Iliopsoas Syndrome (Hip flexor pain)

Iliopsoas syndrome is a collection of conditions relating to the area at the front of your hip. The reason that we call it this is because of the anatomy of the area. We previously wrote an article on this, and we at Hawkes Physiotherapy thought that it was about time that we updated it with more up to date research and evidence.

Iliopsoas hip flexors

As a basic overview Iliopsoas syndrome is an umbrella term covering several different issues ranging from overuse of the Iliopsoas muscles, weakness, disuse, shortening and/or tightness of the Iliopsoas. To make things even more complicated these issues can give rise to other secondary problems such as bursitis, tendinopathy, vascular issues and back pain to name a few.

Before we get stuck in we firstly need to know a little about the anatomy of the area and this is extensive! Scroll down a bit if you know the anatomy to find out more practical information such as ‘how to treat Iliopsoas syndrome’.

Bones – Ilium, Ischium, Pubis, Femur



  • Acetabulum (lunate surface, margin of acetabulum)
  • Anterior inferior iliac spine
  • Anterior superior iliac spine
  • Ala (wing of ilium) (gluteal surface and iliac fossa))
  • Iliac crest (outer lip, tuberculum, intermediate zone, inner lip)
  • Gluteal lines (anterior, inferior and posterior)
  • Posterior superior iliac spine
  • Posterior inferior iliac spine
  • Greater sciatic notch
  • Body of Ilium
  • Illiopubic eminence
  • Arcuate line
  • Auricular surface for the sacrum
  • Iliac tuberosity


  • Ischial spine
  • Lesser sciatic notch
  • Body of Ischium
  • Ischial tuberosity
  • Ramus of ischium
  • Obturator foramen
  • Acetabulum
  • Acetabular notch


  • Superior pubic ramus
  • Pubic tubercle
  • Obturator crest
  • Inferior pubic ramus
  • Acetabulum
  • Pecten pubis (pectineal line)
  • Symphyseal surface
  • Obturator groove


  • Head
  • Fovea
  • Neck
  • Intertrochanteric crest
  • Intertrochanteric line
  • Trochanteric fossa
  • Greater trochanter
  • Lesser trochanter
  • Calcar Femorale
  • Pectineal line
  • Gluteal tuberosity
  • Shaft
  • Linea aspera (medial and lateral lip)

Joints of the hip

  • Femoroacetabular – Synovial: spheroidal. Closed packed position: full extension, internal rotation and abduction.
  • Pubic symphysis – Amphiarthrodial
  • Sacroiliac – Synovial: plane



  • Iliofemoral – Anterior inferior iliac spine to the intertrochanteric line of femur. Limits extension of the hip.
  • Ischiofemoral – Posterior inferior acetabulum to the apex of the greater tubercle. Limits internal rotation and extension of the hip.
  • Pubofemoral – Obturator crest of the pubic bone to blend with the capsule of hip and the iliofemoral ligament. Limits hip hyperabduction.
  • Ligament of the head of the femur – margin of acetabular notch and transverse acetabular ligament to head of the femur. Carries the blood flow to supply to the head of the femur.

Pubic symphysis:

  • Superior pubic ligament – Connects the superior aspect of right and left pubic crests. Reinforces the superior aspect of joint.
  • Inferior pubic ligament – Connects the inferior aspect of right and left pubic crests. Reinforces the inferior aspect of joint.
  • Posterior pubic ligament – Connects posterior aspect of right and left pubic crests. Reinforces the inferior aspect of the joint.


  • Posterior sacroiliac – iliac crest to tubercles of S1-S4. Limits movement of the sacrum on iliac bones.
  • Anterior sacroiliac – Anterosuperior aspect of sacrum to anterior ala of ilium. Limits movement of the sacrum on iliac bones.
  • Sacrospinous – Inferior lateral border of the sacrum to the ischial spine. Limits gliding and rotary movement of the sacrum on iliac bones.
  • Sacrotuberous – Middle lateral border of the sacrum to the ischial tuberosity. Limits gliding and rotary movement of the sacrum on iliac bones.

