Ischiofemoral Impingement
Reading time: 5 minutes
In recent years, ischiofemoral impingement (IFI) has been increasingly recognized for its role in non-discogenic, atypical hip and thigh pain. (6,7) The condition is one of many potential causes of deep gluteal syndrome. In five minutes, you’ll learn the essential skills for successfully managing ischiofemoral impingement syndrome.
1. What is ischiofemoral impingement syndrome?
Short answer: Chronic buttock pain caused by compression of the quadratus femoris muscle.
Deeper dive: The quadratus femoris is a flat, rectangular muscle attaching the ischial tuberosity to the posteromedial proximal femur; therein occupying the ischiofemoral space between the lesser trochanter of the femur and the ischial tuberosity. (3,8) The expected average ischiofemoral space is approximately two centimeters. (4) Patients with ischiofemoral impingement can exhibit a 30-50% reduction in ischiofemoral space. (4) A narrowed ischiofemoral distance allows the lesser trochanter to bump against the ischium and compress the intervening soft tissues with subsequent edema. (49)
2. What causes ischiofemoral impingement syndrome?
Short answer: Many factors, but hip abductor weakness is a common (fixable) contributor.
Deeper dive: The literature describes many congenital, acquired, or functional/ positional factors that lead to ischiofemoral space narrowing. (9,12)
Functional or positional triggers are of greatest interest to manual therapy providers as they are the most modifiable factors. Functional triggers include hip instability and muscle imbalances of the abductor/adductor, flexor/extensor, and internal/external rotator groups. (9,12) Abnormal pelvic tilt is another known contributor. (15) In particular, pelvic retroversion entails flattening of the lumbar spine and sacrum, which move the ischial tuberosities closer to the lesser trochanters. (9) Perhaps the greatest functional threat is uncompensated hip adduction from hip abductor weakness. (13,14) Hip abductor weakness allows uncontrolled thigh adduction, which approximates the femur and ischial tuberosity. Hip abductor (gluteus medius) tendinopathy or rupture is a known contributing factor. (16)
Congenital factors include variations of pelvic bony anatomy like a larger cross-section of the femur, prominence of the lesser trochanter, posteromedial positioning of the femur, lower ischiopubic ramus, coxa profunda, coxa valga, or coxa breva. (9,12-14)
Acquired contributors occur secondary to hip osteoarthritis, hip fracture, total hip replacement, Legg-Calve-Perthes disease (childhood femoral head avascular necrosis), expansile bony lesions, or proximal hamstring enthesopathy. (13)
3. Who gets ischiofemoral impingement?
Short answer: Anyone with a hip and pelvis, but especially active females.
Deeper dive: IFI is common in runners with long stride lengths, race walkers, ballet dancers, and rowers who force themselves into hip extension at the end of their stroke phase. (49) Females are significantly more predisposed to ischiofemoral impingement, possibly due to broader positioning of the ischial tuberosities. (4,12,13,17,18) IFI affects both hips in 25 to 40% of cases; not surprising since many of the contributing factors occur bilaterally. (17)
Pro tip: Symptoms usually begin insidiously without a precipitating injury. (4) However, the condition can originate traumatically following an uncontrolled eccentric contraction of the quadratus femoris in an attempt to limit hip internal rotation or abduction. (20)
4. What are the symptoms of ischiofemoral impingement?
Short answer: Chronic buttock pain
Deeper dive: Ischiofemoral impingement symptoms typically present as chronic, nonspecific buttock pain that has been present for months or years. (4,9,14,17,19)
Symptoms are often mild-to-moderate and are gradually progressive. (9)
Discomfort refers to the medial thigh, anterior groin, and lower buttock. (14)
Frequently mimics hamstring tendon pain. (5)
Sciatic radicular complaints are possible due to the proximity of the sciatic nerve to the quadratus femoris muscle. (9,14,17)
Increased pain with prolonged weight-bearing or sitting. (9,14)
Difficulty with long-stride walking. (9,14,21)
Limitation of hip extension may force walkers and runners to adopt a compensatory shorter gait cycle. (14)
Patients often assume an antalgic sitting posture to unload the affected ischium. (22)
Complaints of crepitus and snapping may accompany ischiofemoral impingement. (9,14,21)
