Evaluation and Management of the Snapping Iliopsoas Tendon

Revision of hip flexor anatomy and function in modern humans, and implications for the evolution of hominin bipedalism

Hip flexor musculature was instrumental in the evolution of hominin bipedal gait and in endurance running for hunting in the genus Homo. The iliacus and psoas major muscles were historically considered to have separate tendons with different insertions on the lesser trochanter. However, in the early 20th century, it became "common knowledge" that the two muscles insert together on the lesser trochanter as the "iliopsoas" tendon. We revisited the findings of early anatomists and tested the more recent paradigm of a common "iliopsoas" tendon based on dissections of hips and their associated musculature (n = 17). We rediscovered that the tendon of the psoas muscle inserts only into a crest running from the superior to anterior aspect of the lesser trochanter, separate from the iliacus. The iliacus inserts fleshly into the anterior portion of the lesser trochanter and into an inferior crest extending from it. We developed 3D multibody dynamics biomechanical models for: (a) the conjoint "iliopsoas" tendon hypothesis and (b) the separate insertion hypothesis. We show that the conjoint model underestimates the iliacus' capacity to generate hip flexion relative to the separate insertion model. Further work reevaluating the primate lower limb (including human) through dissection, needs to be performed to develop those datasets for reconstructing anatomy in fossil hominins using the extant phylogenetic bracket approach, which is frequently used for tetrapods clades outside of paleoanthropology.

Hip Flexor Injuries in the Athlete

Athletic injuries to the hip flexors and iliopsoas have been described in populations across all levels of competitive sports. Overall estimates of hip flexor pathology have ranged from 5% to 28% of injuries among high-risk sport specific groups. Although most of these injuries are successfully treated with conservative management, and high rates of return to play are observed, significant rehabilitation time can be involved. As the understanding of hip pathology with imaging modalities such as MRI has advanced, greater importance has been placed on accurately diagnosing hip flexor injuries and initiating rehabilitation protocols early to minimize time loss from sport.

Magnetic Resonance Imaging Appearance of the Hip Musculature After Arthroscopic Labral-Level Iliopsoas Tenotomies

BACKGROUND

Iliopsoas (IP) muscle atrophy is a known consequence of open IP tenotomy, but the severity of IP muscle atrophy that occurs after arthroscopic labral-level IP tenotomies has not been documented.

PURPOSE

To document the severity of muscle atrophy that occurs in the iliacus, psoas, and adjacent hip musculature after arthroscopic labral-level IP tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-eight patients who had magnetic resonance arthrograms (MRAs) obtained prior to and 3 months to 5 years after arthroscopic labral-level IP tenotomies are the basis of this report. The pre- and postoperative MRAs of each patient were examined in consensus by 2 musculoskeletal radiologists who graded the postoperative muscle atrophy from 0 (no fatty infiltration) to 4 (>75% fatty infiltration) and noted any compensatory muscle hypertrophy or abnormal IP tendon morphology. Patients also were assessed with the Byrd 100-point modified Harris Hip Scoring system (MHHS) preoperatively and at the time of their postoperative MRA.

RESULTS

Postoperative MRAs were obtained on average 1.7 years (range, 3 months to 5 years) after hip arthroscopy. None of the patients had muscle atrophy on their preoperative MRAs. In contrast, 89% of patients had iliacus and psoas muscle atrophy on their postoperative MRAs, but only 2 (7%) developed grade 4 atrophy, and the majority (64%) had either grade 1 (n = 15) or no atrophy (n = 3). In addition, there were no significant differences in the MHHS of the patients with mild (grades 0-1), moderate (grades 2-3), or severe (grade 4) postoperative atrophy. Postoperative MRAs also demonstrated low-grade atrophy (grades 1-2) in the quadratus femoris (n = 5) and rectus femoris (n = 1) muscles, and 16 patients (57%) had distortion of the tendon, but none had a gap in their tendon.

CONCLUSION

A majority of patients (89%) developed IP muscle atrophy after arthroscopic labral-level IP tenotomies, and although this percentage was similar (89% vs 90%) to that reported with lesser trochanteric IP tenotomies, the patients did not (1) develop atrophy of the gluteus maximus and vastus lateralis muscles, (2) have chronic IP tendon disruption, or (3) develop the severity of IP atrophy (55% grade 4 vs 7% grade 4) that has been reported after arthroscopic lesser trochanteric IP tenotomies.

