What Is the Best Test for Hip Flexor Tendonitis? Research Says THIS...
Key insights: 60-second read
- A recent study compared 11 clinical tests for identifying iliopsoas tendinopathy (tendonitis), a potential cause of persistent groin and front-of-hip pain.
- The HEC test performed best overall in this study, with reported sensitivity of 94%, specificity of 88%.
- Seated resisted hip flexion and seated resisted hip external rotation also performed well, providing other useful clinical assessment options.
- The Thomas test, straight leg raise in neutral and snapping hip test were classified as poor tests according to the study's criteria.
- The results are promising, but the study included only 44 patients. No single test should be used in isolation to diagnose the cause of hip or groin pain.
If you have persistent pain in the front of your hip, one possible cause can be iliopsoas tendinopathy or tendinopathy, a problem involving one of the main hip flexor muscles and its tendon. One difficulty with hip flexor tendon dysfunction is that its symptoms can overlap with several other hip conditions, making an accurate diagnosis challenging.
So, what is the best clinical test for hip flexor tendon pain? A 2025 study published in Clinical Orthopaedics and Related Research compared 11 clinical tests for iliopsoas tendinopathy, including a newer test called the hip-external rotation-flexion-ceiling (HEC) test.
The HEC test performed best overall in this study, with two seated resistance tests also showing promising results.
So let's break down what this study found and what you can take away from it.
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What is iliopsoas tendinopathy?
The iliopsoas is a major hip flexor muscle group that helps lift your knee towards your trunk. Iliopsoas tendinopathy - or "tendonitis" as it used to be called - involves a problem affecting its tendon and can be associated with pain in the groin or front of the hip, particularly during certain hip movements or activities.
The challenge is that groin pain is not specific to the iliopsoas. Other possible causes include problems within the hip joint, labral or cartilage injuries, hip joint impingement, and even referred pain and dysfunction from the lower back. Pain location alone may not be enough to establish the diagnosis, so it's helpful to have a range of testing options to help zero in on the issue in question.
The important question is not simply whether a test reproduces groin pain, but how accurately its findings help distinguish iliopsoas-related pain from other possible causes.
Interestingly, an image-guided injection of local anaesthetic around the iliopsoas tendon has been used to help investigate suspected iliopsoas-related pain. However, injections are invasive and rarely practical for many to use clinically. This study therefore investigates whether basic physical assessment tests can help us make better-informed diagnostic decisions.
How was the study conducted?
Vandeputte and colleagues conducted a retrospective study examining 48 consecutive image-guided iliopsoas tendon injections performed for persistent groin pain between October 2023 and May 2024. After excluding four patients without the required clinical test data, 44 patients were included in the analysis.
Study details
- Participants: 44 patients, with a mean age of 48 years. Approximately 34% were male.
- Hip type: 48% had undergone a total hip replacement, and 52% had not.
- Tests assessed: The researchers compared the HEC test to 10 other conventional clinical tests.
- Reference standard: The researchers assessed changes in characteristic groin pain following a fluoroscopy-guided iliopsoas injection.
What is the HEC test?
HEC stands for hip-external rotation-flexion-ceiling. In the study, the patient lies on their back with the hip positioned in a figure-four configuration, combining hip flexion, abduction and external rotation. They then lift the foot towards the ceiling. Reproduction of the patient's characteristic groin pain is assessed as part of the clinical examination.
The rationale is to assess the iliopsoas in a position that combines hip flexion with external rotation, rather than relying only on tests that emphasise hip flexion. It's by no means a perfect test because other tissues will always be involved, but it's a good reference point.
What is the best test for hip flexor tendon pain?
In this study, the HEC test ranked best overall for identifying iliopsoas tendinopathy. Of the 44 patients, 36 experienced satisfactory pain reduction after injection and were classified as having iliopsoas tendinopathy according to the study's reference standard.
Diagnostic accuracy of the HEC test
The HEC test demonstrated a reported sensitivity of 94%, specificity of 88% and AUC of 0.99. These results were better overall than those of the other tests assessed in this study.
| Clinical test | Sensitivity | Specificity | AUC |
|---|---|---|---|
| HEC test | 94% | 88% | 0.99 |
| Resisted hip external rotation, seated | 96% | 81% | 0.98 |
| Resisted hip flexion, seated | 94% | 89% | 0.96 |
| Straight leg raise in external rotation | 78% | 80% | 0.88 |
Figures reported in Vandeputte et al. (2025). Diagnostic performance can vary across populations and clinical settings.
Key finding: Three tests met the researchers' criteria for a "good" test: the HEC test, seated resisted hip flexion and seated resisted hip external rotation. The Thomas test, straight leg raise in neutral and snapping hip test were classified as "poor" according to those same criteria.
What do sensitivity, specificity and AUC mean?
- Sensitivity describes how often a test identifies people who have the condition according to the study's reference standard.
- Specificity describes how often a test correctly identifies people who do not have the condition according to that reference standard.
