The syndrome of iliopectineal bursitis may be overlooked easily in making a differential diagnosis of lesions of the hip joint if its likelihood is not kept in mind. This point is well illustrated by the occurrence of a large tumor mass in the right groin of an elderly man. Competent internists, surgeons and orthopedists examined the mass and made several diagnoses, but iliopectineal bursitis was not mentioned, even indirectly. As a matter of fact, the correct diagnosis was established by operation and by a study of the literature, which confirmed my opinion that this disease has not received the clinical attention that it deserves. The history and symptoms were fairly typical of slowly progressive hypertrophic arthritis involving many joints over a period of years; the right hip joint.
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General Discussion Do you or your patients or clients suffer from anterior hip joint pain, especially with any physical exertion? This could be as a result of irritation to the iliopectineal bursae, which is usually due to tight hip flexors Iliopsoas, Rectus Femoris and a tight hip joint capsule. Although there are many conditions that cause anterior hip and thigh pain like hip degenerative arthritis, femoral nerve entrapment, lumbar facet syndrome and inguinal hernias; a simple cause is iliopectineal bursitis.
This article will focus on the etiology, anatomy, kinesiology, clinical signs and symptoms, assessment and a few treatment techniques for manual therapist. Etiology: Friction trauma from muscle hypertonicity — common in cross country skiers, kickers, dancers, gymnasts and long distance runners.
The strongest is the iliofemoral, sometimes described as the Y ligament of Bigelow as it looks like a inverted Y. These ligaments are such that they twist and compress the joint with every step or stance phase of gait. This action compresses the articular cartilage and thus bathes the articular surfaces in synovial fluid. The synovial membrane of the hip joint lines the fibrous layer of the capsule. This is interesting to note as synovial fluid can travel from the joint capsule to the bursae and vice versa.
This means that with joint irritation, degenerative joint disease or synovial effusion, the bursae may also become swollen or irritated. There are three clinically significant bursae surrounding the hip out of 18 ; they are the Trochanteric, Ischiogluteal and Iliopectineal or iliopsoas bursae.
The rather large iliopectineal bursa overlies the anterior aspect of the hip joint and the pubis and lies beneath the Iliopsoas muscle as it crosses in front of the hip joint.
This bursa often communicates with the hip joint anteriorly through a space between the Pubofemoral and Iliofemoral ligaments. This may be a factor in the characteristic anterior pain experienced by patients with hip joint disease.
How would you describe your level of activity? Athlete versus weekend athlete. Are there any periods of prolonged sitting or inactivity? Periods of prolonged sitting followed by physical exertion can shorten the Psoas muscle and may contribute to the bursae irritation. Any previous hip injuries or leg length differences?
This could lead to secondary arthritis, which can contribute to the bursa swelling. Can you identify the site of irritation? The patient can usually identify the site of the pain in or about the inguinal ligament but pain can radiate to the low back, thigh, gluteal area or even the knee. Is there an increase in pain with weight bearing activity like walking, running, hiking, kicking or hip stretching?
There is usually an increase in pain with these activities. Does the hip pain increase or radiate into the leg s with coughing, sneezing or strained bowel movements?
If the answer is yes to any of the above questions, this is a red flag. The problem may be related to other pathologies like inguinal hernias, disc injuries or space occupying lesions. The patient should then be referred to a physician. Palpation: There may be localized tenderness anteriorly if the iliopectineal bursa is inflamed or distended.
The iliopsoas muscles may be tender and sensitive or painful to the touch. Range of motion assessment: A full range of motion assessment should be done both in closed kinetic and open kinetic chains weight bearing and non weight bearing.
Perform your active range of motion, followed by passive with passive overpressures to determine the joint endfeels. All endfeels should be capsular except hip flexion which is soft. Resisted motion assessment and appropriated selective muscle testing to determine muscle imbalances. Key finding: There will likely be pain and weakness with resisted hip flexion and localized pain with passive hip extension, as both motion tests will compress the bursa. Neurological and referred pain: The low back should be examined for nerve root involvementExamine the L1, L2, L3 dermatomes for sensory loss and reflexes of L4 and S1 Patella, Achilles The femoral nerve L may also be compressed under the inguinal ligament when the bursa swells narrowing the space between the hip joint and the inguinal ligament.
Special tests: There are a few key special tests that can be performed to confirm iliopecteal bursitis or differentiate other conditions. In truth, by the time you have performed your active, passive and resisted testing you should be well on your way to confirming this condition. The four special tests I have chosen to confirm this condition are as follows:.
Procedure: Supine patient flexes on knee to chest while keeping the other leg straight, the examiner observes for straight leg elevation. Test is usually positive. Procedure: Patient supine, examiner instructs patient to cross legs into a figure 4 position ankle placed above contralateral knee , examiner then stabilizes pelvis and applies gentle downward pressure over the flexed knee.
This test should be negative unless the bursae is pressing on the nerve. Scour Test: For joint degeneration, which may be a co-existing condition. This test should be negative, however, the patient will complain of a pinching feeling in the hip joint crease with the test position of flexion, adduction and internal rotation. You may have already discovered this during you range of motion assessment.
As slight resistance is maintained, the hip is taken into abduction while maintaining flexion in an arc of movement. Lateral and axial distractions, grades sustained glides and grades oscillations.
Treatment frequency: usually per week for weeks.
Iliopectineal Bursitis: Case Report
The iliopectineal bursa or the iliopsoas bursa is a large synovial bursa that separates the external surface of the hip joint capsule from the normally just the tendon of the iliopsoas muscle. The most proximal of part the iliopectineal bursa lies on the iliopubic eminence of the superior pubic ramus. The iliopectineal bursa passes across the front of the capsule of the hip joint and extends distally downwards almost as far as to the lesser trochanter. The iliopectineal bursa frequently communicates by a circular aperture with the cavity of the hip joint.