What is the treatment for ischial trochanteric impingement?

Treatment of Ischial Trochanteric Impingement

The optimal treatment for ischial trochanteric impingement begins with conservative management including rest, activity modification, NSAIDs, and rehabilitation procedures, with surgical intervention reserved for cases refractory to conservative treatment. 1

Diagnosis and Imaging

• Initial imaging: Radiographs should be the first test ordered for evaluation of chronic hip pain 2
• Advanced imaging: MRI without IV contrast is recommended when radiographs are negative, equivocal, or nondiagnostic 2
  • MRI findings suggestive of ischiofemoral impingement include:
    • Quadratus femoris muscle edema/fatty replacement
    • Narrowing of the ischiofemoral space and quadratus femoris space 1

Conservative Management

Conservative treatment should be attempted first and includes:

1. Rest and activity modification

   • Avoid positions that exacerbate symptoms (adduction, extension, and external rotation of the hip) 3

2. Medications

   • NSAIDs for pain management and reducing inflammation 1

3. Physical therapy

   • Eccentric strengthening exercises for hip muscles
   • Deep transverse friction massage to reduce pain 4

4. Diagnostic and therapeutic injections

   • Ultrasound-guided injections into the ischiofemoral space using:
     • Local anesthetic (ropivacaine or 1-2% lidocaine)
     • Corticosteroid (methylprednisolone 40-80 mg or equivalent) 5, 4
   • These injections serve dual purposes:
     • Diagnostic: Temporary relief confirms the diagnosis
     • Therapeutic: May provide longer-term symptom relief 5

Surgical Management

For patients with persistent symptoms despite 3-6 months of conservative treatment, surgical intervention may be considered:

1. Endoscopic approach

   • Less invasive option with quicker recovery
   • Involves arthroscopic resection of the lesser trochanter 6, 5
   • May include iliopsoas tenotomy when appropriate 5
   • Post-operative protocol:
     • Crutches for 4-6 weeks
     • Progressive rehabilitation 5

2. Open decompression

   • Through a posterior approach
   • Includes ischiofemoral decompression with sciatic nerve neurolysis
   • Indicated for severe cases or when endoscopic approach is not feasible 3

Treatment Algorithm

1. First-line: Conservative management (3-6 months)

   • Rest, NSAIDs, physical therapy
   • Ultrasound-guided corticosteroid injection

2. Second-line: Repeat injection if first provided temporary relief

3. Third-line: Surgical intervention if conservative measures fail

   • Endoscopic approach preferred for most patients
   • Open decompression for complex cases

Outcomes and Prognosis

• Most patients respond well to conservative treatment 1
• Surgical outcomes show significant improvement in pain and function:
  • One study reported improvement from average preoperative Harris hip score of 43 points to 91 points at 12 months post-surgery 5
  • Another case reported improvement of iHOT score from 53 to 85 points after endoscopic intervention 6

Important Considerations

• Differential diagnosis should include other causes of hip pain such as greater trochanteric bursitis, gluteus medius tendinosis, and adverse reactions to metal debris in patients with hip arthroplasty 4
• Accurate diagnosis is crucial as treatment approaches differ for various hip pathologies
• Patients should be counseled about expected recovery timeframes and potential need for surgical intervention if conservative measures fail

By following this structured approach to treatment, most patients with ischial trochanteric impingement can achieve significant pain relief and functional improvement.