The forgotten cause of bottom pain.
I see a lot of patients in clinic who have a pain in the bum. Sometimes they come along, convinced that they have a form of sciatica, and may even have been through failed caudal epidural injections. Every now and then when a patient describes a certain kind of pain they are getting deep in their buttock, it strikes a chord with me. I ask myself, might this be Ischiofemoral Impingement?
If you’ve not come across this strange beast before, then don’t be surprised because it’s probably not that common. But never the less, if you learn to recognise the symptoms you can really help a patient back to comfort quickly. Many patients who have deep buttock pain might be able to blame their lumbar spine. It’s common to have a form of radiculopathy or pain referred from facet joints. Posterolateral hip pain can also be a form of gluteus medius tendinopathy or an ischial bursitis.
Many patients are utterly convinced they have hamstring symptoms, and they’ve diligently been carrying out eccentric training as it if were their full-time job. When these patients don’t get better, there is a diagnostic quandary to overcome.
So, what on earth is Ischiofemoral Impingement and what does it really mean for patients?
Let’s get a little clearer on what we’re talking about here. It’s a condition that affects the quadratus femoris (Q.F.) muscle, which is basically a small muscle which made the mistake of deciding to live between the ischial tuberosity and the lesser trochanter. Normally this is usually a generous anatomical space and Q.F. gets to nestle in there quite happily, doing whatever it is that Q.F. does (typically, externally rotating the hip).
Life may not always be bliss for poor old quadratus; he can be pinched, or fall victim of a shearing type injury, which leads to oedema and swelling. Like anything in an enclosed space, this then leads to pain and further swelling. You’ve guessed where this is heading.
If you’ve read any of the orthopedic literature, you’ll see case studies of Ischiofemoral Impingement, relating to old ladies who’ve had hip surgery. Such patients might have had a fall which precipitated a femoral fracture and the literature describes patients who have an anatomical predisposition. There are even surgeons out there who make a living from making this bony space bigger. Ouch.
Because I love all things hip, I’ll probably see about four or five cases of Ischiofemoral Impingement each week, and I think that most people who present with this problem will tend to fall into one of the following scenarios.
In the elite sporting world, we may come across cases of Ischiofemoral Impingement in professional dancers who stand with their hips in extreme turn-out. If you’re generally a hypermobile person, it’s not too tricky to oppose your lesser trochanter against your ischial tuberosity.
I also see it in patients who have inadvertently slipped and put themselves through an exotic kind of splits maneuver. If their affected leg has gone through a bit of a swoop, and the hip moves into flexion with external rotation, in addition to tweaking their proximal hamstring they might also tear Q.F.
Sometimes we see a case when a patient has had a severe hip extension, which might literally be a case of slipping on ice or wet restaurant floor.
Every now and then we meet a cyclist, who has done a three sixty in the air and landed on their derriere.
Here’s how you spot it.
Often the patient will describe this really unpleasant burning sensation, and they want to get the weight off their buttock when they are seated. This is a bit like someone presenting with a hamstring paratendinopathy or an enthesopathy.
The difference is when you examine them and you load up the hammy you don’t tend to provoke much pain. Additionally, it may quite be difficult to palpate the sore area. The patient even tells you that they can’t put their finger on it, but never the less, it hurts like hell. You might find that if you put them into a supine position, with their hip in external rotation and their knee flexed (think ‘bent knee fall out’) it may reproduce their pain in their buttock.
So, why should we be concerned with Ischiofemoral Impingement?
It matters because I suspect some of the time, we are wasting effort and resources on trying to get a supposed hamstring problem better when actually it’s the next-door neighbor who is the trouble maker.
These patients can have their diagnosis readily confirmed on MRI imaging. Along with robust rehab, they will often respond quite beautifully to a CT guided cortisone injection, which bathes the Ischiofemoral space. This kick starts a reduction of pain and oedema in the area and enables them to get normal function and rotation in the hip.
Next time you have a patient who feels like they are sitting on a red-hot poker, consider this as a possibility in the differential diagnosis.
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Dr Cath x