A MRI study of the lesser trochanteric version and its relationship to proximal femoral osseous anatomy

The purpose of this study is to quantify the lesser trochanteric version and determine the angle and the relationship between lesser trochanter and femoral neck version. Investigate the influence of the lesser trochanter version in the width of ischiofemoral space. Two hundred and fifty asymptomatic hips were evaluated with axial magnetic resonance image. The lesser trochanter version was calculated. The difference between the femoral neck version and the lesser trochanter version formed the angle between each structure. The width of ischiofemoral space was measured and its relationship with the lesser trochanter version was determined. The mean lesser trochanter version was -24° ± 11.5° (range, - 54° to + 17°) with a coefficient variation of 47.45%. The mean femoral neck version measured 14.0° ± 10.8° (range, -16° to 50°), with a coefficient variation of 81.32%. The lesser trochanter/femora neck angle was 38.4° ± 9.6° (range, 8° to 67°), coefficient variation of 30%, with a moderate correlation between the structures (r = 0.63, P < 0.01). The mean ischiofemoral space was 22.9.0 ± 7.0 mm (range, 10.3 to 55 mm), and a weak correlation was found between ischiofemoral space and lesser trochanteric version (r = -0.16, P < 0.05). The lesser trochanteric version showed a high variation with a moderate relationship with the femoral neck version. The lesser trochanteric version does not influence the width of the ischiofemoral space.

Surgical management of internal snapping hip syndrome: a systematic review evaluating open and arthroscopic approaches

PURPOSE

This systematic review explored reported outcomes addressing internal snapping hip as well as comparing outcomes between open and arthroscopic management of internal snapping hip syndrome.

METHODS

Two databases (Embase and Medline) were screened for clinical studies involving the surgical management of internal snapping hip syndrome. Two reviewers conducted a full-text review of eligible studies and the references of these studies. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies.

RESULTS

We identified 11 eligible studies involving 248 patients. The mean age of the participants was 26.5 years (range, 14 to 62 years). The 2 most commonly reported standardized outcome measures were the modified Harris Hip Score (27%) and the Western Ontario and McMaster Universities Osteoarthritis Index (18%). Six studies (54%) presented return to the same level of competition or activities of daily living as an outcome. Among patients undergoing arthroscopic management for this condition, postoperative improvements in the modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score were greater in the studies involving transection at the lesser trochanter compared with the transcapsular technique. Standardized outcome measures were not reported among patients undergoing open procedures. Resolution of snapping was seen in 100% of patients who underwent arthroscopic release and 77% of open procedure patients. Complication rates were higher in patients undergoing an open procedure (21%) compared with an arthroscopic procedure (2.3%).

CONCLUSIONS

This review shows a decreased failure rate, fewer complications, and decreased postoperative pain with arthroscopic management of internal snapping hip syndrome in comparison with open management. However, given the lack of high-quality evidence or direct comparison data, these results should be interpreted with caution. This review also highlights the need for the development of a standardized outcome tool for consistent reporting of clinical outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Extra-articular hip endoscopy: A review of the literature

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

Accessibility of extra-articular pathologies of iliopsoas tendon and bursitis of greater trochanter in hip arthroscopy

PURPOSE

Different pathologies leading to psoas tendon pain and chronic bursitis of the greater trochanter are well known. The purpose of the study was to underline the accessibility of the psoas tendon at lesser trochanter, reproduce the results and measure the distances to anatomical landmarks.

METHODS

Twelve hips of six human cadavers underwent hip arthroscopy. The accessibility of the iliopsoas tendon at the lesser trochanter and the bursa at the greater trochanter was documented with the camera. In addition to the usual access portals, alternative ventral ports were analysed concerning accessibility of the lesser trochanter. Afterwards, arthroscopy needles were placed along the extra-articular portals followed by dissection. The distances of the portals in relation to important anatomical landmarks were analysed.

RESULTS

The accessibility to the iliopsoas tendon at the lesser trochanter and to the bursa at the greater trochanter throughout the conventional portals was reproducible. Sufficient distances to the important anatomical landmarks could be shown. The mean distance of the distal ventro-lateral and the wide distal ventro-lateral portal to the nervous cutaneous femoris lateralis was 26.8 ± 5.4 mm and 32.2 ± 3.9 mm. The mean distance from the more ventral located portals to the nervous arteria and vena femoralis was 28.3 ± 2.1 mm.

CONCLUSION

This is the first study known to us that describes in detail the accessibility of the extra-articular structures underlined by anatomical preparation. In addition, it was demonstrated that a more ventrally located portal had sufficient distance to the important neurovascular structures of the ventral femur and can also be used in addendum if necessary.

