Is Your Hip or Groin Pain Coming From the Psoas? The Clues That Help Tell

Pain at the front of the hip or deep in the groin can be surprisingly difficult to pin down. You may feel it when climbing stairs, lifting your leg into the car, getting up from a chair, running, or simply trying to stand fully upright. Because the hip joint, lower spine, groin muscles and iliopsoas tendon all sit close together, several very different conditions can produce pain in roughly the same area.

One possible cause is psoas tendinitis, more commonly discussed medically as iliopsoas tendinitis or iliopsoas tendinopathy. The iliopsoas is one of the body’s main hip flexors. When its tendon becomes irritated or overloaded, the most characteristic complaint is deep pain in the front of the hip or groin, particularly during activities that require repeated or forceful hip flexion. However, the discomfort can sometimes extend toward the thigh, pelvis, buttock or lower back. ^[1]

That overlap is exactly why psoas pain is frequently confused with a hip joint problem, groin strain, bursitis or pain coming from the lumbar spine.

The location of the pain provides an important clue, but it is rarely enough by itself. What triggers the pain, what does not trigger it, and whether there are symptoms such as stiffness, clicking, numbness or weakness often tell us much more.

The psoas major is a deep muscle that begins along the lumbar spine. It travels through the pelvis and joins with the iliacus muscle to form the iliopsoas, which attaches to the upper part of the thigh bone at an area called the lesser trochanter.

Together, these muscles form the body’s most important hip-flexing unit. They help bring your thigh toward your trunk when you walk, run, climb stairs, get into a vehicle or lift your knee. The iliopsoas also contributes to hip stability and has an anatomical relationship with the lumbar spine. ^[2]

Repetitive loading of the iliopsoas can irritate the tendon. This is particularly relevant in runners, dancers and athletes whose activities involve repeated hip flexion, sprinting or kicking, although psoas problems are not limited to athletes. Prolonged sitting, altered movement patterns, abrupt changes in activity and some hip or spinal conditions can also contribute. ^[1]

You may see several names used for similar problems, including:

• Psoas tendinitis
• Iliopsoas tendinitis
• Iliopsoas tendinopathy
• Psoas syndrome
• Iliopsoas syndrome
• Iliopsoas bursitis
• Iliopsoas impingement

These terms are not technically identical. For example, tendinitis implies inflammation of the tendon, while tendinopathy is a broader term that can include tendon degeneration and chronic overload. Iliopsoas bursitis involves irritation of the fluid-filled bursa located near the tendon. In everyday clinical practice, however, symptoms can overlap considerably. ^[1]

The classic location of psoas tendinitis pain is the front of the hip and deep groin.

People often have difficulty pointing to one exact spot because the iliopsoas tendon lies deep rather than directly under the skin. Instead of superficial soreness, the pain may feel as though it is coming from somewhere inside the front of the hip.

The pain may be felt in one or more of these areas:

• Deep in the groin
• Front of the hip
• Upper front of the thigh
• Pelvic region
• Lower abdomen near the crease of the hip
• Lower back
• Buttock or sacral region in some cases

Psoas syndrome is described as typically producing anterior groin pain that may radiate toward the thigh or lumbar region. Altered walking mechanics can also contribute to discomfort around the lower spine. ^[1]

This means that psoas tendinitis does not always feel like straightforward hip pain.

The sensation varies according to how irritated the tendon is and how long the problem has been present.

Some people describe a persistent deep ache in the groin. Others notice a sharper pain only when they lift the leg against resistance.

Common descriptions include:

• Deep aching pain at the front of the hip
• Sharp groin pain when lifting the knee
• Tightness through the front of the hip
• Pulling discomfort when extending the hip
• Pain when transitioning from sitting to standing
• Clicking, snapping or catching at the front of the hip
• Pain that improves with rest but returns with activity

Psoas pain is often movement-dependent. That is an important distinction.

If you are reasonably comfortable while resting but experience a familiar deep pain every time you lift your thigh, climb stairs or extend the hip behind you, the iliopsoas becomes more suspicious as a source.

Because the iliopsoas is heavily involved in hip flexion, symptoms commonly appear during activities that repeatedly bring the thigh toward the body.

Pain may increase while:

Every step requires the hip flexors to lift the leg onto the next stair. Repeated stair climbing can therefore reproduce iliopsoas pain.

This is a particularly useful clue. Getting into a vehicle often involves lifting the thigh while rotating the hip. Someone with an irritated iliopsoas may notice a sharp or deep groin pain during this movement.

