Ischiofemoral Impingement
Birgit Ferber-Busse
This more or less uncommon disease was first described by Johnson 1977 at a post-operative issue. Described in three case studies how parts of the sicatic nerve are compressed postoperatively. Pain was reduced by surgical reduction of lesser trochanter. The pain triggering maneuver was the same for the three patients: hip extension and adduction, the direction of rotation was mentioned but in this publication not described. Increased external rotation would favor compression, internal rotation would give constant length stress on the quadratus femoris and make it more vulnerable to lesions (Kivlan et al 2017, Kerr 2012).
Note: Kivlan et al proved the extension, adduction, rotation maneuver in a cadaver study
(picture B.Ferber-Busse: Pir piriformis, GM gemelli, QF quadratus femoris, OI obturator internus, HA hasmtrings, SN sciatic nerve
Based on his caver studies Kivlan et al 2017 postulated: " The pirifomis and superior gemellus had a larger change in length when adducting the hip from 90° of hip and knee flexion. The obturator internus and inferior gemellus had a greater length change when internally rotating the hip from neutral flexion/extension.
Most ischiofemoral space occured in neutral hip extension/flexion, neutral abduction/adduction and internal rotation (Finnoff et al 2015).
Definiton
Ischiofemoral impingement is a compression syndrome around quadratus femoris muscle, not a tendinopathy. It is caused by edema, fat infiltration or tearing of musculus quadratus femoris and mainly diagnosed with ultrasound (Wu et al 2022).
Pain localization: Posterior buttock pain, very rare groin pain, snapping or clucking around buttock
Aggravating factors: Long duration of weigth bearing or hip extension and adduction, even with hip extension and posterior pelvic tilt position (Atkins et al 2027, Grimaldi et al 2026).
Predisposing factors: Toe in posture due to anteversion of femoral angle tightens deep gluteal muscles (quadratus femoris, obturator externus) "overstretched" muscles are more vulnerable to strain injury (Finnoff et al 2023).
Due to pain, spinal stenosis come along with spine extension deficit which reduce the ischiofemoral space because of posterior pelvic tilt. Less hip extension may lead to lower back pain a positive Trendelenburg sign is evident when gluteus medius muscle is weak. Sensory disturbances like numbness, tingling, prickling may present if sciatic nerve is involved.
Appropriate testing: (pictures private)
long-stride walking test: grab side lying affected side up: examiner buttock lateral to ischium, extend press the buttock slightly lateral to the painful hip; short strides don`t ischium after passive extension of hip, provoke any pain pain is provoked as neutral/adduction but not in abduction (IF impingement test)
side lying affected side up: in knee flexion externally rotate the extented hip, examiners thumb over ischium to provoke symptom
affected side in standing: passive flexion knee of affected side, extension external rotation and adduction hip (quadriceps femoris elongation)
Differential diagnosis
Possible source of symptoms could arise from structures or muscles proximity to the greater sciatic notch: posterior band of gluteus medius, gluteus minimus, piriformis, superior and inferior gemelli.
Hamstrings syndrome: painful prolonged sitting, palpation hamstrings tendinous insertion distal to myotendinous junction provokes pain, in hip flexion do knee extension (lag of >20° suggest hamstrings tightness) or SLR manoveur is positive (Florentino et al 2025).
Management
So far no randomized controlled clinical trials are available (Grimaldi et al 2026) only expert opinions and case studies.
Recommandation: load management and exercise based rehabilitation framework
- reducing exposure to positions and movements that cause compression of soft tissues in ischiofemural space
- avoid hip extension adduction external rotation
Postural training: Bring patients ankle-hip (greater trochanter)-shoulder in a vertival alignement to reduce compression.
Avoid: Hanging on one hip (too much adduction)
In a true leg length difference (>1cm) a shoe insert external lift may be trialed, scoliosis >20° Cobb angle should be considered an helped by a bracing (Grimaldi et al 2016).
Sport: Runners should reduce stride length and increase step rate
Exercises: In a systematic review Nakano et al 2020 showed some opportunities for conservative management, but unfortunately physiotherapy was listed without any special interventions beside: rest, acitivity modification, medication and so on. The study focused on injection under controlled ultrasound as a non-surgical management.
