Quadratus femoris tendinitis as a cause of groin pain

Ischiofemoral impingement syndrome: a case report and review of literature

Introduction

The etiology of ischiofemoral impingement (IFI) syndrome, an unusual and uncommon form of hip pain, remains uncertain. Some patients demonstrate narrowing of the space between the ischial tuberosity and lesser trochanter from trauma or abnormal morphology of the quadratus femoris muscle. Combined clinical and imaging aid in the diagnosis.

Case report

A 32-year-old female presented with a 3 years history of pain over the lower aspect of the right buttock, aggravated by movements of the right hip, and partially relieved with rest and medications. The right hip showed extreme restriction of abduction and external rotation. MRI of the right hip showed reduced ischiofemoral space and quadratus femoris space when compared to the left hip. The patient underwent endoscopic resection of the right lesser trochanter, with no recurrence of pain at 2 years.

Conclusion

An unusual cause of hip pain, IFI syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle. Management is tailored to address the inciting factors that precipitated the IFI syndrome.

Traumatic Obturator Internus and Quadratus Femoris Injury in a Pediatric Patient: A Case Report

We present the case of a 11-year-old White female patient with a traumatic quadratus femoris and obturator internus tear after a sprint while at school. She felt immediate pain, swelling, and point tenderness in her posterosuperior thigh with a severely antalgic gait. Magnetic resonance imaging demonstrated a quadratus femoris tear, obturator internus tear, and ischial spine avulsion fracture. Although a less common etiology for acute hip pain in the pediatric population, traumatic injury to the short external rotators should not be excluded. The prognosis is favorable with a full return to previous activities expected using an appropriate rehabilitation program.

Quadratus Femoris muscle causing deep gluteal syndrome: A rare cause of refractory sciatica of extraspinal origin in the presence of an anatomic variation

BACKGROUND

Sciatica of extraspinal origin represents both a diagnostic and a therapeutic challenge for spine specialists. Among these, quadratus femoris muscle (QF) is often overlooked as a pain-generator.

REPORTED CASE

A 62-year old man was referred from general practitioner for isolated sciatica in the left leg, refractory to conservative treatments. Plain x-rays of the spine did not show any pathological finding nor did magnetic resonance imaging (MRI). MRI and CT showed QF with unusual morphologic features and agenesis of the contralateral QF. Ultrasonography-guided injection in the muscle was performed with mepivacaine and methylprednisolone obtaining relief of the symptoms.

DISCUSSION

Leg pain can be very disabling and, when combined with a normal MRI of the spine, diagnosis can be tricky. Several causes of sciatica of extraspinal origin have been described, some of them originating from the so-called "deep gluteal space". Anecdotal communications on anatomical variations of the quadratus femoris muscle are reported in literature.

CONCLUSIONS

Differential diagnosis of sciatica of extraspinal origin must rule out sacroiliac and hip joint so as deep gluteal space structures. Among these, quadratus femoris muscle is often overlooked as a pain-generator. Ultrasonography-guided intramuscular injections and a program of stretching and strengthening exercises can achieve durable control on the symptoms.

Contact-Related Strain of Quadratus Femoris, Obturator Externus, and Inferior Gemellus in an Australian Football Player: A Case Report

CONTEXT

Muscle injuries of the hip stabilizers are considered rare in sport.

OBJECTIVE

This report presents a previously unreported case of a contact injury resulting in acute strain of quadratus femoris, obturator externus, and inferior gemellus in an amateur Australian rules football player.

DESIGN

Level 4-case report.

CASE PRESENTATION

A player was tackled ipsilateral to the injured leg, while in hip flexion in a lunged position. The case describes the diagnostic process, initial management, and return to play for this athlete.

RESULTS

Following rehabilitation, the player was able to return to sport at 8 weeks without ongoing issues.

CONCLUSIONS

A literature search for sports-related contact injuries to either muscle returned only one result. All other documented cases of injury to these muscle groups are confined to noncontact mechanisms or delayed presentations. Despite conventional teaching, the action of the deep external rotators of the hip appears to be positionally dependent. Knowledge of this type of injury and mechanism may be useful for future clinical reasoning and differential diagnosis in patients with this type of presentation.

Acute ischiofemoral impingement?

