Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis


Ischiofemoral impingement syndrome (IFI) is an underrecognized form of atypical, extra-articular hip impingement defined by hip pain related to narrowing of the space between the ischial tuberosity and the femur. The etiology of IFI is multifactorial and potential sources of ischiofemoral engagement include anatomic variants of the proximal femur or pelvis, functional disorders as hip instability, pelvic/spinal instability, or abductor/adductor imbalance, ischial tuberosity enthesopathies, trauma/overuse or extreme hip motion, iatrogenic conditions, tumors and other pathologies. Magnetic resonance imaging (MRI) is the diagnostic procedure of choice for assessing IFI and may substantially influence patient management. The injection test of the ischiofemoral space (IFS) has both a diagnostic and therapeutic function. Endoscopic decompression of the IFS appears useful in improving function and diminishing hip pain in patients with IFI but conservative treatment is always the first step in the treatment algorithm. Because of the ever-increasing use of advanced MRI techniques, the frequent response to conservative treatment, and the excellent outcomes of new endoscopic treatment, radiologists must be aware of factors that predispose or cause IFI. In addition, focused treatment in these conditions is often more important than in secondary impingement. In this article, we briefly describe the anatomy of the IFS, review the clinical examination and symptoms, assess the diagnostic imaging criteria and pathophysiological mechanisms, and develop an understandable classification of IFI, with particular focus on its etiology, predisposing factors, and associated musculoskeletal abnormalities. We also assess the role of the radiologist in the diagnosis, treatment, and preoperative evaluation of both primary and secondary IFI.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Fig. 27
Fig. 28


  1. 1.

    Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. Am Fam Physician. 2014;89(1):27–34.

    PubMed  Google Scholar 

  2. 2.

    Tosun O, Algin O, Yalcin N, Cay N, Ocakoglu G, Karaoglanoglu M. Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability. Skelet Radiol. 2012;41(5):575–87.

    Article  Google Scholar 

  3. 3.

    Sutter R, Pfirrmann CW. Atypical hip impingement. AJR Am J Roentgenol. 2013;201(3):437–42.

    Article  Google Scholar 

  4. 4.

    Ali AM, Teh J, Whitwell D, Ostlere S. Ischiofemoral impingement: a retrospective analysis of cases in a specialist orthopaedic centre over a four-year period. Hip Int. 2013;23(3):263–8.

    Article  PubMed  Google Scholar 

  5. 5.

    López-Sánchez MC, Armesto Pérez V, Montero Furelos LÁ, Vázquez-Rodríguez TR, Calvo Arrojo G, Díaz Román TM. Ischiofemoral impingement: hip pain of infrequent cause. Reumatol Clin. 2013;9(3):186–7.

    Article  PubMed  Google Scholar 

  6. 6.

    Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. AJR Am J Roentgenol. 2009;193(1):186–90.

    Article  PubMed  Google Scholar 

  7. 7.

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

    Article  PubMed  Google Scholar 

  8. 8.

    Aung HH, Sakamoto H, Akita K, Sato T. Anatomical study of the obturator internus, gemelli and quadratus femoris muscles with special reference to their innervation. Anat Rec. 2001;263(1):41–52.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Honma S, Jun Y, Horiguchi M. The human gemelli muscles and their nerve supplies. Kaibogaku Zasshi. 1998;73(4):329–35.

    CAS  PubMed  Google Scholar 

  10. 10.

    Wilson JT. Abnormal distribution of the nerve to the quadratus femoris in man, with remarks on its significance. J Anat Physiol. 1889;23(Pt 3):354–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Beltran L, Ghazikhanian V, Padron M, Beltran J. The proximal hamstring muscle-tendon-bone unit: a review of the normal anatomy, biomechanics, and pathophysiology. Eur J Radiol. 2012;81(12):3772–9.

    Article  PubMed  Google Scholar 

  12. 12.

    Hernando MF, Cerezal L, Pérez-Carro L, Abascal F, Canga A. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skelet Radiol. 2015;44(7):919–34.

    Article  Google Scholar 

  13. 13.

    Hatem MA, Palmer IJ, Martin HD. Diagnosis and 2-year outcomes of endoscopic treatment for ischiofemoral impingement. Arthroscopy. 2015;31(2):239–46.

