Anatomy: The deep hip flexor (M iliopsoas) consists of two muscles. The Psoas muscle originate from the lumbar vertebrae and the Iliacus muscle from the inside of the femur. The two muscles fuse and are both fastened on the inside of the femur (trochantes minor). The iliopsoas is the strongest flexor muscle of the hip.

Symptoms: With certain movements in the hip joint the deep hip flexor (M iliopsoas) can be made to slip over one of the bone projections on the pelvis or the hip joint, whereby a slipping sensation, often accompanied by discomfort, is felt and often heard.

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain or lack of progress a medical examination should be carried out to ensure the diagnosis. A normal medical examination is usually sufficient in order to make the diagnosis, however, if there is any doubt concerning the diagnosis a dynamic ultrasound scan can be performed, where the tendon can be seen slipping as this triggers the symptoms (article 1) (article 2), (article 3).

Treatment: The treatment primarily comprises relief. If progress is not smooth the treatment can be supplemented with rheumatic medicine (NSAID) or the injection of corticosteroid, which should be done with ultrasound guidance to ensure the optimal effect and minimal risk. Only in very rare cases is surgical treatment necessary.

Complications: If progress is not smooth it should be considered whether the diagnosis is correct or if complications have arisen. In particular the following should be considered:

• Degenerative arthritis in the hip joint
• Rupture of the superficial hip flexor (ruptura musculus rectus femoris)
• Rupture of the deep hip flexor (ruptura musculus iliopsoas)
• Outer snapping hip
• Fluid accumulation in the joint (traumatic synovitis/coxitis)
• Stress fracture in the femoral neck
• Arthritis in the hip joint

Anatomy: Externally from the iliac crest to the shin bone runs a strong tendon (tractus iliotibialis), on which many of the thighs muscles are fastened. The tendon runs close above the outer femoral bone projection (trochanter major).

Symptoms: Upon certain movements in the hip joint, a sudden slipping, and unpleasant sensation can suddenly be produced on the outside of the thigh, which is often audible.

Acute treatment: Click here.

Examination: Usually the diagnosis can be made by an ordinary medical examination. You can often prevent the tendon from slipping over the outer bone projection by holding the tendon aside, while the movements provoking the condition are performed. The pain will decrease for approx. one hour after the injection of a local anaesthetic (diagnostic blockade) around the outer hip bone projection. If the diagnosis does not appear to be certain, ultrasound is recommended (Ultrasonic image), (article), or possibly a MRI scan.

Treatment: The treatment primarily comprises relief, stretching of the external tendon and rehabilitation. It is crucial that shoes have good shock absorbing soles. In cases of inappropriate foot stance, this should be corrected with shoes or inlays. In case of lack of progress the treatment can be supplemented with medical treatment in the form of rheumatic medicine (NSAID) or the injection of corticosteroid, which advantageously can be guided by ultrasound. In severe cases with no effect from relief, correct rehabilitation or medical treatment, you can operatively split the tendon.

Complications: In case of lack of progress it should be considered whether the diagnosis is correct. This will often require supplemental examinations (X-ray, ultrasound or MRI scan). In particular the following should be considered:

• Inner snapping hip
• Bursitis on the front of the hip joint (bursitis iliopectinea)
• Other bursitis
• Degenerative arthritis in the hip joint
• Fluid accumulation in the hip joint (traumatic synovitis/coxitis)
• Stress fracture in the femoral neck

Special: Shock absorbing shoes or inlays will reduce the load. In case of lack of progress or recurrences after successful rehabilitation it can be considered to have a running style analysis performed, to evaluate whether correction of the running style is indicated.

Anatomy: The piriformis muscle is a small muscle which origin from the sacrum and fastens on the outer femoral bone projection (tronchanter major). The muscle assists in rotating the thigh outwards.

Symptoms: Pain deep in the buttock, with periodic radiation into the leg.

Examination: The diagnosis will be rendered probable under clinical examinations by demonstrating tenderness by applying pressure on the muscle deep within the buttock, as well as provoking pain by stretching and activating the muscle. There is no suitable method to provide a pictorial image of the muscle (MR scanning can be attempted in the event of suspicions of nerve impingement) (article).

Treatment: The treatment usually comprises stretching and subsequent strength training of the muscles surrounding the lower back and buttocks. It is only in very rare cases involving nerve impingement that surgery is indicated. Uncomfortable pain can be treated medicinally in the form of paracetamol, or possibly rheumatic medicine (NSAID) . If this treatment does not provide the desired relief, ultrasound guided injection of corticosteroid in the most tender part of the muscle can be attempted (article 1), (article 2).

Special: Shock absorbing shoes or inner inlays will reduce the risk of various forms of muscle infiltrations. In the event of unsatisfactory progress, or relapse after successful rehabilitation, consideration must be given to performing an analysis of the patient’s running style to establish whether a correction of the running style should be recommended.

Complications: If progress is not smooth, the correctness of the diagnosis should be considered or whether complications have arisen. The following should be considered in particular:

• Bursitis at the ischiatic bone
• Rupture of the posterior thigh muscle fastening on the ischiatic bone
• Bursitis at the outer femoral bone projection (bursitis trochanterica)
• Degenerative arthritis in the hip joint
• Rupture of the superficial hip flexor (M rectus femoris)
• Rupture of the deep hip flexor (M iliopsoas)
• Outer snapping hip
• Inner snapping hip
• Fluid accumulation in the joint (traumatic coxitis)
• Lumbago
• Slipped disc

Anatomy: On the outside of the outer femoral bone projection (trochanter major) is a large bursa which reduces the load on muscles and tendons when these slide over the bone projection.

