Evaluation of clinical tests to diagnose iliopsoas tendinopathy

Key Points

1. Diagnosing iliopsoas tendinopathy can be challenging due to nonspecific pain patterns and clinical signs commonly seen with many other conditions.
2. This study showed that the hip–external rotation–flexion-ceiling test is the most accurate clinical tool for diagnosing iliopsoas-related groin pain.

BACKGROUND AND OBJECTIVE

Diagnosing iliopsoas tendinopathy can be challenging due to nonspecific pain patterns and clinical signs commonly seen with many other conditions (1). Traditional clinical tests usually focus on hip flexion, the primary action of the iliopsoas. The newly described hip–external rotation–flexion-ceiling (HEC) test combines the primary action of the iliopsoas with the secondary action (external rotation), possibly improving diagnostic reliability.

The objectives of the study were three-fold:

1. To determine the accuracy of the new HEC test and 10 other common tests for iliopsoas-related groin pain

2. To determine whether tests were “good” or “poor” for diagnosing iliopsoas tendinopathy

3. To rank all tests to determine the best diagnostic tool.

The newly described hip–external rotation–flexion-ceiling (HEC) test combines the primary action of the iliopsoas with the secondary action (external rotation), possibly improving diagnostic reliability.

Clinicians should consider incorporating the described hip–external rotation–flexion-ceiling (HEC) test in their routine evaluations of patients with groin pain.

METHODS

• 44 participants with persistent groin pain (mean age 48; 34% male) completed this study. Participants had native hips (52%) and hips that had undergone THAs (48%).

• Eleven clinical tests, including the HEC test (see Video 1), were performed before and after a fluoroscopy-guided iliopsoas injection. Improvement in the participant’s characteristic groin pain was identified as the diagnostic gold standard.

VIDEO 1 - HEC TEST

• A test was deemed as “good” if it met the three following criteria:

  • Significant mean VAS pain score was reduced by greater than or equal to three points after injection.
  • Significant optimal cutoff value for pain reduction was greater than or equal to four.
  • Significant area under the curve (AUC) of greater than or equal to 0.80 was found.

• If a test met none of these three criteria, it was considered “poor.”

• Using the criteria above, each clinical test with at least 30 valid observations received a ranking position for each criterion. The test with the lowest total score was deemed the best.

RESULTS

• In 82% of patients who experienced pain reduction after injection and who were subsequently diagnosed with iliopsoas tendinopathy, the following tests had the most clinically important pain reduction after infiltration: the HEC test, resisted hip flexion (seated), and SLR in exorotation (see table 1).

• The HEC test demonstrated a sensitivity of 94%, specificity of 88%, and an AUC of 0.99, with a VAS score reduction of 5, outperforming all other conventional tests.

• Only three tests—the HEC test, resisted hip flexion (seated), and resisted hip external rotation (seated)—met all three criteria to be classified as “good” tests. The Thomas test, SLR in neutral, and the snapping hip test were deemed “poor” tests.

• Overall, the HEC test was ranked best to detect iliopsoas tendinopathy, the resisted hip flexion (seated) test was ranked second and the SLR in exorotation was ranked third.

LIMITATIONS

Readers should acknowledge two limitations of this study:

1. Due to the proximity of various anatomical structures, a decrease in pain following an iliopsoas injection may not be specific to iliopsoas tendinopathy.

2. Participants had “persistent” groin pain, possibly capturing a population with more severe symptoms than other patients.

CLINICAL IMPLICATIONS

The objectives of this study were to:

1. Determine the accuracy of the new HEC test and 10 other common tests for iliopsoas-related groin pain The HEC was determined to be the most accurate at determining iliopsoas-related groin pain when compared to the 10 other clinical tests that were included in the study.

2. Determine whether tests were “good” or “poor” for diagnosing iliopsoas tendinopathy Based on their performance using the metrics described in the methods, tests were categorized as the following:

“Good” tests:

• The HEC test
• Resisted hip flexion (seated)
• Resisted hip external rotation (seated)

“Poor” tests:

• Thomas test
• SLR in neutral
• Snapping hip test

3. Rank all tests to determine the best diagnostic tool. See results table.

Clinicians should re-evaluate the clinical examination techniques they use for assessment of iliopsoas tendinopathy and consider incorporating the HEC test in their routine evaluations of patients with groin pain.

According to this study, the HEC test gives a more objective and reliable diagnosis that does not include the use of invasive procedures. Future studies need to assess interobserver reliability and performance in a more diverse patient population and include level of activity of participants.

+STUDY REFERENCE

Vandeputte F, Driesen R, Timmermans A, Corten K (2025) Evaluation of Clinical Tests to Diagnose Iliopsoas Tendinopathy. Clinical orthopaedics and related research, Advance online publication.

SUPPORTING REFERENCE

1. Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K. M., Lovell, G., Meyers, W. C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A. G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., Tyler, T., … Hölmich, P. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British journal of sports medicine, 49(12), 768–774.