    Article  PubMed  Google Scholar 

  14. 14.

    Stafford GH, Villar RN. Ischiofemoral impingement. J Bone Joint Surg (Br). 2011;93(10):1300–2.

    CAS  Article  Google Scholar 

  15. 15.

    Taneja AK, Bredella MA, Torriani M. Ischiofemoral impingement. Magn Reson Imaging Clin N Am. 2013;21(1):65–73.

    Article  PubMed  Google Scholar 

  16. 16.

    Hayat Z, Konan S, Pollock R. Ischiofemoral impingement resulting from a chronic avulsion injury of the hamstrings. BMJ Case Rep. 2014 . pii: bcr2014204017.

  17. 17.

    Guillin R, Marchand AJ, Roux A, Niederberger E, Duvauferrier R. Imaging of snapping phenomena. Br J Radiol. 2012;85(1018):1343–53.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Tosun Ö, Çay N, Bozkurt M, Arslan H. Ischiofemoral impingement in an 11-year-old girl. Diagn Interv Radiol. 2012;18(6):571–3.

    PubMed  Google Scholar 

  19. 19.

    Ali AM, Whitwell D, Ostlere SJ. Case report: Imaging and surgical treatment of a snapping hip due to ischiofemoral impingement. Skelet Radiol. 2011;40:653–6.

    Article  Google Scholar 

  20. 20.

    Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy. 2011;27:172–81.

    Article  PubMed  Google Scholar 

  21. 21.

    Maraş Özdemir Z, Aydıngöz Ü, Görmeli CA, Sağır Kahraman A. Ischiofemoral space on MRI in an asymptomatic population: normative width measurements and soft tissue signal variations. Eur Radiol. 2015;25(8):2246–53.

    Article  PubMed  Google Scholar 

  22. 22.

    Sproul RC, Reynolds HM, Lotz JC, Ries MD. Relationship between femoral head size and distance to lesser trochanter. Clin Orthop Relat Res. 2007;461:122–4.

    PubMed  Google Scholar 

  23. 23.

    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.

    CAS  PubMed  Google Scholar 

  24. 24.

    Kassarjian A. Signal abnormalities in the quadratus femoris muscle: tear or impingement? AJR Am J Roentgenol. 2008;190(6):W379. author reply W380-1.

    Article  PubMed  Google Scholar 

  25. 25.

    Finnoff JT, Bond JR, Collins MS, Sellon JL, Hollman JH, Wempe MK, Smith J. Variability of the Ischiofemoral Space relative to Femur Position: An Ultrasound Study. PM R. 2015 Mar 12. doi:10.1016/j.pmrj.2015.03.010.

  26. 26.

    Tennant S, Kinmont C, Lamb G, Gedroyc W, Hunt DM. The use of dynamic interventional MRI in developmental dysplasia of the hip. J Bone Joint Surg (Br). 1999;81(3):392–7.

    CAS  Article  Google Scholar 

  27. 27.

    Singer A, Clifford P, Tresley J, Jose J, Subhawong T. Ischiofemoral impingement and the utility of full-range-of-motion magnetic resonance imaging in its detection. Am J Orthop (Belle Mead NJ). 2014;43(12):548–51.

    Google Scholar 

  28. 28.

    Blankenbaker DG, Tuite MJ. Non-femoroacetabular impingement. Semin Musculoskelet Radiol. 2013;17(3):279–85.

    Article  PubMed  Google Scholar 

  29. 29.

    Subhash Gujar, Sanjay Vikani, Jigna Parmar, K V Bondre. A correlation between femoral neck shaft angle to femoral neck length. Int J Biomed Adv Res ISSN: 2229–3809 (Online).

  30. 30.

    Bredella MA, Azevedo DC, Oliveira AL, Simeone FJ, Chang CY, Stubbs AJ, et al. Pelvic morphology in ischiofemoral impingement. Skelet Radiol. 2015;44(2):249–53.

    Article  Google Scholar 

  31. 31.

    Stevens PM, Coleman SS. Coxa breva: its pathogenesis and a rationale for its management. J Pediatr Orthop. 1985;5(5):515–21.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Sussman WI, Han E, Schuenke MD. Quantitative assessment of the ischiofemoral space and evidence of degenerative changes in the quadratus femoris muscle. Surg Radiol Anat. 2013;35:273–81.

