Iliopsoas Tendinopathy: Overview and Evidence Summary

Condition Overview

Iliopsoas tendinopathy refers to irritation, degeneration, or overload of the iliopsoas tendon as it crosses the anterior hip. Because of its deep location and complex function, this condition is often misunderstood or misdiagnosed. The iliopsoas is not just a hip flexor — it is a key stabiliser of the lumbar spine, a guide for hip mechanics, and an important contributor to gait, stair climbing, athletic acceleration, and postural control. When the tendon becomes overloaded or irritated, patients may experience deep anterior hip or groin pain that can mimic hip joint pathology, sports hernia, or even abdominal conditions.

The tendon passes through a tight anatomical corridor, gliding over the iliopectineal eminence and attaching to the lesser trochanter of the femur. With repetitive loading — especially activities involving hip flexion, sprinting, uphill running, kicking, dance movements, or prolonged sitting — the tendon can become irritated. In some individuals, the iliopsoas bursa becomes inflamed alongside the tendon, adding a component of compressive irritation.

Unlike acute strains, iliopsoas tendinopathy typically develops gradually. Patients often describe a dull ache at the front of the hip that worsens with lifting the knee, transitioning from sitting to standing, walking uphill, or performing dynamic movements like lunges or kicks. Runners and athletes may feel their stride become “tight” or “restricted,” with reduced hip extension contributing to altered mechanics.

Central to understanding iliopsoas tendinopathy is recognising that it rarely reflects a single insult. Instead, it emerges from cumulative loading, impaired lumbopelvic control, reduced hip extension mobility, or compensatory movement patterns. Successful rehabilitation therefore requires more than simply treating the tendon — it involves restoring healthy hip extension, improving core–pelvic stability, addressing gait mechanics, and gradually reintroducing load in a structured, patient-specific manner.

Summary of Current Evidence for Iliopsoas Tendinopathy

Evidence-Based Management Discussion

Anatomical Considerations and Mechanisms

The iliopsoas complex consists of the psoas major and iliacus muscles, merging into a common tendon that attaches to the lesser trochanter. This structure is responsible for powerful hip flexion, but equally important is its stabilising role: it anchors the lumbar spine, helps maintain upright posture, and controls hip translation during movement.

Several mechanical and lifestyle factors contribute to tendinopathy:

• Prolonged sitting places the iliopsoas in a shortened position, leading to stiffness or adaptive shortening that increases compressive loads during activity.

• High-volume hip flexion activities—running, martial arts, cycling, swimming flutter kicks—can overload the tendon, especially when performed with insufficient recovery.

• Reduced hip extension forces the iliopsoas to compensate during gait, magnifying strain.

• Weakness in gluteal musculature shifts stabilising demands to the iliopsoas, making it work harder to control the pelvis.

Degenerative changes within the tendon may occur over time, often without overt inflammation. This aligns with contemporary understanding of tendinopathy: the tissue becomes less tolerant of load, more prone to pain with stress, and sensitive to mechanical compression.

Clinical Presentation

Patients typically describe deep, aching pain in the anterior hip or groin, sometimes radiating slightly toward the thigh. Pain intensifies with:

• Active hip flexion (lifting the knee)

• Rising from a seated position

• Walking uphill or climbing stairs

• Running, especially at faster paces

• Straight-leg raises in exercise settings

On examination, resisted hip flexion, active straight-leg raise, and palpation near the iliopsoas tendon can reproduce symptoms. Reduced hip extension in gait is often notable. Clinicians must distinguish iliopsoas tendinopathy from intra-articular hip pathology, femoral neck stress injury, sports hernia, and lumbar spine referral.

Ultrasound and MRI can identify tendon thickening or bursitis when diagnosis is unclear; however, clinical reasoning remains central.

Rehabilitation: Building Load Tolerance and Restoring Function

Early Phase: Load Management and Pain Reduction

Initial goals include calming tendon irritability while maintaining movement. Complete rest is rarely helpful; instead, patients modify aggravating activities while performing comfortable mobility work.

Gentle stretching of the iliopsoas may reduce anterior hip stiffness, but must be applied carefully—overstretching a reactive tendon can worsen symptoms. Short, frequent bouts of comfortable hip extension mobility are preferable to intense static stretches.

Isometric hip flexor loading (e.g., resisted marches) may help modulate pain and preserve tendon capacity in this early stage.

Middle Phase: Strengthening and Biomechanical Correction

As pain decreases, structured loading becomes the centrepiece of treatment. Exercises typically progress from simple to complex:

• Isotonics such as hip flexion with resistance bands, seated resisted marches, and standing hip flexor lifts.

• Hip extension mobility and gluteal strengthening to reduce reliance on the iliopsoas during gait and activity.

• Core training emphasising deep stabilisers to improve lumbopelvic control.

This phase often reveals compensatory patterns: excessive lumbar extension, pelvic tilt abnormalities, or insufficient gluteal activation. Correcting these is essential for long-term improvement.

Late Phase: Return-to-Sport and Dynamic Loading

In athletic populations, tendons must withstand rapid contraction and stretch cycles. Progressions include:

• Faster hip flexion drills

• Running stride mechanics training

• Plyometric or elastic loading for the hip flexors

• Sport-specific drills (kicking, sprint starts, dance movements)

By this stage, pain should be minimal and tendons demonstrating good tolerance to progressively higher loads.

Manual Therapy and Adjunctive Methods

Manual therapy alone does not fix tendinopathy but supports recovery by reducing muscle tension, improving joint mobility, and facilitating movement. Techniques may include:

• Psoas soft-tissue release

• Hip joint mobilisation (especially improving extension)

• Lumbar mobilisation

• Myofascial work to surrounding structures such as rectus femoris, adductors, and quadratus lumborum

Bursa injections may help in clear cases of iliopsoas bursitis, but should complement—not replace—rehabilitation.

Long-Term Outcomes and Prevention

Outcomes are excellent when rehabilitation is comprehensive and progressive. Recurrence often occurs when athletes return to high-intensity training too quickly, or when underlying hip extension deficits persist.

Preventive strategies include:

• Maintaining hip extension range

• Strengthening gluteals and deep core

• Graded running or sport programming

• Balanced training loads

• Avoiding prolonged sitting without movement breaks

References

Blankenbaker, D. et al. “Iliopsoas Tendinopathy and Bursitis: Imaging Features and Clinical Correlates.” American Journal of Roentgenology.

Goom, T. et al. “Tendinopathy: Rehabilitation Strategies and Clinical Reasoning.” Journal of Orthopaedic & Sports Physical Therapy.

Philippon, M. et al. “The Role of the Iliopsoas in Hip Function and Pathology.” Clinical Sports Medicine.

Hogan, C. et al. “Clinical Diagnosis and Management of Iliopsoas-Related Hip Pain.” Manual Therapy and Rehabilitation Review.

Reiman, M., et al. “Lumbopelvic Control and Hip Mechanics in Overuse Hip Injuries.” Sports Physical Therapy International.

Disclaimer:
The information in this article is intended for educational purposes within the context of continuing education for massage therapists, continuing education for athletic trainers, continuing education for physical therapists, continuing education for chiropractors, and continuing education for rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Although every effort has been made to ensure accuracy and reflect current understanding at the time of publication, practitioners must always work within the legal scope of their professional practice and follow all regional regulatory guidelines.

Hands-on techniques and clinical applications described in this material should only be performed by appropriately trained and licensed professionals. Individuals experiencing pain or symptoms should be referred to a qualified healthcare provider for assessment. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use or misuse of the information provided in this content.