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Highly Unusual Tendon Abnormality:
Spontaneous Rupture of the Distal Iliopsoas Tendon
Distal İliopsoas Tendonunun Spontan Rüptürü:
Sıradışı Tendon Patolojisi
Sıradışı Tendon Patolojisi / Unusual Tendon Abnormality
1
Gökçen Çoban1, Gülay Maçin1, Nefise Çağla Tarhan1, Fuldem Yıldırım Dönmez1, İsmail Cengiz Tuncay2
Departments of Radiology, 2Departments of Orthopedics, Baskent University Faculty of Medicine, Ankara, Turkey
Özet
Abstract
İliopsoas tendon yaralanmaları yaygın değildir ve genellikle atletik bir yaralanma
Iliopsoas tendon injuries are not common and usually occur due to avulsion of
veya travma nedeniyle torakanter minor ayrılması ile iliopsoas tendonunun kop-
the iliopsoas tendon with detachment of the lesser trochanter, secondary to
ması sonucu oluşur. Aksi kanıtlanana kadar travma yokluğunda, yetişkinde görü-
an athletic injury or trauma. In the absence of a trauma, avulsion of the lesser
len torakanter minör ayrılması metastatik hastalık işareti olarak kabul edilir. Tam
trochanter in an adult is regarded as a sign of metastatic disease until proven
iliopsoas tendon yırtıkları şimdiye kadar sadece ileri yaşlı kadınlarda tanımlanmış-
otherwise. Complete iliopsoas tendon tears have thus far only been described in
tır. Travma ya da altta yatan bir sistemik hastalık olmaması, cinsiyet farklılığının
elderly women, and without trauma or an underlying systemic disease, a hormonal
hormonal nedenli olduğunu düşündürmektedir. İliopsoas tendon spontan yaralan-
basis may be a reason for the gender differences. In this article, we present an
ma yüzdesi çok düşüktür. Bu yazıda, travma öyküsü ve torakanter minor kırığı ol-
87-year-old woman with spontaneous rupture of the left distal iliopsoas tendon
madan, sol iliopsoas tendonda spontan rüptür saptanan 87 yaşındaki bir kadın
unassociated with fracture of the lesser trochanter and in the absence of a recent
hasta sunuldu. Akut kalça ağrısı ve yürüyememe ile başvuran hastanın radyogra-
trauma history. This elderly patient presented with acute groin pain and normal
fileri normaldi. Manyetik rezonans görüntüleme iliopsoas tendon patolojilerini ta-
plain radiographs. Magnetic resonance imaging must be kept in mind as a modal-
nımlamak için tercih edilen bir yöntem olarak akılda tutulmalıdır.
ity of choice for identifying iliopsoas tendon abnormalities.
Anahtar Kelimeler
Keywords
İliopsoas Tendon; MRG; Rüptür
Iliopsoas Tendon; MRI; Rupture
DOI: 10.4328/JCAM.3220
Received: 09.01.2015 Accepted: 22.01.2015 Printed: 01.06.2014
Corresponding Author: Gokcen Coban, Hocacihan Mah. Saray Cad. No:1 Selcuklu, 42080, Ankara, Turkey.
T.: +90 3322570606 F.: +90 3322570632 E-Mail: [email protected]
1 | Journal of Clinical and Analytical Medicine
J Clin Anal Med 2014;5(suppl 3): 357-9
Journal of Clinical and Analytical Medicine | 357
Sıradışı Tendon Patolojisi / Unusual Tendon Abnormality
Introduction
Iliopsoas tendon injuries are not common and usually occur in
children as a result of athletic activities [1]. In the elderly, isolated fractures of the lesser trochanter are rare, but can occur
as a result of trauma. Avulsion of the lesser trochanter in an
adult, in the absence of a trauma, is usually regarded as a sign
of metastatic disease or a primary bone malignancy [2]. It can
also be due to systemic disorders such as osteoporosis or osteomalacia and chronic renal failure [3-5]. In the diagnosis of
iliopsoas tendon injuries, physical examination and plain radiography are insufficient.
Spontaneous distal iliopsoas tendon rupture has been reported
rarely in the literature [3, 4]. However, iliopsoas tendon tears
without lesser trochanteric avulsion are distinctly uncommon. In
this article, we present an 87-year-old woman with spontaneous rupture of the left distal iliopsoas tendon unassociated with
fracture of the lesser trochanter and with no history of recent
trauma.
Case Report
An 87-year-old woman admitted to our orthopedics department with bilateral hip pain. She had been treated with diphenyl-hydantoin for epilepsy. She complained of inability to walk
and severe pain with flexion and extension of the right hip. On
physical examination, she had limited right hip motion and bilateral hip pain. Pelvis and hip radiographs were normal. Magnetic resonance imaging (MRI) of the hip was performed using
1.5 T (Siemens, Symphony, Erlangen, Germany) unit. On MRI,
bilateral insufficiency fractures were demonstrated at the level
of the femoral necks, but both iliopsoas tendons and muscles
were seen as normal (Fig. 1). A right femoral prosthesis implant
Figure 2. Follow-up MRI of the left hip. Coronal STIR image (a) shows the prosthesis causing artifacts on the right side, there is still mild edema at the left femoral
insufficiency fracture. Axial proton density (PD)-weighted fat-saturation image (b)
shows prominent decrease of the edema of left iliopsoas tendon.
