Iliopsoas Release / Tendon Lengthening

Why this approach — at MOS

Iliopsoas release is a relatively brief procedure in experienced hands, but the decision of when to perform it — and at which level — requires careful clinical judgment. At MOS, Dr. Christoforetti evaluates every patient with suspected snapping hip for coexisting intra-articular pathology. MRI arthrogram assesses the labrum, cartilage, and tendon sheath. Dynamic ultrasound can confirm the snapping mechanism in real time.

When intra-articular disease (labral tear, FAI) is present alongside snapping, it is addressed in the same procedure. Addressing the joint problem alone sometimes resolves the snapping by changing the hip's mechanics; when it does not, the release is added.

Patients should have realistic expectations about hip flexor strength after surgery. Published research confirms that arthroscopic iliopsoas release results in measurable iliopsoas volume reduction (approximately 25%) and a small reduction in seated hip flexion strength (approximately 19%) at one year, though this is rarely clinically significant for non-elite athletes. Athletes engaged in explosive hip flexion activities (high-level sprinters, gymnasts, martial artists) are counseled specifically about this finding.

For patients with groin pain after hip replacement, endoscopic iliopsoas release at the lesser trochanter is a reliable and minimally invasive solution that avoids the joint replacement itself.

Patients across Montgomery County dealing with the frustrating combination of painful snapping, groin pain, and failed injections are encouraged to request a consultation at (301) 515-0900.

Who is a candidate?

Indications

• Symptomatic internal snapping hip (internal coxa saltans) confirmed by clinical exam and often by ultrasound (dynamic snapping visualized in real time)
• Painful snapping that has not responded to 3–6 months of physical therapy, activity modification, and cortisone injection
• Iliopsoas impingement causing groin pain after total hip arthroplasty (endoscopic release at the lesser trochanter)
• Iliopsoas tendinitis secondary to hip arthroscopy or hip replacement (rare complication)

Contraindications

• Asymptomatic or minimally symptomatic snapping — snapping without significant pain does not require surgery
• Underlying intra-articular hip problem (labral tear, FAI) that is the primary pain generator — must be addressed simultaneously or first
• External snapping hip (iliotibial band snapping over greater trochanter) — a different condition requiring different treatment
• Inability to comply with post-operative restrictions

Conservative Treatment First

The vast majority of patients with internal snapping hip improve without surgery. Physical therapy targeting iliopsoas stretching, hip flexor strengthening, and movement pattern correction eliminates snapping and pain in many patients — particularly those with muscular imbalance contributing to the mechanics of snapping. Ultrasound-guided cortisone injection into the iliopsoas tendon sheath reduces inflammation and pain in the acute phase.

Surgery is reserved for patients in whom snapping remains painful and functionally limiting after 3–6 months of consistent conservative care, or those with confirmed iliopsoas impingement after hip replacement.

The procedure

What Is Iliopsoas Release / Tendon Lengthening?

Iliopsoas release — also called iliopsoas tendon lengthening — is an arthroscopic procedure that partially cuts or lengthens the iliopsoas tendon to eliminate painful internal snapping of the hip (internal coxa saltans) or relieve iliopsoas impingement on the hip joint or a hip replacement. It is performed through small portals with same-day discharge.

The iliopsoas is the primary hip flexor — a powerful muscle formed by the fusion of the iliacus (from the inner pelvis) and psoas major (from the lumbar spine). The combined tendon passes anterior to the hip joint capsule, crosses the iliopectineal eminence of the pelvis, and inserts on the lesser trochanter of the femur.

Internal snapping hip (internal coxa saltans) occurs when the iliopsoas tendon catches and snaps over the iliopectineal eminence or the underlying femoral head during hip motion — typically as the hip moves from flexion to extension. In some patients this snapping is painless and a simple curiosity; in others it is painful and causes significant functional limitation. The snap is felt (and often heard) as a loud or prominent click deep in the groin with certain hip movements.

Iliopsoas impingement is a related but distinct condition in which the tendon impinges on a hip replacement acetabular component or on the hip joint capsule itself — producing persistent groin pain after total hip arthroplasty.

When conservative management fails to control symptoms, surgical release of the iliopsoas tendon — a partial tenotomy that releases the tendon's mechanical tension without completely transecting the muscle — reliably resolves snapping and impingement in the large majority of patients.

What Happens During Iliopsoas Release?

The procedure is performed at an ambulatory surgery center under general anesthesia with a nerve block. The patient is positioned on a hip arthroscopy traction table (supine or lateral decubitus depending on approach).

Approach: Transcapsular (from inside the joint) or Lesser Trochanter Level

There are two arthroscopic approaches to iliopsoas release:

Transcapsular approach: The surgeon enters the hip joint through standard arthroscopic portals, inspects the intra-articular anatomy, and then makes a small window through the hip joint capsule to access the iliopsoas tendon where it lies immediately anterior to the capsule. The tendon is then partially cut (tenotomy) under direct visualization.

Lesser trochanter approach (endoscopic): The surgeon creates periarticular portals at the level of the lesser trochanter — the bony prominence on the posteromedial femur where the iliopsoas inserts. The tendon is visualized directly at its insertion and a partial tenotomy is performed with an electrocautery device or knife. This approach avoids entering the joint entirely and is commonly used for iliopsoas impingement after hip replacement.

Both approaches achieve the same goal: reducing the mechanical tension in the iliopsoas tendon by partially releasing it, eliminating snapping and impingement while preserving the continuity of the muscle belly. The muscle does not lose all hip flexion function because the myotendinous junction remains intact and the muscle itself continues to function.

If intra-articular pathology (labral tear, FAI) coexists, it is addressed through the standard arthroscopic portals during the same procedure. The release typically adds 15–20 minutes to the total operative time when combined with intra-articular work.

Recovery timeline

Frequently Asked Questions