- AUC summarises how well a test distinguishes between the two groups across different thresholds. An AUC closer to 1 indicates stronger discriminatory performance in the population studied.
What does this mean in practice?
The findings give clinicians another option when investigating persistent groin pain that may be related to the iliopsoas. They also reinforce the value of comparing several clinical findings rather than relying on one movement or test alone.
- Consider the HEC test as part of an assessment. It performed best overall in this study, but it should be interpreted alongside the patient's history and other examination findings.
- Do not overlook seated resistance tests. Seated resisted hip flexion and external rotation also performed well and may provide useful information during a clinical examination.
- Do not rely on a single traditional test. Some tests performed poorly under the study's criteria, highlighting the importance of choosing examination manoeuvres carefully.
- Consider other causes of groin pain. Hip joint problems and other nearby structures can produce overlapping symptoms. Further assessment or investigations may be appropriate when the diagnosis remains uncertain.
For patients, the practical takeaway is not that you need to perform the HEC test on yourself. Rather, if you have persistent groin or front-of-hip pain, a clinician can use the history, examination and, where appropriate, further investigations to help determine the most likely source.
A useful clinical test can help narrow the possibilities, but the best diagnosis comes from interpreting the test in the context of the whole person.
Limitations of the research
Although the findings are promising, there are several important limitations to keep in mind before treating the HEC test as the definitive answer to diagnosing iliopsoas tendinopathy.
- Small sample: Only 44 patients were included, so the results may not generalise to the wider population with hip or groin pain.
- Retrospective design: The researchers reviewed existing clinical records rather than conducting a prospective diagnostic study designed in advance.
- Selected patient group: Participants had persistent groin pain and had already proceeded to an image-guided injection. They may differ from people presenting with less persistent symptoms in general practice.
- Mixed hip populations: The sample included both normal hips and hips after total hip replacement. The study was too small to establish how well the findings apply separately to these groups.
- Reference-standard limitations: Improvement after an injection was used to classify iliopsoas-related pain. An injection response is useful information, but it is not a perfect reference standard and may be influenced by factors such as anaesthetic spread to nearby tissues.
- Further validation is needed: Larger prospective studies should investigate reproducibility between clinicians and confirm the results in more diverse patient populations.
This study offers an encouraging step towards improving the clinical assessment of iliopsoas tendinopathy. Of the 11 tests compared, the HEC test ranked best overall, while seated resisted hip flexion and external rotation also showed promising diagnostic performance.
The important qualification is that these findings come from a small, selected group of patients. The HEC test is a promising clinical tool, not a standalone answer for every person with groin pain.
As a physiotherapist, I find research like this useful because it encourages more thoughtful assessment. The goal is not simply to find a test that reproduces pain, but to build a clearer picture of what may be causing it and what needs to happen next.
- Grant
Frequently asked questions
What is iliopsoas tendinopathy?
Iliopsoas tendinopathy is a problem affecting the tendon of a major hip flexor muscle group. It can cause pain around the front of the hip, but these symptoms can also arise from other hip conditions.
What is the best test for hip flexor tendonitis?
In a 2025 study of 44 patients, the HEC test ranked best overall among 11 clinical tests for iliopsoas tendinopathy. It showed 94% sensitivity and 88% specificity in that sample. The results are promising, but further research is needed before it can be considered definitive across broader patient groups.
How is the HEC test performed?
The HEC test is performed lying on your back, with the hip positioned in a figure-four configuration combining flexion, abduction and external rotation. The foot is then lifted towards the ceiling while the clinician assesses whether the patient's characteristic groin pain is reproduced. It is best performed and interpreted by a trained clinician.
What if I cannot perform the HEC test?
The study also found promising results for seated resisted hip flexion and seated resisted hip external rotation. A clinician can select appropriate examination tests according to your symptoms, mobility and clinical presentation.
Does groin pain automatically mean I have iliopsoas tendinopathy?
No. Groin pain can come from several structures, including the hip joint, surrounding muscles and tendons. A clinician should consider your history, examination findings and whether further investigation is needed before settling on a diagnosis.
One key insight from this research
The HEC test showed the strongest overall diagnostic performance among 11 clinical tests in one small study of iliopsoas tendinopathy. It is a promising addition to clinical assessment, but it should be interpreted alongside the patient's symptoms and other findings, with further research needed to confirm its accuracy.
Reference
Vandeputte, F. J., Driesen, R., Timmermans, A., & Corten, K. (2025). Evaluation of Clinical Tests to Diagnose Iliopsoas Tendinopathy. Clinical Orthopaedics & Related Research, 483(11), 2123-2132. https://doi.org/10.1097/CORR.0000000000003520
Need personalised guidance for your groin or hip pain?
If you would like help making sense of your groin pain, hip dysfunction, or any musculoskeletal issue, you can book with Grant either in Port Macquarie or via an online telehealth consultation.
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