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 retrospectivechart 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.

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 junction may result from traumatic or overuse etiology.I0J5Presenting symptoms include anterior hip pain that is aggravated by activity. The condition may also be associated with a deep snapping sensation, which is described in the literature as internal snapping hip syndrome. The snap, which has been recently documented using real-time ultrasonography? results from sudden movement of the iliopsoas tendon over l of 3 possiKey Words: iliopsoas bursitis, iliopsoas strain, hip pain ble bony prominences: the anterior inferior iliac spine, the iliopectineal eminence, or the bony ridge on the lesser trochanter.I4 To avoid confusion about terminology,I0 we use the term iliopsoas syndrome in this article to define the anterior hip pain, with or without an associated snap. Family Medicine Resident, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Physical examination of patients Physical Therapist, Sport Medicine Centre, Faculty of Kinesiology, The University of Calgary,Alberta, Canada. with iliopsoas syndrome reveals a Associate Professor, Sport Medicine Centre, Faculty of Kinesiology, The University of Calgary, Al- number of consistent findings, inberta, Canada. Send correspondence to). F? Wiley, The University of Calgary Sport Medicine Centre, 2500 University cluding tenderness in the femoral triangle, restricted hip extension Dr. N w Calgary,AB, T2N 1 N4 Canada. E-mail: wiley@ucalgary.ca

flexibility, positive snapping hip sign, and weakness on resisted hip external and internal rotation with the hip flexed to 90 degrees.I0 Radiologic investigations are typically ~nremarkable,'~ although a variety of imaging techniques may detect bursal enlargement 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 iliopsoas syndrome has traditionally included rest, stretching and strengthening exercises, oral anti-inflammatory medications, and local physical therapy. Jacobson and Alleng noted that "stretching exercises involving hip extension for 6 to 8 weeks are generally 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 successful in achieving pain relief and restoring complete range of motion. Conservative measures proposed in a review article emphasized ultrasound to the femoral triangle and postisometric stretching of the iliopsoas m u s ~ l eTwo 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 conservative management of this condition have been essentially anecdotal. The lack of published literature dealing with iliop soas syndrome suggests that the etiology and conservative 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 rehabilitation program was presented previously10 and the rationale for our program is presented below. It has been our experience that most iliopsoas syndrome conditions arise insidiously over time rather than through 1 specific incident. The insidious onset of symptoms suggests that overuse is a prime component of the etiology associated with this condition. We also believe that subtle dysfunction of the hip joint musculature (eg, excessive or poorly timed muscle contraction) may play a role. Subtle hip dysfunction, when repeated over the course of hundreds of thousands of bipedal weight-bearing movements, likely alters the mechanical stress on the anterior hip structures, causing irritation to the iliopsoas muscletendon unit and impingement of the bursa. Associations 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 assessment of patients with iliopsoas syndrome in all reviewed cases.1 We believed that these strength and flexibility deficiencies were representative of underlying muscle imbalance. Our rehabilitative program, the first to be discussed in the literature, attempted to correct these deficiencies through the use of specific stretching, strengthening, and retraining exercises.

METHODS

Subject Recruitment
All patients diagnosed and treated for iliopsoas syndrome at the University of Calgary Sport Medicine Centre from 1993 to 1996 and who had previously completed a consent form approved by the University of Calgary Medical Bioethics Committee had their charts reviewed. Our diagnostic criteria included anterior hip pain with activity (with or without 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, duration 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 followup; duration of treatment; time of follow-up after treatment onset; patient benefit from the rehabilitation 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 received 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 compliance 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 performed consistently, but not daily; (3) noncompliant-exercises performed at best sporadically; and each patient's response was entered as the corresponding number. Similarly, activity restriction related 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 activity; 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 dernonstrating exercise in left hip).

FIGURE 2. External rotation right hip strengthening exercise.

Rehabilitation Program
The hip rotation rehabilitation program has been described previously.1 The initial strengthening component of the rehabilitation program targets both internal and external rotator muscle groups. The exercises 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 rotation 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 posterolateral hip region when performing the internal rotation exercise and in the anteromedial hip region when performing the external rotation exercise. The rotation strengthening exercises were performed daily and only on the affected side for 2 weeks before the exercises changed to incorporate a more functional position of the hip joint (iei the hip was exercised closer to the neutral position). The strengthening exercise performed at this stage involved a side-lying abduction/external rotation mo220

tion with the hip in approximately 45 degrees of flexion (Figure 3). The side-lying abduction/external rotation exercise 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 performed 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.

FIGURE 3. Side-lying abduction right hip strengthening exercise.

J Orthop Sports Phys Ther .Volume 2 . Number 4.April 1999 9

TABLE 1. Characteristics of study patients diagnosed with iliopsoas syndrome.'

