Iliopectineal Bursa Injection

Indications and Clinical Considerations

Bursae are formed from synovial sacs that allow easy sliding of muscles and tendons across one another at areas of repeated movement. These synovial sacs are lined with a synovial membrane invested with a network of blood vessels that secrete synovial fluid. Inflammation of the bursa results in an increase in the production of synovial fluid with swelling of the bursal sac. With overuse or misuse, this bursa may become inflamed, enlarged, and on rare occasions infected. Although there is significant intrapatient variability as to the number, size, and location of bursae, anatomists have identified a number of clinically relevant bursae, including the iliopectineal bursa. The iliopectineal bursa lies between the psoas and iliacus muscle and the iliopectineal eminence ( Fig. 128.1 ). This bursa may exist as a single bursal sac or in some patients as a multisegmented series of sacs that may be loculated.

The iliopectineal bursa is vulnerable to injury from both acute trauma and repeated microtrauma. Acute injuries frequently take the form of direct trauma to the bursa via hip injuries, as well as overuse injuries. If the inflammation of the iliopectineal bursa becomes chronic, calcification of the bursa may occur.

The patient with iliopectineal bursitis frequently reports pain in the anterior hip and groin. The pain is localized to the area just below the crease of the groin anteriorly, with referred pain noted into the hip joint and anterior pelvis. Often the patient is unable to sleep on the affected hip and may note a sharp, “catching” sensation with range of motion of the hip. Iliopectineal bursitis often coexists with arthritis of the hip joint.

Physical examination may reveal point tenderness in the upper thigh just below the crease of the groin. Passive flexion, adduction, and abduction, as well as active resisted flexion and adduction of the affected lower extremity, reproduce the pain. Sudden release of resistance during this maneuver markedly increases the pain.

Plain radiographs of the hip may reveal calcification of the bursa and associated structures consistent with chronic inflammation. Magnetic resonance imaging and ultrasound imaging may also help identify the presence of bursitis or other painful conditions ( Fig. 128.2 ). Magnetic resonance imaging is indicated if occult mass or tumor of the hip or groin is suspected. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The iliopectineal bursa lies between the psoas and iliacus muscles and the iliopectineal eminence. This is the point at which the ilium and the pubis bone merge. The psoas and iliacus muscles join at the lateral side of the psoas, and the combined fibers are referred to as the iliopsoas muscle. Like the psoas, the iliacus flexes the thigh on the trunk or, if the thigh is fixed, flexes the trunk on the thigh, as when moving from a supine to sitting position. This action can irritate the iliopectineal bursa, as can repeated trauma from repetitive activity including sit-ups or overuse of exercise equipment for lower extremity strengthening. The iliacus muscle is innervated by the femoral nerve.