    Article  PubMed  Google Scholar 

  33. 33.

    Delaunay S, Dussault RG, Kaplan PA, Alford BA. Radiographic measurements of dysplastic adult hips. Skelet Radiol. 1997;26(2):75–81.

    CAS  Article  Google Scholar 

  34. 34.

    Tomás A, Domínguez R, Veras M, Roche S, Merino X, Pineda U. Ischiofemoral impingement: spectrum of findings. European Congress of Radiology, 2013/C-1005. Scientific exhibit. doi: 10.1594/ecr2013/C-1005.

  35. 35.

    De Sa D, Alradwan H, Cargnelli S, Thawer Z, Simunovic N, Cadet E, et al. Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy. 2014;30(8):1026–41.

    Article  PubMed  Google Scholar 

  36. 36.

    Tsatalas T, Giakas G, Spyropoulos G. The effects of muscle damage on walking biomechanics are speed-dependent. Eur J Appl Physiol. 2010;110(5):977–88.

    Article  PubMed  Google Scholar 

  37. 37.

    Vital JM, García Suárez A, Sauri Barraza JC, Soderlund C. Sagittal balance in spine disorders. Rev Ortop Traumatol. 2006;50:447–53.

    Article  Google Scholar 

  38. 38.

    Miokovic T, Armbrecht G, Felsenberg D, Belavy DL. Differential atrophy of the postero-lateral hip musculature during prolonged bedrest and the influence of exercise countermeasures. J Appl Physiol. 2011;110(4):926–34.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Chen CK, Yeh L, Chang WN, Pan HB, Yang CF. MRI diagnosis of contracture of the gluteus maximus muscle. AJR Am J Roentgenol. 2006;187(2):W169–74.

    Article  PubMed  Google Scholar 

  40. 40.

    Ni B, Li M. The effect of children’s gluteal muscle contracture on skeleton development. Sichuan Da Xue Xue Bao Yi Xue Ban. 2007;38(4):657–9. 677.

    PubMed  Google Scholar 

  41. 41.

    Singer AD, Subhawong TK, Jose J, Tresley J, Clifford PD. Ischiofemoral impingement syndrome: a meta-analysis. Skelet Radiol. 2015;44(6):831–7.

    Article  Google Scholar 

  42. 42.

    Viala P, Vanel D, Larbi A, Cyteval C, Laredo JD. Bilateral ischiofemoral impingement in a patient with hereditary multiple exostoses. Skelet Radiol. 2012;41(12):1637–40.

    Article  Google Scholar 

  43. 43.

    Mehta M, White LM, Knapp T, Kandel RA, Wunder JS, Bell RS. MR imaging of symptomatic osteochondromas with pathological correlation. Skelet Radiol. 1998;27(8):427–33.

    CAS  Article  Google Scholar 

  44. 44.

    Uri DS, Dalinka MK, Kneeland JB. Muscle impingement: MR imaging of a painful complication of osteochondromas. Skelet Radiol. 1996;25(7):689–92.

    CAS  Article  Google Scholar 

  45. 45.

    Patti JW, Ouellette H, Bredella MA, Torriani M. Impingement of lesser trochanter on ischium as a potential cause for hip pain. Skelet Radiol. 2008;37:939–41.

    Article  Google Scholar 

  46. 46.

    Backer MW, Lee KS, Blankenbaker DG, Kijowski R, Keene JS. Correlation of ultrasound-guided corticosteroid injection of the quadratus femoris with MRI findings of ischiofemoral impingement. AJR Am J Roentgenol. 2014;203(3):589–93.

    Article  PubMed  Google Scholar 

  47. 47.

    Kim WJ, Shin HY, Koo GH, Park HG, Ha YC, Park YH. Ultrasound-guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome. Pain Pract. 2014;14(7):649–55.

    Article  PubMed  Google Scholar 

  48. 48.

    Truong WH, Murnaghan ML, Hopyan S, Kelly S. Ischioplasty for ischiofemoral impingement, a case report. JBJS Connect. 2012;26:e51.

    Google Scholar 

  49. 49.

    Monahan E, Shimada K. Verifying the effectiveness of a computer-aided navigation system for arthroscopic hip surgery. Westwood JD, Haluck RS, Hoffman HM, et al. Medicine meets virtual reality 16–parallel, combinatorial, convergent: Nextmed by design. Stud Health Technol Informl. 2008;132:302–7.

