Treating Runners with Gluteal Pain

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Runners are often a pain in the butt—mainly because they have pain in their butt! This population of patients requires attention to detail so we can quickly get them back to the sport. Today’s blog will cover the differential diagnosis of the two most common extraarticular hip diagnoses affecting runners: Piriformis Syndrome (PS) and Ischiofemoral Impingement (IFI).

PS vs. IFI

Similarities

1. Patients present with chronic pain in the deep gluteal region usually present without a precipitating traumatic injury. (1) Most symptoms begin following repetitive microtrauma, like long-distance walking/running, stair climbing, or chronic compression- i.e.sitting on the edge of a hard surface or a wallet. (2,3)

2. The pain may radiate distally to the lower extremity, usually not extending distal to the knee. (4) Local trigger point referral may extend into the proximal thigh, sacroiliac, and hip regions. (2)

3. There is a strong correlation with runners due to repetitive eccentric contraction of hip external rotators attempting to control internal hip rotation during the gait cycle. (5)

Differences

1. Symptoms are provoked in both IFI and PS through passive flexion and internal rotation of the hip due to compression of the sciatic nerve and associated stretch of both muscles. However, only IFI symptoms are provoked by passively extending, adducting, and externally rotating the hip. This maneuver is called the Ischiofemoral Impingement Test. (6) The IFI test has a sensitivity of 82% and a specificity of 85%. (7)

2. IFI patients complain of pain with end-range hip extension associated with faster runners/walkers. (Walking and running fast increases hip extension) Gómez-Hoyos et al. exploited this finding with the Long Stride Walking Test. It consists of the patient taking large steps while walking to reproduce their gluteal pain. It has a sensitivity of 92% and a specificity of 82%. (7)

3. Reproduction of symptoms during palpation often reveals the most valuable information in your differential diagnosis.  PS usually consists of trigger points and hypertonicity near the muscle's origin as it attaches to the sacrum.  IFI will present with tenderness lateral to the ischial tuberosity within the belly of the quadratus femoris.  

Rehabilitation Plan

Phase 1

STANDING PIRIFORMIS STRETCH - Begin standing in front of a waist-height bed or table. Position the outside of your affected thigh on the table in front of you; knee bent at 90 degrees. Slowly lean forward over your leg until a stretch is felt in the affected hip and buttock. Against the resistance of the table, attempt to push the affected knee into the table for seven seconds. Relax and increase the stretch by leaning further forward with your upper body. "Lock-in" to each new position, and do not allow any slack. Repeat as directed.

HIP AIRPLANE - Begin on all fours. Extend your unaffected leg. While keeping your leg straight, slowly rotate your torso up toward the ceiling, then slowly lower back toward the floor in a full range of motion. Allow your hip to drop toward the ground, then rotate up toward the ceiling in a slow controlled manner. Perform as directed.

Phase 2

HIP AIRPLANE 4 - Begin standing in a semi-flexed position with both arms supported on a table. Extend your unaffected leg. Slowly rotate your hips up toward the ceiling, then back down toward the floor in a slow controlled manner. Progress slowly through internal and external rotation of the hip. Perform two sets of 10 repetitions or as otherwise directed.

SCIATIC NERVE FLOSS SIDE LYING - Begin lying on your unaffected with your spine in a neutral position. Slowly flex your hip to bring your straightened leg in front of you until you feel a stretch in the back of your leg or buttock. Do not move into a position that reproduces sharp or radiating pain. At the same time that you are moving your leg forward, extend your head to look at the wall behind you. (as to nod "yes.") Return to the start position. 

Treatment Tips

1. Joint Manipulation/Mobilization

Manual manipulation for PS (8) and IFI may be necessary to correct lumbar, sacroiliac, and lower extremity joint dysfunction. Hip Mobilization is another powerful tool to improve hip extension in those patients lacking adequate ROM.  A patient who sits for long periods loses the ability to fully extend their hip, resulting in muscular compensations surrounding the hip.

2. Running Advice

Patients with PS and IFI usually describe worsening of symptoms or snapping during full extension of the symptomatic hip, e.g., during running or taking larger steps. (8)Smaller steps through increased running cadence and a wider stance phase will decrease the reactive ground forces through the hip and knee stabilizers.  (10,11)

3. Sitting

Gluteal and posterior thigh symptoms increase with maintaining any position for longer than 15-20 minutes - particularly prolonged sitting or standing. Standing up or positional changes will provide transient relief. Also, have your patients avoid activities that involve hip internal rotation, like sitting cross-legged, as it may exacerbate symptoms. 

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• References

  1. Foster MR. Piriformis syndrome. Orthopedics. 2002 Aug 1;25(8):821-5. Link

  2. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Lippincott Williams & Wilkins; 1983.

  3. Stafford GH, Villar RN. Ischiofemoral impingement. J Bone Joint Surg Br 2011;93(10):1300.

  4. Torriani M, Souto SCL, Thomas BJ, et al. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. Am J Roentgenol 2009;193(1):186–90.

  5. O’Brien SD, Bui-Mansfield LT. MRI of quadratus femoris muscle tear: another cause of hip pain. Am J Roentgenol 2007;189(5):1185–9.

  6. Safran M, Ryu J. Ischiofemoral impingement of the hip: a novel approach to treatment. Knee Surg Sports Traumatol Arthrosc 2014; 22: 781–5.

  7. Gomez-Hoyos J, Martin RL, Schroder R et al.  Accuracy of 2 clinical tests for ischiofemoral impingement in patients with posterior hip pain and endoscopically confirmed diagnosis. Arthroscopy 2016; 32: 1279–84.

  8. Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis syndrome: a case study. Journal of manipulative and physiological therapeutics. 2006 Jul 1;29(6):486-91. Link

  9. Hans Gollwitzer, Ingo J Banke, Johannes Schauwecker, Ludger Gerdesmeyer, Christian Suren, How to address ischiofemoral impingement? Treatment algorithm and review of the literature, Journal of Hip Preservation Surgery, Volume 4, Issue 4, December 2017, Pages 289–298,

  10. Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomech. 2012;11:464-472. 

  11. Bramah C, Preece SJ, Gill N, Herrington L. A 10% Increase in Step Rate Improves Running Kinematics and Clinical Outcomes in Runners With Patellofemoral Pain at 4 Weeks and 3 Months. The American journal of sports medicine. 2019 Oct 28:0363546519879693.