Hip Flexor Pain and Back Pain Related to Total Hip Replacement

Some form of hip flexor pain and/or back pain with total hip replacement seems to be a common experience among those of us with THR. I frequently get questions about it from students and I have read accounts from others with THR.

I remembered that several weeks after my second THR surgery I began to feel discomfort in my right groin. It was painful to raise my leg in flexion. I did some research and learned there are many reasons for hip flexor pain so with some sleuthing I began to understand what was happening in my body.

What are Hip Flexor muscles?

The iliopsoas muscle is the major flexor of your hip joint. It consists of three muscles: the iliacus , the psoas major, and the psoas minor. The three work together to flex your hip, and they also stabilize your hip and lower back during activities like yoga, dancing, walking, and standing up from a chair.

hip flexor pain

Functions of the Iliopsoas Muscles

In the physical body, The iliopsoas muscle helps maintain a healthy and balanced posture; it participates in almost every body movement. A tight iliopsoas can limit our freedom of movement when walking (and practicing yoga). A loose or damaged iliopsoas can contribute to instability.

In the emotional body, the psoas affects our ability to relax and influences our feelings of wellbeing and stability. A pliable, well-balanced psoas enables the flow of subtle energy and increases whole body sensitivity.
There are several reasons for pain related to the iliopsoas muscle and depending on the type of iliopsoas issue, the pain may show up in different locations, usually either the groin or the back.

Groin pain and iliopsoas and how it relates to Hip Flexor Pain

Ilipsoas tendinitis and iliopsoas bursitis:  The two are almost interchangeable because of their close proximity to each other. They are characterized by hip flexor pain and pain in the groin.

 Tendonitis or bursitis can occur because of the surgery itself. The surgeon has to manipulate your leg during surgery and this stretches the hip flexors and can cause strain and irritation. In addition, it is normal for the joint capsule to be inflamed after surgery and this tends to cause friction on the hip flexor tendon. Patience while healing and ice! ice! ice! is a good idea following surgery in order to help the healing process and to avoid hip flexor problems.

Muscles atrophy and shorten before and after the surgery due to lack of activity and so do tendons. As you return to your activities be aware that tendons, ligaments, and muscles build at different rates. Muscle strength can build within just a few days, while tendons and ligaments can take a few weeks before seeing improvement. If you have an aggressively ambitious yoga practice you may be getting your muscle strength ahead of your tendon strength and this puts extra stress on your tendons. Take it slow and easy as you return to your yoga practice or to other physical activities.

Iliopsoas injury (Psoas Syndrome)  

Psoas Syndrome is caused by overuse of the hips or by injury. THR surgery can also traumatize the pos[a]s muscle. When you have an injured or strained muscle the best way to treat it at first is with rest and ice. When the acute phase of injury is past then you want to rejuvenate the muscle with strengthening postures like Plank Pose/Kumbhakasana, Boat Pose/Navasana, or gentle “peddling” on your back. Avoid deep stretches like Dancer Pose/Natarajasana or Pigeon Pose/Eka Pada Raja Kapotasana until you can move without pain.

Hip Flexor Pain

Symptoms of Psoas Syndrome:
Low back pain, stiffness or tightness
Pelvic pain
Hip pain
Groin pain
Buttock pain

Prosthesis Impingment:

“Iliopsoas impingement” can occur after total hip replacement. This is a condition where a portion of the prosthesis (usually the new cup) rubs on the iliopsoas tendon, causing pain and immflammation as well as limiting range of motion. Its frequency is very low (4.4%) but still it is something to be aware of if you are experiencing groin pain and limited motion. Your surgeon is the person to talk to about this condition.

Back Pain and Iliopsoas, How it relates to Hip Flexors

As mentioned above, the iliopsoas muscle can atrophy and shorten with the inactivity associated with THR. When this muscle shortens it can put undue stress on the low back by bringing it into an unnatural lordosis. The best way to “lengthen” this muscles is at first to warm it up with poses like Plank Pose/Kumbhakasana, Boat Pose/Navasana, or gentle “peddling” on your back. Then begin gentle stretching in poses like Warrior I/Virabhadrasana I or Locust pose/Salabasana. These poses require strength combined with stretching and are a safer way to start limbering the iliopsoas muscle.