We report a case of rare clinical entity, which comes within the spectrum of hip impingements. The case deals with a 36 year old female, Olympic athlete, who developed ischiofemoral impingement 14 months after a surgical hamstring reattachment. She was treated conservatively and fully recovered. When looking into literature on this matter, we found that it is probably an under-diagnosed problem, particularly in patients with no history of prior surgery. To our knowledge, this is the first case reported after a hamstrings tendon reattachment.

Effect of dry needling on myofascial pain syndrome of the quadratus femoris: A case report

This case report describes a 40-year-old male who presented with posterior thigh pain managed unsuccessfully with massage therapy, chiropractic adjustments, and physical therapy. The diagnosis of myofascial pain syndrome (MPS) involving the quadratus femoris (QF) was purely clinical, based on palpatory findings and ruling out other conditions through deductive reasoning. This is potentially a first time report, describing the successful management of MPS of the QF with dry needling (DN) using a recently published DN grading system. Immediate improvements were noted in all the outcome measures after the first treatment, with complete pain-resolution maintained at a 4-month follow-up.

Ischiofemoral impingement and hamstring dysfunction as a potential pain generator after ischial tuberosity apophyseal fracture non-union/malunion

PURPOSE

The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement.

METHODS

All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS).

RESULTS

Ten patients with a mean age of 18 years (range 14-28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7-3.5), the median post-operative mHHS was 89.7 (65.7-96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal.

CONCLUSION

Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.

LEVEL OF EVIDENCE

IV.

A Rare Case of Quadratus Femoris Muscle Rupture After Yoga Exercises

We present a case of a female patient with left groin pain after intense yoga exercises. The patient presented abnormal pattern of gait with no swelling over the groin, thigh, or buttock. Magnetic resonance imaging demonstrated a tear of the quadratus femoris muscle with an associated extensive hematoma formation. Patient was treated with a rehabilitation program consisting of nonsteroidal anti-inflammatory drugs and physiotherapy. At the follow-up control, the patient had improved her pain and flexibility of the hip, and gradually she returned to daily activities and yoga exercises. Such an entity is a rare cause of hip pain after exercise and should be kept in mind by the orthopedic surgeon, in cases of gluteal pain after intense physical activity. Moreover, such a condition should be included in the diagnostic algorithm of unknown origin hip pain.

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.

Ischiofemoral Impingement Syndrome: A Case Report and a Review of Literature

Background

Ischiofemoral impingement syndrome is characterized by a hip pain associated with abnormalities in quadriceps femoris muscle and ipsilaterally reduced distance between the lesser trochanter and the ischium. Thus far, the congenital variant of this entity has been reported exclusively in women.

Case Report

We report a case of a 22-year old male with painful hips in whom on the basis of the imaging studies the constitutional variant of ischiofemoral impingement was diagnosed.

Conclusions

Ischiofemoral conflict should be taken into consideration in the differential diagnosis of hip pain, particularly among women, but also in patients with valgus hip deformity and other abnormalities leading to reduction of the space between femoral and ischial bones independent of gender.

Using proximal hamstring tendons as a landmark for ultrasound- and CT-guided injections of ischiofemoral impingement

Ischiofemoral impingement has been reported in a number of cases as an association between hip pain and quadratus femoris MRI signal abnormality, with concurrent narrowing of the ischiofemoral space. While the literature has included much emphasis on the imaging characteristics useful in the diagnosis of this entity, information on treatment has been scant, with few case reports of surgical resection of the lesser trochanter and incomplete descriptions of steroid injection techniques. We report a case of ultrasound- and CT-guided steroid injection into the ischiofemoral space via the proximal hamstring tendons in a 57-year-old female who had imaging and clinical characteristics of ischiofemoral impingement. The technique is described as a safe alternative to other possible injection techniques.

Ischiofemoral impingement: hip pain of infrequent cause

Hip pain is a frequent cause of medical attention in the daily clinical practice. Among the different causes included in the differential diagnosis we find ischiofemoral impingement, described initially in patients after joint replacement surgery, but later found in patients with no history of a causal disease.

Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability

OBJECTIVE

The aim of this study was to describe the magnetic resonance imaging (MRI) findings in patients with ischiofemoral impingement (IFI) and to evaluate the reliability of these MRI findings.

