Persistent pain after total hip arthroplasty (THA) has many potential
causes. The most common are aseptic loosening, infection, and heterotopic
ossification. Irritation of the iliopsoas tendon due to the acetabular
component is an underestimated cause of persistent groin pain and functional
disability after THA with rare incidence. Pain specific to iliopsoas tendonitis
includes activities such as hyperextension of the hip, forced flexion, and
activities of daily living (eg, ascending stairs). This article presents a case
of a 50-year old man with clinical and radiological signs of osteoarthritis of
the right hip joint. A THA was performed. After a symptom-free interval of
several weeks postoperatively, the patient reported pain projecting from the
right groin and radiating ventromedially along the leg. Finally, magnetic
resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity
to the femoral nerve causing an iliopsoas tendonitis. The patient was taken to
the operating room and surgical resection of the cyst was performed by an
anterior approach; a conjunction to the hip joint was not present. The
implanted components of the prosthesis showed good osseointegration with no
signs of loosening. The cyst was removed and the iliopsoas tendon was released.
A few weeks after the operation, the patient was pain free. At 17-month
follow-up, no problems were reported. In cases such as this, finding the
correct diagnosis may be difficult and misleading. Conservative and operative
therapeutic options are discussed and compared with divergent findings in the
The most common causes of persistent pain after total hip arthroplasty
(THA) are aseptic loosening, infection, heterotopic ossification, irritation of
the greater trochanter, and referred pain from the spine or knee.1-3
Soft tissue irritation and impingement of the iliopsoas tendon due to the
acetabular component are underestimated causes of persistent groin pain and
functional disability after THA with rare incidence.4 Pain specific
to iliopsoas tendonitis includes activities such as hyperextension of the hip,
forced flexion, and activities of daily living (eg, ascending
Diagnosis may be difficult and misleading. Conservative and operative
therapeutic options are discussed and compared with divergent findings in the
A 50-year-old man presented with clinical and radiological signs of
osteoarthrosis of the right hip joint and a cementless THA was performed. After
a symptom-free interval of several weeks postoperatively, the patient reported
pain projecting from the right groin and radiating ventromedially along the
leg. Certain movements, such as getting up to an upright position, worsened the
pain. Other weight-bearing activities did not aggravate the symptoms.
Clinical examination revealed no rotational or strain pain, but a
painful arc after forced flexion over 70°. No suspicious swelling in the
groin could be observed and an abdominal hernia was excluded.
Native radiographs and computed tomography (CT) scans showed a
well-positioned and osseointegrated THA with no anterior overhang of the
acetabular cup or malpositioning (Figures 1, 2). An aspiration puncture of the
right hip ruled out an infection. Scintigraphy displayed no pathological
findings. Finally, magnetic resonance imaging of the hip showed a fluid-filled
cyst in anatomical proximity to the femoral nerve (Figure 3).
|Figure 1: Native
mediolateral radiograph 3 months after THA. Abbreviation: R, right.
Figure 2: CT of the pelvis showing a good position and
osseointegration of the cup 4 months postoperatively.
|Figure 3: MRI of the
pelvis (axial reconstruction) showing a fluid-filled cyst (*) originating from
the iliopsoas tendon and is connected to the femoral nerve (N) 2 years
postoperatively. Abbreviations: A, artery; V, vein.
The patient underwent resection of the cyst via an anterior approach.
Intraoperatively, it became obvious that the cyst was originating from the
iliopsoas tendon muscle (Figure 4) and in direct contact to the femoral nerve,
thus becoming irritated. A conjunction to the hip joint was not present. The
implanted prosthetic components showed good osseointegration with no signs of
loosening. A minimal ventral overhang of the inlay due to its design was
observed (Figures 1, 2). The cyst was removed and the tendon was released.
Intraoperative situs with fluid-filled cyst originating from the iliopsoas
Histopathological examination disclosed synovial tissue on a neomembrane
typical for a cyst with no signs of malignancy.
Postoperative full weight-bearing activities were allowed. Wound healing
was without complications. The patient was pain free a few weeks
postoperatively. At 17-month follow-up, the patient remained symptom free.
Clinical examination at that time revealed a normal range of motion without
local pressure pain. Activities of daily living as well as sports (eg,
bicycling, taking a walk) were possible with no problems.
