Introduction
Materials and methods
Search strategy
Study selection (inclusion and exclusion criteria)
Inclusion criteria |
1. All levels of evidence |
2. Written in the English language |
3. Studies on humans |
4. Studies reporting the outcome of treatment for ischiofemoral impingement |
Exclusion criteria |
1. Studies describing trial protocols without any results 2. Animal studies 3. Basic science studies (e.g. cadaveric studies) 4. Diagnostic studies without any description of treatments 5. Technical notes without any results 6. Reviews, systematic reviews |
Data extraction and analysis
Statistical analyses
Results
Parameter | |
---|---|
Studies analysed | 17 studies |
Levels of evidence: 4 | 17 studies (100%) |
Case series | 3 studies (17.6%) |
Case report | 14 studies (82.4%) |
Participants (cases) | |
Male | 15 (35.7%) |
Female | 27 (64.3%) |
Mean follow-up time (range) | 8.4 months (2 weeks–2.3 years) |
Mean participant age (range) | 41.0 (11–72) years |
Approach of treatment | |
Non-surgical treatment | 8 studies (47.1%) |
Open surgery | 4 studies (23.5%) |
Endoscopic surgery | 5 studies (29.4%) |
References | Year | Country | LOE | Number of cases | Mean follow-up period | Age | Condition before the treatment | Treatment method | Result | Others | |||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Male | Female | Total | Mean | Range | |||||||||
Conservative treatment | |||||||||||||
Kim et al. [22] | 2016 | South Korea | 4 | 8 | 6 | 14 | 2 weeks | 53.4 | 33–72 | Patients had lower buttock pain which localised at a point halfway between the lateral prominence of the greater trochanter and the ischial tuberosity corresponding to the location of the QF belly. Mean VAS before injection was 6.7 (range 3–10) | Under ultrasound guidance, 8 mL of 0.25% lidocaine was injected into the QF. The number of QF injection was: 1, five patients; 2, seven patients; 3, one patient; 4, one patient (The average frequency of injection was 2.5 times) | Two weeks after the last injection, 10 of 14 patients expressed their satisfaction as excellent or good (3 patients expressed it as fair and 1 patient expressed it as poor). There were no complications observed. At the final follow-up, mean VAS was 3.4 (range, 0–8) | |
Chen et al. [3] | 2017 | USA | 4 | 0 | 1 | 1 | 5 months | 34 | 34 | 11-month history of left posterior gluteal pain. It initially presented as a dull ache in the buttock and hamstring area, exacerbated after 30 min of running or cycling, rated at NPR of 5/10 but changed to 7/10 with activity. The patient denied the history of prior trauma. Prior treatments include physical therapy, chiropractic, as well as fluoroscopically guided corticosteroid injection of the ischial bursa, sacroiliac joint, intra-articular hip joint and piriformis muscle, all without improvement | After local anaesthesia, 100 units incobotulinum toxin A reconstituted in 2.5 mL of sterile saline was injected throughout the QF | Patient’s symptoms had complete resolved and she had returned to her premorbid functional status | |
Volokjina et al. [40] | 2013 | USA | 4 | 0 | 1 | 1 | 9 months | 57 | 57 | The chronic right hip pain of 1-year duration. She described the pain as constant and deep, radiating from the lateral right groin region into the buttock, waking her up at night. Her pain was not relieved with non-steroidal anti-inflammatory drugs and was worse with athletic activities, particularly hiking. She reported no snapping symptoms | The patient received three injections into the ischiofemoral space of combinations of 3 ml of lidocaine and 40 mg Depo-medrol | After the first injection, immediate relief of symptoms lasting for 9 months was achieved. The second US-guided injection resulted in 3 weeks of symptom relief. The third injection was performed with computed tomography (CT) guidance, and the patient had continued relief for 9 months | |
Kim et al. [23] | 2014 | South Korea | 4 | 2 | 0 | 2 | 6.5 months | 23.5 | 23–24 | Initial management which consisted of NSAIDs, tramadol and physical rehabilitation for 1 month did not work. One patient had a surgical history of iliotibial band release 2 years previously and a subsequent iliopsoas tendon release 1 year previously. Preoperative VAS was 9–10/10 in both patients | The patients were treated by prolotherapy with polydeoxyribonucleotide sodium mixed with local anaesthetics injected into QF under fluoroscopic and ultrasound guidance | Patient (1) The pain intensity using the VAS decreased from 9 to 10/10 to 1–2/10, and the patient did not experience any pain for > 6 months. Follow-up MRI a month after the treatment showed that the enhancement of QF was decreased compared with that on MRI before treatment. Patient (2) The pain intensity score decreased from an initial 9–10/10 to 0–1/10, and the patient did not experience any pain for > 7 months. Follow-up MRI a month after treatment showed that the enhancement of QF was decreased compared with that on MRI before treatment | Prolotherapy refers to the injection of an irritant into a joint space, ligament, or tendon insertion site with the main aim being pain relief. Current hypotheses suggest that the presence of a local irritant may attract inflammatory mediators and possibly stimulate the release of growth factor or act as a vascular sclerosant |
