Persistent groin pain after hip replacement

Ross Hauser, MD and Danielle Matias, PA-C

People will send us emails that go something like this:

  • I had hip replacement surgery over a year ago. I have had chronic groin pain ever since. Now my doctors are suggesting that I have some type of hip impingement and will need another replacement and a hardware adjustment.  I am looking at alternatives to this second hip replacement surgery.

Often we will hear from people that they have leg, or hip, or back pain following hip replacement. Sometimes they will tell us about groin pain that has restricted their ability to return to sports or work. Sometimes they will tell us that their pain is a “mystery” to their doctors. For more on this subject, please see our article: What causes long-term hip pain after hip replacement?

In this article, we will focus more on the issue of groin pain following hip replacement.

Part 1: What can cause groin pain after hip replacement?

In this section, we will go over some of the causes of groin pain after hip replacement and cite the opinions of doctors and researchers in addressing this problem.

Is it the size of the implant? Possibly, but that may not be all.

In December 2020, doctors at the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, the University of Toronto, and the Adult Reconstruction and Joint Replacement Division, at the Hospital for Special Surgery in New York combined to assess the causes of chronic groin pain after hip replacement with a focus on possibly the oversized femoral implant head size characteristic of implants used in dual mobility total hip replacement. (1) Dual mobility hip replacement adds an additional polyethylene component which is seen as superior in younger patients who are more active and this type of device reduces or even eliminates the risk of dislocation of the implant. What this research study found was that “Overall, 8.7% of hip replacement patients reported groin pain at one year. Patients with groin pain were younger and had lower body mass index (BMI)” Suggesting a more active patient. They also added the dual mobility hip replacement did not put the patient at any more of greater risk for groin pain. The researchers note: “In this (study’s) population of hip arthroplasty patients, the incidence of groin pain one year after surgery did not differ among patients undergoing dual mobility and conventional hip replacement; dual mobility hip replacement, in particular, was not associated with a higher risk of groin pain, despite its comparatively larger femoral head sizes. Traditional hip replacement, on the other hand, was associated with a higher risk of pain.”

Impingement of the iliopsoas tendon

In an April 2017 paper, doctors at the Mayo Clinic writing in the Journal of Bone and Joint Surgery (2) suggest that a potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoas tendon. Treatment options include conservative management, tenotomy, and acetabular revision (surgery to adjust or replace the hip socket component).

In looking to suggest treatment options the Mayo doctors looked at 49 patients with a diagnosis of iliopsoas impingement after primary total hip arthroplasty

  • 21 patients underwent acetabular revision,
  • 8 patients underwent tenotomy,
  • and 20 patients had nonoperative management (conservative treatments).

At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution compared with 22 patients (76%) in the operative group.

Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. In patients with minimal acetabular component prominence, iliopsoas release provided a high rate of success.

A March 2023 paper in The Journal of Arthroplasty (3) “found an incidence of 2.2% of iliopsoas tendinopathy patients after anterior (front) approach total hip replacement that compromised outcomes. Younger age and previous spine fusion were identified as the most important risk factors. These patients were 5 times more likely to report low back pain and greater trochanter pain post-total hip replacement.”

Part 2: Treatments for groin pain after hip replacement


In tenotomy revision surgery the answer to iliopsoas impingement generated pain after hip replacement?

A September 2021 editorial by Dr. Andrew Blackman published in the Journal of Arthroscopic and related surgery (4) discusses the challenges of diagnosing and treating Iliopsoas tendon pain following hip replacement.

“Iliopsoas tendon pain can be a frustrating condition for both patients and surgeons after total hip arthroplasty. It is difficult to diagnose definitively, as there is no imaging modality that offers reliable information and there are numerous causes of persistent groin pain in this patient population. The pain can ruin the results of an otherwise well-functioning total hip arthroplasty.”

Dr. Blackman continues on who would best benefit and least benefit from iliopsoas tenotomy.