Multiple differential diagnoses of groin pain after THA exist. Soft
tissue irritation and impingement of the iliopsoas tendon is an underestimated
cause of persistent groin pain and functional disability after THA. An
oversized acetabular cup, protruding screws, or bone cement may cause iliopsoas
impingement. A relationship was also seen depending on the used material
combination.5 Ala Eddine et al4 reported an incidence of
postoperative iliopsoas tendonitis of 4.3%. Pain specific to iliopsoas
irritation included activities such as hyperextension of the hip, forced
flexion, active raising of the straightened leg, and activities of daily living
(eg, ascending stairs).3,4 A relationship to weight-bearing
activities is uncommon and differentiates this entity from component loosening.
The delayed symptoms seem to be variable, but a pain-free period occurs
after the primary surgical procedure.4
Diagnosing iliopsoas tendonitis may be difficult. Different imaging
modalities (eg, radiograph, ultrasound, CT) may be helpful to rule out
bursitis, malposition of components, or aseptic loosening. Magnetic resonance
imaging is the most sensitive study to determine soft tissue pathologies
despite frequent artifacts due to metallic implants.6,7
In our patient, the components had a good position and were well
osseointegrated with no anterior overhang or malpositioning of the acetabular
To confirm the diagnosis, local steroid and anaesthetic injections of
the iliopsoas bursa are possible. A study from Nunley et al8 found
an improvement of the Harris Hip score and pain relief after local injections,
but nonsurgical treatment may not solve the problem. Therefore, different
surgical procedures such as tenotomy of the iliopsoas or revision of the
acetabular component are possible with good functional outcomes.9-11
Especially in rare patients like the one presented, with local cysts as the
cause of persistent pain, surgical resection should be performed.
Iliopsoas tendonitis should be considered in the differential diagnosis
of all patients with the presented symptoms. Other causes (eg, infection,
aseptic loosening) should be ruled out. Correct cup position and size are
necessary to avoid anterior overhang and impingement symptoms. Malpositioning
of the acetabular cup can be detected by radiograph or CT, but malposition may
not necessarily be the cause of a diagnosis such as in our patient, where the
design of the acetabular inlay was the cause of pain. Temporary pain relief can
be achieved by local injections. For final therapy, a surgical treatment,
consisting of the release of iliopsoas tendon alone with removal of possible
cysts or in combination with acetabular revision for an anterior overhanging
component is recommended.
- Nolan DR, Fitzgerald RH Jr, Beckenbaugh RD, Coventry MB.
Complications of THA treated by reoperation. J Bone Joint Surg Am. 1975;
- Postel M. Les prothèses douloureuses. Les causes possibles.
Rev Chir Orthop Reparatrice Appar Mot. 1975; 61(Suppl II):57-61.
- Jasani V, Richards P, Wynn-Jones C. Pain related to the psoas muscle
after total hip replacement. J Bone Joint Surg Br. 2002;
- Ala Eddine T, Remy F, Chantelot C, Giraud F, Migaud H, Duquennoy A.
Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and
conservative treatment in 9 cases. Rev Chir Orthop Reparatrice Appar
Mot. 2001; 87(8):815-819.
- Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ. The Prevalence of groin
pain after metal-on-metal total hip arthroplasty and total hip resurfacing.
Clin Orthop Rel Res. 2010; 468(9):2346-2356.
- Cyteval C, Sarrabère MP, Cottin A, et al. J Comput Assist
Tomogr. 2003; 27(2):183-188.
- Potter HG, Nestor BJ, Sofka CM, Ho ST, Peters LE, Salvati EA.
Magnetic resonance imaging after total hip arthroplasty: evaluation of
periprothetic soft tissue. J Bone Joint Surg Am. 2004;
- 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 Rel Res. 2010; 468(2):519-526.
- Dora C, Houweling M, Koch P, Sierra RJ. Iliopsoas impingement after
total hip replacement: the results of non-operative management, tenotomy or
acetabular revision. J Bone Joint Surg Br. 2007; 89(8):1031-1035.
- Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis
after total hip arthroplasty. J Am Acad Orthop Surg. 2009;
- OSullivan M, Tai CC, Richards S, Skyrme AD, Walter WL, Walter
WK. Iliopsoas tendonitis a complication after total hip arthroplasty. J
Arthroplasty. 2007; 22(2):166-170.
Drs Wuenschel and Kunze are from the Orthopedic Department, University
Hospital Tüebingen, Germany.
Drs Wuenschel and Kunze have no relevant financial relationships to
Correspondence should be addressed to: Beate Kunze, MD, Department of
Orthopedics, Eberhard Karls University Tübingen, Hoppe-Seyler-Str 3, 72076