Massage Therapy Vancouver, Vancouver Massage Therapy
General Discussion
Do you or your patients or clients have
Iliopectineal Bursitis? Do they 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 hyper tonicity common in cross country
skiers, kickers, dancers, gymnasts and long distance runners. (1)
Anatomy/ Kinesiology:
The hip joint capsule is composed of three very strong ligaments
(iliofemoral, pubofemoral and ischiofemoral). The strongest being 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. The synovial cavity often communicates
anteriorly with the iliopectineal bursa. (2)
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 about
the hip, out of eighteen; 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. (3)
Assessment:
In this section I will explore some key points involved with assessment
of this condition. It is not meant to replace comprehensive
assessment(s) involved with differential diagnosis or massage therapy
diagnosis.
A. Key history taking/red flags:
1. 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.
2. Any previous hip injuries or leg length differences?
- This could lead to secondary arthritis, which can contribute to the bursa swelling.
3. 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.
4. 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.
5. 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 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.
B. Observation:
Observe patients' gait and standing posture for any obvious abnormalities.
(guarded or antalgic gait, increased pelvic angle and heights, sway back, lumbar scoliosis)
C. Palpation:
There may be localized tenderness interiorly if the iliopectineal bursa
is inflamed or distended. The iliopsoas muscles may be tender and
sensitive or painful to the touch. (4)
D. Range of motion assessment:
A full range of motion assessment should be performed 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. If a capsular pattern of restriction is present, there may be joint effusion and or osteoarthritis/capsular fibrosis.
Key finding: there will likely be pain and weakness with resisted hip
flexion and localized pain with passive hip extension, as both of these
motion tests will compress the bursa.
For your reference:
Active Range of Motion:
|
|
120 degrees
|
|
|
30 degrees |
|
|
45 degrees |
|
|
30 degrees
|
|
|
45 degrees |
|
|
35 degrees
|
Capsular Pattern of Restriction:
Flexion, Abduction, and Medial Rotation > Extension, Adduction and Lateral Rotation. (5)
E. Neurological and referred pain:
The low back should be examined for nerve root involvement.
Examine the L1, L2, L3 dermatomes for sensory loss and reflexes of L4 and S1 (Patella, Achilles).
The femoral nerve (L2-4) 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 chosen to confirm this condition are as follows:
Thomas test: to show shortening hip flexors. This test is usually positive.
Procedure: Supine patient flexes on knee to chest while keeping the
other leg straight, the examiner observes for straight leg elevation. (6)
Faber's test: to show shortening of the adductors, flexors and hip
joint capsule and any sacroiliac involvement. This test is usually
positive.
Procedure: Patient supine, examiner instructs patient to cross legs
into a figure (4) position (ankle placed above contra lateral knee),
examiner then stabilizes pelvis and applies gentle downward pressure
over the flexed knee. (7)
Femoral Nerve Stretch test: to show any involvement of the femoral nerve. This test should be negative unless the bursae are pressing on the nerve.
Procedure: Patient prone with knee flexed 90 degrees, with one hand
examiner applies downward pressure over the PSIS, & lifts the
patient's knee off the examining table & attempt to extend the
thigh with the other hand. (8)
Scour test: to 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.
Procedure: The examiner flexes and adducts the patient's hip so that
the hip faces the patient's opposite shoulder and resistance to the
movement is felt. As slight resistance is maintained, the patient's hip
is taken into abduction while maintaining flexion in an arc of
movement. (9) (Perform with care!)
Treatment/ Management:
In the sub acute and chronic state of the condition, what I have found to be very helpful is:
- Manual stretch and trigger point release of the Iliopsoas, Iliacus and Rectus Femoris;
- Active Release techniques for the hip flexors;
-
Lateral and axial distractions, grades 2-3 sustained glides and grades 3-4 oscillations;
-
Frequency of treatments usually 1-2 per week for 6-8 weeks;
-
Providing hip flexor stretching exercises and strengthening the abductors to create hip/pelvis stability.
Other suggestions:
Ice or cold applications to the affected area after activity or when irritation or swelling are present.
Ultrasound/interferential may be used to reduce inflammation and swelling.
References:
