What is the treatment for ischiotrochanteric impingement?

Treatment of Ischiotrochanteric Impingement Syndrome

The treatment of ischiotrochanteric impingement syndrome should begin with conservative management including NSAIDs, physical therapy, and exercise programs, progressing to surgical intervention only for cases refractory to non-operative treatment. 1

Diagnostic Approach

• Initial evaluation should include:
  • Radiographs to assess the ischiofemoral space and rule out other hip pathologies 2
  • MRI without contrast (gold standard) to evaluate:
    • Quadratus femoris muscle edema
    • Narrowing of the ischiofemoral space
    • Measurement of ischiofemoral and quadratus femoris spaces 2, 3

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Pharmacological interventions:

   • NSAIDs for pain relief and anti-inflammatory effects 1
   • Muscle relaxants if muscle spasm is present

2. Physical therapy interventions:

   • Stretching exercises focusing on hip external rotators
   • Strengthening of hip stabilizers
   • Gait training to modify movement patterns that exacerbate impingement
   • Avoidance of positions that worsen symptoms (adduction, extension, and external rotation) 4

3. Activity modifications:

   • Temporary reduction in activities that provoke symptoms
   • Avoidance of positions that narrow the ischiofemoral space

Second-Line Treatment: Interventional Procedures

For patients with persistent symptoms despite conservative management:

1. Image-guided injections:
   • Corticosteroid and anesthetic injections into the affected area can be both diagnostic and therapeutic 2
   • Ultrasound guidance is recommended for accurate needle placement

Third-Line Treatment: Surgical Management

For cases refractory to conservative treatment (typically after 3-6 months of failed non-operative management):

1. Endoscopic lesser trochanter resection:

   • Minimally invasive approach
   • Allows for resection of the lesser trochanter to increase ischiofemoral space
   • Provides immediate clinical and functional improvement 5
   • Reported improvement in patient-reported outcome scores (iHOT score improvement from 53 to 85 points in one case) 6

2. Open ischiofemoral decompression:

   • Performed through a posterior approach
   • Includes sciatic nerve neurolysis
   • Indicated for severe cases with significant sciatic nerve involvement 4

3. Lateralizing intertrochanteric osteotomy:

   • Alternative surgical approach for cases with underlying femoral deformities
   • Addresses Coxa valga, Coxa antetorta, or short femoral neck
   • Restores biomechanics and preserves iliopsoas tendon insertion
   • Requires 6 weeks of touch-toe weight bearing followed by gradual increase 7

Follow-up and Monitoring

• Regular clinical assessment to evaluate symptom improvement
• Follow-up imaging to assess structural changes if symptoms persist
• Gradual return to activities as symptoms improve

Pitfalls and Caveats

1. Differential diagnosis: Ensure other causes of hip/buttock pain are excluded (lumbar radiculopathy, spinal stenosis, other hip pathologies) 1

2. Patient selection for surgery: Surgical intervention should be reserved for patients who have failed an adequate trial of conservative management

3. Surgical approach selection: The choice between endoscopic and open procedures should consider:

   • Anatomical factors
   • Surgeon experience
   • Associated pathologies (e.g., sciatic nerve involvement)

4. Rehabilitation compliance: Success of both conservative and surgical management depends on patient adherence to rehabilitation protocols

By following this treatment algorithm, most patients with ischiotrochanteric impingement can achieve significant pain relief and functional improvement, with surgical intervention reserved for refractory cases.