Moving from prolonged hip flexion in sitting to standing can stretch and load the iliopsoas. Some people feel pain or stiffness during the first few steps after sitting.

Running repeatedly loads the hip flexors, particularly when accelerating, running uphill or increasing training volume suddenly.

Soccer, martial arts and other kicking activities combine rapid hip flexion with substantial force and can aggravate the iliopsoas.

Exercises that repeatedly lift the legs or trunk can heavily recruit the hip flexors.

A long stride places the hip farther into extension behind the body. Stretching an irritated iliopsoas tendon in this position may provoke symptoms.

Clinical descriptions of iliopsoas-related groin pain emphasize pain with resisted hip flexion and pain when the hip flexors are stretched into extension. ^[3]

Yes, it can—but lower back pain by itself does not establish that the psoas is the problem.

The psoas major originates along the lumbar vertebrae before passing through the pelvis. This anatomical connection helps explain why irritation, tightness or altered function of the iliopsoas can be associated with discomfort around the lower back.

People with psoas syndrome may notice lower back pain during walking, difficulty standing fully upright or discomfort when moving from sitting to standing. Pain may also be felt near the sacrum, pelvis or buttock. ^[1]

However, lower back pain is extraordinarily common and can arise from muscles, joints, discs, nerves and many other structures. For that reason, assuming that a “tight psoas” explains chronic back pain without a proper examination can easily lead someone in the wrong direction.

The more convincing pattern is lower back or pelvic discomfort occurring together with anterior hip or groin pain that is reproducible when the hip flexors are loaded or stretched.

This is one of the hardest distinctions because both problems can produce deep groin pain.

A useful starting point is this:

Psoas tendinitis tends to hurt when the hip flexor tendon itself is loaded. Hip joint disorders are more likely to hurt when the joint is compressed, rotated or moved through certain ranges.

This is not an absolute rule, but it helps clinicians decide where to look next.

Anterior hip pain can arise from several sources, while intra-articular hip pain in younger adults commonly involves femoroacetabular impingement or a labral tear and in older adults commonly involves osteoarthritis. ^[4]

A hip labral tear is particularly easy to confuse with iliopsoas problems.

Both may cause:

• Deep groin pain
• Clicking or catching
• Pain with physical activity
• Pain during hip movement
• A sensation that something is moving inside the joint

There are, however, some differences.

A labral tear is more likely to produce deep joint pain associated with hip rotation, pivoting or twisting. Some people experience locking, instability or a persistent clicking sensation. Labral tears can also cause stiffness. ^[9]

With psoas tendinitis, symptoms are often particularly reproducible when you actively lift the thigh or when someone applies resistance while you try to flex the hip.

Internal snapping of the iliopsoas tendon can further confuse the picture. The American Academy of Orthopaedic Surgeons notes that the iliopsoas tendon can catch over structures at the front of the pelvis, producing a snapping sensation. Labral and cartilage problems can also cause catching or locking, which is why clicking alone cannot identify the source. ^[5]

In fact, iliopsoas tendinopathy itself may produce a catching or slipping sensation in the groin, so a physical examination and sometimes imaging are required to tell these conditions apart. ^[1]

Hip osteoarthritis can also cause groin pain, particularly in middle-aged and older adults.

The biggest clue is often stiffness and loss of hip motion.

Hip arthritis commonly causes:

• Groin pain
• Hip stiffness
• Reduced range of motion
• Difficulty bending at the waist
• Limping
• Pain that may spread into the thigh, buttock or knee
• Grinding, catching or clicking. ^[10]

Psoas tendinitis usually does not cause the same generalized loss of hip joint movement. Instead, particular movements that load or stretch the hip flexor tend to be disproportionately painful.

If putting on socks, tying shoes and rotating the hip in several directions are becoming increasingly difficult because the entire joint feels stiff, osteoarthritis becomes more likely than isolated psoas tendinitis.

The two conditions can also coexist.

“Hip bursitis” usually refers to greater trochanteric pain syndrome, which produces pain over the outer side of the hip rather than deep in the groin.

This distinction can sometimes be quite helpful.

Greater trochanteric pain syndrome typically produces:

• Pain directly over the outside of the hip
• Tenderness when pressing over the bony prominence at the side of the hip
• Pain while lying on the affected side
• Pain during walking or stair climbing
• Pain that may spread down the outside of the thigh

Psoas tendinitis generally causes anterior hip or groin pain, not isolated tenderness over the outer hip.

There is another condition called iliopsoas bursitis, however, and this can produce symptoms extremely similar to psoas tendinitis because the bursa and tendon are located close together. Iliopsoas bursitis may cause groin, hip or anterior thigh discomfort. ^[6]

A hip flexor strain usually follows a more obvious episode of muscle overload or injury.

