Iliopsoas Bursa Injection

Iliopsoas bursa injection with corticosteroid is an effective treatment of the chronic bursitis of the iliopsoas bursa that’s caused by overuse, especially activities involving repeated hip flexion, such as running, hurdling, etc.

Iliopsoas bursa chronic bursitis is characterized by pain in groin; painful passive flexion, adduction, abduction, extension; resisted flexion and adduction.
Scoop test: passive circular compression of femur from full flexion into adduction.

Equipment Needed

• Syringe: 2.5 ml
• Needle: Spinal , 22 gauge / 3.5 inches (90 mm)
• Kenalog 40: 20 mg
• Lidocaine: 2 ml, 2%
• Total volume: 2.5 ml

Related Anatomy

The psoas bursa lies between the iliopsoas tendon and the anterior aspect of the capsule over the neck of the femur. It is situated deep to three major structures in the groin, the femoral vein, artery and nerve, lying at the level of the inguinal ligament. For this reason, careful placement of the needle is essential. The following technique aims to pass the needle obliquely upwards and medially beneath the neurovascular bundle.

See Also: Snapping Hip Syndrome

Iliopsoas Bursa Injection Technique

• Patient lies supine
• Identify femoral pulse at midpoint of inguinal ligament. Mark a point three fingers distally and three fingers laterally, in line with the anterior superior iliac spine on medial edge of sartorius
• Insert needle at this point and aim 45 degrees cephalad and 45 degrees medially. Visualize needle sliding under the three major vessels through the psoas tendon until point touches bone on the hard anterior aspect of neck of femur
• Withdraw slightly and inject as a bolus deep to tendon.

Aftercare recommendations: avoidance of the activities that irritated the bursa must be maintained until symptom free, and then stretching of the hip extensors and a muscle-balancing programme can be initiated.

Notes

Although iliopsoas bursa injection might appear intimidating at the first attempt, in our experience the approach outlined above is safe and effective. Occasionally, it is possible to catch a lateral branch of the femoral nerve and cause temporary loss of power in the quadriceps. If the patient complains of a tingling or burning pain during the process, either reposition the needle before depositing solution or abandon the procedure and reschedule.

In view of the many differential diagnoses outlined above, a high index of suspicion should be maintained until the clinician is satisfied with the diagnosis. If in doubt, a diagnostic injection of local anaesthetic alone is an option. For large patients, a longer spinal needle might be required.

Iliopsoas tendonitis is uncommon after THA but should be considered in the differential diagnosis of all patients who present with groin pain after THA. Selective steroid and anesthetic iliopsoas bursa injection give adequate pain relief in the majority of patients and should be considered part of the nonoperative treatment plan before surgical release of the iliopsoas tendon or component revision.

Patients with groin pain and a clinically suspected snapping iliopsoas tendon can benefit from iliopsoas bursa injection even if the snapping tendon is not visualized sonographically. The use of a corticosteroid may provide long-term pain relief, and pain relief after injection is a predictor of good outcome after surgical release of the iliopsoas tendon.

References & More

1. Nunley RM, Wilson JM, Gilula L, Clohisy JC, Barrack RL, Maloney WJ. Iliopsoas bursa injections can be beneficial for pain after total hip arthroplasty. Clin Orthop Relat Res. 2010 Feb;468(2):519-26. doi: 10.1007/s11999-009-1141-y. PMID: 19851816; PMCID: PMC2807015.
2. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip. Skeletal Radiol. 2006 Aug;35(8):565-71. doi: 10.1007/s00256-006-0084-6. Epub 2006 Mar 29. PMID: 16570171.
3. Injection Techniques in Musculoskeletal Medicine. A Practical Manual for Clinicians in Primary and Secondary Care. Fifth Edition.