5. What are the best ischiofemoral impingement tests?
Short answer: The long-stride walking test and ischiofemoral impingement test are validated orthopedic tests for ischiofemoral impingement. (9,24-26,50)
Deeper dive: Like nearly every other MSK diagnosis, there is no single clinical exam finding specific to the diagnosis of ischiofemoral impingement. However, a collection of findings may help confirm the diagnosis. (27)
Palpation typically demonstrates tenderness over the quadratus femoris muscle and its attachment sites on the ischium and lesser trochanter. (4,14) Palpatory tenderness and symptoms are typically exacerbated by the combination of hip extension, adduction, and external rotation. (5,9,14,23-25)
The long-stride walking test has a reported sensitivity of 92% and specificity of 82%. (26)
An ischiofemoral impingement test that reproduces pain upon adduction (but not abduction) shows high sensitivity (82%) and specificity (85%) for ischiofemoral impingement. (26)
Ischiofemoral Impingement Test
Long Stride Walking Test
6. What’s in the ischiofemoral impingement treatment protocol?
Short answer: Chiropractic manual therapy
Deeper dive: In the absence of progressive pathology, the first line of ischiofemoral impingement therapy should be conservative. (35-37)
Myofascial release and stretching may be appropriate for the quadratus femoris, piriformis, hamstring, and gluteal muscles.
Sciatic nerve release or sciatic nerve flossing can help address concurrent irritation of the neighboring sciatic nerve.
Symptomatic IFI limits terminal hip extension, which leads to significantly increased facet loads (>30%) in the lower lumbar spine. (39,40) Accordingly, clinicians should manipulate any joint restrictions in the lumbar sacroiliac and pelvic regions.
The long-term resolution requires identifying and eliminating concurrent underlying contributors, i.e., foot hyperpronation, spinal instability, hip abductor weakness, etc. (14)
STM- Quadratus Femoris
Sciatic Nerve Release at the Piriformis
Sciatic Nerve Floss
Subscribers can visit their condition reference library 24/7 to review the complete ischiofemoral impingement protocol, including all of the associated tutorial videos.
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7. What are the best ischiofemoral impingement exercises?
Short answer: Hip abductor strengthening
Deeper dive: Hip abductor weakness is perhaps the most likely contributory comorbidity. Incompetent hip abductors allow uncontrolled adduction of the knee with a corresponding reduction in ischiofemoral space. (38)
The ischiofemoral impingement treatment protocol would include strengthening exercises for the hip abductors i.e., clam, clam with band, advanced clam, posterior lunge, and side plank with abduction. Additional exercises could include the heel squeeze. (49)
Patients with spinal segmental instability will benefit from core-strengthening exercises, including the dead bug, bird dog, side bridge, or curl up.
Clinicians must address foundational functional deficits, including pes planus or foot hyperpronation, via strengthening exercises for the posterior tibialis and considering arch supports or orthotics.
Clam
Advanced Clam
Heel Squeeze
8. What’s the essential home advice…?
Short answer: 4 clicks
Deeper dive: We’re glad you asked because we made this one crazy simple. Watch this 1-minute video to learn how.
Like what you see? You can immediately start creating reports like these for your patients in less than 4 clicks!
