Ischial-femoral impingement: you have to know what it is to make the diagnosis and know how to treat it. How many times have you had a client come in with pain high up in the ischial area, often explaining that it feels like a high hamstring pull. Others come in and say they have deep gluteal pain, deep in the buttock near the “sit bones”. Often they do not have a “hamstring-type event” that could be the cause of this injury or pain. I see this “high hamstring” pain often in runners, mostly distance runners but in high velocity cutting sports as well. I see this one often, and it was a difficult fix until I recognized what it truly was and what was generating the pain and problem. Often the problem is at the quadratus femoris muscle. This muscle has an origin off of the ischial tuberosity and inserts into the trochantric interval. The problem arises when the space, the interval, between these bony prominences is closed causing the quadratus femoris to become compressed or pinched in the small space. This can occur from too much frontal plane drift of the pelvis (side shift/drift) and this is almost always met by a relative adduction of the femur. This adduction narrows the space. Frontal plane drift of the pelvis and adduction of the femur, as either genu valgum or a cross over gait, are highly suspicious culprits in getting to the bottom of this clinical entity. Do you know how to test and evaluate the quadratus femoris muscle ? How about the similarly functioning obturator externus, upper vastus medialis or iliac division of the gluteus maximus ? Can you reasonably tease them out on your physical examination? If you know the common motion amongst them all you will know why they all can be a culprit of the pain and impinging mechanism, and why in treating this problem you likely will have to evaluate and treat one or more of them since they all support external rotation of the femur especially in varying degrees of hip flexion, and thus are used eccentrically to a significant degree to control the rate and degree of internal rotation of the lower limb during contact phase of gait. Losing this control and compounding frontal pelvis drift (and thus femur adduction) will close off the interval for the ischium of the pelvis moving past the femur’s lesser trochanter. I know you have seen this problem in your clinics and gyms. Have you missed it and called it a hamstring tendonopathy, or have you nailed it ? It is out there, but you have to know something exists to recognize it, and to fix it. You have to recognize it and understand the pieces of the problem, the anatomy and the pathomechanics and understand what is going on in their gait that could be causing it. This is not a psoas related entity although that should remain on your differential list. This is not to be mistaken for a hamstring tear as I suggested earlier, look at this study’s findings, it is not the same entity, although it is possible to have both simultaneously: “Abnormalities of the quadratus femoris muscle included edema (100%), partial tear (33%), and fatty infiltration (8%). The hamstring tendons of affected subjects showed evidence of edema (50%) and partial tears (25%).” - Torriani (3) I cannot find any research out there correlates weakness of the gluteals and of the lateral chains with weakness of this quadratus femoris muscle and its synergists with femur adduction and cross over gait styles in this clinical impingement phenomenon. These components are closely related and functional in my experience.  Certainly I cannot be the first to entertain this conceptual layered idea with the cross over gait /frontal plane drift predisposers. So, please come forward if you have seen the same things and had similar successes, lets compare notes and share your nuances in caring for it. There is something here though, because my clients progress nicely when the multiple muscles that support this spiral-natured external rotation are cleaned up, active, strong and paired nicely in a motor pattern that stacks the foot, knee, hip and pelvis reducing femoral adduction and in the functional components that reduce frontal plane drift which I have discussed here many times on the gait guys blog (type in “cross over gait” in the blog search box).   Dr. Shawn Allen, the gait guys references: 1. Am J Orthop (Belle Mead NJ). 2014 Dec;43(12):548-51.Ischiofemoral Impingement and the Utility of Full-Range-of-Motion Magnetic Resonance Imaging in Its Detection.Singer A1, Clifford P, Tresley J, Jose J, Subhawong T. 2. Magn Reson Imaging Clin N Am. 2013 Feb;21(1):65-73. doi: 10.1016/j.mric.2012.08.005. Epub 2012 Oct 13.Ischiofemoral impingement.Taneja AK1, Bredella MA, Torriani M. 3. AJR Am J Roentgenol. 2009 Jul;193(1):186-90. doi: 10.2214/AJR.08.2090.Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femorismuscle.Torriani M1, Souto SC, Thomas BJ, Ouellette H, Bredella MA. 4. J Bone Joint Surg Br. 2011 Oct;93(10):1300-2. doi: 10.1302/0301-620X.93B10.26714. Ischiofemoral impingement. Stafford GH1, Villar RN.