Patient
1 2 3 4 5 6 7 8 9 Mean SD

Gender

Age (v)
36 58 50 23 42 31 18 32 30 35.6 12.7

Height (m)
172.7 167.6 167.6 167.6 157.5 171.5 165.1 162.6 177.8 167.8 5.9

Weight (ke)
63.6 61.3 54.5 61.3 52.3 50.9 51.8 59.1 72.7 58.6 7.1

F F F F F F F F M

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 program occurred at the 1-month stage. The exercise involved the individual standing against a wall, weightbearing 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 portion 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 component 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 continued 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 voluntarily 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 volJ Orthop Sports Phys Ther*Volume 29.Number 4.April 1999

The success of the rehabilitation program was assessed 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 demographic 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 iliopsoas 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 assessed by chart review. Eight women and 1 man were assessed. Patient characteristics are identified in Table 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 syndrome and any treatments that were attempted prior
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 Running Running upstairs Cycling Baseball Post-arthroscopy Running on treadmill Highland dancing Fall while rollerblading Running

Prior Treatment
Orthotics, physical therapy Chiropractor, physical therapy Chiropractor, massage therapy, physical therapy, rest Rest Physical therapy Rest Chiropractor Rest Athletic therapist, rest

(m~n)

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 trauma. 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 activity levels, and 2 (22%) reported a 1-level improvement. 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
TABLE 3. Patient details regarding outcome of treatment. Duration of Symptoms Prior to Diagnosis (mod 9 16 10 6 4 1 60 5 2 12.6 18.4 Duration of Treatment (mod 3 3 45 1 0.5 6 3 8 1 3.3 2.3

from the physical therapy home program, 7 answered yes, and 1 replied no. For 1 patient this question was not applicable because the follow-up was done by chart review. When asked about the exercise effectiveness, 3 patients felt the strengthening exercises 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 individual who indicated no benefit was received stated that all the exercises caused hip pain and the quadriceps stretch was especially painful. The patients were also asked about functional benefits derived from the physical therapy home program. Using the 4point activity restriction scale, 2 patients (patients 2 and 4) showed no change in activity 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 improved by 1 point on the activity restriction scale after 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-

Patient 1# 2 3 4 5 6 7 8 9 Mean S D

Activity Restriction Prior to Diagnosis* 1 2 2 2 1 1 2 1 1 1.4

Time of Follow-up after Onset of Treatment Current Activity Compliance with Activity Restriction (mod Restriction* Home Program after Treatment* 3 2 3 2 2 4 4 3 4 3 3 14 4 9 13 12 10 32 22 13.2 9.0 N/A 2 3 3 4 4 4 4 4 3.5 N/A 1 2 3 31 1 2 2 1 2 2

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), after being unable to do sport, had regained full activityPatients stated that strengthening, and more frequently, stretching exercises continued to be used after treatment had ended. Concurrent treatments were used by the noncompliant patient (insole provided by podiatrist) and in the other case (chiropractic, massage therapy, and yoga) as a continuing part of her normal health care.

DISCUSSION

This study retrospectively reviewed the effectiveness of a rehabilitation program in treating iliopsoas syndrome. From this study, it appears the rehabilitation program contributed to reduction of the activity restriction imposed on patients by iliopsoas syndrome. 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 primary data studies of iliopsoas syndrome in the literature (literature totals of 23 male:45 female and mean The age of 25.4 years) 5.8.9~11~'6~1~n symptoms of iliop soas syndrome resulted more frequently from overuse (7 patients) than from trauma (2 patients) in this study. In the literature, 8 individuals diagnosed with iliopsoas syndrome were the result of trauma5.8.~ I .' and 57 were attributable to an active life21 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 increasing 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 CONCLUSION course of patient monitoring. Seven patients indicated in a telephone interview that they benefited from We have conducted a retrospective analysis of a rethe physical therapy home program. Only 1 patient habilitation program for the treatment of iliopsoas stated that this program was ineffective.As noted syndrome. A rehabilitation program of hip rotation previously, 1 patient was unavailable for telephone instrengthening and stretching appears to improve terview but has been included in the following analypain and function of those patients with iliopsoas sis. With the persons who reported benefiting from syndrome. Although this study was a retrospective the physical therapy home program, 6 patients had case series, it provided one of the few documented improved activity levels at the point their treatment rehabilitation studies in the literature, providing a had ended. Only 1 of these patients had further imbasis for the development of future experimental provement at the time of telephone follow-up. Two study designs. patients had no change from their initial condition after treatment had ended, and only 1 showed improvement at the time of patient follow-up. All paACKNOWLEDGMENTS tients, with the exception of l who showed no initial improvement after treatment, were either moderately The authors thank the office staff for their help or very compliant. These data suggest that the rehawith identifying the appropriate patient charts and bilitation program, when performed consistently, was Hugh Tyreman for his assistance in maintaining and successful in decreasing pain and permitted the paaccessing the patient computer database. The auJ Onhop Sports Phys Ther*Volume 29.Number 40April 1999

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 present for 12.6 18.4 months and ranging from a minimum of 1 to a maximum of 60 months prior to diagnosis 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 patients with no control group. Our conclusions, therefore, 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 survey to each patient. Because some interpretation of the patient's responses was necessary, bias was potentially introduced into the study. Despite this, it is important to note that this is the first study in the literature outlining a detailed rehabilitation program for iliopsoas syndrome. Therefore, it provides a foundation 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 primarily 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.

thors a s thank Geoff Elliott for his assistance in lo preparing this manuscript.
~

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