2023 Collings et al published a lower limb training focused on hip muscles: gluteus maximus, medius and minimus and established following exercises as appropriate:
- gluteus maximus: loaded split squat, loaded single-leg Romanian dead lift, loaded single-leg hip thrust
- gluteus medius: body weight side plank, loaded single-leg squat, loaded single-leg Romanian dead lift
- gluteus minimus: body weigth sied plank, loaded single-leg Romanian dead lift
Note: Collings et al publication refers to 14 female football players age 18 to 32 years
Based on Collings et al`s work, 3 systematic phases showed up
- De-load: Reduce excessive compressive loading on quadratus femoris muscle. Shorten walking stride to avoid terminal hip extension, avoid deep crossing legs (adduction).
- Reset: Restore dynamic control of the pelvis and femur. Utilize hip-flexed isometric holds to build localized capacitiy in an open-space position.
- Build: Progessivly strengthen the hip abductors and external rotators. Gradually introduce dynamic loading (like standing weigth-bearing shifts or side-lying abductions) while ensure the available space can tolerate muscle hypertrophy.
Summary
The ischiofemoral impingement syndrome maybe rare and underestimated but could be a source of longstanding buttock pain with certain functional limitations. A good clinical reasoning procedure helps to rule in or out this syndrom and give an overview about contributing factors concerning other relevant componends.
References:
Collings TJ, Bourne MN, Barrett RS, Meinders E, Goncalves B, Shield AF, Diamond LE. Gluteal Muscle Forces during Hip-Focused Injury Prevention and Rehabilitation Exercises. Med Sci Sports Ecerc.2023 Apr 1; 55(4): 650-660. doi: 10.1249/MSS.0000000000003091.PMID: 36918403
Finnoff JT, Bond JR, Collins MS, Sllon JL, Hollman JH, Wempe MK, Smith J. Variabiltity of the Ischiofemoral Space Relative to Femur Position: An Ultrasound Study. PM R. 2015 Sep; 7(9): 930-937.doi: 10.1016/j.pmrj.2015.03.010. Epub 2015 Mar 12. PMID: 25772723
Florentino SA, Sangvhi P, Adelstein JM, Berk AN, Good LM, Calcei JG, Voos JE, Salata MJ. Increased Incidence of Hamstring Injuries in the United States From 2015 to 2024 and Projected Growth Through 2030. Arthrosc Sports Med Rehabil. 2025 Oct 21; 7(6): 101295. doi: 10.1016/j.asmr.2025. 101295. PMID: 41541515; PMCID: PMC12800840
Grimaldi A, Ganderton C, Nasser A. Ischiofemoral impingement: Clinical perspectives for enhancing diagnosis and rehabilitation. Musculoskeletal Science & Practice, 2026; 84
Johnson KA. Impignement of the lesser tronachter on the ischial ramus after total hip arthroplasty. Report of three cases. J Bond Joint Surg Am 1977; 59: 268-269.
Kivlan BR, Martin RL, Martin HD. Ischiofemoral impingement: defining the lesser trochanter-ischial space. Knee srug Sprots Traumatol Arthrosc. 207 Jan; 25 (1): 72-76. doi: 10.1007/s00167-016-4036-y. Epub 206 Feb 11. PMID: 26869034.
Nakano N, Shoman H, Khanduja V: Treatment strategies for ischiofemoral impingement: a systematic review Surgery, Sports Traumatology, Arthroscopy (2020) 28: 2772-2787 doi.or/10.1007/s00167-018-5251-5
Patti JW, Quellette H, Bredella MA, Trorriani M. Impingment of lesser trochanter on ischium as a potential cause for hip pain. Skeletal Radiol 2008; 37-939-941.
Roger M. Kerr, M.D. Ischiofemoral Impingement Syndrome MRI Web Clinik - October 2012
Torriani M, Souto SC, Thomas BJ, Quelette H, Bredella MA: Ischiofemoral impingement syndrome: and entity with hip pain and abnormalities of the quadratus femoris muscle. AJR 2009; 193: 186-190
Wu,W,-T.; Chang, K.-V,; Mezian, K; Nanka, O,; Ricci,V,; Chang, H.-C,; Wang, B,; Hung, C.-V,; Özcakar, L. Ischiofemoral Impingement Syndrome: Clinical and Imaging/Guidacne Issues with Special Focus on Ultrasonography. Diagnostics 2023,13,139. doi.org/10.3390/diagnostics13010139
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