  50. 50.

    Lee S, Kim I, Lee SM, Lee J. Ischiofemoral impingement syndrome. Ann Rehabil Med. 2013;37(1):143–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Ata AM, Yavuz H, Kaymak B, Ozcan HN, Ergen B, Ozçakar L. Ischiofemoral impingement revisited: what physiatrists need to know in short. Am J Phys Med Rehabil. 2014;93(12):1104.

    Article  PubMed  Google Scholar 

  52. 52.

    Cho KH, Lee SM, Lee YH, Suh KJ, Kim SM, Shin MJ, et al. Non-infectious ischiogluteal bursitis: MRI findings. Korean J Radiol. 2004;5(4):280–6.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Robinson P, White LM, Agur A, Wunder J, Bell RS. Obturator externus bursa: anatomic origin and MR imaging features of pathologic involvement. Radiology. 2003;228(1):230–4.

    Article  PubMed  Google Scholar 

  54. 54.

    Stibbe EP. Complete absence of the quadratus femoris. Anatomical notes. J Anat. 1929;64(Pt 1):97.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. 55.

    O’Brien SD, Bui-Mansfield LT. MRI of quadratus femoris muscle tear: another cause of hip pain. AJR Am J Roentgenol. 2007;189(5):1185–9.

    Article  PubMed  Google Scholar 

  56. 56.

    Jr Klinkert P, Porte RJ, de Rooij TP, de Vries AC. Quadratus femoris tendinitis as a cause of groin pain. Br J Sports Med. 1997;31(4):348–9.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Lewis PB, Ruby D, Bush-Joseph CA. Muscle soreness and delayed-onset muscle soreness. Clin Sports Med. 2012;31(2):255–62.

    Article  PubMed  Google Scholar 

  58. 58.

    Yulia Volokhina, DO, and David Dang, MD. Using proximal hamstring tendons as a landmark for ultrasound- and CT-guided injections of ischiofemoral impingement. Radiol Case Rep. 2013; 8(1).

  59. 59.

    Safran M, Ryu J. Ischiofemoral impingement of the hip: a novel approach to treatment. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):781–5.

    Article  PubMed  Google Scholar 

  60. 60.

    Howse EA, Mannava S, Tamam C, Martin HD, Bredella MA, Stubbs AJ. Ischiofemoral space decompression through posterolateral approach: cutting block technique. Arthrosc Technol. 2014;3(6):661–5.

    Article  Google Scholar 

  61. 61.

    Crock HV. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg (Br). 2001;83(1):149–50.

    CAS  Google Scholar 

  62. 62.

    Chung SM. The arterial supply of the developing proximal end of the human femur. J Bone Joint Surg Am. 1976;58(7):961–70.

    CAS  PubMed  Google Scholar 

  63. 63.

    De Sa D, Alradwan H, Cargnelli S. Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy. 2014;30(8):1026–41.

    Article  PubMed  Google Scholar 

  64. 64.

    Miller SL, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2 Pt 1):108–16.

    PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Moisés Fernández Hernando.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Human and animal rights and informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent was obtained from all individual participants included in the study.


All authors have no financial relationships to disclose.

Electronic supplementary material

Video 1

Ultrasound (US) video shows a normal ultrasound study in this 65-year-old man found to have impingement changes on MRI. Note the impact of the ischial tuberosity (located on the left hand side of the image) and the lesser trochanter (located on the right) with the consequent entrapment of the QFM, which comes between them. Also note the posterior excursion of the sciatic nerve when the lesser trochanter approaches the ischial tuberosity. (MP4 6634 kb)

Video 2

4D-high-resolution multidetector CT video. Specific software generated this model of dynamization and preoperative templating of extra-articular impingement. (MP4 1857 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hernando, M.F., 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 45, 771–787 (2016). https://doi.org/10.1007/s00256-016-2354-2

Download citation


  • Ischiofemoral impingement
  • Impingement
  • Deep gluteal syndrome
  • Quadratus femoris muscle
  • External rotators
  • Sciatic nerve
  • Sciatic neuritis
  • Piriformis syndrome
  • Hip. Hip pain
  • Injection test