Is it Ischiofemoral Impingement Instead of PHT?

: On today's episode, is this ischiofemoral impingement instead of PHT? physiotherapist, recreational athlete, creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. recording a podcast episode that breaks a record in one way or another. This one is definitely the earliest podcast I've ever recorded. I have woken up on a public holiday, Labor Day here in Australia or Victoria, and it is 5 45am and just trying to squeeze in a podcast recording while Mackenzie is sleeping. So she usually wakes up in about 45 minutes. So I should be good for now. Even though there is a public holiday, I don't have any client calls, but the content creation must go on and an episode needs to go out this week. So here I am here. I find myself with the first in the earliest I've ever recorded something. Um, today you may, well, let me start off with on the run smarter podcast as of this year, as of three months ago, sort of, um, changed the approach and direction slightly and now sort of. doubling down on recent research and what does the research show when it comes to running smarter. You know, I had been doing a bit of everything to help people run smarter, but it seems like people were appreciating and differentiating my content because of the research focused evidence based stuff. And so I wanted to continue differentiating myself. So I have put in place a few systems to try and capture recent research and what's relevant and what might be interesting and I'm starting to do that more and more often interviewing researchers into reviewing papers and that sort of stuff and amongst those systems to capture run smarter content. I've also done the same for proximal hamstring tendinopathy and just hamstring research and It's pretty niche, pretty narrowed down. So not a lot comes through, but just so you know, when there are interesting papers that do come out revolving around this topic, you're definitely gonna hear from them. So the most up-to-date stuff will be filtered through here. And today's episode is one of those papers that kind of fell into my lap. And the title was Ischiofemoral Impingement Syndrome Masked by Proximal Hamstring Tendonopathy. as a cause of gluteal pain in a marathon runner. So this is a case report or a case study. It's not looking at a large sample size and doing treatments and those sorts of things. It is just one case that the authors think the, you know, the wider community can learn from because ischiofemoral impingement, while they say it is rare, it does very much mask the same signs and symptoms as PHT and the treatment approach is extremely different. So it's good that we familiarize ourselves with this condition, familiarize ourselves with how to, I guess, differentiate the diagnosis and what we can do about it and better help you understand your symptoms. So, and also this is pretty timely, this paper, because this is only two months old, this paper, but I've found myself in the past couple of months. bringing this conversation up quite a lot with some of my clients and some people that just reach out to either rule out impingement syndrome or at least, you know, consider the possibility that maybe it is maybe treated as such and see if it gets better. First of all, what is ischiofemoral impingement? We'll break down the term. So ischiofemoral means the ischium, which is your sit bone, and the femoral, meaning your femur. Those two bits of bone are in very close proximity to one another. I think the best way, if you want to learn this, I could try my best communicating the anatomy and what exactly happens. But a quick Google search of ischiofemoral impingement, go to Google Images, you'll be able to see where the sit bone is positioned in relation to the femur because sometimes those two bones can come quite close together and irritate or inflame the structures in between those two bones. Sometimes there's a lot of space between those two bones and everything's just operating functionally and no symptoms occur but if those two things are close together and they do irritate the structures that flow in between those things, things can become irritated. And as you'll learn in a second, some of those muscles is your quadratus femoris muscle, which is one of your external rotators in your hip. It's one of those deep glute muscles. But the other one that's very relevant is your sciatic nerve. That is also one of the structures that's in between those bones. And impingement can happen are just by repetition. If you extend your hip back, so if you're standing up straight and you kick your leg backwards, those two bones are coming closer together. When you swing your leg forwards, they're coming, they're going further apart. So I would say a lot of extension based stuff, say running, if done too often or if done in a way that is irritating those structures and then done hundreds of thousands of times that impingement can irritate those structures and therefore we need to wait for those structures to settle down. Okay. I hope I've done an okay job of talking about what it is. Let's talk about this paper and then I'll dive into a few other things. So the paper. I mentioned the title of the paper is ischiofemoral impingement syndrome masked by PhD as a cause of glute pain in a marathon runner. So this marathon runner thought they had PhD, turns out it was impingement syndrome. So the paper reads, a 45 year old female marathon runner was referred with a two year history of atraumatic left-sided glute pain. 45 year old runner had pain for two years, and they say atraumatic left-sided glute pain. So atraumatic meaning there was no one instance