studies of iliopsoas syndrome in the litera- ture (literature totals of 23 male:45 female and mean age of 25.4 years) 5.8.9~11~'6~1~n The symptoms of iliop soas syndrome resulted more frequently from over- use (7 patients) than from trauma (2 patients) in this study. In the literature, 8 individuals diagnosed with iliopsoas syndrome were the result of trau- ma5.8.~ I .2'1 and 57 were attributable to an active life-

style or athletic b a c k g r ~ u n d . ~ - ~ J ~ J ~ ~ * ~ ~ Although the mean values of the activity restriction

data themselves have no statistical meaning, the in- creasing trend (1.4 at diagnosis, 3.0 after treatment, and 3.5 at follow-up) indicated that on a group level, patient activity had become less restricted over the course of patient monitoring. Seven patients indicat- ed in a telephone interview that they benefited from the physical therapy home program. Only 1 patient stated that this program was ineffective. As noted previously, 1 patient was unavailable for telephone in- terview but has been included in the following analy- sis. With the persons who reported benefiting from the physical therapy home program, 6 patients had improved activity levels at the point their treatment had ended. Only 1 of these patients had further im- provement at the time of telephone follow-up. Two patients had no change from their initial condition after treatment had ended, and only 1 showed im- provement at the time of patient follow-up. All pa- tients, with the exception of l who showed no initial improvement after treatment, were either moderately or very compliant. These data suggest that the reha- bilitation program, when performed consistently, was successful in decreasing pain and permitted the pa-

tient to return to full activity. Patients were told they could expect to see improvement in their condition after 4 to 6 weeks, although the results of this study suggest that the program should be continued for a %month period.

It seems unlikely that these effects could have been possible without the physical therapy program, because symptoms of iliopsoas syndrome were pres- ent for 12.6 + 18.4 months and ranging from a min- imum of 1 to a maximum of 60 months prior to di- agnosis and treatment at the Sport Medicine Centre.

This study design is descriptive and observational by nature, and its strength is based on its ability to describe a number of similar cases. However, the study design involved only a small number of pa- tients with no control group. Our conclusions, there- fore, are preliminary, and replication of our results awaits further study with an experimental design. One of the authors who was not involved in prescrib ing the rehabilitation program administered the sur- vey to each patient. Because some interpretation of the patient's responses was necessary, bias was poten- tially introduced into the study. Despite this, it is im- portant to note that this is the first study in the liter- ature outlining a detailed rehabilitation program for iliopsoas syndrome. Therefore, it provides a founda- tion from which future prospective studies can assess the effectiveness of rehabilitation programs for this condition.

Rehabilitation is an ongoing process that requires patients to take responsibility for their own health. Because our program was done by the patients pri- marily at home, it was an extremely cost-effective form of treatment. It seems possible to reduce the activity restriction placed on a patient by iliopsoas syndrome by using a home program consisting of hip strengthening and stretching exercises.

m CONCLUSION

We have conducted a retrospective analysis of a re- habilitation program for the treatment of iliopsoas syndrome. A rehabilitation program of hip rotation strengthening and stretching appears to improve pain and function of those patients with iliopsoas syndrome. Although this study was a retrospective case series, it provided one of the few documented rehabilitation studies in the literature, providing a basis for the development of future experimental study designs.

ACKNOWLEDGMENTS

The authors thank the office staff for their help with identifying the appropriate patient charts and Hugh Tyreman for his assistance in maintaining and accessing the patient computer database. The au-

J Onhop Sports Phys Ther*Volume 29.Number 40April 1999

thors also thank Geoff Elliott for his assistance in preparing this manuscript.

- ~

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J Orthop Sports Phys Ther .Volume 29. Number 4.April 1999