Iliopsoas-related pain is more likely when symptoms are reproduced by loading the hip flexors, particularly during resisted seated hip flexion, and when tenderness localizes to the iliopsoas region. Hip-joint pathology is more likely when pain is strongly linked to joint motion, rotation, catching or mechanical symptoms. Because the two can coexist, no single test should be used in isolation.
Two structures in the same place
The iliopsoas is formed by the psoas major and iliacus. Its tendon runs down across the front of the hip joint to attach at the lesser trochanter of the femur, separated from the joint capsule by the iliopsoas bursa. Because the tendon sits directly in front of the joint, pain from the tendon, the bursa and the joint itself can all be felt deep in the groin or at the front of the hip.
That anatomical overlap is why a recent systematic review described the diagnosis of iliopsoas-related groin pain as challenging, citing symptom overlap with other hip pathologies and limited imaging accuracy (Vandeputte, 2026). It is also why one area of pain can have more than one source.
What points toward the iliopsoas
Under the Doha groin-pain framework, iliopsoas-related symptoms are supported by iliopsoas tenderness and become more likely when resisted hip flexion or hip-flexor stretching reproduces the pain (Weir, 2015). That is a clinical pain pattern. It does not prove a specific microscopic change in the tendon.
Newer studies have tested which examination findings are most useful, using the response to an image-guided anesthetic injection as the reference:
- The HEC test and resisted seated hip flexion. A 2025 diagnostic study found the HEC test and resisted seated hip flexion more useful than several traditional hip-flexor tests. The Thomas test and a simple snapping-hip test performed poorly as stand-alone diagnostic tools. The study reviewed 44 patients, about half with native hips and half after hip replacement. Only the HEC test, resisted seated hip flexion and resisted seated hip external rotation met all three criteria for a "good" test, and the HEC test ranked best, with a sensitivity of 94% and specificity of 88% (Vandeputte, 2025).
- Seated hip-flexion weakness, pain and tenderness. A 2026 injection-referenced clinical study found that weakness or pain during seated hip flexion and focal iliopsoas tenderness were more sensitive than MRI findings for identifying iliopsoas-related pain. In 135 injections in 105 patients, absolute seated hip-flexion weakness was 96.2% sensitive, focal tenderness 92.6% sensitive and pain with seated hip flexion 76.1% sensitive (Johnstone, 2026).
The HEC test combines resisted hip flexion with external rotation, the iliopsoas's secondary action. The newest systematic review found that no single examination test is definitive for iliopsoas-related groin pain, but the HEC test and resisted seated hip flexion performed best among the available diagnostic maneuvers. The diagnostic studies were few and at high risk of bias, so these accuracy estimates should be treated as preliminary rather than absolute (Vandeputte, 2026). The 94% and 88% figures come from a single retrospective study of 44 patients, and independent confirmation is still needed.
Typical history features include pain with running, hills, kicking, lifting the leg into a car or repeated hip flexion, sometimes with snapping. None of these is specific on its own.
Reading these studies carefully
Injection response is a practical reference standard, but not a perfect one, and the evidence comes from specialist hip practices. The 2025 study was retrospective and included many patients after hip replacement, a group with a different mechanism of pain. The 2026 clinical study reviewed charts from a single surgeon's practice; its patients averaged 41 years of age and 74.8% were women. Results may differ in younger athletes, in runners or in people seen earlier in the course of their symptoms. The practical message is consistent across the studies, though: focused loading tests and palpation carry more weight than a supine stretch or a scan on their own.
Tendinopathy or bursitis?
The iliopsoas tendon and the bursa beneath it sit side by side, and their symptoms overlap. Clinically, they often cannot be separated with confidence, and both can coexist with hip-joint pathology. Imaging may show tendon thickening or bursal fluid, but those findings are interpreted alongside the examination. For treatment planning, the more important questions are usually whether the pain is load-related, whether snapping is part of the picture and whether the hip joint is involved.
Why traditional stretch tests mislead
Many people are told they have a tight or injured hip flexor because a supine stretch test was uncomfortable. The systematic review found that supine provocation tests showed high sensitivity but poor specificity (Vandeputte, 2026). In practice, that means they often hurt in people who do have iliopsoas pain, but also in many who do not. The Thomas test, a long-standing hip-flexor test, was rated "poor" for diagnosing iliopsoas tendinopathy in the 2025 study.
What points toward the hip joint
Hip examination should be part of every persistent anterior hip or groin assessment. Possible intra-articular sources include:
- femoroacetabular impingement (FAI)
- labral pathology
- chondral (cartilage) injury
- osteoarthritis, where age-appropriate
- other intra-articular problems
Clues that favor the joint include pain that feels deep inside the hip, painful or restricted rotation, reduced range of motion, catching or locking, and pain reproduced by joint-specific provocation rather than by loading the hip flexors alone.