of this like, you know, slip on the ice and do the splits and all of a sudden, there's this immediate pain in the upper hamstring glute region. That would be a traumatic episode, but this is an a traumatic so nothing, it sort of just came on, you know, on seriously. The pain was aggravated with running and relieved with rest. She was initially diagnosed with diagnosed clinically with proximal hamstring tendinopathy and underwent physiotherapy for one year without improvement. This is where I chime in and say, well, I've seen people with PhD for five years doing physiotherapy without improvement. And then I see what they've actually done with treatment and they've been doing glute bridges for three years without progressing. And I say, well, pretty much haven't started treatment. So this is where I'd scratch my head and say, okay, exactly what was the treatment done? But if there was someone who was doing the right treatment for a year and not seeing improvement, then yes, I would also be scratching my head. I continue. On physical examination, there was tenderness in the gluteal region. So like on palpation touching and feeling that tenderness. Point of care ultrasound revealed edema of the quadratus femoris muscle in the symptomatic leg compared to the opposite leg. as well as they found bilateral hamstring origin tendinopathic changes. So edema just means swelling. They found swelling on ultrasound, uh, the, and it was around the quadratus femoris muscle, which is that muscle that's in between those two bones. Um, they found that swelling on the sore side and not, and it was absent on the other side, but they also found, um, compared to the, they also found like proximal hamstring tendon changes. Now the ultrasound that they used was they called it point of care ultrasound, which I didn't really, I wasn't familiar with that term. Um, I guess is an ultrasound that they can do dynamically. So they can have, uh, it's not just like an MRI where you stay resting on a, you know, on a bed and then they scan you. They can put the probe on the skin. see all the muscles and then get you to move your leg and get you to do certain things. So they say the point of care ultrasound revealed the sedema and those sorts of things. And then they said dynamic movement of the affected muscle, the quadratus femoris correlated with symptoms. I had to do some digging to see what they actually meant by dynamic movement. It was dynamic hip rotation. So if you could imagine, I'm just guessing here, but something like a clam shell where you're lying on your side and you got your knees slightly bent at 90 degrees, and then you bring your top knee up towards the ceiling. So you're opening like a clam shell. That would be like a dynamic hip rotation type of exercise. Maybe that was used. I could imagine that's probably what I would do. And this type of movement, reproduce symptoms. It's very important. MRI of the left hip was performed, which confirmed ischiofemoral impingement with narrowing of the ischiofemoral interval, as marked compression endema of the quadratus femoris muscle, in addition with severe hamstring origin tendinosis. So the MRI comes back and says you have has a lot of tendinosis, a lot of changes. It has a tendon pathology essentially. But they've also found this other stuff. They found this edema around this quadratus femoris muscle. They've also found narrowing of the two bones, the ischiofemoral interval, which is just like the space is narrowed. And so they treated as such, they did an ultrasound guided steroid injection. Well, they said, the injection was offered due to the non resolving nature of the patient's symptoms. So they said, okay, there's clinical rationale for this to, they've tried physio to treat this hamstring tendinopathy for years and they haven't found any reduction in symptoms. So let's offer the steroid injection. And I would say that this isn't like a PRP or corticosteroid injection for PHT. Like what they would do, they would inject in and around the tendon. Uh, if you did suspect PhD and you had done a corticosteroid injection, that's where they would, the injection would go. But because they're suspecting this. Impingement and found narrowing while they found edema of the quadratus femoris muscle, then they would definitely do the injection, the corticosteroid injection around that. muscle and not the PHT, if that makes sense. So if you've, I'm just saying that just because if you've had PHT and you've had a corticosteroid injection and you say, well, you know, hopefully it takes care of both diagnoses, it would probably be in a slightly different direction, a slightly different location. The patient was advised after that injection on appropriate stretching and strengthening exercises. Unfortunately, they didn't. dive into in this paper what those stretches and strengthening exercises were. I could imagine after that steroid injection, things calmed down, things calmed down in several weeks. They can do some light stretches of their hips, their hamstring, their rotators, their glutes, the strengthening exercises. Once things are calmed down, that edema has settled. My guess is it's probably just hip. stabilizing exercises, sure bridges might be one of them, but like a step down or say squats, providing that we avoid narrowing and compression of those two bones, so keeping things wide, probably keeping things double leg to start with. I'm just guessing because like I say they didn't go into details but generic strengthening exercises would suffice. And they say at six weeks post injection, the patient reported 70% overall pain reduction and had returned to competitive