Cause
Movement of iliopsoas tendon over femoral head / iliofemoral ridge / iliofemoral ligament
Can be seen following THA with cup impingement
Symptoms
Audible or palpable snap in the groin
Hip moves
- from flexed / abducted / externally rotated position
- to extended / internally rotated position
Incidence
10% of the population - usually painless
Examination
Move hip
- from flexed / abducted / externally rotated position
- to extended / internally rotated position
Diagnosis
Dynamic ultrasound
Arthroscopy
May see inflammation of labrum medially
Management
Nonoperative
Physical therapy
NSAIDS
Ultrasound guided injections into iliopsoas bursa
Operative release
Options
Arthroscopic versus open release
- systematic review of surgical options for internal snapping
- 11 studies and 248 patients
- resolution of snapping seen in 100% arthroscopic and 77% open procedures
- complications seen in 2% arthroscopic and 21% open procedures
Trans-capsular fractional lengthening (arthroscopic) versus release at lesser tuberosity (endoscopic)
Ilizaliturri et al Arthroscopy 2009
- prospective RCT of 19 patients
- no difference in outcomes
Ilizaliturri et al Arthroscopy 2014
- comparative study of 20 patients
- one recurrence in group undergoing trans-capsular fractional lengthening
Arthroscopic trans-capsular technique / fractional lengthening
Technique
Arthroscopic technique article
Identify psoas tendon medially
- iliopectineal groove
- at this level the iliopsoas is half tendon and half muscle
- perform fractional lengthening
- release tendon but not muscle
Arthroscopic release at lesser tuberosity
Use image intensifer to triangulate to lesser tuberosity
Psoas tendon Diathermy release Cleared lesser tuberosity
Results
Efficacy
Gouveia et al Am J Sports Med 2021
- systematic review of outcomes after arthroscopic psoas release
- 21 studies with 875 hips
- majority trans-capsular / level of labrum (93%) versus at lesser tuberosity (7%)
- 93% resolution of internal snapping
- those evaluating strength identified normal strength in 2 studies, and mild decrease in 2 studies
- compared cohort of patients undergoing labral repair and psoas release to those undergoing labral repair only
- >350 in each group
- no difference in outcomes
- having an arthroscopic fractional lengthening of the psoas tendon did not adversely affect outcomes
- compared competitive athletes undergoing FAI surgery to those undergoing FAI surgery + iliopsoase release
- 91% resolution in painful snapping
- no difference in return to sport rates (90%) between two groups
Complications
Weakness
- incidence unclear
- may be decreased with trans-capsular fractional lengthening versus complete release at lesser tuberosity
Continued painful snapping
- may be less common with release at lesser tuberosity
Hip dislocation
- two case reports after psoas release
- important to perform interportal closure in those at high risk
Abdominal compartment syndrome
- associated with hip arthroscopy and trans-capsular psoas release
- allows fluid extravasation into peritoneal compartment
- consider performing after central and peripheral compartment arthroscopy