[Hip arthroscopy - indications and limits]

Through continuous improvement and advancement of technology over the last 10 years, hip arthroscopy has developed into a standard orthopedic procedure and this has greatly expanded the range of indications. The main indications for hip arthroscopy include any disorder of the synovial membrane, damage to the labrum acetabulare, lesions of the ligament of the head of the femur, loose bodies, degenerative and traumatic cartilage lesions and especially disorders of the joint mechanism caused by femoroacetabular impingement. Increasingly, endoscopic procedures additionally allow the treatment of periarticular pathologies. Hip arthroscopy is limited in particular due to the difficult anatomy, a large distance from the skin to joint cavity and the problematic visualization of the posteromedial joint area. Furthermore, a time-limited distraction of the joint must be considered in the choice of therapy.

Soft tissue pathology around the hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes

BACKGROUND

An arthroscopic iliopsoas tendon release will alleviate painful snapping of the tendon. One question that remains is whether athletes can return to sports after this procedure. This study presents the results of 5 competitive and 10 recreational athletes who had an arthroscopic release of their iliopsoas tendon.

HYPOTHESIS

Athletes can return to full participation in their sport after an arthroscopic iliopsoas tendon release.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifteen athletes (2 college, 3 high school, 10 recreational) with painful snapping hips and no pain relief after anesthetic magnetic resonance arthrography had an ultrasound evaluation of their iliopsoas tendon and an anesthetic injection into the psoas bursa. In all 15 patients, the injection relieved their hip pain, and in 10 patients, real-time imaging demonstrated snapping of the tendon. All hips were assessed with Byrd's 100-point hip scoring system before the release and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

Preoperative hip scores averaged 41 and 44 points for the competitive and recreational athletes, respectively. After surgery, the 2 groups used crutches for 4 weeks, and had 6-week scores that averaged 87 and 63 points. At 6 months, their scores averaged 94 and 98 points, and at 12 months, 96 and 97 points, and none had recurrence of their snapping or pain. All 15 athletes returned to full participation in their sport at an average of 9 months after surgery.

CONCLUSION

A return to college, high school, and recreational sports can be expected after an arthroscopic release of the iliopsoas tendon.

Clinical outcome following a modified approach for psoas lengthening for coxa saltans in adults

Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different surgical approaches have been suggested in the literature with varying results. We describe a modified surgical approach for internal snapping of hip in adults with good results. Patients who failed conservative treatment for internal snapping over 11/2 years were included. A skin crease incision was made just lateral to the ASIS in supine position. The psoas tendon was reached sub-periosteally along the internal iliac surface and a hole was made in periosteum. Then the tendon was hooked into the wound and divided releasing its musculotendinous junction. The patients were allowed to mobilise as able in the postoperative period. There were 8 snapping hips (7 patients, 6 females) with average age of 30 years (17-51 yrs). The mean follow-up was 11 months. The average duration of symptoms before operation was 4.5 years (range 2-10 years). Painful symptomatic clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh. The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extrapelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and subperiosteal approach through oblique inguinal incision in adults, psoas muscle release at musculotendinous junction seems a safe and effective method and could be used as an alternative surgical approach for treatment of internal snapping of hip in adults.

Arthroscopic treatment of the painful "internal" snapping hip: results of a new endoscopic technique and imaging protocol

BACKGROUND

Traditional surgical treatment for a painful snapping iliopsoas tendon has been an open lengthening of the tendon.

HYPOTHESIS

An endoscopic release will alleviate painful snapping of the tendon.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Six patients with painful snapping hips who had no pain relief after magnetic resonance arthrography, which included injection of bupivacaine into the hip joint, subsequently had an ultrasound evaluation of their iliopsoas tendons and an anesthetic injection into the psoas bursa. In all 6 patients, the injection relieved their hip pain, and in 4, real-time imaging demonstrated snapping of the tendon. All hips were evaluated with the 100-point Harris hip scoring system before and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

Preoperative hip scores averaged 58 points. After surgery, all patients had hip flexor weakness, used crutches for 5 weeks, and had 6-week scores that averaged 62 points. The patients continued to improve, and at 6 and 12 months, their scores averaged 90 and 96 points, respectively, and none had recurrence of their snapping or pain.

CONCLUSION

Ultrasound-guided anesthetic injection of the psoas bursa is useful to confirm snapping of the iliopsoas tendon as the cause of a patient's hip pain. Endoscopic release of the tendon is a safe outpatient procedure that provides effective relief of the snapping and pain.