running. So a good outcome so far. Ischiofemoral impingement is a rare cause of hip pain and typically presents as predominantly gluteal and posterior proximal thigh pain. Neuropathic radicular symptoms, this is just meaning like nerve symptoms in the posterior thigh, hamstring and the calf are not uncommon and are commonly secondary to irritation or compression of the sciatic nerve which passes superficially through the quadratus femoris. Like I said before, the sciatic nerve is a pretty close structure in and amongst that impingement and can become irritated. So if your femoral impingement can be a localized pain, it can present purely as localized but In some cases, maybe in severe cases, the irritation impacts the sciatic nerve and you can start getting referred distal symptoms. So pain into the hamstring, belly, pain to the calf, even symptoms down into the feet. If your particular symptoms radiate down past the knee, or pretty much past the mid-hamstring. I think PHT sometimes can radiate into the upper hamstring muscle, sometimes mid-belly a little bit. But if it's any further down from that, I would suspect, well, it definitely isn't PHT, let's put it that way. There are other structures that may be impacting those symptoms radiating so far down. And one of these may be the sciatic nerve. may be a particular diagnosis, may be this impingement. Okay, while the exact pathophysiology of ischiofemoral impingement is not fully understood, narrowing of the space between the ischial tuberosity and the lesser trochanter, which is just a bony prominence that's on the femur, is believed to result in quadriceps femoris compression, that muscle. If you have femoral impingement and proximal hamstring tendinopathy are both associated with physical activity and can coexist concurrently, which makes a clear diagnosis challenging in gluteal pain. Very clear, which is why I sort of want to bring this up to you. Um, yes, it can, you can have both of those things. Um, it can be clear that maybe if you started and developed PhD that You start moving differently, you start moving your leg differently, you start, um, in whatever sense, moving those two bones together. And that can start to irritate things, uh, very, uh, that's a real possibility. The paper finishes in conclusion, a stepwise approach to diagnosis, the use of a point of care, dynamic ultrasound imaging and appropriate use of ultrasound guided interventions. can be helpful to diagnose and manage ischiofemoral impingement in the settling of gluteal pain. So just saying to conclude that point of care dynamic ultrasound, very effective because the tricky part with these impingements is you can't really diagnose or see what's happening with one snapshot. Often with an ultrasound or CT or X-ray or MRI, you are just lying flat and they are just looking at what they see. but the impingement doesn't occur until you move and you can't observe it until you move the patient. And so this dynamic ultrasound where they put the probe on the skin and they actually rotate your hip or extend your hip and see what's happening with the structures can be very useful. And then they say also an ultrasound guided, well, they say intervention, but they probably mean steroid injection, meaning that they get that ultrasound They're not just injecting the steroid in the location that they're guessing is best. They are actually guiding it with ultrasound. So they can see the injection on their monitor. They can see exactly precisely where they want to inject that steroid to calm everything down. And so it's a lot more accurate. And therefore they're not injecting into the tendon. They're injecting sort of around the edema and can often be effective. So my key takeaways with this paper, it was a very short case study. One, they had pain with running and it eased with rest. I'd say, you know, most people with PHT, most runners with PHT would say that that's probably the case for them. They say that the treatment for PHT, they treated for PHT for one year without any resolution or without any, I guess, improvement. I would quite like, that's where I would usually question in my career that I found myself in, I would dive deeper into what that treatment actually was because that can be very important, but still no resolution. They did find PHT, they found PHT on ultrasound, they found PHT on MRIs, and this is where we need to very much consider incidental findings. I think PHT and a lot of other conditions are very, very common in the healthy population. I've talked about this on the podcast before, but same with the lower back. We know this very extensively through research with the lower back. Pathology is in almost every lower back. It is very, very uncommon to scan a back and not see pathology, even in the healthy population who have never had back pain. I have had people have ultrasound of, well, I guess imaging of both hamstrings and they're only, they've only ever had pain on one side and they find pathology on both. They say, yes, you have mild hamstring, you have mild hamstring tears, tendon tears, you have mild tendinopathy or tendinosis. So yes, this is the diagnosis. Oh, by the way, you have both on the same side. Oh, you have both on both sides. You have mild tears on both and you have mild hamstring tendipity on both. And then this just leaves the patient scratching the head being like, yeah, but I've only ever had pain on one side. So this is where we need to be very careful with how we interpret symptoms and how we go about, yeah, I guess interpreting and communicating with you and your scans, because you could easily go down the PHT. diagnosis because that's what