For example, pain may begin suddenly while:

• Sprinting
• Kicking a ball
• Changing direction rapidly
• Jumping
• Performing an explosive exercise

A more chronic iliopsoas tendinopathy often develops gradually as repeated loading exceeds the tendon’s ability to recover.

That distinction is not perfect. The iliopsoas is itself part of the hip flexor group, and both muscle and tendon injuries can occur together. But sudden pain after an explosive movement is more suggestive of an acute strain, whereas gradually worsening pain during repeated hip flexion is more typical of tendinopathy.

Not all groin pain comes from the hip flexors.

The adductor muscles run along the inner thigh and are commonly injured in sports involving kicking, cutting and twisting.

Adductor-related groin pain is typically associated with:

• Tenderness near the adductor attachment in the groin
• Pain when squeezing the legs together
• Pain with resisted hip adduction
• Inner-thigh discomfort

By comparison, iliopsoas-related pain is more likely to occur with resisted hip flexion and stretching of the hip flexors. Sports medicine literature specifically uses these movement patterns to help distinguish adductor-related from iliopsoas-related groin pain. ^[3]

Importantly, more than one source of groin pain can exist at the same time, particularly in athletes.

Pain originating in the lumbar spine may be mistaken for hip pain, while true hip and iliopsoas problems may occasionally be mistaken for spinal pain.

There are several clues that make a nerve problem more likely.

Lumbar radiculopathy can cause:

• Lower back pain
• Burning or shooting pain into the leg
• Numbness
• Tingling
• Pins-and-needles sensations
• Muscle weakness ^[8]

These neurological symptoms are not typical features of isolated psoas tendinitis.

Psoas syndrome can sometimes produce pain that radiates toward the thigh or lower back, but pain from iliopsoas irritation generally does not follow the classic nerve-root pattern of numbness, tingling and weakness extending down the leg. A recent review specifically lists iliopsoas tendinopathy and bursitis among musculoskeletal conditions that can mimic lumbar radiculopathy. ^[7]

If symptoms extend well below the knee or include obvious sensory changes or weakness, a spinal or neurological cause deserves particular attention.

It can be one of the stronger clues.

Imagine sitting in a chair and lifting your knee toward your chest. The iliopsoas contracts strongly to perform that movement.

If this reliably reproduces deep anterior hip or groin pain—particularly when the movement is resisted—it raises suspicion that the iliopsoas is involved.

Clinicians may therefore assess pain during resisted hip flexion in several positions. Current clinical approaches to iliopsoas-related groin pain also consider tenderness over the hip flexor complex and pain when the iliopsoas is stretched. ^[3]

That does not mean you should use a painful leg-lifting exercise to diagnose yourself. Several hip conditions can hurt during the same movement.

This is another potentially useful clue.

When you stand upright after sitting, your hip moves from flexion toward extension. An irritated or shortened iliopsoas is stretched during that transition.

Some people with psoas syndrome therefore feel as though they cannot immediately straighten fully after getting out of a chair. They may take a few shortened steps before standing more comfortably upright. ^[1]

A similar pattern can appear after prolonged sitting at a desk or during a long car journey.

Again, this is suggestive rather than diagnostic.

Yes.

The iliopsoas tendon can move over bony structures at the front of the hip and produce an audible or palpable snap. This is sometimes called internal snapping hip syndrome.

Snapping itself is not always painful and can occur without a significant injury. When the snapping becomes painful, however, irritation of the tendon or nearby bursa may be involved.

A painful snap in the front of the hip is more suggestive of the iliopsoas than a snap over the outside of the hip.

However, deep catching, locking or clicking may also come from cartilage or a labral tear inside the joint. Symptoms alone cannot always separate them.

There is no single home test that can prove that hip or groin pain comes from the psoas.

Diagnosis usually begins with a careful history.

A clinician may ask:

• Where exactly is the pain?
• Did it develop suddenly or gradually?
• Does lifting the knee reproduce it?
• Does stretching the hip backward reproduce it?
• Is there clicking or snapping?
• Does the pain travel below the knee?
• Is there numbness or tingling?
• Has your running or exercise volume recently changed?
• Have you had previous hip surgery?
• Do you have back pain as well?

The physical examination may include palpating the iliopsoas area and testing hip flexion against resistance. The Thomas or modified Thomas test may also be used to assess hip flexor tightness or reproduce symptoms. ^[3,7]

However, no isolated examination maneuver should be considered definitive. The clinician also needs to assess the hip joint, lumbar spine and surrounding groin structures.