Muscles of the hip:

  • Posterior (back):
  • Gluteus maximus – Posterior border of the ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament to the iliotibial tract of fascia lata and gluteal tuberosity of the femur. Extension, external rotation and some abduction of the hip joint.
  • Piriformis – Anterior aspect of the sacrotuberous ligament to the superior greater trochanter of the femur. External rotation of the extended hip, abduction of flexed hip, steady femoral head in the acetabulum.
  • Superior Gemellus – Ischial spine to the trochanteric fossa of the femur. External rotation of the extended hip, abduction of flexed hip, steady femoral head in the acetabulum.
  • Inferior Gemellus – Ischial tuberosity to the trochanteric fossa of the femur. External rotation of the extended hip, abduction of flexed hip, steady femoral head in the acetabulum.
  • Obturator internus – Internal surface of obturator membrane, border of obturator foramen to the trochanteric fossa of the femur. External rotation of the extended hip, abduction of flexed hip, steady femoral head in the acetabulum.
  • Quadratus femoris – Lateral border of ischial tuberosity to the quadrate tubercle of femur. Lateral rotation of the hip and steadies the femoral head in the acetabulum.
  • Semitendinosus – Ischial tuberosity to the superomedial aspect of the tibia. Hip extension, knee flexion, medial rotation of knee in knee flexion.
  • Semimembranosus – Ischial tuberosity to the posterior aspect of medial condyle of the tibia. Hip extension, knee flexion, medial rotation of knee in knee flexion.
  • Biceps Femoris – Long head: ischial tuberosity and short head: linea aspera and lateral supracondylar line of the femur to the lateral aspect of the head of the fibula and lateral condyle of the tibia. Knee flexion, hip extension and knee external rotation with the knee flexed.

Lateral (outside):

  • Gluteus medius – External superior border of the ilium and gluteal aponeurosis to the lateral aspect of greater trochanter of the femur. Hip abduction and internal rotation, maintains level pelvis in single-leg stance.
  • Gluteus minimus – External surface of the ilium and margin of the greater sciatic notch to the anterior aspect of the greater trochanter of the femur. Hip abduction and internal rotation, maintains level pelvis in single-leg stance.
  • Tensor fasciae latae – Anterior superior iliac spine and anterior aspect of the iliac crest to the iliotibial band that attaches to the lateral condyle of the tibia. Hip abduction, internal rotation and flexion, aid maintaining knee extension.

Anterior (front):

  • Psoas Major – Lumbar transverse processes to the lesser trochanter of the femur. Flexes the hip, assists with external rotation and abduction. Plays a major role in maintaining upright posture by supporting the Lumbar lordosis (inward curvature). Iliopsoas as they are both termed collectively also assists lumbar spine movement.
  • Psoas minor – Lateral bodies of T12 and L1 to iliopectineal eminence and arcuate line of the ilium. Flexion of pelvis on the lumbar spine.
  • Iliacus – Superior iliac fossa, iliac crest and ala of the sacrum to the lateral tendon of psoas major and distal to the lesser trochanter. Flexes the hip, assists with external rotation and abduction. The psoas and Iliacus muscles are collectively termed Iliopsoas and this is best at producing inner range hip flexion (knee up near hip height, and above). In this inner range, Iliopsoas is far more mechanically effective in flexing the hip than Rectus Femoris.
  • Rectus femoris – Anterior inferior iliac spine to base of the patella through the patella tendon to the tibial tuberosity. Hip flexion and knee extension. When the hip is in a mid and outer range flexed position then Rectus Femoris has a far more effective lever-arm to flex the hip.
  • Sartorius – Anterior superior iliac spine and notch just inferior to the superomedial aspect of the tibia. Flexes, abducts and externally rotates the hip, flexes the knee.
  • Obturator Externus – Margin of the obturator foramen and obturator membrane to the trochanteric fossa of the femur. Hip external rotation, steadies the head of the femur in the acetabulum.

