Iliopectineal bursitis is a common cause of anterior hip and groin pain. The iliopectineal bursa is one of the larger bursae in the body and lies between the psoas and iliacus muscles and the iliopectineal eminence (Fig. 123.1). The iliopectineal eminence is the point at which the ilium and pubis bone merge. The bursa serves to cushion and facilitate sliding of the musculotendinous unit of the psoas and iliacus muscles over the bony protuberance of the iliopectineal eminence (Fig. 123.2). The iliopectineal bursa is subject to inflammation from a variety of causes with acute trauma to the hip and repetitive microtrauma being the most common. Acute injuries to the bursa can occur from direct trauma from seat belts during motor vehicle accidents as well as from overuse injuries that required repeated hip flexion, such as javelin throwing and ballet. Direct pressure that forces the iliopectineal bursa against the iliopectineal eminence when sitting while leaning forward for prolonged periods has also been implicated in the development of iliopectineal bursitis. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur. Gout and other crystal arthropathies may also precipitate acute iliopectineal bursitis as may bacterial, tubercular, or fungal infections.

The patient suffering from iliopectineal bursitis most frequently presents with the complaint of severe anterior hip and groin pain with any pressure on the area overlying the anterior hip joint and inflamed iliopectineal bursa. Flexion and rotation of the hip will exacerbate the pain. Physical examination of the patient suffering from iliopectineal bursitis will reveal point tenderness over the medial anterior hip. The pain may radiate into the anterior thigh and pelvis. If there is significant inflammation, rubor and color may be present and the entire area may feel boggy or edematous to palpation. Swelling, which at times can be quite dramatic, is often present and may actually compress adjacent nerves causing numbness, which can confuse the clinical picture (Fig. 123.3). Often, the swelling of iliopectineal bursitis is misdiagnosed as an inguinal hernia. If calcification or gouty tophi of the bursa and surrounding tendons are present, the examiner may appreciate crepitus with active flexion and adduction of the hip, especially in the sitting position. Often, the patient will not be able to sleep on the affected side.

Plain radiographs are indicated in all patients who present with hip pain to rule out occult bony pathology. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging (MRI) or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other hip bursitis, calcific tendonitis, tendinopathy, triceps tendonitis, or other hip pathology (Fig. 123.4). MRI or ultrasound imaging of the affected area may also help delineate the presence of calcific tendonitis or other hip pathology. Rarely, the inflamed bursa may become infected, and failure to diagnose and treat the acute infection can lead to dire consequences.

The iliopectineal bursa lies between the psoas and iliacus muscles and the iliopectineal eminence, the bony prominence at the point at which the ilium and the pubis bones fuse (see Figs. 123.2 and 123.5). 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 cause inflammation of 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.