Treating Hip Flexor Tendinopathies

Most Recent Literature/EBP

Project Overview:
To find the most recent literature regarding treating chronic hip flexor tendinopathies.

Hip flexor tendinopathies can be difficult to treat, and while there is a decent amount of
literature based on treating patellar and achilles tendinopathies, there is little to none regarding
iliopsoas tendinopathies.1 The iliopsoas is a major decelerator of the hip; therefore, eccentric
based training has thought to an important aspect of rehabilitation. Eccentric based training has
been a commonly researched method of treatment for tendinopathies; however, it has shown
mixed results.1
Eccentric training exercise has been shown to increase collagen production and improve
tendon structure in abnormal tendons.2 For acute/reactive tendinopathies and for athletes who are
already loading the tendon a significant amount, adding eccentric exercises may overstimulate an
intact tendon matrix and yield conflicting results. For chronic/degenerative tendinopathies,
eccentric training may provide a positive stimulus for cell tendon matrix reconstruction/healing. 2
True eccentric based training occurs with loads that can only be moved eccentrically; therefore,
training at loads that can be moved concentrically may not eccentrically load the tendon enough
to yield positive adaption results.1
Isolated eccentric exercise has been the primary conservative treatment for patellar and
achillies tendinopathies; however, up to 45% of patients do not respond. 3 One study found, that
for achillies and patellar tendinopathies, heavy slow resistance (HSR) concentric-eccentric
training yielded better results than eccentric loading only. HSR training resulted in improved
tendon diameter when compared to eccentric loading only program. HSR appears to have a
better effect on tendon adaption/collagen turnover. 3 Since HSR may prove to beneficial when
treating lower limb tendinopathies, iliopsoas tendinopathies may also respond well to this form
of treatment.
A systematic review looked to determine the effectiveness of isometric, eccentric or HSR
training for patellar tendinopathy. Th results indicated that isometric training may prove to be
more beneficial for immediate pain relief or for athletes who are currently in season. However,
the findings also stated eccentric only or HSR training proves more beneficial for long term pain
relief and overall knee function.4
Overall, there is limited research on how to properly rehabilitate hip flexor
tendinopathies; however, using the research found on patellar and achillies tendinopathies it
could potentially translate. While eccentric only training has been thought to be the gold standard
research suggest it may potentially overstimulate acute tendinopathy injuries; therefore, I would
suggest using heavy isometrics for acute injuries and for athletes who are in season. However,
for chronic/degenerative stages of hip flexor tendinopathies eccentric only or heavy slow
 resistance training may provide the load needed to stimulate construction of the tendon cell
matrix. Research states eccentric only or heavy slow resistance training has been more beneficial
for long term pain relief and overall function when compared to isometrics for
chronic/degenerative stages of healing.
When determining the potential route of treatment, it will be important to determine not
only the patient’s current stage of healing (acute vs chronic) but also whether they are frequently
loading the tendon on a daily basis.

Protocol as described by Malliaris et al. (2015) (level of evidence: 2a) [6]

Stage Indication Dosage

1. Isometric More than minimal pain during isometric 5 repetitions of 45 seconds, 2 to

loading exercise 3 times per day; progress to
70% maximal voluntary
contraction as pain allows

2. Isotonic Minimal pain during isotonic exercise 3 to 4 sets at a load of 15RM,

loading progressing to a load of 6RM,
every second day; fatiguing load

3. Energy- Adequate strength and consistent with other Progressively develop volume
storing side and load tolerance with initial-level energy and then intensity of relevant
loading storage exercise (ie, minimal pain during energy-storage exercise to
exercise and pain on load tests returning to replicate demands of sport
baseline within 24 hours)

4. Return to Load tolerance to energy-storage exercise Progressively add training

sport progression that replicates demands of training drills, then competition, when
tolerant to full training
Articles:
1. Rauseo C. THE REHABILITATION OF A RUNNER WITH ILIOPSOAS
TENDINOPATHY USING AN ECCENTRIC-BIASED EXERCISE-A CASE REPORT.
Int J Sports Phys Ther. 2017;12(7):1150-1162. doi:10.26603/ijspt20171150
Findings: In the correct stags of tendon pathology, eccentric based isolated
exercise can lead to a successful outcome
2. Cook, J L, Purdam, C R. Is tendon pathology a continuum? A pathology model to explain
the clinical presentation of load-induced tendinopathy. British Journal of Sports
Medicine. 2009;43(6):409-416. doi:10.1136/bjsm.2008.051193
Findings: Caution against eccentric based training for acute/reactive
tendinopathies; however, eccentric based training has shown to be beneficial
when treating degenerative/chronic tendinopathies.
3. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy
loading programmes : a systematic review comparing clinical outcomes and identifying
potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286.
doi:10.1007/s40279-013-0019-z
Findings: Heavy Slow resistance eccentric-concentric training should be
considered alongside or instead of instead of eccentric only training when treating
patellar or achillies tendinopathies.
4. Lim, Hui Yin, Wong, Shi Hui. Effects of isometric, eccentric, or heavy slow resistance
exercises on pain and function in individuals with patellar tendinopathy: A systematic
review. Physiotherapy research international : the journal for researchers and clinicians in
physical therapy. 2018;23(4):e1721-n/a. doi:10.1002/pri.1721
Findings: Eccentric and heavy slow resistance training were shown to be more
beneficial for long term pain relief and overall knee function. Isometric training
was shown to be more beneficial for immediate pain relief and for athletes who
are in season.
5. Holden, Sinéad, Lyng, Kristian, Graven-Nielsen, Thomas, et al. Isometric exercise and
pain in patellar tendinopathy: A randomized crossover trial. Journal of science and
medicine in sport. 2020;23(3):208-214. doi:10.1016/j.jsams.2019.09.015
Findings: There was no difference between isometric training or dynamic exercise
for patients with patellar tendinopathy. Pain was reduced during treatment when
performing single leg dynamic squat for the isometric training group; however,
pain returned 45 mins post treatment.