Not always.

Many cases can initially be evaluated clinically. Imaging becomes more useful when the diagnosis is uncertain, symptoms persist despite appropriate treatment, or another condition needs to be excluded.

Magnetic resonance imaging can show abnormalities involving the iliopsoas tendon, bursa and surrounding structures. Musculoskeletal ultrasound can also evaluate the tendon and bursa and has the advantage of showing the iliopsoas dynamically while the hip moves. ^[1,7]

In selected cases, an image-guided injection of local anesthetic around the iliopsoas may also help determine whether it is actually the source of the pain.

X-rays do not show the iliopsoas tendon well but may be useful for identifying or excluding problems involving the bones and hip joint.

Most activity-related iliopsoas problems are not emergencies. But not every deep groin or psoas-region pain is a tendon problem.

Seek prompt medical assessment if hip, groin or lower abdominal pain is accompanied by:

• Fever or chills
• Unexplained weight loss
• Severe or rapidly worsening pain
• Significant night pain without an obvious mechanical trigger
• Inability to bear weight
• Major trauma
• New leg weakness
• Significant numbness
• Loss of bladder or bowel control
• Severe abdominal symptoms
• A new groin lump or swelling

The psoas lies deep within the abdomen and pelvis, close to several organs and important structures. Less common conditions such as infection, a psoas abscess, malignancy, kidney stones and abdominal or pelvic disorders can occasionally produce pain that resembles a musculoskeletal psoas problem. ^[1,2]

If there is one useful way to think about psoas tendinitis, it is this:

Do not focus only on where the pain is. Pay attention to what makes it appear.

Deep pain at the front of the hip or groin that repeatedly worsens when you lift your knee, climb stairs, run, get out of a car or stretch the hip backward fits the iliopsoas pattern better than pain based on location alone.

Outer hip tenderness—especially pain when sleeping on that side—points more toward greater trochanteric pain syndrome.

Deep groin pain with stiffness, loss of hip rotation or progressive limitation may suggest a problem within the hip joint.

Catching or locking during rotation may raise concern for labral or cartilage pathology.

Back pain accompanied by numbness, tingling, weakness or pain extending farther down the leg makes a spinal nerve problem more likely.

And none of these patterns are absolute. Hip, groin and spinal disorders frequently overlap.

That is why persistent “psoas pain” should not automatically be treated as a tight muscle that simply needs more stretching. Correctly identifying whether the pain is coming from the iliopsoas tendon, hip joint, outer hip, groin muscles or lumbar spine is usually the most important first step toward choosing the right treatment.

Psoas tendinitis most often causes a deep ache or sharp pain in the front of the hip or groin. Pain may sometimes extend into the upper thigh, pelvis, buttock or lower back.

Yes. Groin pain is one of the most characteristic symptoms of iliopsoas tendinitis or iliopsoas tendinopathy. It often worsens during movements involving hip flexion.

It can. The psoas attaches to the lumbar spine, and psoas syndrome can be associated with lower back or lumbosacral discomfort. However, many other conditions cause back pain, so back pain alone is not enough to diagnose a psoas problem.

The iliopsoas is a primary hip flexor. Lifting the thigh requires it to contract. If its tendon is irritated, active or resisted hip flexion may reproduce pain.

It can, particularly with longer strides, fast walking, hills or prolonged activity. Some people develop a subtle limp or shorten their stride because hip extension is uncomfortable.

Prolonged sitting can aggravate symptoms in some people because the hip remains flexed for an extended period. Pain may be most noticeable when first standing after sitting.

Psoas-related pain can extend toward the upper thigh, but pronounced numbness, tingling, burning, weakness or pain traveling well below the knee should raise greater suspicion for a neurological or spinal problem.

Typical greater trochanteric pain syndrome causes pain and tenderness over the outside of the hip, often worsening when lying on that side. Psoas tendinitis more commonly causes deep anterior hip or groin pain, especially during resisted hip flexion.

Both can cause groin pain and clicking. Psoas pain tends to be reproduced by loading the hip flexor, while labral problems may produce deeper joint pain, catching, locking or pain during twisting and hip rotation. Clinical examination and sometimes imaging may be needed to distinguish them.

Stretching is sometimes included in rehabilitation, but aggressively stretching an already irritated tendon is not automatically helpful. Treatment should be based on whether the problem is primarily tendon overload, muscle tightness, hip joint disease or another cause. Persistent symptoms are better evaluated before repeatedly stretching through pain.

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