Symptoms: Pain when applying pressure on the thigh corresponding to the bursa, which sometimes (but far from always) can feel swollen. The pain can radiate down the thigh.

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain or lack of progress, a medical examination should be carried out to ensure the diagnosis and commencement of any treatment. A normal medical examination is usually sufficient in order to make the diagnosis, however, if there is any doubt concerning the diagnosis an ultrasound scan can be performed (Ultrasonic image).

Treatment: The treatment primarily comprises relief. If the direct cause of the complaint is known, it should of course be removed. The treatment can be supplemented with rheumatic medicine (NSAID) or injection of corticosteroid in the bursa, which is best performed under the guidance of ultrasound.

Complications: If progress is not smooth, the correctness of the diagnosis should be considered or whether complications have arisen:

• Tendinitis at the sitting (ischiatic) bone
• Rupture of the rear femoral muscle fastening on the sitting (ischiatic) bone
• Piriformis syndrome
• Degenerative arthritis in the hip joint
• Rupture of the superficial hip flexor (ruptura musculus rectus femoris)
• Rupture of the deep hip flexor (ruptura musculus iliopsoas)
• Outer snapping hip
• Inner snapping hip
• Fluid accumulation in the joint (traumatic synovitis/coxitis)
• Stress fracture of the femoral neck

Special: Shock absorbing shoes or inlays will reduce the load. In case of lack of progress or recurrences after successful rehabilitation it can be considered to have a running style analysis, to evaluate whether correction of the running style is indicated.

Anatomy: The large posterior thigh muscles (hamstring muscles) have a common muscle tendon fastening on the ischiatic bone (tuber ischii). The posterior thigh muscles flex the knee and stretch the hip.

Symptoms: In slight cases a local tenderness is felt after being subjected to load (“sprained muscle”, “imminent pulled muscle”). In severe cases sudden shooting pains are felt in the muscle (“partial muscle rupture”, “pulled muscle”) and in the worst case a sudden snap is felt rendering the muscle unusable (“total muscle rupture”). The following three symptoms are characteristic in connection with muscle injuries: pain upon applying pressure, stretching and activation of the muscle (flexing knee) against resistance. With total ruptures a defect and a swelling (the contracted muscle belly and bleeding) can often be seen and felt in the posterior thigh muscle just below the ischiatic bone and below. 

Acute treatment: Click here.

Examination: In very slight cases with only minimal tenderness and no discomfort when walking, medical examination is not necessarily required. The severity of the tenderness is however, not always a measure of the extent of the injury. In cases of more pronounced tenderness or pain, medical examination is required to ensure the diagnosis and treatment. The diagnosis is usually made following normal medical examination, however, if there is any doubt concerning the diagnosis, ultrasound scanning (or MRI scanning) can be performed, as these are the most suitable examinations to ensure the diagnosis (article). The larger the bleeding as assessed by ultrasound scanning, the longer the period needed to heal the injury. Tears on the ischiatic bone will usually be visible on x-rays.

Treatment: Treatment comprises relief and rehabilitation. The aim of the rehabilitation is to strengthen the posterior thigh muscles to enable the muscles to manage the loads which previously caused the rupture. It is only in very rare cases where there is a total rupture at the muscle fastening or tearing of a large piece of bone from the ischiatic bone that surgery is considered (article). Even large ruptures in the thigh muscles will usually be able to be healed and rehabilitated without giving functional disorder (but often cosmetic disfigurement with an irregular thigh muscle).

Complications: If steady progress is not experienced it should be considered if the diagnosis is correct or whether complications have arisen. The following should in particular be considered:

• Bursitis at the ischiatic bone
• Tendinitis at the ischiatic bone
• Tearing off of a bone fragment from the ischiatic bone

Anatomy: The large posterior thigh muscles (hamstring muscles) have a common muscle tendon fastening on the ischiatic bone (tuber ischii). Below the tendon fastening there is a bursa which reduces the load on the tendon when the tendon slides against the bone. The posterior thigh muscles flex the knee and stretch the hip.

Symptoms: Pain upon applying pressure on the bursa (sitting position), which sometimes (but far from always) may feel swollen. Aggravated upon stretching and activation of the posterior thigh muscles (flexing of the knee against resistance) (article).

Acute treatment: Click here.

Examination: In slight cases with only minimal tenderness, medical examination is not necessarily required. In cases of more pronounced pain or lack of progress, a medical examination should be carried out to ensure a correct diagnosis and commencement of treatment. The diagnosis is usually made on the basis of a normal medical examination, however, if there is any doubt surrounding the diagnosis, it can easily and quickly be confirmed under an ultrasound scan.

Treatment: The treatment primarily consists of relief. The treatment can be supplemented with rheumatic medicine (NSAID) or the injection of corticosteroid in the bursa preceded by draining of the bursa, which can advantageously be done under ultrasound guidance.

Complications: If progress is not smooth, it should be considered if the diagnosis is correct or whether complications have arisen. The following should in particular be considered:

• Tendinitis at the ischiatic bone
• Muscle rupture of the tendon fastening on the ischiatic bone
• Piriformis syndrome
• Degenerative arthritis in the hip joint
• Rupture of the deep hip flexor (M iliopsoas)
• Outer snapping hip
• Inner snapping hip
• Fluid accumulation in the hip joint
• Complications of muscle ruptures
• Lumbago
• Slipped disc