None of these clues settles the question on its own. A positive FADIR test does not equal FAI, and clicking does not equal a labral tear. The Doha consensus noted that most clinical hip tests have weak diagnostic properties when studied in isolation (Weir, 2015). Hip-joint findings are interpreted together, and imaging is used when the clinical picture warrants it.
The two often coexist
Iliopsoas-related pain and hip-joint pathology are not mutually exclusive. A 2025 review of groin pain recommended hip radiographs and MRI when iliopsoas-related groin pain is suspected because there is often concomitant hip pathology (Maloy, 2025). The newest systematic review found that, in native hips, iliopsoas release provided no clear benefit beyond treatment of the associated intra-articular problem (Vandeputte, 2026). A treatment plan aimed only at the tendon can stall if a joint problem is also present, and the reverse is also true.
Adductors and rectus femoris
Two muscle groups commonly overlap with iliopsoas symptoms:
- Adductors. Under the same Doha framework, adductor-related groin pain is identified by adductor tenderness with pain on resisted adduction. Adductor and iliopsoas pain can overlap anatomically, so the examination should load each tissue separately. See adductor tendinopathy and groin pain.
- Rectus femoris. This hip flexor crosses both the hip and the knee. It is more likely with superficial front-of-thigh pain, a kicking or sprinting injury, or pain when hip flexion is combined with knee extension.
Pubic, inguinal and other causes
Pain centered on the pubic symphysis or in the inguinal canal suggests different entities, compared in adductor groin pain vs. hip, iliopsoas and pubic pain. Femoral neck or pelvic stress injury, nerve symptoms, referral from the lumbar spine and abdominal, urologic or gynecologic conditions also belong in the differential. Progressive weight-bearing pain, night pain, numbness or other atypical features need prompt medical evaluation.
What imaging can and cannot tell you
Imaging helps most when it answers a specific question.
- MRI. MRI is valuable for evaluating the hip joint and other structural causes. In the 2026 injection-referenced study, however, MRI abnormalities were present in only 18.1% of scanned hips, giving a sensitivity of 19.2% and specificity of 85.0% for iliopsoas-related pain. The authors concluded that MRI should be considered for ruling out other sources of hip pain (Johnstone, 2026). MRI remains useful for excluding or characterizing other hip pathology rather than serving as a stand-alone iliopsoas pain test. A normal or minimally abnormal MRI does not exclude clinically meaningful iliopsoas-related pain.
- Dynamic ultrasound. When the complaint is painful snapping, dynamic ultrasound can show the tendon moving during the motion that produces the snap. That is covered in internal snapping hip.
- Image-guided injection. Research studies use the response to an anesthetic injection around the iliopsoas as their reference standard. In clinical practice, an injection is a medical decision made with a physician rather than a routine first step.
What a thorough anterior hip examination includes
- the exact location of pain and focal palpation of the iliopsoas region
- resisted seated hip flexion, including strength compared with the other side
- the HEC test and related iliopsoas loading tests
- passive hip range of motion and hip-joint provocation
- adductor, rectus femoris, abdominal and inguinal testing
- whether snapping occurs and whether it reproduces the familiar pain
- running, hill, kicking or stair tolerance where relevant
- prior surgery, including hip replacement, which changes the differential
Findings are interpreted together. History, focused examination, the hip-joint differential and selective imaging matter more than one scan or one test.
After hip replacement, the question changes
Iliopsoas pain after total hip arthroplasty is a mechanically distinct problem, usually related to the relationship between the tendon and the implant. Conservative treatment succeeds less often in that group, and outcomes of surgical options depend strongly on implant position and patient selection (Vandeputte, 2026). It should not be managed as routine athletic iliopsoas tendinopathy.
How Novo approaches anterior hip pain
We first decide whether the iliopsoas, the hip joint, the adductors or another structure is responsible, using focused loading tests, hip-joint examination and selective imaging. When iliopsoas-related pain is confirmed, treatment is built around progressive hip-flexor loading, with manual treatment or shockwave therapy considered as adjuncts. See how we approach iliopsoas and hip flexor pain.
References
- Vandeputte FJ, Sergooris A, Roose S, Timmermans A, Corten K. Clinical diagnosis and treatment of iliopsoas-related groin pain: a systematic review. Journal of Clinical Medicine. 2026;15(15):5912. PMID 42590015. (link)
- Vandeputte FJ, Driesen R, Timmermans A, Corten K. Evaluation of clinical tests to diagnose iliopsoas tendinopathy. Clinical Orthopaedics and Related Research. 2025;483(11):2123-2132. PMID 40388705. (link)
- Johnstone T, Pierre K, Roh E, Fredericson M, Safran MR. Can a clinician accurately diagnose iliopsoas tendinitis on a physical examination? American Journal of Sports Medicine. 2026;54(7):1705-1711. PMID 41823309. (link)
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine. 2015;49(12):768-774. PMID 26031643. (link)
- Maloy W, Merrigan B, Hulsopple CD. Groin pain and injuries: evaluation and management. American Family Physician. 2025;111(4):337-343. PMID 40238976. (link)