MATERIALS AND METHODS

Seventy hips of 50 patients with hip pain and quadratus femoris muscle (QFM) edema and 38 hips of 30 control cases were included in the study. The QFM edema and fatty replacement were assessed visually. Ischiofemoral space (IFS), quadratus femoris space (QFS), inclination angle (IA), hamstring tendon area (HTA), and total quadratus femoris muscle volume (TQFMV) measurements were performed independently by two musculoskeletal radiologists. The intra- and interobserver reliabilities were obtained for quantitative variables.

RESULTS

IFS, QFS, and TQFMV values of the patient group were significantly lower than those of controls (P < 0.001). HTA and IA measurements of the patient group were also significantly higher than in controls (P < 0.05). The QFM fatty replacement grades were significantly higher in the patient group than in the control group (P < 0.001). Inter- and intra-observer reliabilities were strong for all continuous variables.

CONCLUSION

Clinicians and radiologists should be aware of IFI in patients with hip or groin pain, and MRI should be obtained for the presence of the QFM edema/fatty replacement, narrowing of the IFS-QFS, and other features that may help in the clinical diagnosis of IFI for the proper diagnosis and treatment of the disease.

ISCHIOFEMORAL IMPINGEMENT - AN ETIOLOGY OF HIP PAIN: CASE REPORT

An association between hip pain and quadratus femoris muscle abnormality on magnetic resonance imaging (MRI) with concurrent narrowing of the ischiofemoral space has been reported in the recent literature. This raises the possibility that the muscle damage observed is due to ischiofemoral impingement. This diagnosis has been noted in middle-aged females either with or without a history of trauma or surgery, is a rarely described feature. We report here on a 31-year-old woman who presented with non-traumatic hip pain and evidence of narrowing of the ischiofemoral space and edema in the quadratus femoris. Nonsurgical treatment was administered, which relieved her hip pain. The diagnosis of ischiofemoral impingement should be considered in female patients complaining of hip pain without any other evident cause.

Ischiofemoral impingement

Femoroacetabular impingement is a well-documented cause of hip pain. There is, however, increasing evidence for the presence of a previously unrecognised impingement-type condition around the hip - ischiofemoral impingement. This is caused by abnormal contact between the lesser trochanter of the femur and the ischium, and presents as atypical groin and/or posterior buttock pain. The symptoms are gradual in onset and may be similar to those of iliopsoas tendonitis, hamstring injury or bursitis. The presence of ischiofemoral impingement may be indicated by pain caused by a combination of hip extension, adduction and external rotation. Magnetic resonance imaging demonstrates inflammation and oedema in the ischiofemoral space and quadratus femoris, and is distinct from an acute tear. To date this has only appeared in the specialist orthopaedic literature as a problem that has developed after total hip replacement, not in the unreplaced joint.

Differential atrophy of the postero-lateral hip musculature during prolonged bedrest and the influence of exercise countermeasures

As part of the 2nd Berlin BedRest Study (BBR2-2), we investigated the pattern of muscle atrophy of the postero-lateral hip and hamstring musculature during prolonged inactivity and the effectiveness of two exercise countermeasures. Twenty-four male subjects underwent 60 days of head-down tilt bedrest and were assigned to an inactive control (CTR), resistive vibration exercise (RVE), or resistive exercise alone (RE) group. Magnetic resonance imaging (MRI) of the hip and thigh was taken before, during, and at end of bedrest. Volume of posterolateral hip and hamstring musculature was calculated, and the rate of muscle atrophy and the effect of countermeasure exercises were examined. After 60 days of bedrest, the CTR group showed differential rates of muscle volume loss (F = 21.44; P ≤ 0.0001) with fastest losses seen in the semi-membranosus, quadratus femoris and biceps femoris long head followed by the gluteal and remaining hamstring musculature. Whole body vibration did not appear to have an additional effect above resistive exercise in preserving muscle volume. RE and RVE prevented and/or reduced muscle atrophy of the gluteal, semi-membranosus, and biceps femoris long head muscles. Some muscle volumes in the countermeasure groups displayed faster recovery times than the CTR group. Differential atrophy occurred in the postero-lateral hip musculature following a prolonged period of unloading. Short-duration high-load resistive exercise during bedrest reduced muscle atrophy in the mono-articular hip extensors and selected hamstring muscles. Future countermeasure design should consider including isolated resistive hamstring curls to target this muscle group and reduce the potential for development of muscle imbalances.

