Abstract
Hip pain can have a number of different etiologies. Ischiofemoral impingement (IFI), an etiology causing extra-articular hip pain, shares many of the same symptoms as other causes of gluteal or inguinal pain, making its diagnosis difficult. We present a case of a young female with persistent deep gluteal pain who was diagnosed with IFI based on radiographic findings; however, a diagnostic injection into the quadratus femoris did not confirm IFI as the primary pain generator. The patient subsequently failed several trials of physical therapy designed to address this diagnosis. The diagnosis was expanded to include piriformis syndrome and the modified treatment approach resulted in complete resolution of her pain. The similarities of these pathologies resulted in a delay of definitive treatment and would have potentially required unnecessary surgery. This case study highlights the diagnostic conundrum clinicians face in the evaluation of gluteal hip pain and provides an algorithm for considering alternate diagnoses when conservative management fails to achieve expected results.
Highlights
Ischiofemoral impingement (IFI) is a cause of extra-articular hip pain due to narrowing of the space between the ischial tuberosity and the lesser trochanter, resulting in entrapment of the quadratus femoris muscle
First described by Johnson in 1977 in patients following total hip arthroplasty, this diagnosis is becoming increasingly recognized as an underdiagnosed cause of hip pain [2,3]
Patients present clinically with gluteal and/or groin pain without an inciting event [4]. These symptoms are shared with a number of other intra- and extra-articular conditions to include femoroacetabular impingement, labral tears, low back pain, sacroiliac (SI) joint dysfunction, piriformis syndrome, cluneal nerve entrapment, snapping hip syndrome, psoas tendinitis, hamstring injuries, and gluteus minimus and medius tendinopathy
Summary
Ischiofemoral impingement (IFI) is a cause of extra-articular hip pain due to narrowing of the space between the ischial tuberosity and the lesser trochanter, resulting in entrapment of the quadratus femoris muscle. The differential diagnosis for this patient’s symptoms on initial evaluation at the time of presentation to the IPMC included low back pain, SI joint dysfunction, IFI, and piriformis syndrome. While she did have degenerative changes at L4-S1 on x-ray and MRI, these findings were mild and provocation testing to the facet joints did not reproduce her symptoms; low back pain was less likely. She ran the distance of five light posts (150 meters) and climbed four flights of stairs until reproduction of pain (5/10 level) Her physical examination revealed asymmetrical pelvic landmarks and positive motion palpation and pain provocation tests for left-sided SIJ joint dysfunction; both of the IFI tests were negative. While the treatment duration to meet her jogging goal was initially estimated as eight weeks, the actual time period for meeting the patient goals was 16 weeks
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