Hayat et al. [11] | 2014 | UK | 4 | 1 | 0 | 1 | 1 year | 16 | 16 | The patient had an 18-month history of a dull, deep ache in his left groin, exacerbated by exercise, following an injury playing football. A plain radiograph revealed a chronic apophyseal avulsion fracture of the ischium with excessive callus formation. CT scan and MRI revealed that the bony protuberance was responsible for symptomatic IFI | Non-operative management was undertaken with painkillers as needed, rest, activity modification and physiotherapy exercise regime | Over the 12 months after treatment, the patient’s symptoms settled and he reported only a mild, infrequent ache in the groin in the final follow-up. He has resumed normal sporting activities without discomfort | |
Lee et al. [24] | 2013 | South Korea | 4 | 0 | 1 | 1 | 6 weeks | 48 | 48 | Hip MRI revealed the increased signal intensity of QF with concurrent narrowing of the ischiofemoral space. On axial T2-weighted fat-suppressed MRI, there were diffuse oedema and increased signal intensity within QF. Initial VAS was 7–8/10 | NSAIDs and gabapentin were prescribed for pain relief. Hot pack, ultrasound, and interferential current therapies were applied around the hip area. The patient received an exercise program for stretching of the hip muscle and connective tissues | After 6 weeks of treatment, the pain was decreased gradually to 2–3/10 in VAS | |
Yanagishita et al. [41] | 2012 | Brazil | 4 | 0 | 1 | 1 | 3 months | 31 | 31 | Radiographic examinations demonstrated a valgus femoral neck, ischiofemoral space narrowing, and the presence of cysts in the ischium. MRI showed increased signal in QF on T2-weighted sequences | Non-surgical treatment including a taking NSAIDs for 7 days and daily physical therapy for stretching and strengthening the pelvic muscles were conducted | After 3 months of treatment, the patient showed significant functional improvement and resumed Pilates activities without any restriction | |
Tosun et al. [38] | 2012 | Turkey | 4 | 0 | 1 | 1 | NA | 11 | 11 | The patient complained of hip and groin pain, which gradually increased during the last 2 months. MRI demonstrated narrowing of the ischiofemoral space, which was most prominent in the transverse T1-weighted sequence, and moderate oedema in QF on the fat-suppressed T2-weighted sequence | Conservative methods including rest, activity restriction, and taking NSAIDs were conducted | The patient was successfully treated conservatively | |
Open surgical treatment | |||||||||||||
Papoutsi et al. [31] | 2016 | UK | 4 | 0 | 1 | 1 | 12 months | 40 | 40 | The patient suffered from IFI secondary to an intermuscular lipoma (2.7 × 2.6 × 0.5 cm), which was revealed on MRI and confirmed at surgery. She described the pain as a constant ache scoring 9/10 on VAS with occasional sharp shooting pains triggered by prolonged sitting and walking | The entire lipomatous tumour was excised by open surgery in the lateral position using posterior incision | The patient’s symptoms improved markedly (VAS: 0.5/10). She was able to sit without any discomfort and there was no sign of ongoing sciatic nerve irritation or IFI. The patient returned to full-time work and no longer requires any analgesia | Histology confirmed the presence of a benign intermuscularlipoma of the quadratus femoris muscle |
Schatteman et al. [36] | 2015 | Belgium | 4 | 1 | 0 | 1 | NA | 22 | 22 | The patient suffered from groin pain, aggravating by external rotation of the hip. Standard radiographs of the hip revealed a large sessile exostosis at the medial aspect of the lesser trochanter. On MRI, a marked narrowing of the ischiofemoral space with accompanying oedema of QF was seen. Initial conservative treatment was not successful | Open resection of the exostosis was conducted | The immediate post-operative recovery was uneventful | Histological examination of the resection specimen confirmed the diagnosis of a benign cartilaginous exostosis |