“Patients who respond best to arthroscopic iliopsoas tenotomy are those with isolated pain with hip flexion activities and reproducible pain with resisted hip flexion (typically a band that provides resistance against bending your knee upwards towards your head) on examination or other provocative iliopsoas maneuvers.

Patients with these symptoms in addition to more generalized pain findings (pain with weight-bearing, pain at night, pain with passive range of motion) tend not to respond as favorably to isolated iliopsoas tenotomy.”

Success of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty

A July 2019 paper in The Journal of Arthroplasty (5) wrote: “Iliopsoas impingement after total hip arthroplasty (replacement) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision.” In this paper, the researchers wanted to demonstrate the effectiveness and risks in patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after total hip replacement.

  • 60 patients with iliopsoas impingement after total hip arthroplasty (replacement) treated with endoscopic iliopsoas tenotomy were retrospectively evaluated.
  • The outcomes assessed were resolution of pain, function, and complications.

Results:

  • At the last follow-up (average 5.5 months), 93.3% of patients had resolution of pain. Clinically important improvements in function, and low rate of complications. According to the paper: “Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after total hip arthroplasty.”

In February 2021 doctors writing in the journal Cureus (6) wrote that “Controversy exists over the risks and benefits of tenotomy versus revision as a surgical solution.” In this paper, the doctors reported on their “limited experience with combined acetabular revision (replacing the cup component of the hip replacement) and partial iliopsoas tenotomy when other conservative treatments have failed.”

The doctors assessed eight patients diagnosed with iliopsoas impingement following hip replacement. All patients had prolonged groin pain for an average of two years and had failed conservative treatment for at least six months.

All patients underwent acetabular revision with partial psoas tendon release.

  • Of the eight patients, seven had a positive diagnostic challenge with an image-guided injection (a painkiller was injected to see if it resolved the groin pain).
  • During the revision surgery, the cup hardware was adjusted.
  • There were no major postoperative complications.
  • At an average follow-up of 3.3 years, the mean Hip disability and Osteoarthritis Outcome Score for Joint Replacement was 75 points (range: 32-100 points).
  • Conclusion iliopsoas impingement may be effectively managed with combined acetabular revision and tenotomy. The challenges of implant placement and positioning may be aided with intraoperative imaging.

Cortisone for iliopsoas tendonitis

A December 2022 from Rush University Medical Center, published in The Journal of Arthroplasty (7) evaluated the effectiveness of ultrasound-guided corticosteroid injections for iliopsoas tendonitis following total hip replacement. In this study, 42 patients who received an ultrasound-guided corticosteroid injection for iliopsoas tendonitis after primary hip replacement were assessed at one-year follow-up for the need for another surgery, groin pain at last follow-up, the need for additional intra-bursal injection and pain and function scores. Further, scans were taken to determine hardware failure or mispositioning (anterior cup overhang) as a cause of iliopsoas tendonitis.

Among the 22 patients who did not have anterior cup overhang, four (18.2%) had persistent groin pain at an average follow-up of 40 months after ultrasound-guided corticosteroid injections. Three patients had a second injection, none had groin pain at the most recent follow-up. No patients required acetabular revision. Resolution of groin pain was demonstrated in 78.6% of patients in the group; however, those who did not have acetabular overhang had higher rates of success. The overall revision surgery rate was 11.9%. The study concludes: “Ultrasound-guided corticosteroid injections appear to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary total hip replacement.”

