After total hip arthroplasty (THA), some patients continue to have groin pain. Conditions that can cause groin pain include infection or tumor, aseptic loosening of the components, and soft tissue inflammation. Occasionally the soft tissue inflammation is tendinitis of the iliopsoas tendon. This condition commonly occurs because the anterior metal wall of the cup protrudes above the anterior bony acetabular wall [1], such as would occur with a lateralized cup, especially if capsulectomy has been done (Fig. 1). This also could occur if the cup is placed in a retroverted position, for which revision has been required [1]. This pain can be relieved by surgical release of the iliopsoas tendon. Over 6 years, we have treated 5 patients who had persistent groin pain after THA without evidence of infection or loosening of the cup. Cup position was measured as satisfactory in each hip [2]. All of these patients complained of groin pain that occurred with activities that required use of the iliopsoas muscle, including straight-leg raising and active flexion of the hip, such as ascending stairs, lifting the operative leg into bed, and lifting the leg to get into and out of a car. Occasionally, there would be some pain radiation to the anterior thigh, which also was more pronounced with these activities. Level walking did not cause symptoms because the iliopsoas muscle is not active during walking on level ground. The pain-specific activities of active flexion of the hip helped to differentiate iliopsoas tendinitis from septic or aseptic loosening, which causes pain with any weight bearing. Little has been written about iliopsoas tendinitis. Mostly this condition has been described in sports medicine and radiology literature [3–5]. There is only 1 report of iliopsoas tendinitis after THA; it described 2 hips in which the acetabular component was placed in retroversion, which caused fraying and inflammation of the tendon as it passed over the edge of the shell and required revision surgery of the cup [1]. One of our patients had a prominent anterior edge of the cup as a cause (Fig. 2). The patient had a previous operation because of anterior dislocation of the hip and groin pain. That operation was done through an anterior incision that exposed the cup, and a new liner was placed with the hood anteriorly. The dislocations stopped, but the groin pain with flexion activities continued until the tendon was released by us. An increase of the hip offset or hip length of 1 cm also could cause this tendon irritation. One of the 5 patients operated by us had an increased offset of 1.8 cm, and 2 of 5 patients had increased hip lengths of 2.1 cm and 1 cm. When the groin pain is caused by iliopsoas tendinitis, it can be eradicated by surgical release of the tendon from the lesser trochanter. Pain relief occurred in all 5 of our patients.
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