A 29-year-old male warehouse worker noticed pain in his right lower quadrant. The pain was intense and poorly localized (arrow) and increased with lifting or resisted hip flexion. Appendicitis was diagnosed, but pain persisted post-operatively. Necrotizing fasciitis was suspected, but repeated debridements failed to relieve the pain.
Explore this issue:November 2006
The inguinal ligament runs parallel to the inguinal crease (pink pencil line—see right). About midway in its length, the ligament became difficult to identify due to an exquisitely tender doughy area (arrow). Palpation of this area reproduced the patent’s symptoms, along with poorly localized lower abdominal pain. An attempted sit-up caused similar symptoms.
The iliopsoas bursa is located where the inguinal ligament, the iliopsoas tendon, and the transversus tendon intersect. An inflamed iliopsoas bursa is palpable as a doughy mass below the midpoint of the length of the inguinal ligament, lateral to the femoral artery. Most often the opposite, unaffected side demonstrates a normal, pencil-thin, easily defined, non-tender inguinal ligament.
The iliopsoas bursa is the largest bursa in the body and communicates with the hip joint in 15% of patients. Bursitis/tendonitis is caused by overuse and friction as the tendon rides over the iliopectineal eminence of the pubis. The condition is associated with lifting, unloading trucks, and participating in sports requiring extensive use of the hip flexors (e.g., soccer, ballet, uphill running, hurdling, jumping). Iliopsoas bursitis/tendonitis is characterized by deep groin pain, sometimes radiating to the anterior hip or thigh, and is often accompanied by a snapping sensation. The patient may limp.
The pain is difficult for patients to localize and challenging for clinicians to reproduce. In fact, the average time from the onset of symptoms to diagnosis is 31 to 42 months. It is common for many other diagnoses to be entertained and treated with no improvement. Physical examination will reveal pain on deep palpation over the femoral triangle, where the musculotendinous junction of the iliopsoas can be palpated as a doughy diffuse area of tenderness at the midpoint of the inguinal ligament.