Iliopsoas Tendon Rupture

Iliopsoas Tendon Rupture

The iliopsoas tendon and bursa are prone to the development of tendinitis. Untreated, iliopsoas tendinitis can progress to severe tendinopathy including partial tears and complete rupture of the tendon. Complete rupture of the iliopsoas tendon can be either spontaneous or traumatic and may be associated with coexistent muscle bursitis, muscle strains, and bony abnormalities including senile fractures.

Occurring primarily in the elderly, iliopsoas tendon rupture should be included in the differential diagnosis of any patient presenting with the acute onset of hip and groin pain and the incidence of this painful condition is much less common than acute fractures of the pelvis and hip. The presence of risk factors that may predispose the patient to tendon rupture include quinolone use, corticosteroids, rheumatoid arthritis, collagen-vascular diseases, chronic renal failure, gout, and diabetes.

What are the Symptoms of Iliopsoas Tendon Rupture

In most patients, the pain of iliopsoas tendon rupture occurs acutely and is accompanied by an inability or refusal to bear weight. Associated ipsilateral lower extremity edema and rubor may mimic acute thrombophlebitis.

Passive range of motion of the affected hip may exacerbate the pain. Occasionally, an inguinal mass secondary to hematoma formation may be palpated.

How is Iliopsoas Tendon Rupture diagnosed?

Plain radiographs are indicated for all patients who present with hip pain given the incidence of hip and pelvic fractures in the elderly. Based on the patient’s clinical presentation, additional testing may be indicated, including a complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing.

Computed tomography and magnetic resonance imaging of the hip is indicated if tendinopathy or tear of the iliopsoas tendon is suspected and to identify other pathology responsible for the patient’s symptomatology. The injection technique described later may serve as both a diagnostic and a therapeutic maneuver.

Differential Diagnosis

Iliopsoas tendon rupture is uncommon with an incidence of below 1% in patients presenting with acute hip and pelvis pain that was severe enough to result in magnetic resonance imaging of the painful area.

The clinical presentation of iliopsoas tendon rupture mimics the presentation of acute hip and pelvic fractures, especially in the elderly. In addition to hip and pelvic fractures, iliopsoas tendinitis, bursitis, septic arthritis, retroperitoneal abscess, retroperitoneal hematoma, groin abscess, thrombophlebitis, and tears of the gluteal, quadriceps, and adductor muscles should be considered when evaluating a patient with acute hip and groin pain. In some clinical situations, consideration should be given to primary or secondary tumors involving the hip and pelvis. The pain of acute herpes zoster, which occurs before eruption of a vesicular rash, can also mimic iliopsoas tendon rupture.

Differential Diagnosis in Patients With Suspected Iliopsoas Tendon Rupture

  • • Hip
  • • Pelvic fractures
  • • Iliopsoas tendinitis
  • • Bursitis
  • • Septic arthritis
  • • Retroperitoneal abscess
  • • Retroperitoneal hematoma
  • • Septic joint
  • • Groin abscess
  • • Thrombophlebitis
  • • Tears of the gluteal, quadriceps, and adductor muscles
  • • Hip and groin tumors

Treatment

Initial treatment of the pain and functional disability associated with iliopsoas tendon rupture includes a combination of nonsteroidal antiinflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. Physical modalities, including local heat, toe touch weight bearing, and gentle range-of-motion exercises, should be introduced several days after the patient undergoes injection.

Vigorous exercises should be avoided, because they will exacerbate the patient’s symptoms. Occasionally surgical repair of the tendon is undertaken if the patient is experiencing significant functional disability and pain. For patients who do not respond to these treatment modalities and appear to have significant local pain in the region of the tendon rupture, injection with local anesthetic is a reasonable next step. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.

Complications and Pitfalls

Given the uncommon nature of rupture of the iliopsoas tendon, its diagnosis must be one of exclusion. Given the fact that a number of conditions that mimic the clinical presentation of iliopsoas tendon rupture are associated with significant morbidity, it is important to rule this pathological condition out. The above injection technique is safe if careful attention is paid to the clinically relevant anatomy.

Sterile technique must be used to avoid infection, along with universal precautions to minimize any risk to the operator. Trauma to other elements of the tendon from the injection itself is also a possibility. Tendons that are highly inflamed or previously damaged are subject to rupture if they are injected directly.

This complication can often be avoided if the clinician uses a gentle technique, considers the use of ultrasound guidance, and stops injecting immediately if significant resistance is encountered.

Clinical Pearls

The iliopsoas musculotendinous unit is susceptible to the development of tendinitis for several reasons. First, the musculotendinous unit has several actions including flexion and lateral rotation of the hip and lateral flexion of the lumbar spine. Second, the musculotendinous unit passes between the pectineal eminence medially and the iliac spine laterally, making it subject to bony impingement.

Third, the musculotendinous unit is made up of contributions from not only the iliopsoas muscle, but the fibers from the iliacus. These fibers travel a long distance through the posterior mediastinum through the retroperitoneum to its insertion in the thigh on the lesser trochanter and infratrochanteric area of the femur. This subjects the iliopsoas musculotendinous unit to myriad infectious and inflammatory processes along its entire course.

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