psoas bursitis test

Articular and muscular lesions of the hip

>>> Efficient clinical reasoning is the key element for more successful treatments...

The patient is describing some pain in the groin area:

  • is there a psoas or rectus femoris lesion?
  • Or, some kind of "impingement" in the hip such as an internal derangement (loose body?)
  • Or, could there be a psoas bursitis instead?

    A good basic clinical  examination will be helpful to reach a diagnosis and to set an efficient treatment plan.

The capsular pattern at the hip, as originally described by Dr. Cyriax, is a normal range of lateral rotation and adduction, with limitation in the other directions. Medial rotation and abduction are the most limited movements, flexion is more limited than extension.

However, in more recent literature there seems to be some controversy on the validity of this capsular pattern.

The key elements are a limited medial rotation and flexion, while other movements are less limited.

The clinical pattern of osteoarthrosis is a capsular pattern with a hardened end-feel. Sometimes there is no direct relation between medical imaging and the intensity of the symptoms : one can have marked degeneration, visible on medical imaging, without hardly any symptoms.

Besides, negative medical imaging does not exclude other pathology.  Hence, a basic idea in the Cyriax method is to treat clinical patterns instead of medical imaging.

It is functionally important to maintain the best possible range of hip extension, in order to avoid putting too much strain on the lumbar spine.

Treatment

If the osteoarthrosis is not too advanced, capsular stretching is highly recommended ; the pain at night and the pain on walking quickly improve considerably. The range of movement, however, does not change appreciably.

The capsule is stretched mainly in three directions : flexion, extension and medial rotation ; it can also be stretched towards abduction.

A treatment session consists always of a combination of these three (four) techniques. Keep in mind that a good dosis of capsular stretch produces an hour or two after pain. We need to adapt the intensity of the stretch accordingly.

If the osteoarthrosis is too advanced for capsular stretching and while awaiting surgery, other options could be the desensitization of the posterior capsule (infiltration of 50 cc procaine, 0.5 %). The improvement lasts a few months and the infiltration can be repeated as often as needed, until surgery is called for. Or, repeated injections of hyaluronic acid can also offer temporary relief.

This disorder is not rare, but the diagnosis is seldom made since the fragment(s), if they are not bony fragments, do not show on medical imaging.

The history is typical of internal derangement : intermittent twinges felt in the front of the thigh and giving way of the limb. During an acute phase, the capsular pattern of osteoarthrosis becomes non-capsular : passive flexion is now more limited than usual and we don’t reach the hard end feel anymore which was typical for the arthrotic joint. Possibly, passive lateral rotation now hurts more than medial rotation. If the loose body is not bony, then manipulation offers immediate relief of symptoms. If loose bodies are bony, surgery is called for.

Spontaneous onset of anterior thigh/groin pain. Clinically we find :

  • pain on passive flexion, lateral rotation and extension, with a soft end-feel.
  • Passive adduction in 90° hip flexion, as a complementary test, is generally the most painful movement. THE psoas bursitis test.
  •  In most cases, treatment consists of infiltration of a local anaesthetic, which also confirms the diagnosis. In a minority of cases, triamcinolone is added.

     Some enlarged bursae have been reported to produce a palpable mass in the groin, causing extrinsic pressure on adjacent neurovascular structures, possibly resulting in paraesthesia.

    Muscular lesions at the hip are rather uncommon, except for an adductor or psoas lesion. When more resisted tests prove positive, we first have to exclude a bursitis.
  • The psoas bursitis test

    Resisted adduction hurts at the upper inner thigh. Most often, the lesion lies at the musculotendineous junction, sometimes at the tenoperiosteal junction.
    Important : when we think of a tendinitis, palpation should be positive at one of these sites. If not, a fracture or dislocation or metastases in the os pubis should be suspected and medical imaging examination is called for. (Healing of the fracture - stress or injury - is expected in 6-8 weeks.)

     A psoas muscle strain is rather uncommon but can be treated quickly and efficiently by deep friction. The resisted hip flexion is painful of course, but we should make sure that the test is performed in 90° hip flexion, to avoid too much involvement of the upper quadriceps, which would influence the test in an unwanted way.
    The lesion generally lies in the lower part of the muscle belly, just below the inguinal ligament, medial to the sartorius muscle. Here too, palpation should be positive.

    A simple tendinitis is extremely rare ; usually the lesion is a traction fracture of the SIAS in an adolescent.
    History : while running, the patient felt a sudden painful click in the groin and the thigh ; since then, he can only walk with pain and cannot run. The examination shows pain and weakness on resisted flexion and lateral rotation ; resisted knee flexion also hurts. On palpation, there is local tenderness at the SIAS and the cranial 2 cm of the muscle. Spontaneous recovery is expected in two to three weeks.

    A muscle lesion here is very rare. When resisted abduction or extension hurts, a bursitis is suspected first ; a lesion of a contractile structure is only our second thought. e) Iliotibial band The lesion usually lies just above the greater trochanter ; it gives rise to the same symptoms as a gluteal/trochanteric bursitis.
    The signs are : pain on trunk side flexion away from the painful sinde, and pain on passive hip adduction. A complementary test, trunk side flexion with the legs crossed, hurts more. Deep friction is the treatment of choice. Occasionally, the clinical pattern resembles that of a gluteal/trochanteric bursitis ; if passive abduction also hurts, bursitis is more likely (the bursa will be squeezed in).
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