Persistent groin pain following total hip replacement treated with physical therapy

A March 2022 paper in the journal Physiotherapy Theory and Practice (5) wrote that hip impingement syndrome can occur after total hip replacement and that nonoperative treatment is inconsistently recommended and surgical options include iliopsoas tenotomy. In this case, a patient with persistent groin pain after total hip replacement and iliopsoas tenotomy is presented:

  • The patient was a 72-year-old male who had a 4-year history of persistent groin pain following total hip replacement and an unsuccessful iliopsoas tenotomy. He had pain and limited right hip range of motion during active and passive hip flexion, abduction, and external rotation.
  • This patient was treated with (physical therapy) high-grade joint mobilization to improve the range of motion of the right hip and an exercise program.
  • The patient was treated for six visits over 3 weeks. Clinically important improvements were noted in pain, function, and perceived level of improvement. Pain during hip flexion improved on the Numeric Pain Rating Scale, and function improved on the Lower Extremity Functional Scale. Improvements in the range of motion and strength were also observed. At 6-month follow-up, he reported maintenance of improvements. Discussion: Joint mobilization and exercise were effective for improving range of motion, groin pain, and function in a patient with a 4-year history of persistent groin pain after total hip replacement and subsequent iliopsoas tenotomy.

Prolotherapy for groin-related pain after hip replacement

Prolotherapy is a regenerative treatment that can successfully treat groin pain after hip replacement by way of repairing the ligaments and tendons stretched or cut during the hip replacement procedure. Prolotherapy injections to the sacrotuberous ligaments and the hamstring tendon attachment will stimulate the repair of these damaged areas. A comprehensive exam by the experienced Prolotherapist is vital for a thorough treatment. Sometimes pain in other areas is also involved. For instance, pain in the ischial tuberosities may be coupled with pain in the pubic symphysis. There may also be pain in the sacroiliac joints.

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have about your pain.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

1 Stavrakis AI, Khoshbin A, Joseph A, Lee LY, Bostrom MP, Westrich GH, McLawhorn AS. Dual Mobility Total Hip Arthroplasty Is Not Associated with a Greater Incidence of Groin Pain in Comparison with Conventional Total Hip Arthroplasty and Hip Resurfacing: A Retrospective Comparative Study. HSS Journal®. 2020 Dec;16(2_suppl):394-9. [Google Scholar]
2 Chalmers BP, Sculco PK, Sierra RJ, Trousdale RT, Berry DJ. Iliopsoas impingement after primary total hip arthroplasty: operative and nonoperative treatment outcomes. Jbjs. 2017 Apr 5;99(7):557-64. [Google Scholar]
3 Verhaegen JC, Vandeputte FJ, Van den Broecke R, Roose S, Driesen R, Timmermans A, Corten K. Risk Factors for Iliopsoas Tendinopathy After Anterior Approach Total Hip Arthroplasty. The Journal of Arthroplasty. 2023 Mar 1;38(3):511-8. [Google Scholar]
4 Blackman A. Editorial Commentary: Iliopsoas Tenotomy for Pain After Total Hip: A Great Operation IF the Diagnosis Is Right. Arthroscopy: the Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2021 Sep 1;37(9):2830-1. [Google Scholar]
5 Bell CD, Wagner MB, Wang L, Gundle KR, Heller LE, Gehling HA, Duwelius PJ. Evaluation of endoscopic iliopsoas tenotomy for treatment of iliopsoas impingement after total hip arthroplasty. The Journal of arthroplasty. 2019 Jul 1;34(7):1498-501. [Google Scholar]
6 Yun A, Qutami M, Pasko KB. Surgical Management of Iliopsoas Impingement With Combined Acetabular Revision and Partial Psoas Tenotomy. Cureus. 2021 Feb;13(2). [Google Scholar]
7 Weintraub MT, Barrack T, Burnett III RA, Serino III J, Bhanot S, Della Valle CJ. Ultrasound-Guided Iliopsoas Bursal Injections for Management of Iliopsoas Bursitis after Total Hip Arthroplasty. The Journal of Arthroplasty. 2022 Dec 16. [Google Scholar]
8 Peterson S. Physical therapy management of a patient with persistent groin pain after total hip arthroplasty and iliopsoas tenotomy: a case report. Physiotherapy Theory and Practice. 2020 Jun 6:1-1. [Google Scholar]

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