Ischiofemoral impingement, IFI, Ischiofemoral tightness, hip pain, buttock pain, hip impingement, pain related to walking, piriformis syndrome, morning stiffness, walking pain
Ischiofemoral impingement (IFI), also known as ischiofemoral pinching, is a condition that causes deep buttock pain and possible radiating pain down the leg. It occurs when the sciatic nerve becomes compressed between the ischial tuberosity and the lesser trochanter of the femur (the muscle attachment area near the hip joint). This condition is relatively rare and its symptoms resemble those of Piriformis syndrome, which it's often confused with. However, it is important to differentiate between the two conditions for proper treatment, as they have their own unique characteristics and treatment approaches.
IFI typically develops as a result of an impact injury or after hip surgery, but spontaneous onset is also possible. In these cases, there may be an anatomical abnormality in the area that predisposes the ischiofemoral space to compression and sciatic nerve impingement, or increased loading on the muscles in the area, causing constant muscle tension. In both cases, the ischiofemoral space becomes narrow and the sciatic nerve becomes compressed between either bony structures or muscles.
Etiology
Congenital narrowing of the ischiofemoral space, female sex, a blunt force injury to the buttocks, and hip surgery can all contribute to the development of IFI. Initially, swelling or fatty infiltration of the Quadratus femoris muscle may be observed, resulting in a narrowing of the space between the ischial tuberosity and the femur. Hamstring injuries near their origin can also increase the risk of IFI. With a narrowed space, the sciatic nerve can become compressed or irritated, particularly in situations where the femur rotates outwards or extends. Other hip movements can also cause nerve irritation and pinching. If left untreated, continued compression and irritation can cause symptoms of nerve irritation deep in the buttock or upper thigh.
There are several potential causes of Ischiofemoral impingement, including:
Inflammation of muscles or tendons after trauma or surgery
Formation of scar tissue after surgery
Narrowing of the Ischiofemoral space following hip or femur fracture
Blunt force injury to the buttocks
Abnormal development of the hip, such as from Coxa valga causing alignment changes in the lower extremities
Overuse of the deep gluteal muscles
Shifting of a hip replacement implant after surgery
Lower back or pelvic problems that increase tension in the deep gluteal muscles
Excessive or abnormal training
Foot-related challenges that alter lower limb function
In Ischiofemoral Impingement Syndrome, the sciatic nerve gets compressed or irritated between the ischial tuberosity and the lesser trochanter of the femur. Changes in the surrounding muscles can also contribute to the development or worsening of this condition, and the Quadratus femoris muscle is particularly important due to its anatomical location.
Symptoms
Typical symptoms include a deep pain or tingling sensation felt in the buttock or upper part of the hamstring. Sometimes the pain can also radiate down to the knee, casusing knee pain as the primary symptom. Pain can also be felt in the groin or inner thighs, but deep buttock pain is the most typical sign of IFI. Clicking or snapping in the hip or buttock may also occur when moving the hip joint.
Pain worsens in situations where the Ischiofemoral space narrows, either as the ischial tuberosity and femur come closer together or when the muscles in the area become tense, further reducing the space. Typical situations that worsen symptoms include fast walking with long strides that cause increased hip extension. Activities that require external rotation of the thigh are also said to worsen the symptoms, but in reality, any movement or muscle tension that affects the hip can aggravate the symptoms in this condition.
Pain often eases during gentle walking or swimming or when in positions where the muscles in the affected area can relax and the bony compression is at its minimum.
Ischiofemoral impingement is often confused with Piriformis syndrome or lumbar radiculopathy, as their clinical symptoms resemble each other. However, in Piriformis syndrome, the symptoms are provoked in different situations than in IFI, and there are no neurological deficits, such as those seen in lumbar radiculopathy, associated with IFI.
Treatment
The primary treatment for IFI is conservative. Treatment options include a combination of pharmacological and non-pharmacological pain management methods, as well as physiotherapy. Exercise aims to improve the biomechanical properties of the lower limbs and reduce the increased load on the buttock area.
The goal of treatment is to relieve pain and improve function and work capacity. This is achieved through a precise, progressive, and individualized exercise program, which often includes mobility-enhancing and maintaining exercises, as well as manual therapy.
Pharmacological treatment commonly involves a combination of non-steroidal anti-inflammatory drugs and muscle relaxants. Possible inflammation and tissue swelling should also be treated with cold therapy, which should be repeated several times a day.
Surgical procedures should only be considered when conservative treatment doesn't achieve the desired results or if the patient has severe pain that impairs function. In surgery the space between the ischial tuberosity and the lesser trochanter of the femur can be increased by shaving off "excess" bone from either the ischial tuberosity or the trochanter minor of the femur. Surgical removal of scar tissue adhesions can also increase the space for the sciatic nerve and reduce possible compression.
Physiotherapy
Physiotherapy always begins with a thorough assessment of the patient's background factors, which can be used to create an individualized rehabilitation program. It is important to separate the underlying factors and determine which factors have contributed to the development of the pain.
Based on the detailed assessment, a treatment plan is created that is tailored to individual findings and aims to reduce the increased load and impingement in the Ischiofemoral space and improve function.
Physiotherapy may include the following methods when treating IFI:
Manual therapy: soft tissue treatment and joint mobilization reduce muscle tension and increase mobility. Manual therapy also reduces pain, increases fluid circulation and improves function.
Strengthening exercises: improve pelvic stability and reduce peak loads in deep gluteal muscles.
Pain management: heat and cold therapy, manual therapy, acupuncture
Biomechanical challenges assessment and treatment
Myofascial treatment: releases the mobility of fascia tissues
Mobility exercises: improve overall mobility and reduce increased load on specific areas.
A combination of manual therapy and home exercise program has been shown to produce good results in the treatment of IFI.
Self care
Exercise regularly: Exercise can help reduce symptoms caused by Ischiofemoral impingement in the hip and improve muscle function. Recommended types of exercise include gentle walking, swimming, and water aerobics.
Strengthen your muscles: Strengthening exercises develop the muscles in the area and improve stability. However, these exercises should be started cautiously and the load increased gradually over time. Overloading the muscles can often increase tension and symptoms.
Avoid prolonged standing or sitting: Prolonged standing or sitting can worsen symptoms and increase the static tension in the muscles. Take a break from sitting every 20 minutes.
Use cold: Cold therapy can help relieve pain and possible inflammation. You can use ice, cold packs, or cold gel.
Try heat: Heat therapy relaxes muscles and reduces pressure on nerve tissue caused by tense muscles. You can use a heat pack or heat gel.
Stretch regularly: Dynamic stretching of the hamstrings and glutes can promote blood flow and increase mobility. However, avoid hard and long stretches, as these often only increase tension in the area.
Use a massage ball or foam roller to treat deep gluteal muscles and surrounding tissues. The treatment should be continued until the pain caused by the treatment decreases by about half compared to the initial feeling. The treatment can be repeated 1-2 times a week.
Get enough rest: Adequate sleep and rest help the body recover and can help alleviate symptoms related to Ischiofemoral impingement.
Consult a physiotherapist: If your pain persists despite self-care measures or interferes with your daily activities, consult a physiotherapist.