Viala et al. [39] | 2012 | France | 4 | 0 | 1 | 1 | 6 months | 37 | 37 | The patient presented with hip pain of 2-year duration. Radiograph, CT, and MRI showed coxa valga and splaying of the intertrochanteric region and femoral neck as well as exostoses of the ischial tuberosity. Exostoses and femoral metaphyseal widening resulted in a narrowing of the ischiofemoral spaces | Open surgical resection of the ischial exostosis was made through an anterior approach | Six months post-operatively, hip pain was improved, appearing only after walking long distances | The patient had a past history of surgical resections of exostoses from the left knee at age 13, right knee at age 18, and right humerus at 28. At pathological examination, a typical benign exostosis was found |
Ali et al. [2] | 2011 | UK | 4 | 0 | 1 | 1 | 10 weeks | 17 | 17 | The patient showed a painful hip following an acute abduction injury to the hip while accidentally performing the splits. Seven months later, she noticed an audible and palpable clunk in her hip upon walking. MRI showed selective narrowing of the ischiofemoral space and QF space. CT-guided steroid and local anaesthetic injection around QF provided relief of her pain but not the clunking, for 24 h | Open surgical resection of the lesser trochanter was performed | The post-operative radiograph showed adequate decompression of the ischiofemoral space. At 4 weeks following the surgery, the pain had diminished to a mild discomfort and there was no clunking. At 10 weeks following surgery, the patient was asymptomatic | Before the resection of the lesser trochanter, the patient had iliotibial band Z-plasty which had no effect on the patient’s symptoms |
Endoscopic surgical treatment | |||||||||||||
Wilson et al. [41] | 2016 | USA | 4 | 1 | 6 | 7 | 12 months | 46 | 15–66 | All patients had symptomatic, MRI-documented IFI. The preoperative scores averaged 43 points in mHHS (range 20–76 points) | The entire lesser trochanter was removed arthroscopically in the supine position | At 12 months, mHHS averaged 91 (range 76–100). There were no complications occurred. None of the patients had tenderness to palpation of the ischiofemoral space, and none had a positive IFI test or a positive long-stride walking test. None of the patients had a recurrence of their snapping, or groin or buttock pain, and all of the athletes returned to full participation in their sport | Four patients had labral tears. Two of them were repaired. Osteoplasties were performed to treat pincer impingement in two, and combined CAM and pincer deformities in four patients |
Jo et al. [20] | 2015 | Australia | 4 | 0 | 1 | 1 | 4 months | 17 | 17 | The patient complained of a 3-year history of soreness and clunking in the hip, especially in an adducted and externally rotated position. MRI revealed oedema and atrophy in the QF adjacent to the ischium, but no intra-articular pathology was observed. A plane radiograph showed a prominent anterior inferior iliac spine. The symptoms did not respond to physiotherapy, a cortisone injection and PRP treatment over a 1-year period. Psoas tendon lengthening had been performed and provided no relief of symptoms. CT-guided injection of local anaesthetic into the QF provided temporary pain relief | Endoscopic lesser trochanteric resection was conducted in the supine position | The patient’s resting pain and provocation pain on adduction and external rotation disappeared within 1 week from the operation. The symptom relief is maintained at 4-month follow-up | |
Hatem et al. [10] | 2015 | USA | 4 | 2 | 3 | 5 | 2.3 years | 33.9 | 16–59 | The mean duration of symptoms until surgery was 29.2 months (range 5–66 months). The injection was performed to rule out intra-articular pathology as a cause of posterior hip pain. The ischiofemoral and QF spaces on MRI were considered for the diagnosis. All patients had the impingement between the lesser trochanter and ischium confirmed at surgery. The mean mHHS was 51.3 (range 34.1–73.7) preoperatively. The mean preoperative VAS for pain was 6.6 (range 6–7.3) | Patients underwent endoscopic treatment with partial resection of the lesser trochanter in the supine position | The mean post-operative mHHS was 94.2 (range 78.1–100). The mean post-operative VAS for pain was 1 (range 0–4). The mean duration to return to the sport after surgery was 4.4 months (range 1–7 months). No complication was observed | Intra-articular abnormalities were observed in three patients and were treated with labral debridement, acetabuloplasty, femoroplasty, and labrum repair |
Safran et al. [34] | 2014 | USA | 4 | 0 | 1 | 1 | 2 years | 19 | 19 | The patient had oedema of QF, consistent with the diagnosis of IFI. She had undergone a hip MRI arthrogram with intra-articular anaesthetic with 95% relief of her pain. She had tried NSAIDs with some relief, and physical therapy without any benefit. The preoperative iHOT score was 32 | Patients underwent endoscopic treatment with partial resection of the lesser trochanter in the supine position | At 2 years after surgery, the patient had no hip pain or involuntary snapping. On examination, she had no pain and full strength with resisted straight leg raise. Her seated hip flexion strength was 5-/5. The post-operative iHOT score was 85 | |