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1. Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magnetic Resonance Imaging Clinics. 2013 Feb 1;21(1):65-73. Link
2. Ahmad SS, Kerber V, Konrads C, Ateschrang A, Hirschmann MT, Stöckle U, Ahrend MD. The ischiofemoral space of the hip is influenced by the frontal knee alignment. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 May 5:1-7. Link
3. Singer AD, Subhawong TK, Jose J, Tresley J, Clifford PD. Ischiofemoral impingement syndrome: a meta-analysis. Skeletal radiology. 2015 Jun;44(6):831-7. Link
4. Stafford GH, Villar RN. Ischiofemoral impingement. The Journal of bone and joint surgery. British volume. 2011 Oct;93(10):1300-2. Link
5. Stafford GH, Villar RN. Ischiofemoral impingement. The Journal of bone and joint surgery. British volume. 2011 Oct;93(10):1300-2. Link
6. Park JW, Lee YK, Lee YJ, Shin S, Kang Y, Koo KH. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. The bone & joint journal. 2020 May;102(5):556-67. Link
7. Siebenrock KA, Steppacher SD, Haefeli PC, Schwab JM, Tannast M. Valgus hip with high antetorsion causes pain through posterior extraarticular FAI. Clinical Orthopaedics and Related Research®. 2013 Dec;471(12):3774-80. Link
8. Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magnetic Resonance Imaging Clinics. 2013 Feb 1;21(1):65-73. Link
9. Hernando MF, Cerezal L, Pérez-Carro L, Canga A, González RP. Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis. Skeletal radiology. 2016 Jun 1;45(6):771-87. Link
10. Mehta K, Tubbs RS. The Nerve to Quadratus Femoris. InSurgical Anatomy of the Sacral Plexus and Its Branches 2021 Jan 1 (pp. 35-39). Elsevier. Link
11. Nakano N, Shoman H, Khanduja V. Treatment strategies for ischiofemoral impingement: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Sep;28(9):2772-87. Link
12. Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magnetic Resonance Imaging Clinics. 2013 Feb 1;21(1):65-73. Link
13. Nakano N, Yip G, Khanduja V. Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. International orthopaedics. 2017 Jul;41(7):1321-8. Link
14. Gollwitzer H, Banke IJ, Schauwecker J, Gerdesmeyer L, Suren C. How to address ischiofemoral impingement? Treatment algorithm and review of the literature. Journal of hip preservation surgery. 2017 Dec;4(4):289-98. Link
15. Alradwan H, Cargnelli S, Thawer Z, Simunovic N, Cadet E, Bonin N, Larson C, Ayeni OR. Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Aug 1;30(8):1026-41. Link
16. Ali AM, Teh J, Whitwell D, Ostlere S. Ischiofemoral impingement: a retrospective analysis of cases in a specialist orthopaedic centre over a four-year period. Hip International. 2013 May;23(3):263-8. Link
17. Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. American journal of roentgenology. 2009 Jul;193(1):186-90. Link
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19. Nakano N, Yip G, Khanduja V. Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. International orthopaedics. 2017 Jul;41(7):1321-8. Link
20. O'Brien SD, Bui-Mansfield LT. MRI of quadratus femoris muscle tear: another cause of hip pain. American Journal of Roentgenology. 2007 Nov;189(5):1185-9. Link
21. Tosun Ö, Çay N, Bozkurt M, Arslan H. Ischiofemoral impingement in an 11-year-old girl. Diagnostic and Interventional Radiology. 2012 Nov 1;18(6):571. Link
22. Hernando MF, Cerezal L, Pérez-Carro L, Abascal F, Canga A. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal radiology. 2015 Jul;44(7):919-34. Link
23. Johnson KA. Impingement of the lesser trochanter on the ischial ramus after total hip arthroplasty. Report of three cases. JBJS. 1977 Mar 1;59(2):268-9. Link
24. Hernando MF, Cerezal L, Pérez-Carro L, Abascal F, Canga A. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal radiology. 2015 Jul;44(7):919-34. Link
25. Hatem MA, Palmer IJ, Martin HD. Diagnosis and 2-year outcomes of endoscopic treatment for ischiofemoral impingement. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2015 Feb 1;31(2):239-46. Link
26. Gómez-Hoyos J, Martin RL, Schröder R, Palmer IJ, Martin HD. Accuracy of 2 clinical tests for ischiofemoral impingement in patients with posterior hip pain and endoscopically confirmed diagnosis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2016 Jul 1;32(7):1279-84. Link
