Hip

Hip Flexor Strain / Iliopsoas Tendinopathy

Hip flexor strains and iliopsoas tendinopathy are common causes of anterior hip and groin pain in athletes and active adults. The iliopsoas (the body's primary hip flexor) is under high demand in running, kicking, and core-intensive activities. Prompt diagnosis and targeted rehabilitation get most patients back to full activity quickly. When symptoms persist, image-guided injection and, rarely, minimally invasive surgical release offer reliable relief.

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What is hip flexor strain / iliopsoas tendinopathy?

The iliopsoas is formed by two muscles: the iliacus (originating from the inner ilium) and the psoas major (from the lumbar vertebrae). They converge into a single tendon inserting on the lesser trochanter of the femur. It is the most powerful hip flexor and plays a key role in lumbar stability.

The iliopsoas is formed by two muscles: the iliacus (originating from the inner ilium) and the psoas major (from the lumbar vertebrae). These converge into a single tendon inserting on the lesser trochanter of the femur. It is the most powerful hip flexor and plays a key role in lumbar stability.

Injury patterns:

Acute strain: Direct muscle tear from a sudden, forceful contraction or overstretching; common in sprinting, kicking sports, and gymnastics
Chronic tendinopathy: Degenerative overuse changes in the tendon; more common in dancers, runners, and cyclists
Snapping hip connection: The iliopsoas tendon can snap over the iliopectineal eminence during hip flexion/extension, producing the internal form of snapping hip syndrome

Pain location: Anterior hip and groin, often poorly localized. Pain may radiate to the anterior thigh. It is worsened by active hip flexion against resistance (walking up stairs, rising from a chair, kicking).

Symptoms — do you recognize these?

Anterior hip pain or deep groin pain
Pain with active hip flexion against resistance — most reliably reproduced by resisted straight-leg raise
Tenderness on deep palpation of the iliac fossa or anterior hip
Hip flexor tightness and reduced hip extension range of motion
Pain at the end range of hip extension (e.g., walking, lunging)
Possible snapping or clicking sensation at the anterior hip (see Snapping Hip)

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

How we diagnose it

Physical examination:

Thomas test: assesses hip flexor tightness (inability to fully extend the hip with the contralateral knee to the chest indicates iliopsoas contracture)
Resisted hip flexion test: pain and/or weakness with a straight-leg raise against resistance
Palpation over the iliacus in the iliac fossa and the lesser trochanteric insertion

Ultrasound: Identifies tendon thickening, partial tears, and bursal fluid around the iliopsoas tendon. Dynamic imaging demonstrates snapping if present.

MRI: Provides detailed characterization of the tendon and muscle, distinguishes partial from complete tears, and excludes labral pathology or femoral stress fracture as alternate diagnoses.

Hip labral pathology must always be considered in athletes with anterior groin pain. Labral tears and iliopsoas tendinopathy commonly co-exist and can produce overlapping symptoms.

Treatment options

Physical therapy is the primary treatment for both acute strain and chronic tendinopathy. Key elements include: - Iliopsoas flexibility and stretching program (progressive hip extension range of motion) - Core and lumbopelvic strengthening - Progressive hip flexor loading (isometric → concentric → eccentric) - Gradual return to sport protocol Activity modification: Reducing hip flexion-intensive activities during the acute phase; transitioning to low-demand cross-training. Ultrasound-guided injection: An image-guided injection into the iliopsoas bursa or around the tendon (corticosteroid or PRP) reduces acute inflammation, facilitates engagement with PT, and can serve as a diagnostic confirmation of the pain source. PRP is preferred for chronic tendinopathy to support tendon healing. Iliopsoas endoscopic release: Reserved for patients with refractory snapping or tendinopathy who have failed 4–6 months of conservative care. The tendon is released arthroscopically at the level of the hip joint or lesser trochanter, relieving impingement and snapping.

Surgical Procedure

Iliopsoas Release / Tendon Lengthening

Arthroscopic lengthening of the iliopsoas tendon (at the hip joint level or at the lesser trochanter) to resolve internal snapping hip (coxa saltans interna) and painful anterior hip impingement.

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Recovery & rehabilitation

Acute strain: Return to sport in 2–6 weeks depending on severity
Chronic tendinopathy PT program: 8–12 weeks for significant improvement
Post-injection: Resume activity within 1–2 days; full PT continues
After endoscopic release: 4–6 weeks before return to full sport

Frequently Asked Questions

Is a hip flexor strain the same as a groin pull?

Not exactly. "Groin pull" typically refers to an adductor strain (inner thigh muscles). Hip flexor strain involves the iliopsoas. Both produce groin pain, but their physical examination findings and treatment differ.

Can stretching make my hip flexor worse?

In the acute phase, aggressive stretching can worsen a strain. Initial treatment emphasizes rest and gentle range of motion, progressing to stretching once the acute pain subsides. Your physical therapist will guide this progression.

What if my anterior hip pain doesn't improve with PT?

Persistent symptoms despite adequate PT should prompt evaluation for a hip labral tear, femoroacetabular impingement, or hip chondral defect. These conditions commonly co-exist with iliopsoas tendinopathy and require separate management.

How long does a hip flexor strain take to recover from?

A mild hip flexor strain typically resolves within one to three weeks with relative rest, ice, and gentle stretching. Moderate strains may take four to eight weeks, and severe strains or iliopsoas tendinopathy that has become chronic can take two to four months of structured rehabilitation. Returning to sport or strenuous activity too quickly is a common cause of re-injury, so your MOS provider will guide you through a progressive return-to-activity plan based on your symptoms and functional testing rather than a fixed time frame.

What is the snapping or clicking I feel in the front of my hip? Is it related to my hip flexor?

A snapping or clicking sensation in the front of the hip is often caused by the iliopsoas tendon flicking over a bony prominence. This is a condition called internal snapping hip or coxa saltans interna. It is closely related to iliopsoas tendinopathy and can accompany hip flexor pain and tightness. In most cases it is not harmful and resolves with stretching and strengthening. When snapping is painful or persistent, ultrasound-guided iliopsoas bursa injection or, rarely, arthroscopic tendon lengthening may be considered. Your MOS surgeon can determine which option is appropriate for you.

Meet the specialists

John J. Christoforetti, MD

Orthopedic Surgery · Sports Medicine · Hip, Knee & Shoulder Arthroscopy · Shoulder Replacement

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Medically reviewed by John J. Christoforetti, MD, FAAOS

Last reviewed May 1, 2026

References

Morelli V, Smith V. Groin injuries in athletes. Am Fam Physician. 2001;64(8):1405–1414. https://www.aafp.org/pubs/afp/issues/2001/1015/p1405.html
Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. 2008;190(3):576–581. https://doi.org/10.2214/AJR.07.2375
Blankenbaker DG, Tuite MJ. The painful hip: new concepts. Skeletal Radiol. 2006;35(6):352–370. https://doi.org/10.1007/s00256-006-0087-5
Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521–533. https://doi.org/10.1177/03635465010290042501
American Academy of Orthopaedic Surgeons. Hip Flexor Strain. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/hip-flexor-strain/