Hernandez et al. [12] | 2017 | Spain | 4 | 0 | 2 | 2 | 6 months | 43.5 | 42–45 | Complaint of progressive, bilateral, posterior buttock pain with distal neuropathic pain radiation. On physical examination, the patient had tenderness to palpation of the ischiofemoral space and a positive long-stride walking test. Pain could be reproduced in extension, abduction and external rotation of the hip | The entire lesser trochanter was removed arthroscopically in the supine position | Patients experienced progressive improvement with immediate partial remission of their distal neuropathic radiated pain. Post-operative MRI showed a remarkable improvement of the ischiofemoral distance in both cases. Gait also improved progressively, and at the 6-month follow-up, they reported full clinical and functional recovery of the affected limb |
Study | 1. Were patient’s demographic characteristics clearly described? | 2. Was the patient’s history clearly described and presented as a timeline? | 3. Was the current clinical condition of the patient on presentation clearly described? | 4. Were diagnostic tests or assessment methods and the results clearly described? | 5. Was the intervention(s) or treatment procedure(s) clearly described? | 6. Was the post-intervention clinical condition clearly described? | 7. Were adverse events (harms) or unanticipated events identified and described? | 8. Does the case report provide takeaway lessons? | Total score | % |
---|---|---|---|---|---|---|---|---|---|---|
Joanna Briggs Institute critical appraisal tool for case reports
Yes = 2/Unclear = 1/No = 0/NA
| ||||||||||
Ali et al. [2] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 2 | 12/16 | 75 |
Chen et al. [3] | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 16/16 | 100 |
Hayat et al. [11] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 2 | 12/16 | 75 |
Hernandez et al. [12] | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 16/16 | 100 |
Jo et al. [20] | 2 | 2 | 2 | 2 | 2 | 1 | 0 | 2 | 13/16 | 81.25 |
Kim et al. [23] | 2 | 2 | 2 | 2 | 2 | 2 | 0 | 2 | 14/16 | 87.5 |
Lee et al. [24] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 1 | 11/16 | 68.75 |
Papoutsi et al. [31] | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 16/16 | 100 |
Safran et al. [34] | 2 | 1 | 2 | 2 | 2 | 2 | 0 | 2 | 13/16 | 81.25 |
Schatteman et al. [36] | 1 | 0 | 2 | 2 | 1 | 0 | 2 | 2 | 10/16 | 62.5 |
Tosun et al. [38] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 1 | 11/16 | 68.75 |
Viala et al. [39] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 2 | 12/16 | 75 |
Volokhina et al. [40] | 2 | 2 | 2 | 2 | 2 | 1 | 0 | 2 | 13/16 | 81.25 |
Yanagishita et al. [41] | 2 | 2 | 2 | 2 | 1 | 1 | 0 | 1 | 11/16 | 68.75 |
Study | 1. Were there clear criteria for inclusion in the case series? | 2. Was the condition measured in a standard, reliable way for all participants included in the case series? | 3. Were valid methods used for identification of the condition for all participants included in the case series? | 4. Did the case series have the consecutive inclusion of participants? | 5. Did the case series have the complete inclusion of participants? | 6. Was there clear reporting of the demographics of the participants in the study? | 7. Was there clear reporting of clinical information of the participants? | 8. Were the outcomes or follow-up results of cases clearly reported? | 9. Was there clear reporting of the presenting site(s)/clinic(s) demographic information? | 10. Was statistical analysis appropriate? | TTOTAL | %% |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Joanna Briggs Institute critical appraisal tool for case series
Yes = 2/Unclear = 1/No = 0/NA
| ||||||||||||
Hatem et al. [10] | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 20/20 | 100 |
Kim et al. [22] | 2 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 18/20 | 90 |
Wilson et al. [41] | 2 | 2 | 2 | 2 | 2 | 1 | 2 | 2 | 2 | 0 | 19/20 | 95 |
Non-surgical treatment | |
Kim et al. [22] | 90 |
Chen et al. [3] | 100 |
Volokjina et al. [40] | 81.3 |
Kim et al. [23] | 87.5 |
Hayat et al. [11] | 75 |
Lee et al. [24] | 68.8 |
Yanagishita et al. [41] | 68.8 |
Tosun [38] | 68.8 |
Mean | 80 |
Open surgical treatment | |
Papoutsi [31] | 100 |
Schatteman [36] | 62.5 |
Viala [39] | 75 |
Ali [2] | 75 |
Mean | 78.1 |
Endoscopic surgical treatment | |
Wilson [41] | 95 |
Jo [20] | 81.3 |
Hatem [10] | 100 |
Safran [34] | 81.3 |
Hernandez [12] | 100 |
Mean | 91.5 |