Medial (inside):

  • Adductor Longus – Inferior to pubic crest to the middle third of linea aspera of femur. Hip adduction.
  • Adductor Brevis – Inferior ramus of the pubis to the pectineal line and proximal linea aspera of femur. Hip adduction and assists with hip extension.
  • Adductor Magnus – Adductor part: inferior pubic ramus, ramus of ischium, hamstring part: ischial tuberosity, to adductor part: gluteal tuberosity, linea aspera, medial supracondylar line, hamstring part: adductor tubercle of femur. Hip adduction, adductor part: hip flexion, hamstring part: hip extension.
  • Gracilis – Inferior ramus of the pubis to the superomedial aspect of the tibia. Hip adduction and flexion, assists with hip internal rotation.
  • Pectineus – Superior ramus of the pubis to the pectineal line of femur. Hip adduction and flexion, assists with hip internal rotation.

Bursae (There are as many as 20 bursae around the hip)


  • Iliopectineal bursa
  • Trochanteric bursa
  • Iliopsoas bursa
  • Gluteus medius bursa
  • Ischiogluteal bursa
  • Obturator externus bursa
  • And more…

Connective Tissue

  • Iliotibial band (ITB) – This is a connective tissue band that originates at the anterolateral iliac tubercle portion of the external lip of the iliac crest and inserts at the lateral condyle of the tibia. The ITB and its associated muscles help to extend, abduct, and laterally rotate the hip. The ITB also contributes to lateral knee stabilisation. The gluteus maximus and the tensor fasciae latae insert into the ITB.
  • Labrum – This is a ring of cartilage that surrounds the acetabulum (the socket of the hip joint). It deepens the acetabulum, making it more difficult for the head of the femur to slip out of place. The Labrum increases the surface area of the acetabulum by 28%, aids stability: deepening the joint by 21%, shock absorption & joint lubrication.

What causes Iliopsoas Syndrome?

It is often caused by repetitive hip flexion (bending of the hip) in a sport or activity, that demands this movement be done frequently. The excessive use causes chronically shortened hip flexors and essentially irritates the area. Iliopsoas syndrome is the result of repetitive active hip flexion in abduction (Laible et al 2013).

Other factors include:

  • Performing speed/track work without a proper ramp-up phase or correct training techniques
  • Shortened hip rotators
  • Poor Core stability and strength
  • Excessive Lumbar lordosis (arch of the lower back)
  • Pelvic asymmetry and leg length discrepancy
  • Overpronation of the foot.
  • Shortening of the Quadriceps (Rectus Femoris is a hip flexor)
  • Hip joint restrictions (stiffness: soft tissue related or osteoarthritis)

What sports commonly cause it?


It is very common in Cyclists and Ballet Dancers. In Ballet dancers it is secondary to excessive turn out demands but it can, of course, occur in anyone if the above issues are present. Research shows that 85% of athletes engaged in the cycling will suffer from an overuse injury (Linder et al 2014) and 20% of all lower extremity overuse injuries in competitive cyclists are of a vascular source (Linder et al 2014). Vascular impairment can be responsible for the occurrence of early fatigue and reduced performance in cycling (Alencar et al 2013). This is due to iliopsoas hypertrophy and compression from the cycling position.

What are the symptoms?

As always, It can depend, so you don’t have to have all of these symptoms but generally, the following can be felt:

  • Lower abdominal pain
  • Inguinal/Groin pain
  • Buttock pain
  • Thigh and leg pain
  • Hip pain
  • Sacroiliac Joint pain
  • Stiffness or snapping/clicking in the hip
  • Even lower Back pain: Research highlights that Iliopsoas syndrome may manifest as low back pain & often poses a diagnostic challenge (Tufo et al 2012) and results suggest increased activity of the Psoas Major in Lower Back pain patients (Arbanas et al 2013)

How do you diagnose Iliopsoas Syndrome?

It is quite often misdiagnosed due to its pain referral patterns to the hip, lower back and thigh so it is important to perform a thorough examination.

