Buttock pain is complex. There are many causes of buttock pain, such as sciatica, sacroiliac joint arthritis, piriformis syndrome, and hamstring tendonitis. However, a less common cause of buttock pain is ischiofemoral impingement. We think that abnormal contact between the long bone of the leg (femur) and the pelvic bone leads to pinching and buttock pain. So, what is ischiofemoral impingement, and what should we do to improve it? Also, is an ischiofemoral impingement injection an option?
What is ischiofemoral space?
The ischiofemoral space sits between the upper part of the femur (lesser trochanter) and the lower part of the pelvic bone (ischium). Sitting between these two bones in this space is the quadratus femoris muscle. This muscle, along with the other muscles in the buttock, rotates the hip outwards). Unfortunately, this space is too narrow for some people, causing pinching and leading to muscle swelling and pain.
Ischiofemoral impingement symptoms
Generally, people with ischiofemoral impingement develop buttock pain. Often, pain can move to the hip, groin, or back of the thigh. Pain is often worse with sitting. Sometimes, people feel a snapping of the hip when taking a large stride or rotating the hip into external rotation.
Overall, this condition is more common in middle-aged females rather than males. Dancers and rowers are particularly at risk.
Sometimes, people have more than one condition, such as piriformis syndrome or high hamstring tendonitis.
When doctors examine you, we look for signs of pinching at the back of the hip. Often, pressing on the quadratus femoris muscle is sore. Usually, moving and rotating the hip (flexion and internal rotation) makes the buttock sorer.
Ischiofemoral impingement test
We use a simple test with the person lying on their tummy with the hip stretched, and the hip is rotated inwards and outwards. A positive test means the person feels pain in the buttock. However, this test is also positive for other causes such as piriformis syndrome.
Ischiofemroal impingement syndrome radiology
Generally, we use imaging to confirm the diagnosis and rule out other causes. Usually, an MRI scan of the buttock is our first choice for investigation. In ischiofemoral impingement, we see swelling in the quadratus femoris muscle. On MRI scan, swelling is seen as brighter than the surrounding tissue. Often, the space between the pelvis and the femur narrows. Sometimes, in more severe cases, there is a shrinking of the muscle.
In some cases, people have other problems, such as high hamstring origin tendonitis – which causes further narrowing of the ischiofemoral space.
Ischiofemoral impingement treatment
Generally, simple treatments should be instigated before more invasive treatments. Recent studies suggest that most cases resolve without the need for surgery. Usually, we start with physical therapy. In general, treatment aims to improve the strength and stability of the hip and pelvis. In particular, strengthening should focus on hip muscle rotators and the posterior chain. Strengthening exercises include one-legged squats, crab walks with a theraband, side leg raises, squats, lunges, hip thrusters, and Bulgarian squats.
In addition, soft tissue release and joint mobilisation of the hip and lumbar spine may help improve pelvic movement and reduce pinching of the quadratus femoris.
Also, directing a needle into the quadratus femoris and injecting cortisone can help in cases that fail simple treatments.
Finally, surgery should only be reserved for cases that fail other treatments. The surgery aims to open the ischiofemoral space to reduce pressure on the quadratus muscle. Often, surgeons achieve decompression using keyholes. However, results are not guaranteed; risks include infection, nerve damage, and unsuccessful pain relief.
More about ischiofemoral impingement injection
Injecting cortisone into the quadratus femoris muscle can reduce swelling and pinching of the muscle. Generally, ultrasound guidance is preferable as we can accurately place the needle in the muscle and avoid other structures, such as the sciatic nerve. The risks of cortisone are minimal. However, you need to be aware of the small risks of infection and temporary cortisone flare lasting up to a week. So, an ischiofemoral impingement injection is an option.
Some doctors say a CT scan is needed for an ischiofemoral impingement injection. Is this correct?
No. Ultrasound can see the quadratus femoris muscle. Getting a needle into the muscle is accessible by an experienced practitioner. Other benefits of ultrasound include a much cheaper procedure and no exposure to radiation, unlike CT-guided injection, which exposes patients to a high dose of harmful radiation.
Final word from Sportdoctorlondon about ischiofemoral impingement
Ischiofemoral impingement is an uncommon cause of buttock pain. Generally, we must rule out other reasons, such as sciatica, hamstring tendonitis, and sacroiliac joint arthritis. Nevertheless, simple treatments such as physical therapy and an ultrasound-guided cortisone injection are effective.
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