You had the hip replacement. On the flip side, the surgery went well. Consider this: you did the PT. Still, you hit your milestones. And then — weeks or months later — a deep, nagging ache shows up in the front of your hip. Maybe it catches when you lift your leg to put on socks. Maybe it hurts when you stand up after sitting too long. Also, your surgeon says the implant looks perfect. Your physical therapist says your glutes are firing. So what gives?
Chances are, nobody mentioned the iliopsoas Simple, but easy to overlook. Surprisingly effective..
What Is Iliopsoas Tendonitis After Hip Replacement
The iliopsoas is actually two muscles — the psoas major and the iliacus — that merge into one tendon crossing the front of the hip joint. It's your primary hip flexor. Every time you march, climb stairs, or swing your leg forward to walk, this tendon is working.
After a total hip arthroplasty, that tendon sits right up against the new acetabular cup. The result? In real terms, the tendon can rub against the metal or ceramic rim. Inflammation. Tendinopathy. It can get pinched by a prominent screw head. With an implant, the anatomy changes. That's why it can shorten from surgical trauma or postoperative guarding. This leads to in a native hip, there's soft tissue, a capsule, and a bit of give. Sometimes a snapping sensation you can feel — or even hear That's the part that actually makes a difference..
Surgeons call it iliopsoas impingement or tendonitis. Patients call it "that weird pain in the front that won't go away."
It's not rare. But studies suggest anywhere from 4% to 30% of THA patients develop some degree of iliopsoas irritation. The wide range depends on how you define it — clinical symptoms versus imaging findings — but ask any experienced hip PT, and they'll tell you: they see it all the time Simple as that..
Why the Anterior Approach Makes It More Likely
If you had a direct anterior approach (DAA), your risk goes up. That approach goes right between the sartorius and tensor fasciae latae, practically through the iliopsoas neighborhood. The capsule gets incised right where the tendon runs. In practice, retractors sit on the tendon. Postoperative swelling and scar tissue form in exactly the wrong spot.
And yeah — that's actually more nuanced than it sounds.
Posterior and lateral approaches aren't immune either. Plus, component position matters more than approach. Plus, a cup that's too anterior, too lateral, or oversized can all crowd the tendon. So can a prominent anterior rim or screws that back out slightly Nothing fancy..
Why It Matters — And Why It Gets Missed
Here's the frustrating part: iliopsoas tendonitis after hip replacement often masquerades as other things.
Groin pain? Worth adding: maybe the lateral femoral cutaneous nerve. And could be the hip joint. Think about it: could be a hernia. Anterior thigh numbness? Could be referred from the lumbar spine. Could be the adductor tendon. But that deep, catching sensation when you flex past 90 degrees — especially with resistance — that's the psoas talking.
Miss it, and patients spin their wheels. Even so, they get worked up for infection. They get revision surgery they don't need. They stop walking because "something still isn't right." And the whole time, the tendon just needed space and a proper rehab plan.
The stakes are real. In real terms, chronic iliopsoas irritation can lead to tendon fraying, snapping hip syndrome, or even flexion contractures if the patient starts holding the hip bent to avoid the pain. That contracture then pulls on the lumbar spine. Now you've got back pain too And it works..
How Treatment Actually Works
There's no single protocol. Anyone selling you a cookie-cutter "3 exercises to fix psoas pain" is guessing. But the general arc of treatment is predictable: calm it down, build it up, fix the mechanics.
Phase 1: Calm the Fire
First, you have to stop poking the bear.
That means modifying activities that drive the tendon into the anterior rim. Practically speaking, if your PT has you doing straight leg raises with an ankle weight at week 4, and your anterior hip hurts, stop. In real terms, deep flexion — think tying shoes, low chairs, deep squats — is the main aggravator. That's not "working through it.So is resisted flexion against load. " That's inflaming an already angry tendon.
Ice helps. Not the token 5-minute thing. Real icing: 15–20 minutes, 3–4 times daily, especially after activity. Anti-inflammatories (NSAIDs) have a role here — short course, 7–10 days max, if your GI tract and kidneys tolerate them. Topical diclofenac gel works well for superficial tendon irritation and spares the stomach.
Some surgeons inject corticosteroid under ultrasound guidance. That said, one, maybe two. It can be diagnostic and therapeutic. On top of that, if the pain vanishes for weeks, you've confirmed the source. But — and this matters — repeated steroid injections weaken tendon tissue. Not a series.
