Pain After Total Hip Replacement
Recently, we have seen a number of cases of persistent groin pain after total hip replacement. Rarely, there is something significantly wrong such as instability of the prosthesis or an infection.
Our patients have followed up with the surgeon who has done the due diligence and ordered an x-ray to rule out prosthetic failure. However, the pain in the groin persists. One other potential reason for persistent groin pain is impingement of the iliopsoas muscle.
What are the symptoms?
Pain associated with iliopsoas impingement is generally felt when the muscle is contracted, stretched, and palpated. Here are some common times when pain is felt:
-lifting the leg to put socks/shoes/pants on
-transitioning in/out of a car/bed
-standing up from a sitting position, especially in the last stage in trying to stand up straight
What causes the pain?
The most likely reason for the iliopsoas impingement has to do with the size and placement of the acetabular cup. One study found that patients with groin pain after hip replacement had acetabular cup overhand of more than 12 mm, whereas asymptomatic patients had overhang of less than 8mm. The muscle that runs over the cup is then more likely to become irritated. Another potential reason is how the cup is angled. A more downwardly angled cup resulted in greater overhang. A prosthetic cup angled backwards was also found lead to more overhand and thus more potential for iliopsoas impingement.
What is the treatment of iliopsoas impingement?
There is minimal agreement on the best way to treat this problem. One study found no benefit from non-surgical treatment. Another found 50% improvement but there has not been an established protocol. At OrthoWell, we have applied some of our manual approaches and modalities to try to alleviate the pain with some but not full success. Dry needling and active release technique may be helpful in improving pain and improving tissue flexibility. This is a great example of how lack of evidence forces us to apply our clinical reasoning and clinical experience from similar conditions to do the best we can.
This article summarizes the surgical treatment approaches for this problem along with the rsources cited above:
https://dralisongrimaldi.com/blog/iliopsoas-impingement-after-total-hip-replacement/