the imaging shows. So imaging should only ever be one piece of a puzzle, not the puzzle itself. You don't have the answers, you have a piece of data that we need to consider along with the whole range of other pieces of the puzzle that's in there. And the other takeaway was that dynamic ultrasound for diagnosis I think is pretty important because like I say, you could... maybe rule out impingement when you act, in fact, do have impingement, if you just use a traditional ultrasound where you're just standing there or lying there and not doing anything. In preparation for this podcast, I found another paper. It was called, um, issue of femoral impingement syndrome, clinical and imaging slash guided issues with special focus on. Ultra stenography, um, long, complicated title is not going to go into the details there, but it did mention stuff about examination, diagnostic tests, those sorts of things, uh, which I found might be helpful for you, uh, in terms of the location of symptoms, um, and differentiating between PHT. Researchers reported that this impingement syndrome is a little bit more lateral and maybe a little bit lower down. If people grab their sit bone or people are getting pain right on the sit bone, it is something to, it's probably more likely to be PHT. But I do have some people be like, yeah, I've had it before, I've had this sit bone pain. But this other pain that I get is more lateral or more towards the outside, towards the side, I guess, of the PHT. That is more common with impingement. It's more off to the side. And if you look at the anatomy, if you've already done it, gone to Google, looked up impingement syndrome, looked at the orientation of those two bones, it's to the side of the sit bone where those sensitive structures are. So some tests. They do this test called the long stride walking test, which is easy to conduct. It says, conduct by asking the patient to grab their buttock lateral to the ischium, so where these symptoms might be. So the sit bone off to the side, a bit more lateral, and extend the affected hip. If pain is elicited, a diagnosis is likely. So what they're doing is they're grabbing sort of close to where their symptoms are and then they are taking long strides and seeing if pain is reproduced when the hip is extended, when you move your hip back or when you move your foot back I should say. And then they add on, it should be confirmed by the absence of pain during walking with short strides. So if you're not, if you're walking with short steps, pain really shouldn't be that obvious. It should be a lot, a lot more obvious with the long strides because that's what pinches those two bones together. There is something you can do with a therapist. It's called the ischiofemoral impingement test. And it's conducted with you lying on your side, your knees slightly bent, and the affected leg is facing up. And the therapist will press in that sort of buttock area, so lateral to the sit bones, and then will cradle your leg and... move your leg back, so extend your hip backwards. And if pain is provoked, and if it's producing symptoms, particularly if it's producing like your nerve symptoms down the leg and those sorts of things, then impingement is likely. That's very hard to do on your own. It's very hard for a therapist to do. Not a lot of therapists know how to do this test. I have had a couple of clients the last couple of weeks who suspect this might be their case. and I've told them to go to their local therapist, give them a heads up in advance that you suspect that it might be this impingement syndrome and send them the test like there's, if you just put on YouTube, issue a familial impingement test, there's a video there. And that way the therapist will have a heads up of how to do this test. The other test I found was the, it's almost like a quad stretch. They didn't really call it anything, but if one can imagine stretching their quads, like the front of their thigh, in standing, most runners are familiar with this, you sort of bring your heel up, sort of your heel to touch your bum, and you sort of grab your foot, and you stretch your calf, sorry, you stretch your quad. That's the start of the test, but then you would extend the hip, externally rotate the hip. So I would say external rotation would be bringing your heel towards your opposite side. So you're still, again, gonna be hard to explain on a podcast, but let's get into that quad stretch in standing, but you would grab your heel and sort of move it towards the midline that would externally rotate the hip. And you would also adduct the hip. So your knee, that's pointing down towards the floor would go more towards your opposite knee. So we only just, so we're just trying to compress those structures together a little bit. Um, and you do that in the upright position. And again, if that reproduces your symptoms, I would suggest that it is most likely to be this impingement rather than PHT. But then some other tests for PHT would also sort of make this diagnosis less likely. So I've talked about the podcast, the shoe off test. If you were to try to slide in standing, if you would try to, um, take your affected side and let's say your affected side has a shoe on it and you tried to slide off your shoe by pressing your heel into your opposite foot, most people are familiar with sliding off slippers or shoes or flip flops and those sorts of things. Um, if that produces symptoms, I would say it's more likely to be a PhD rather than impingement because. you're not extending the hip in that position. So therefore your structures should be fine if it's, because it's not being impinged. And the other