27. Safran M, Ryu J. Ischiofemoral impingement of the hip: a novel approach to treatment. Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Apr 1;22(4):781-5. Link
28. Ganz R, Slongo T, Turchetto L, Massè A, Whitehead D, Leunig M. The lesser trochanter as a cause of hip impingement: pathophysiology and treatment options. Hip International. 2013 Dec;23(9_suppl):35-41. Link
29. Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magnetic Resonance Imaging Clinics. 2013 Feb 1;21(1):65-73. Link
30. Tosun O, Algin O, Yalcin N, Cay N, Ocakoglu G, Karaoglanoglu M. Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability. Skeletal radiology. 2012 May;41(5):575-87. Link
31. Xing Q, Feng X, Wan L, Cao H, Bai X, Wang S. MRI measurement assessment on ischiofemoral impingement syndrome. HIP International. 2021 Apr 11:11207000211007750. Link
32. Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magnetic Resonance Imaging Clinics. 2013 Feb 1;21(1):65-73. Link
33. Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. American journal of roentgenology. 2009 Jul;193(1):186-90. Link
34. Lee S, Kim I, Lee SM, Lee J. Ischiofemoral impingement syndrome. Annals of rehabilitation medicine. 2013 Feb;37(1):143. Link
35. Patti JW, Ouellette H, Bredella MA, Torriani M. Impingement of lesser trochanter on ischium as a potential cause for hip pain. Skeletal radiology. 2008 Oct;37(10):939-41. Link
36. Nakano N, Shoman H, Khanduja V. Treatment strategies for ischiofemoral impingement: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Sep;28(9):2772-87. Link
37. Safran M, Ryu J. Ischiofemoral impingement of the hip: a novel approach to treatment. Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Apr 1;22(4):781-5. Link
38. Ahmad SS, Kerber V, Konrads C, Ateschrang A, Hirschmann MT, Stöckle U, Ahrend MD. The ischiofemoral space of the hip is influenced by the frontal knee alignment. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 May 5:1-7. Link
39. Gómez-Hoyos J, Khoury A, Schröder R, Johnson E, Palmer IJ, Martin HD. The hip-spine effect: a biomechanical study of ischiofemoral impingement effect on lumbar facet joints. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Jan 1;33(1):101-7. Link
40. Hatem MA, Palmer IJ, Martin HD. Diagnosis and 2-year outcomes of endoscopic treatment for ischiofemoral impingement. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2015 Feb 1;31(2):239-46. Link
41. Ganz R, Slongo T, Turchetto L, Massè A, Whitehead D, Leunig M. The lesser trochanter as a cause of hip impingement: pathophysiology and treatment options. Hip International. 2013 Dec;23(9_suppl):35-41. Link
42. Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. American journal of roentgenology. 2009 Jul;193(1):186-90. Link
43. Kim WJ, Shin HY, Koo GH, Park HG, Ha YC, Park YH. Ultrasound?guided prolotherapy with polydeoxyribonucleotide sodium in ischiofemoral impingement syndrome. Pain Practice. 2014 Sep;14(7):649-55. Link
44. Staubli AE, De Simoni C, Babst R, Lobenhoffer P. TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia–early results in 92 cases. Injury. 2003 Nov 1;34:55-62. Link
45. Ali AM, Whitwell D, Ostlere SJ. Case report: imaging and surgical treatment of a snapping hip due to ischiofemoral impingement. Skeletal radiology. 2011 May;40(5):653-6. Link
46. Milette PC, Fontaine S, Lepanto L, Breton G. Radiating pain to the lower extremities caused by lumbar disk rupture without spinal nerve root involvement. American journal of neuroradiology. 1995 Sep 1;16(8):1605-13. Link
47. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treatment. Muscle & nerve. 2009 Jul;40(1):10-8. Link
48. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best practice & research Clinical rheumatology. 2010 Apr 1;24(2):253-65. Link
49. Tucker J. Re: “Ischiofemoral Impingement.” Message to Tim Bertelsman regarding advice on the management of IFI via direct email on 10/06/2021.
50. Li YP, Li GP, Liu K, Zhao F, Zhao JJ, Wang GN, Liu C. Interpretation of ischiofemoral impingement via a clinical test using hip triaxial dynamic magnetic resonance imaging. Quantitative Imaging in Medicine and Surgery. 2022 Jan;12(1):384. Link
