Ischiofemoral impingement and hip pain
Ischiofemoral impingement (IFI) is an often-misdiagnosed cause of hip pain. IFI occurs with abnormal contact between the lesser trochanter and the ischium and often occurs with trauma or prior hip surgery (total hip arthroplasty, femoral osteotomy).
IFI is defined as the narrowing of the space between the lateral aspect of the ischium and the lesser trochanter of the femur where soft tissue structures are becoming impinged. The hamstrings or hip flexor muscles can be involved but it is most commonly the quadratus femoris muscle which is affected.
Patients usually report pain in the buttocks or groin which may radiate into their knee. Often symptoms are chronic with gradually increasing intensity. Occasionally they also have radiating pain in the sciatic nerve distribution due to its proximity to the quadratus femoris muscle. They may also describe a ‘snapping’ sensation in the affected hip with extension, adduction – mostly load dependent (long stride walking, running). IFI is more common in the female population, likely due to the wider anatomy of their pelvis.
Ischiofemoral impingement: image shows impingement of the quadratus femoris and sciatic nerve between the lesser trochanter and ischium.
Diagnosis and tests Ischiofemoral impingement and hip pain
On objective examination, internal and external rotation may be slightly reduced, with or without pain. Patients may have marked tenderness on palpation of the lateral aspect of the ischium, over the ischiofemoral space. Motor changes are not likely to be present, however sensory changes may be present in the L5 nerve root distribution (lateral aspect of leg and dorsum of foot). Patients will have reduced straight leg raise and a positive FABER sign on the affected hip. Hatem et al. noted that symptoms of IFI may be reproduced with extension, adduction and external rotation. Additional imaging (x ray, MRI) can be completed to confirm the diagnosis of IFI.
Conservative management of IFT focuses on improving the biomechanics of the hip to increase the space between the ischium and lesser trochanter. Initial treatment will include rest, activity restriction and modification and a progressive strengthening program. Physiotherapy treatment will include the following:
o An orthotic device can be used to correct the biomechanics of the foot and ensure balanced loading through the lower limb. Some patients may have a leg length difference, which can be corrected with a heel raise.
o Deep soft tissue massage to muscles surrounding the area, including the adductors, hamstrings, gluteals and hip flexor.
o Gradual strengthening program focusing initially on gluteal strength and then onto lower limb strength and balance retraining.
Activity modification + return to regular activity.
o Training and daily activity can be modified to allow rest to affected structures during the initial phases of treatment. Alternative forms of exercise will be recommended to ensure the area has adequate rest prior to loading to return to normal activities.
If symptoms have not resolved with conservative management, evidence suggests improvement of pain with a guided injection to the quadratus femoris muscle. It is then recommended conservative treatment is continued for three months. If symptoms are still unresolved a second injection can be completed.
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