Phase 2: Restore Length Without Provoking Compression
This is where most rehab goes sideways.
Everyone wants to "stretch the hip flexor." So they lunge. So they do the couch stretch. They yank the knee back into extension. And the tendon gets compressed harder against the cup.
The psoas doesn't need aggressive stretching. It needs slack.
Start with prone lying. Still, just lie on your stomach. That's it. Because of that, gravity gently extends the hip without compression. Because of that, if that's too much, put a pillow under the pelvis. Work up to 5–10 minutes, a few times a day Not complicated — just consistent..
Next: supported standing extension. Repeat 10 times. That said, stand facing a counter. Hands on the surface. Gently push the pelvis forward — not by arching the back, but by squeezing the glutes. Hold 5 seconds. This teaches the posterior chain to share the load Easy to understand, harder to ignore..
Easier said than done, but still worth knowing.
Avoid the Thomas test position (supine, one knee to chest, other leg hanging off table) early on. That drives the tendon straight into the anterior rim Worth keeping that in mind..
Phase 3: Strengthen the Right Stuff
The iliopsoas isn't just a hip flexor. It's a lumbar stabilizer. When it's cranky, the glutes, deep core, and posterior chain have usually checked out Easy to understand, harder to ignore. Which is the point..
Glute max is the antagonist to the psoas. Strong glutes = less psoas overwork. But you can't just do bridges. Bridges can pinch the anterior hip if you hyperextend. Start with isometric glute squeezes. Prone hip extension with knee bent (short lever). Standing kickbacks with a band — light, controlled, no momentum Easy to understand, harder to ignore. No workaround needed..
Add deep core: dead bugs, bird dogs, plank variations. The psoas attaches to the lumbar transverse processes. When the anterior core fails, the psoas tries to stabilize the spine. It wasn't built for that That's the part that actually makes a difference..
Hip abductors matter too. Now, weak glute medius → Trendelenburg gait → compensatory psoas overactivity to clear the foot. Side-lying abduction, clamshells, lateral band walks — done without hiking the hip That's the part that actually makes a difference..
Phase 4: Movement Re-education
This is the phase nobody talks about.
You can have strong glutes and a calm tendon, but if your brain still recruits the psoas first for every step, the pain comes back. Day to day, increase cadence. Gait retraining helps. Worth adding: shorten the stride. Focus on pushing off the stance leg (glute max) rather than pulling the swing leg forward (psoas) Easy to understand, harder to ignore..
Most guides skip this. Don't The details matter here..
Treadmill walking with a mirror or video feedback works. So does marching in place with hands on the anterior hip — feel for the tendon popping. If you feel it, slow down. Shorten the range. Repattern.
Stairs are a great test. Going up: drive through the heel, squeeze
the glute at the top. Practically speaking, stop. But coming down: control the descent with the stance leg quad and glute, knee tracking over the second toe. If the front of the hip pinches, you’re pulling with the psoas. No crashing. Don't yank the knee up. Reset.
Running drills come last. A-skips, B-skips, high knees — but only when the tendon tolerates load and the pattern is clean. Now, high knees are a psoas feast. Consider this: keep them low and fast initially. Think "stiff ankle, quick turnover," not "knee to chest.
Phase 5: Load Tolerance and Capacity
Pain-free doesn't mean ready.
The tendon needs to handle volume and velocity. Start tempo runs: 3 x 8 minutes at 70% effort, walk 2 minutes between. No hills. Flat, soft surface. Next week, 4 x 8. Then 3 x 12. Build the tendon’s work capacity before you add intensity.
Then strides. 4 x 20 seconds at 5k pace. Full recovery. Watch the form. If the knee drive gets sloppy or the pelvis drops, you’ve exceeded the tendon’s current capacity. Back off Surprisingly effective..
Plyometrics — pogo hops, split squat jumps, bounds — are the final gate. They demand high-rate loading. The psoas must absorb and transmit force without buckling. If you can do 3 sets of 10 split squat jumps pain-free, with quiet landings and no anterior hip pinch, you’re clear.
The Long Game
Iliopsoas tendinopathy isn’t a muscle strain. Now, it’s a load management failure. The tendon didn’t snap; it accumulated microtrauma because the system around it — glutes, core, gait mechanics, training volume — failed to protect it Easy to understand, harder to ignore..
Fix the mechanics. Respect the anatomy. Progress the load.
The couch stretch didn’t cause this, but it won’t fix it either. Slack, stability, and smart progression will Simple as that..
