Iliopectinate Bursitis

Iliopectinate Bursitis – The Clinical Syndrome

A patient with iliopectinate bursitis frequently reports pain in the anterior hip and groin. The pain is localized to the area just below the crease of the groin anteriorly, with referred pain noted into the hip joint and anterior pelvis. Often, the patient is unable to sleep on the affected hip and may report a sharp, “catching” sensation with range of motion of the hip. Iliopectinate bursitis often coexists with arthritis of the hip joint.

The iliopectinate bursa lies between the psoas and iliacus muscles and the iliopectinate eminence. The iliopectinate eminence is the point at which the ilium and the pubis bone merge. The psoas and iliacus muscles join at the lateral side of the psoas, and the combined fibers are referred to as the iliopsoas muscle. Similar to the psoas, the iliacus flexes the thigh on the trunk or, if the thigh is fixed, flexes the trunk on the thigh, as when moving from a supine to sitting position.

This action can irritate the iliopectinate bursa, as can repeated trauma from repetitive activity, including sit-ups or overuse of exercise equipment for lower extremity strengthening. The iliacus muscle is innervated by the femoral nerve.

What are the Symptoms of Iliopectinate Bursitis

Physical examination may reveal point tenderness in the upper thigh just below the crease of the groin. Passive flexion, adduction, and abduction and active resisted flexion and adduction of the affected lower extremity reproduce the pain. Sudden release of resistance during this maneuver markedly increases the pain.

Examination of the hip and of the sacroiliac joint is normal. Careful neurological examination of the affected lower extremity should reveal no neurological deficits. If neurological deficits are present, evaluation for plexopathy, radiculopathy, or entrapment neuropathy should be undertaken. These neurological symptoms can coexist with iliopectinate bursitis, confusing the clinical diagnosis.

How is Iliopectinate Bursitis diagnosed?

Plain radiographs of the hip may reveal calcification of the bursa and associated structures consistent with chronic inflammation. Magnetic resonance imaging (MRI) and ultrasound imaging is indicated if occult mass or tumor of the hip or groin is suspected and help confirm the diagnosis. The injection technique described subsequently serves as a diagnostic maneuver and a therapeutic maneuver.

Differential Diagnosis

Iliopectinate bursitis is often attributed to primary hip or groin pathological conditions. Radiographs of the hip and pelvis combined with electromyography help distinguish iliopectinate bursitis from radiculopathy or plexopathy from pain emanating from the hip.

Most patients with a lumbar radiculopathy have back pain associated with reflex, motor, and sensory changes, whereas patients with iliopectinate bursitis have only secondary back pain and no neurological changes. Ilioinguinal or genitofemoral neuralgia sometimes may be confused with iliopectinate bursitis but can be distinguished by the presence of motor and sensory changes involving these nerves. Lumbar radiculopathy and ilioinguinal nerve entrapment may coexist as the “double crush” syndrome. The pain of iliopectinate bursitis may cause alteration of gait, which may result in secondary back and radicular symptoms that may coexist with less common forms of bursitis.

Treatment

Initial treatment of the pain and functional disability associated with iliopectinate bursitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. The repetitive movements that incite the syndrome should be avoided. For patients who do not respond to these treatment modalities, injection of the iliopectinate bursa with a local anesthetic and steroid may be a reasonable next step.

The goals of this injection technique are first explained to the patient. The patient is placed in the supine position, and the pulsation of the femoral artery at the midpoint of the inguinal ligament is identified. At a point 21⁄2 inches down and 31⁄2 inches lateral to these femoral arterial pulsations lies the entry point of the needle. This point should be at the lateral edge of the sartorius muscle. Proper preparation with antiseptic solution of the skin overlying this point is done. A syringe containing 9 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 25-gauge, 31⁄2-inch needle.

Before needle placement, the patient should be advised to say “There!” as soon as a paresthesia into the lower extremity is felt, indicating that the needle has impinged on the femoral nerve. If a paresthesia occurs, the needle should be withdrawn immediately and repositioned more laterally. The needle is advanced carefully through the previously identified point at a 45-degree angle cephalad to allow the needle to pass safely beneath the femoral artery, vein, and nerve. The needle is advanced slowly to avoid trauma to the femoral nerve until it hits the bone at the point where the ilium and pubis bones merge. The needle is withdrawn out of the periosteum, and after careful aspiration for blood and if no paresthesia is present, the contents of the syringe are gently injected into the bursa. There should be minimal resistance to injection. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.

Complications and Pitfalls

The proximity to the femoral artery, vein, and nerve makes it imperative that this procedure be done only by clinicians well versed in the regional anatomy and experienced in performing injection techniques. Many patients also report a transient increase in pain after injection of the iliopectinate bursa.

Clinical Pearls

This injection technique is extremely effective in the treatment of iliopectinate bursitis. The technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile techniques to avoid infection and universal precautions to avoid risk to the operator. Most side effects of this injection technique are related to needle-induced trauma to the injection site and underlying tissues. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection. The avoidance of overly long needles helps decrease the incidence of trauma to underlying structures. Special care must be taken to avoid trauma to the sciatic nerve.

The use of physical modalities, including local heat and gentle stretching exercises, should be introduced several days after the patient undergoes this injection technique. Vigorous exercises should be avoided because they would exacerbate the symptoms. Simple analgesics, NSAIDs, and antimyotonic agents such as tizanidine may be used concurrently with this injection technique.



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