Physiotherapy assessment

Static hip extension flexibility (Thomas test) does not appear to be reflective of functional dynamic movements (Schache et al 2000). This is because anterior pelvic tilt & hip extension are coordinated movements during running and walking (Schache et al 2000). So rather than just using the Thomas test, you need to look at pelvic tilt motion and look at movement patterns (Applied Kinesiology and Biomechanics) as a whole to work out dysfunctions that could be causing the pain. However, an MRI is the most accurate way to assess iliopsoas bursitis but Ultrasound is the more cost-effective, easier and faster (Wunderbaldinger et al 2002).

How do you treat Iliopsoas Syndrome?

Conservative treatment

  • Nonsteroidal anti-inflammatory medication can be used in the short term to ease the early phase but the biggest importance is activity modification. Without modifying your activity you will perpetually irritate the area and not recover. This doesn’t mean rest though, it simply means that you need to work out what you can do or how much you can do without creating symptoms and build up slowly from there. Physiotherapy specific to the iliopsoas should be the primary treatment for patients with iliopsoas syndrome according to Laible et al (2013). We can assess and treat Iliopsoas syndrome at our Physio clinics in Stoke-on-Trent.

Here is a specific Iliopsoas strengthening exercise:


  • Techniques such as sports massage, soft tissue release, muscle energy and PNF (Proprioceptive Neuromuscular Facilitation) stretching can be used but some of these are limited due to the depth of the structures involved.
  • As always exercise is the cornerstone of recovery and these exercises will need to be prescribed specifically to you and your issues. Johnson et al (1999) found that exercises with hip rotation improved function & reduced pain in patients with iliopsoas syndrome.

Here is an example of hip rotation strengthening:

  • The biomechanical problems must be addressed otherwise it may not improve or if it does it will come back again in the future. Examples are leg length, foot posture but movement patterns such as dynamic valgus (cutting inwards of the knee). An example exercise to show how to improve this is below:

Another area to target is the Glutes especially the Gluteus medius:



  • If conservative treatment is ineffective then surgery may be needed and this involves lengthening of the iliopsoas tendon. Surgical lengthening of the iliopsoas tendon has an 85% success rate (Jacobson & Allen 1990).
  • Another type of surgery is a resection of the bony prominence of the lesser trochanter, with the aim of reducing friction over the bone.
  • Finally, a complete release of the iliopsoas tendon could be needed.

So there it is everything that you need to know about Iliopsoas Syndrome. As you can see it is extremely difficult to accurately diagnose and everyone’s causes are different, which means that the treatment needed will be very specific to the individual. If you think that you may have iliopsoas syndrome then get in touch for a physiotherapy assessment at our clinics in Stoke-on-Trent.


If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.


The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.

  • Alencar, Thiago Ayala Melo Di, Karinna Ferreira de Sousa Matias, and Bruno do Couto Aguiar. “Lower limb vascular dysfunction in cyclists.” Jornal Vascular Brasileiro 12.2 (2013): 139-150.
  • Arbanas, Juraj, et al. “MRI features of the psoas major muscle in patients with low back pain.” European spine journal 22.9 (2013): 1965-1971.
  • Jacobson, Thomas, and William C. Allen. “Surgical correction of the snapping iliopsoas tendon.” The American journal of sports medicine 18.5 (1990): 470-474.
  • Johnston, C. A. M., David M. Lindsay, and J. P. Wiley. “Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series.” Journal of Orthopaedic & Sports Physical Therapy 29.4 (1999): 218-224.
  • Laible, Catherine, et al. “Iliopsoas syndrome in dancers.” Orthopaedic journal of sports medicine 1.3 (2013): 2325967113500638.
  • Lindner, Dror, et al. “An unusual case of leg pain in a competitive cyclist: a case report and review of the literature.” Sports health 6.6 (2014): 492-496.
  • Schache, Anthony G., Peter D. Blanch, and Anna T. Murphy. “Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension.” British Journal of Sports Medicine 34.4 (2000): 279-283.
  • Tufo, Andrea, Gautam J. Desai, and W. Joshua Cox. “Psoas syndrome: a frequently missed diagnosis.” The Journal of the American Osteopathic Association 112.8 (2012): 522-528.
  • Wunderbaldinger, P., et al. “Imaging features of iliopsoas bursitis.” European radiology 12.2 (2002): 409-415.

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