months later with left knee pain and groin pain on the left thigh
with ecchymosis over the anterior thigh. There was no history
of epilepsy, trauma or falls during this period. MRI of the left hip
were obtained three months after the initial images. Fat saturated proton density-weighted images demonstrated marked
edema of the left iliopsoas muscle and thickening and retraction of the left iliopsoas tendon at the origin of the lesser trochanter (Fig. 3). Further, there was marked soft tissue edema
Figure 3. MRI of the left hip after the right hip surgery. Coronal (a) and axial fat
saturated PD (b) images show marked edema and thickening of the left iliopsoas
muscle and partial tear-retraction of the left iliopsoas tendon at the origin of
lesser trochanter, surrounded by fluid.
around the left iliopsoas tendon, consistent with iliopsoas tendon rupture. The patient had no bone marrow edema or avulsion fracture of the lesser trochanter on the left side. In view
of the patient’s age and her general and neurological status,
conservative treatment was preferred and physical therapy was
continued.
A written permission was obtained from the patient for reproduction.
Figure 1. MRI of the hips in an 87-year-old woman with bilateral hip pain. Coronal
short tau inversion recovery (STIR) image shows bilateral insufficiency fractures
at the level of the femoral necks. Bilateral iliopsoas tendons are intact.
was done due to numbness, weakness and limited motion in her
right leg (Fig. 2). In addition to surgery, physical therapy was
initiated, and the patient continued her daily activities with a
walking cane.
The patient applied to the orthopedics department again three
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Discussion
We would like to present an elderly woman who had a spontaneous rupture of the distal iliopsoas tendon unassociated with
fracture of the lesser trochanter and in the absence of a recent
trauma history. Acute hip pain in the elderly might have several
causes. Bone lesions, degenerative joint disease, bone fractures,
nerve compression, tendon and muscle tears, and digestive and
vascular diseases must all be included in differential diagnosis.
Systemic disorders like hyperparathyroidism, osteoporosis, osteomalacia, rheumatoid arthritis, diabetes, chronic renal failure,
and obesity may cause pathologic tendon changes [4, 5]. Our
Sıradışı Tendon Patolojisi / Unusual Tendon Abnormality
patient does not have any other systemic risk factors for pathologic tendon changes such as hyperparathyroidism, rheumatoid
arthritis, diabetes, chronic renal failure or steroid usage.
Complete iliopsoas tendon tears have thus far only been described in elderly women, and without trauma or an underlying systemic disease, a hormonal basis may be a reason for
the gender differences [2-5]. In our case the fractures and additional pathologies were diagnosed with MRI at the time demonstrating bilateral insufficiency fractures which would imply
underlying osteoporosis.
The iliopsoas tendon is composed of the psoas major tendon,
iliacus tendon, and iliacus muscle fibers. The iliac muscle arises
from the iliac wing and inserts into the psoas tendon and the
lesser trochanter of the femur. The psoas muscle originates
from the transverse processes of T12 and the lumbar vertebrae and extends inferiorly to merge with the iliac muscle at
the L5-S2 level, becoming the iliopsoas muscle. The iliopsoas
muscle passes beneath the inguinal ligament to insert on the
lesser trochanter of the femur via the psoas tendon [6-7]. The
iliopsoas tendon is a thigh flexor and assists the lateral rotation
of the hip.
Iliopsoas injuries are generally considered uncommon. Iliopsoas
injury usually occurs due to avulsion of the iliopsoas tendon with
detachment of the lesser trochanter, secondary to an athletic
injury or trauma [1]. In the absence of a trauma, avulsion of the
lesser trochanter in an adult is regarded as a sign of metastatic
disease until proven otherwise [2]. The prevalence of iliopsoas
tendon tears without lesser trochanteric avulsion is 0.66%, and
they generally occur due to athletic injuries, trauma, senility, or
complications from hip arthroplasty [8]. Furthermore, the percentage of spontaneous injuries is much less. In this article, we
present an 87-year-old woman with spontaneous rupture of the
left distal iliopsoas tendon unassociated with fracture of the
lesser trochanter and in the absence of a recent trauma history.
The spectrum of iliopsoas tendinous and myotendinous abnormalities ranges from a muscle strain and partial tear to a complete tear. On MRI, a muscle strain can be defined as edema in
the muscle fibers with an intact iliopsoas tendon. A partial tear
means partial interruption or attenuation of the tendon fibers,
and a complete tear is defined as complete interruption of the
tendon fibers [8]. Clinically, acute rupture of the tendon generally presents as groin or trochanteric pain, worsened by flexion,
extension and adduction of the hip. Complete tendon tears may
present with a palpable thigh mass or ecchymosis [4]. Iliopsoas
tendon injuries are usually treated conservatively, with rest,
physical therapy, and/or anti-inflammatory medications, often
with good results.
Iliopsoas tendon injuries may mimic other etiologies of hip pain
and are often unsuspected clinically. This diagnosis should be
considered in the elderly patient presenting with acute groin
pain with flexion or extension of the hip, ecchymosis over the
groin, and normal plain radiographs. MRI must be kept in mind
as a modality of choice for identifying iliopsoas tendon abnormalities.
Sıradışı Tendon Patolojisi / Unusual Tendon Abnormality
References
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How to cite this article:
Çoban G, Maçin G, Tarhan NÇ, Dönmez FY, Tuncay İC. Highly Unusual Tendon
Abnormality: Spontaneous Rupture of the Distal Iliopsoas Tendon. J Clin Anal Med
2014;5(suppl 3): 357-9.
Competing interests
The authors declare that they have no competing interests.
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