one is the heel press test. So lying on your back, on the floor, bending your knees and hips at 90 degrees and 90 degrees and having your calves sort of resting on a plyo box or a chair or a bed or something, and then just pushing your heel down. So in clinics, I would sit on a plinth, on a clinician bed have the patient lying on their back, their hips and knees are bent at 90 degrees and their heel is like resting on my shoulder and I would support the leg and tell them to dig their heel into my shoulder as hard as I can and I would feel around the upper hamstring gluteal region see where it's producing symptoms if it's producing symptoms and if it's producing symptoms at the that is producing symptoms, I'd say it's more likely PHT and not impingement because your hips are flexed. So those two bones that are meant to be impinged are further away from one another. So we can do tests for PHT and if positive increases our likelihood it is PHT and not impingement, and then vice versa. There are tests for the impingement. If produced, makes it less likely that it's PHT. I'm working on something. probably going to take a couple of months because it's a big project, but I'm going to do a, um, five day challenge, uh, for PhD. It's like a, an email sequence. I do this for the run smarter podcast. I have my run smarter five day email challenge, which is just receive one email for five days, learning how to run smarter, reduce your risk of injury, increase your performance safely. What does the research show on these topics? Um, and with that being so successful. A lot of people sign up to that and a lot of people love it. I thought, why haven't I done this earlier and done a five day challenge for PHT? And so I am working on it. I tried to get, I wanted this to be really, really comprehensive. And so it will take a bit of time. So bear with me on that. But day one of that PHT email sequence is going to be you know, understanding more about PHT, what is PHT, what are some clear signs and symptoms and what are some potential other diagnoses. So this sort of stuff, this episode, this impingement thing, these tests will be on there. And, you know, that just, there are other diagnoses about it's not just whether it is PHT or impingement syndrome, there are a few others. And so that email will hopefully clear things up and then we dive into day two, day three, day four, where we talk about treatment and we talk about some myths, we talk about sitting, we talk about stretching, what does the research show, those sorts of things. So I'll keep you updated on that particular process. I say it might take a bit of time. I do have a lot on my plate at the moment, as you know, for me doing a 545 podcast episode. Okay, I want to finish off with this. Ultimately, Uh, you can use treatment as your diagnostic tool. I understand you're probably listening to this and you're still a little bit confused, whether you have PhD, maybe you're fairly certain you have PhD or. You've got a mixture of other diagnoses use treatment as your diagnostic tool. Treat it like. PhD do it the right way. Do it in a sensible evidence-based fashion. Follow the advice of this podcast. Are you seeing improvements? Week by week, at least month by month. If you're not seeing improvements month by month, you need to change something. That might be a change in direction for a particular diagnosis. I would wait for PHT, I would wait, you know, give three, four, six months depending how long you've had it and how severe it is. Anywhere between four to six months, give it a good go. If you're still not seeing improvements, significant improvements by that stage, let's consider some other things. But I would at least consider... hope the things are improving month by month to know that we're in the right direction that improvement might be 15% it might be 10% but if the next month is another 15% then we're 30% better after two months and so don't expect a miracle change but I would expect a significant difference like a 50% plus better 60 75 in that six month period like this person in this case study, if you aren't seeing improvement after a year, I would consider other things. And like we say, we did that, like in this paper, they did the injection and they were 70% better in six weeks. So obviously heading in the right direction there. And I can say and finish off with, you know, diagnosis can coexist. You can have a couple of things. And so if you treat it like PhD, if you have both of these things, and you treat it like PHT, I would expect the PHT symptoms to get better, but the impingement symptoms not to get better. So if after six months, you are significantly better, it's probably the PHT symptoms of your overall presentation that have significantly improved, but you might plateau out. You might say, I made an 80% gain, but now this last 20% isn't getting better. Maybe it's the impingement that we haven't addressed that is still lurking there because we haven't treated it as such. So we use treatment as a diagnostic tool and justification for what to do next. I hope this was at least helping you understand more about this very complex scenario. I hope this helps with some direction and maybe some slight changes in direction you want to take. Research, I've already got a couple of other ideas for some papers that have come out, but I'll keep an eye out for any other future papers that come out and anything that helps you with your treatment and your management of PhD. And I hope you enjoyed and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast hosted by me. I'll include the link. along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.