Ischiofemoral Impingement

Overview:

Ischiofemoral Impingement (IFI) is a condition that affects the hip joint, causing discomfort and restricted movement. This condition occurs when there is abnormal contact between the ischium, a bone in the pelvis, and the femur, the thigh bone. As a result, the soft tissues surrounding the hip joint become pinched or compressed, leading to pain and limited mobility. Often times the presenting symptoms are muscular low back pain.

Symptoms & Causes:

Symptoms of Ischiofemoral Impingement may include:

• Pain in the buttock or groin area, particularly during hip movement activities particularly while walking
• Difficulty sitting for prolonged periods due to discomfort
• Reduced range of motion in the hip joint, making movements such as bending or rotating the hip challenging
• Stiffness or tightness in the hip area
• Low back pain

Affected Populations:

Ischiofemoral Impingement can affect individuals of various ages and activity levels, but certain patient populations may be more prone to developing this condition. These include:

Active Individuals & Athletes: Individuals engaging in activities that place excessive stress on the hip joint, such as weightlifting or running, may also be susceptible. Athletes participating in sports that involve repetitive hip movements or high levels of hip flexion, such as soccer, gymnastics, dance, and martial arts, may be at increased risk of developing Ischiofemoral Impingement.

Middle Age to Older Adults: Ischiofemoral Impingement can occur due to age-related changes in the hip joint, including degenerative conditions such as osteoarthritis or hip joint stiffness. It is also more common with abductor tendon tears because the leg will externally rotate more due to muscle weakness. Older adults may develop impingement due to alterations in hip anatomy or biomechanics over time, such as bone spurs or soft tissue changes.

Females: Females are more predisposed to Ischiofemoral Impingement than males due to differences in pelvic anatomy, hormonal factors, or hip joint mechanics. Women with a history of childbirth or pelvic floor dysfunction may have altered pelvic biomechanics, increasing the risk of impingement.

Individuals with Hip Dysplasia or Structural Abnormalities: Congenital or acquired hip abnormalities, such as hip dysplasia, femoroacetabular impingement (FAI), increased femoral anteversion or acetabular retroversion, can predispose individuals to ischiofemoral impingement. Structural variations in the hip joint, such as acetabular over-coverage or abnormal femoral neck morphology, may lead to abnormal contact between the ischium and femur, contributing to impingement. Ischiofemoral impingement can worsen after a peri-acetabular osteotomy (PAO) due to changes in the hip center, which often becomes more medialized.

Patients with Previous Hip Surgery or Trauma: Individuals who have undergone previous hip surgery, such as hip arthroscopy or hip fracture repair, may develop Ischiofemoral Impingement as a procedure complication. Traumatic injuries to the hip joint, such as hip dislocation or pelvic fractures, can also disrupt normal hip anatomy and increase the risk of impingement.

Patients with Previous Back Surgery: People who have had lumbar spine fusions are more prone to ischiofemoral impingement due to loss in spine motion. The bottom 2 lumbar levels are responsible for over 2/3 of back flexion and extension. A lumbar spine fusion decreases spine motion, causing the hip to have to accommodate by moving more.

Diagnosis:

Diagnosis of Ischiofemoral Impingement typically involves a thorough physical examination by a specialist and imaging studies such as X-rays, MRI, or CT scans. These tests help to assess the extent of impingement and rule out other possible causes of hip pain. A prior CT or MRI that has not shown IFI does not rule out IFI because most MRIs are done with the feet turned in or the hip flexed with a pillow under the knees. When an MRI is done to confirm IFI, the feet should be pointed straight up, and the hip should not be flexed.

It is essential for individuals experiencing hip pain or discomfort to seek evaluation by a qualified orthopedic surgeon specializing in hip disorders. With prompt diagnosis and appropriate treatment, many patients with ischiofemoral impingement can experience significant improvement in symptoms and return to their usual activities with greater comfort and mobility.

Treatment:

Non-Surgical Options:

Depending on the severity of the condition, non-surgical treatment options may include:

Activity Modification: Avoiding activities that aggravate hip pain, such as prolonged sitting or repetitive hip movements. Some people can decrease symptoms by standing with their feet farther apart and walking with their toes pointed in slightly.

Physical Therapy: A tailored exercise program designed to strengthen the muscles around the hip joint and improve flexibility. Particular attention is given to the core abdominal muscles and the hip abductor muscles, which internally rotate the leg.

OTC Anti-Inflammatory Medications: Over-the-counter or prescription medications to reduce pain and inflammation.

Corticosteroid Injections: Injections of corticosteroids directly into the ischiofemoral space to alleviate pain and inflammation.

Surgical Options:

Surgical intervention may be recommended for individuals with Ischiofemoral Impingement who do not experience significant improvement with conservative treatments or whose condition is severe enough to warrant surgical correction. Orthopedic surgeons offer several surgical options to address Ischiofemoral Impingement, each tailored to the specific needs and circumstances of the patient. Common surgical intervention options include:

Arthroscopic Decompression: Arthroscopic surgery involves making small incisions around the hip joint and inserting a tiny camera and specialized surgical instruments. During arthroscopic decompression for ischiofemoral impingement, the surgeon trims or removes excess bone or soft tissue that is causing impingement between the ischium and femur. This minimally invasive approach typically results in less postoperative pain, faster recovery, and a quicker return to normal activities compared to traditional open surgery. Portions of the lesser trochanter bone on the femur are removed in order to increase the space between the bones.

Open Surgical Correction: Open surgical correction may be necessary in cases where the impingement is more severe or complex. This procedure involves making a larger incision to access the ischium directly. The surgeon may perform various techniques, such as reshaping the bony structures of the hip or releasing tight soft tissues to alleviate impingement. Open surgical correction allows for greater visibility and access to the affected area, enabling the surgeon to effectively address more extensive impingement or associated hip conditions. This is most commonly done by removing part of the ischium and repairing the hamstring tendons.

Hip Arthroplasty (Total Hip Replacement): When there is coexistent hip joint pain and arthritis, total hip replacement surgery may be recommended. During this procedure, the damaged parts of the hip joint are replaced with artificial components (prostheses) made of metal, plastic, or ceramic. During the hip replacement, the ischiofemoral space is increased by changing the femoral torsion/offset to eliminate IFI. Total hip replacement can effectively relieve pain, restore mobility, and improve overall hip function in patients with advanced hip degeneration and impingement.

Femoral Osteotomy: When the patient has increased femoral anteversion (torsion) or a high neck shaft angle (valgus hip), an osteotomy is necessary to correct the position of the hip. The most common way to do this is with a proximal derotational femoral osteotomy (PDRFO) utilizing a Winquist saw to cut the femur and correct the rotation of the femur. The osteotomy is held in place with a rod in the femur that allows the patient to put full weight on the leg starting the day of surgery. Another way to correct the ischiofemoral impingement is with a varus osteotomy to correct the angle of the hip.