Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

Ischiofemoral impingement may cause pain in the deep posterior gluteal region, the hip, and the groin. Because it is an uncommon condition, its diagnosis is often missed or delayed. When there is compression or irritation of the sciatic nerve, the pain can radiate to the posterior region of the thigh, due to the proximity of the sciatic nerve to the posterior border of the quadratus femoris muscle⁽¹⁾. Although findings of an ischiofemoral space ≤ 15 mm and a quadratus femoris muscle space ≤ 10 mm usually facilitate the diagnosis of ischiofemoral impingement, the reference standard continues to be the presence of symptoms combined with signs of edema in the quadratus femoris muscle on magnetic resonance imaging (MRI)^(2,3).

Ischiofemoral impingement is more frequent in women, as well as in middle-aged or elderly individuals. The etiology is multifactorial, and a number of conditions can predispose an individual to developing ischiofemoral impingement^(4–6), such conditions including postoperative changes; femoral deformities such as coxa valga, coxa brevis, and excessive anteversion; hip instability or dysplasia; pelvic retroversion; and hamstring tendinopathy.

Muscle edema is typically identified in the central portion of the ventral surface of the quadratus femoris muscle, in the area of greatest anatomical narrowing, unlike what would be expected in a muscle strain, in which edema tends to occur along the distal musculotendinous junction⁽¹⁾.

The measurement of the ischiofemoral and quadratus femoris spaces on MRI may vary with the positioning of the patient, being influenced by the degree of flexion, adduction, and rotation of the hip, as well as by the patient decubitus^(7,8). Measures performed on routine MRI may not reflect the variations that occur during activities of daily living or sports activities⁽⁸⁾. The measurement of those spaces tends to be smaller during external rotation, with adduction or extension of the hip. Therefore, hip positioning is an important factor to be considered in ischiofemoral impingement evaluation. That is one of several reasons why prospective studies are important.

In the previous issue of Radiologia Brasileira, we have the opportunity to peruse a prospective study about ischiofemoral impingement⁽⁹⁾, probably the first study of its kind in the literature. The prospective study conducted by Barros et al.⁽⁹⁾ confirmed significant reduction in the ischiofemoral and quadratus femoris spaces in patients diagnosed with ischiofemoral impingement. All of the patients included in the study were evaluated and examined in a standardized manner. However, the study has significant limitations, mainly in relation to the small number of patients included. As in previous studies, no longitudinal evaluation was performed, which limits the conclusions regarding causative or protective factors.

We await future prospective studies involving larger number of patients, and longitudinal studies, in order to increase our knowledge regarding this challenging diagnosis.


REFERENCES

1. Kassarjian A, Tomas X, Cerezal L, et al. MRI of the quadratus femoris muscle: anatomic considerations and pathologic lesions. AJR Am J Roentgenol. 2011;197: 170–4.

2. Akça A, Şafak KY, İliş ED, et al. Ischiofemoral impingement: assessment of MRI findings and their reliability. Acta Ortop Bras. 2016;24:318–21.

3. Singer AD, Subhawong TK, Jose J, et al. Ischiofemoral impingement syndrome: a meta-analysis. Skeletal Radiol. 2015;44:831–7.

4. Johnson KA. Impingement of the lesser trochanter on the ischial ramus after total hip arthroplasty. Report of three cases. J Bone Joint Surg Am. 1977;59:268–9.

5. Hernando MF, Cerezal L, Pérez-Carro L, et al. Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis. Skeletal Radiol. 2016;45:771–87.

6. Carvalho AD, Garcia FL, Nogueira-Barbosa MH. Ischiofemoral impingement secondary to valgus intertrochanteric osteotomy: a case report. Radiol Bras. 2017; 50:335–7.

7. Johnson AC, Hollman JH, Howe BM, et al. Variability of ischiofemoral space dimensions with changes in hip flexion: an MRI study. Skeletal Radiol. 2017;46:59–64.

8. Atkins PR, Fiorentino NM, Aoki SK, et al. In vivo measurements of the ischiofemoral space in recreationally active participants during dynamic activities: a highspeed dual fluoroscopy study. Am J Sports Med. 2017;45:2901–10.

9. Barros AAG, Santos FBG, Vassalo CC, et al. Evaluation of the ischiofemoral space: a case-control study. Radiol Bras. 2019;52:237–41.










Associate Professor of Radiology at Ribeirão Preto Medical School – University of São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil

Email: marcello@fmrp.usp.br