Clinical Diagnosis and Treatment of Iliopsoas-Related Groin Pain: A Systematic Review

Abstract

Background/Objectives: Iliopsoas-related groin pain (IRGP) occurs in native hips and following hip surgery. However, diagnosis is challenging due to symptom overlap with other hip pathologies and limited imaging accuracy. Treatment ranges from conservative management to surgery. This systematic review evaluates the diagnostic accuracy of clinical tests and the effectiveness of conservative and surgical treatments for IRGP. Methods: This systematic review was conducted in accordance with the PRISMA 2020 guidelines and prospectively registered in PROSPERO. A comprehensive search of PubMed, Embase, and Web of Science was performed from database inception to 13 March 2026. Diagnostic accuracy studies evaluating clinical tests for IRGP against reference standards and therapeutic intervention studies assessing treatment effectiveness in individuals with IRGP were included. Risk of bias was assessed using QUADAS-3 for diagnostic studies and the MINORS tool for treatment studies. Due to heterogeneity in populations, interventions, outcomes, and study design, a narrative synthesis was performed. Results: Three diagnostic accuracy studies and 71 treatment studies were included. All three diagnostic studies used an image-guided injection as reference standard and were at high risk of bias. The hip-external rotation-flexion-ceiling (HEC) test showed the highest diagnostic accuracy (sensitivity 94%, specificity 88%), together with resisted seated hip flexion. However, all three diagnostic studies were at high risk of bias, so these estimates should be regarded as preliminary. Supine provocation tests showed high sensitivity but poor specificity. Conservative management achieved high success rates in idiopathic and athletic populations (77-100%) but lower and more variable effectiveness after total hip arthroplasty (THA) (16-50%). Image-guided injections produced short-term improvement in 50-70% of patients, with limited long-term effectiveness in mechanically driven cases after THA. In native hips, four matched comparative cohort studies indicated that arthroscopic iliopsoas release provided no clear benefit beyond treatment of concomitant intra-articular pathology and was associated with measurable iliopsoas atrophy and loss of hip flexion strength. After THA, both iliopsoas tenotomy and acetabular component revision improved pain and function, with outcomes strongly dependent on implant position and patient selection. Methodological quality of the treatment studies was generally low to moderate (MINORS 5-14/16 for non-comparative and 14-21/24 for comparative studies), while all three diagnostic studies were at high risk of bias on QUADAS-3. Conclusions: Current evidence highlights substantial diagnostic and therapeutic uncertainty in IRGP. Clinical tests lack sufficient standalone accuracy and should at least include the HEC test and resisted seated hip flexion. Treatment outcomes depend strongly on the underlying etiology, and the lack of an accurate diagnostic reference standard further complicates their interpretation. High-quality diagnostic studies and comparative intervention trials are needed to support evidence-based clinical pathways. Registration: PROSPERO CRD42025644593.