Iliopsoas bursitis is inflammation of the iliopsoas bursa — the largest bursa in the body — located deep in the front of the hip between the iliopsoas muscle-tendon unit and the hip joint capsule. It often occurs alongside iliopsoas tendinopathy and can produce deep groin or anterior hip pain that closely resembles other intra-articular hip conditions.
Iliopsoas bursitis is frequently a secondary condition — a consequence of an underlying problem rather than a primary diagnosis. The iliopsoas bursa communicates with the hip joint in approximately 15% of patients, which means a significant hip labral tear or hip osteoarthritis generating joint effusion can directly fill and distend the bursa. Iliopsoas bursitis must also be distinguished from the anterior groin pain of femoroacetabular impingement and the clicking-snapping symptoms it shares with internal snapping hip syndrome — MRI is essential for separating these overlapping diagnoses and identifying the correct treatment target.
Causes
Overuse and athletic activity.
Repetitive hip flexion from running, cycling, rowing, ballet, soccer, and gymnastics can progressively irritate the iliopsoas tendon and the bursa beneath it. The iliopsoas is the primary hip flexor, generating enormous force during the swing phase of running and during kicking, and the tendon undergoes significant excursion across the iliopectineal eminence with each stride — a mechanical friction point that, with sufficient repetitive loading, produces cumulative tendon and bursal inflammation. Sudden increases in training intensity are a common trigger, as is a change in running surface or footwear that alters hip flexion loading mechanics.
Other causes.
Direct trauma to the anterior hip, hip osteoarthritis with joint effusion communicating into the bursa, rheumatoid and other inflammatory arthropathies, prior hip surgery — particularly total hip arthroplasty with anterior component impingement of the iliopsoas tendon over the acetabular cup rim — and labral tears with associated joint effusion can all cause or perpetuate iliopsoas bursitis. Component impingement after hip replacement is an underappreciated and treatable cause of new-onset anterior groin pain in post-arthroplasty patients. Infection of the bursa (septic bursitis) is rare but requires urgent recognition and treatment, as bacterial spread to the adjacent hip joint is a serious complication.
Symptoms
Patients typically report deep groin or anterior hip pain that may radiate to the front of the thigh along the course of the femoral nerve distribution. Pain worsens with hip flexion activities including stair climbing, rising from a low chair, getting in and out of a car, and lifting the leg against resistance — all activities that load the iliopsoas and compress the inflamed bursa. A characteristic snapping or clicking sensation at the front of the hip with movement — termed internal snapping hip or coxa saltans interna — is produced when the inflamed and thickened iliopsoas tendon audibly snaps over the iliopectineal eminence during hip flexion and extension. This snapping is distinct from the lateral snapping of IT band syndrome and from intra-articular clicking from a labral tear — distinguishing the three clinically requires careful history and physical examination supplemented by dynamic ultrasound or MRI.
Diagnosis
A physical exam reveals tenderness in the deep groin — at the medial inguinal region rather than over the greater trochanter — and pain with resisted hip flexion in extension (the Thomas test position). The snapping sensation can often be reproduced by having the patient actively move the hip from flexion-abduction-external rotation to extension-adduction, and may be accompanied by an audible click. X-rays are typically unremarkable for soft tissue pathology but may reveal the underlying osteoarthritis or prior arthroplasty components that are driving secondary bursitis. An MRI is the definitive imaging study, visualizing bursal fluid distension and peritendinous edema around the iliopsoas tendon on fluid-sensitive sequences, characterizing tendon integrity — including any partial tears — and simultaneously evaluating the hip joint for labral tears, FAI morphology, and joint effusion that may be communicating with the bursa. Ultrasound provides a complementary role: dynamic real-time visualization of the snapping iliopsoas tendon during provocative hip movement, and precise image-guided access for diagnostic and therapeutic aspiration or injection of the bursa.
Classification
Iliopsoas bursitis is classified by its underlying cause, which determines the treatment strategy.
- Primary (overuse / inflammatory): Bursitis arising from repetitive athletic loading or inflammatory arthropathy without a discrete underlying structural hip lesion. Responds well to conservative management and targeted injection.
- Secondary: Bursitis driven by an underlying hip condition — osteoarthritis, labral tear, or post-arthroplasty component impingement — that must be addressed for durable resolution. Treating only the bursitis without the underlying cause leads to recurrence.
- Septic: Rare bacterial infection of the bursa, most commonly from direct extension of an adjacent joint infection or hematogenous seeding. Presents with fever, severe pain, and systemic illness — requires urgent aspiration, culture, and antibiotic treatment to prevent spread to the hip joint.
Treatments
Treatment depends on the underlying cause, severity of symptoms, and whether associated tendon or joint pathology is present. Secondary bursitis caused by an identifiable structural problem will not resolve durably until the root cause is addressed.
Conservative care: Rest from aggravating activities, ice, and anti-inflammatory medications manage acute pain and reduce bursal inflammation. Physical therapy emphasizes iliopsoas and hip flexor stretching — performed in positions that minimize tendon compression over the iliopectineal eminence — progressive core and hip abductor strengthening, and correction of faulty movement patterns such as excessive anterior pelvic tilt that increases iliopsoas tension. Gait retraining to reduce hip flexion loading during the swing phase is helpful in runners.
Injections
Image-guided corticosteroid injection into the iliopsoas bursa — performed under ultrasound or fluoroscopic guidance to precisely access this deep structure — provides significant and often sustained pain relief when the bursa is the primary pain generator. Bursal aspiration is performed concurrently if a large fluid collection is present, both to decompress the bursa and to obtain fluid for culture if infection is suspected. A diagnostic injection of local anesthetic that abolishes the pain confirms the bursa as the pain source and guides the decision to proceed with corticosteroid treatment.
Surgery
Surgical intervention is reserved for refractory cases that fail comprehensive conservative management. When an underlying correctable cause is present — a labral tear with FAI requiring arthroscopic repair, or component impingement after hip replacement requiring cup repositioning or liner exchange — addressing the root cause is the primary surgical goal, and bursitis typically resolves once the mechanical driver is eliminated. Arthroscopic iliopsoas tendon release (lengthening) reduces tendon tension over the iliopectineal eminence and is effective for internal snapping hip syndrome that has not responded to conservative care. Arthroscopic bursectomy may be performed concurrently. After surgery, a structured rehabilitation program is essential for restoring full hip flexor function and preventing recurrence.
Get an MRI to Confirm Your Diagnosis
Before surgical planning or starting treatment, a clear MRI diagnosis ensures the right path forward. First Look MRI offers self-pay Hip MRI scans — no doctor's order or insurance required — at our locations in Georgia, Texas, and Colorado.