Ischial-femoral impingement: you have to know what it is to make the diagnosis and know how to treat it.

How many times have you had a client come in with pain high up in the ischial area, often explaining that it feels like a high hamstring pull. Others come in and say they have deep gluteal pain, deep in the buttock near the “sit bones”. Often they do not have a “hamstring-type event” that could be the cause of this injury or pain. I see this “high hamstring” pain often in runners, mostly distance runners but in high velocity cutting sports as well.

I see this one often, and it was a difficult fix until I recognized what it truly was and what was generating the pain and problem. Often the problem is at the quadratus femoris muscle. This muscle has an origin off of the ischial tuberosity and inserts into the trochantric interval. The problem arises when the space, the interval, between these bony prominences is closed causing the quadratus femoris to become compressed or pinched in the small space. This can occur from too much frontal plane drift of the pelvis (side shift/drift) and this is almost always met by a relative adduction of the femur. This adduction narrows the space. Frontal plane drift of the pelvis and adduction of the femur, as either genu valgum or a cross over gait, are highly suspicious culprits in getting to the bottom of this clinical entity.

Do you know how to test and evaluate the quadratus femoris muscle ? How about the similarly functioning obturator externus, upper vastus medialis or iliac division of the gluteus maximus ? Can you reasonably tease them out on your physical examination? If you know the common motion amongst them all you will know why they all can be a culprit of the pain and impinging mechanism, and why in treating this problem you likely will have to evaluate and treat one or more of them since they all support external rotation of the femur especially in varying degrees of hip flexion, and thus are used eccentrically to a significant degree to control the rate and degree of internal rotation of the lower limb during contact phase of gait. Losing this control and compounding frontal pelvis drift (and thus femur adduction) will close off the interval for the ischium of the pelvis moving past the femur’s lesser trochanter.

I know you have seen this problem in your clinics and gyms. Have you missed it and called it a hamstring tendonopathy, or have you nailed it ? It is out there, but you have to know something exists to recognize it, and to fix it. You have to recognize it and understand the pieces of the problem, the anatomy and the pathomechanics and understand what is going on in their gait that could be causing it. This is not a psoas related entity although that should remain on your differential list. This is not to be mistaken for a hamstring tear as I suggested earlier, look at this study’s findings, it is not the same entity, although it is possible to have both simultaneously:

“Abnormalities of the quadratus femoris muscle included edema (100%), partial tear (33%), and fatty infiltration (8%). The hamstring tendons of affected subjects showed evidence of edema (50%) and partial tears (25%).” - Torriani (3)

I cannot find any research out there correlates weakness of the gluteals and of the lateral chains with weakness of this quadratus femoris muscle and its synergists with femur adduction and cross over gait styles in this clinical impingement phenomenon. These components are closely related and functional in my experience.  Certainly I cannot be the first to entertain this conceptual layered idea with the cross over gait /frontal plane drift predisposers. So, please come forward if you have seen the same things and had similar successes, lets compare notes and share your nuances in caring for it. There is something here though, because my clients progress nicely when the multiple muscles that support this spiral-natured external rotation are cleaned up, active, strong and paired nicely in a motor pattern that stacks the foot, knee, hip and pelvis reducing femoral adduction and in the functional components that reduce frontal plane drift which I have discussed here many times on the gait guys blog (type in “cross over gait” in the blog search box).  

Dr. Shawn Allen,

the gait guys

references:

1. Am J Orthop (Belle Mead NJ). 2014 Dec;43(12):548-51.Ischiofemoral Impingement and the Utility of Full-Range-of-Motion Magnetic Resonance Imaging in Its Detection.Singer A1, Clifford P, Tresley J, Jose J, Subhawong T.

2. Magn Reson Imaging Clin N Am. 2013 Feb;21(1):65-73. doi: 10.1016/j.mric.2012.08.005. Epub 2012 Oct 13.Ischiofemoral impingement.Taneja AK1, Bredella MA, Torriani M.

3. AJR Am J Roentgenol. 2009 Jul;193(1):186-90. doi: 10.2214/AJR.08.2090.Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femorismuscle.Torriani M1, Souto SC, Thomas BJ, Ouellette H, Bredella MA.

4. J Bone Joint Surg Br. 2011 Oct;93(10):1300-2. doi: 10.1302/0301-620X.93B10.26714. Ischiofemoral impingement. Stafford GH1, Villar RN.