Persistent sciatica induced by quadratus femoris muscle tear and treated by surgical decompression: a case report

INTRODUCTION

Quadratus femoris tear is an uncommon injury, which is only rarely reported in the literature. In the majority of cases the correct diagnosis is delayed due to non-specific symptoms and signs. A magnetic resonance imaging scan is crucial in the differential diagnosis since injuries to contiguous soft tissues may present with similar symptoms. Presentation with sciatica is not reported in the few cases existing in the English literature and the reported treatment has always been conservative.

CASE PRESENTATION

We report here on a case of quadratus femoris tear in a 22-year-old Greek woman who presented with persistent sciatica. She was unresponsive to conservative measures and so was treated with surgical decompression.

CONCLUSION

The correct diagnosis of quadratus muscle tear is a challenge for physicians. The treatment is usually conservative, but in cases of persistent sciatica surgical decompression is an alternative option.

Biceps tendinitis as a cause of acute painful knee after total knee arthroplasty

The case report highlights an unusual case of posterolateral knee pain after total knee arthroplasty. Tendinitis of the patellar tendon or pes anserinus is a common complication after total knee arthroplasty; however, there is no report in the literature regarding the biceps femoris tendinitis causing acute pain in the early postoperative period. In this case, the biceps tendinitis was diagnosed and treated by ultrasound-guided injection into the tendon sheath.

Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport

BACKGROUND

Hamstring strains can be of at least 2 types, 1 occurring during high-speed running and the other during motions in which the hamstring muscles reach extreme lengths, as documented for sprinters and dancers.

HYPOTHESIS

Hamstring strains in different sports, with similar injury situations to dancers, also show similarities in symptoms, injury location, and recovery time.

STUDY DESIGN

Case series (prognosis); Level of evidence, 4.

METHODS

Thirty subjects from 21 different sports were prospectively included. All subjects were examined clinically and with magnetic resonance imaging (MRI). The follow-up period lasted until the subjects returned to or finished their sport activity.

RESULTS

All injuries occurred during movements reaching a position with combined extensive hip flexion and knee extension. They were located proximally in the posterior thigh, close to the ischial tuberosity. The injuries were often complex, but 83% involved the semimembranosus and its proximal free tendon. Fourteen subjects (47%) decided to end their sports activity. For the remaining 16 subjects, the median time for return to sport was 31 weeks (range, 9-104). There were no significant correlations between specific clinical or MRI parameters and time to return to sport.

CONCLUSIONS

In different sports, an injury situation in which the hamstring muscles reach extensive length causes a specific injury to the proximal posterior thigh, earlier described in dancers. Because of the prolonged recovery time associated with this type of injury, correct diagnosis, based on history and palpation, and adequate information to the subject are essential.

MRI of quadratus femoris muscle tear: another cause of hip pain

OBJECTIVE

The objective of this study is to report the MR appearance of quadratus femoris muscle tear, another cause of hip pain. We will review the pertinent anatomy of the quadratus femoris muscle, summarize the current literature on quadratus femoris muscle tear, and report our experience in the diagnosis of quadratus femoris muscle tear on MRI.

CONCLUSION

MRI is an important tool in assisting clinicians to make a correct diagnosis for the patient who presents with hip pain. Although quadratus femoris muscle tear is an uncommon injury, radiologists should be aware of this entity to assist with making a diagnosis that is usually unsuspected clinically.

Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics

BACKGROUND

Hamstring strains can be of 2 types with different injury mechanisms, 1 occurring during high-speed running and the other during stretching exercises.

HYPOTHESIS

A stretching type of injury to the proximal rear thigh may involve specific muscle-tendon structures that could affect recovery time.

STUDY DESIGN

Case series (prognosis); Level of evidence, 2.

METHODS

Fifteen professional dancers with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years.

RESULTS

All dancers were injured during slow hip-flexion movements with extended knee and experienced relatively mild acute symptoms. All injuries were located proximally in the posterior thigh close to the ischial tuberosity. The injury involved the semimembranosus (87%), quadratus femoris (87%), and adductor magnus (33%). All injuries to the semimembranosus involved its proximal free tendon. There were no significant correlations between clinical or magnetic resonance imaging parameters and the time to return to preinjury level (median, 50 weeks; range, 30-76 weeks).

CONCLUSION

Stretching exercises can give rise to a specific type of strain injury to the posterior thigh. A precise history and careful palpation provide the clinician enough information to predict a prolonged time until return to preinjury level. One factor underlying prolonged recovery time could be the involvement of the free tendon of the semimembranosus muscle.