Ischiofemoral Impingement: Symptoms, Diagnosis, Treatment
Hip pain can be a challenging thing to overcome. It might creep in during a run, flare up after a long day at the desk, or stubbornly linger despite your best stretching efforts. While many people are familiar with conditions like bursitis or arthritis, if you’re feeling a deep, literal 'pain in the butt' that makes walking feel like a chore, you might be dealing with a lesser-known culprit: Ischiofemoral Impingement (IFI). Let’s unpack what this is, how it presents, and—most importantly—what you can do about it.
This blog will cover the following topics on Ischiofemoral Impingement:
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What Is Ischiofemoral Impingement?
Ischiofemoral impingement is a condition characterized by hip pain located deep in the lower buttock. The pain is usually related to 'impingement' (more than normal compression) of one of the deep hip rotator muscles, the quadratus femoris, between the ischial tuberosity (the 'sitting' bone) and the lesser trochanter of the femur (a bony prominence on the inside of the top of your thigh bone). This space is called the ischiofemoral space. Repetitive compression of the quadratus femoris may lead to swelling, inflammation and pain. The hamstring or iliopsoas tendons, or occasionally the sciatic nerve may also be sites of irritation (Grimaldi et al., 2026).
What Causes Ischiofemoral Impingement?
This condition can develop for several reasons. There are a wide range of anatomical variations in the bones of the hip and pelvis which may reduce the ischiofemoral space and predispose us to ischiofemoral impingement. These include the shape of the top of the femur, as well as the shape of the pelvis and ischial tuberosities. Women generally have wider pelvic anatomy for childbirth, which naturally positions the ischial tuberosities (sit bones) closer to the femur.
However, your bony structure will have been this way since adolescence, unless you've had a recent fracture or hip replacement, which can reduce the ischiofemoral space. So if your anatomy hasn't changed, why are you only getting pain now?
In many cases of ischiofemoral impingement, the way that we walk, move and position ourselves can have a significant impact on the size of this space and contribute to the symptoms of ischiofemoral impingement, regardless of your structural anatomy.
IFI pain can often be mistaken for gluteal tendinopathy or bursitis, hip arthritis, or a lower back issue. Because symptoms can overlap with other conditions, an accurate assessment is important.
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Symptoms Of Ischiofemoral Impingement?
The hallmark of Ischiofemoral Impingement is a deep-seated lower buttock pain. This pain might wrap around to the saddle/groin region, extend into the upper thigh and even cause some sciatic nerve symptoms.
Common symptoms of ischiofemoral impingement include:
- Deep lower buttock pain - at the outer side of the ischium (sitting bone)
- The pain may sometimes extend into the thigh, saddle area or groin
- Pain with sustained standing and walking, particularly with long strides, or running
- Once aggravated, sitting may also become uncomfortable
Ischiofemoral impingement is commonly aggravated by prolonged standing and walking or running, especially when using large strides. Because symptoms can overlap with other conditions, it can often be mistaken for gluteal tendinopathy or bursitis, hip arthritis, or a lower back issue like sciatica. This is why an accurate assessment is important.
How Is Ishiofemoral Impingement Diagnosed?
Diagnosing ischiofemoral impingement can be tricky because it shares it’s symptoms with many other conditions, such as gluteal tendinopathy and bursitis, hamstring tendinopathy, hip arthritis or lumbar or pelvic pain. The first step to diagnosing IFI is a thorough clinical examination by a physiotherapist or sports physician experienced in the management of hip pain.
This assessment should involve tests likely to reproduce symptoms of ischiofemoral impingement, as well as thoroughly ruling out other possible causes of the pain.
Imaging such as x-ray or MRI is not infallible, however it can provide additional value by identifying risk factors such as a narrow ischiofemoral space. Research suggests that an ischiofemoral space of less than 15mm is highly suggestive of impingement, especially when accompanied by visible swelling in the quadratus femoris muscle on the scan (Torriani et al., 2009; Singer et al., 2015).
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Treatments For Ischiofemoral Impingement
Fortunately, most cases of ischiofemoral impingement respond well to well planned physiotherapy treatment programmes. Your physiotherapist will work with you to address the factors that are most likely to be driving the symptoms, while also developing a gradually progressive exercise program to address any underlying or accompanying weaknesses which may be contributing to the pain.
Treatment for Ischiofemoral Impingement should involve:
Load management for IFI
- Managing exercise and activities of daily living to limit exposure to compressive activities
- Modification of specific postures and guiding you to avoid postures or positions that are compressive or aggravating
- Working with you to modify movement patterns to minimize aggravation of symptoms
Exercise therapy for IFI
- Gentle exercise which avoids impingement
- Movement training
- Graduated hip muscle strengthening, and lengthening where appropriate
Manual therapy for IFI
- Manual therapy has a limited role in the management of IFI, however treatment of underlying capsular restriction may be helpful in some cases
The good news is that corticosteroid injections or surgical interventions are rarely required. Only in persistent cases where high-quality rehabilitation has been unsuccessful, especially when there are structural factors that are hampering progress, a surgical opinion may be required. Before you head to surgery though, ensure you have tried a high quality programme from a physio who is very familiar with this condition, like our team at PhysioTec.
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Author
This blog was written by Andrew Vetter, one of our sports physiotherapists. Andrew has a special interest in treating hip, knee, ankle and shoulder injuries and has had much experience with rehabilitation after joint injury including dislocation and reconstructive surgery, during many years working with elite football athletes, including the Qld Reds. Andrew aims to provide high quality care to his patients, help them perform better, recover from injuries, and get back to doing the things they love.
You can read more about Andrew here.
References:
- Grimaldi A, Ganderton C, Nasser A. Ischiofemoral impingement: Clinical perspectives for enhancing diagnosis, and rehabilitation. Musculoskelet Sci Pract. Published online June 2, 2026. doi:10.1016/j.msksp.2026.103592
- Torriani, M., et al. (2009). Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. American Journal of Roentgenology, 193(1), 186–190.
- Gollwitzer, H., et al. (2017). Ischiofemoral Impingement: Rare or Underdiagnosed? Archives of Orthopaedic and Trauma Surgery, 137(9), 1229–1235.
- Tosun, O., et al. (2012). Ischiofemoral impingement: evaluation with MRI. European Journal of Radiology, 81(7), 1709–1713.
- Singer AD, Subhawong TK, Jose J, Tresley J, Clifford PD. Ischiofemoral impingement syndrome: a meta-analysis. Skeletal Radiol. 2015 Jun;44(6):831-7. doi: 10.1007/s00256-015-2111-y. Epub 2015 Feb 13. PMID: 25672947.
- Nakano N, Shoman H, Khanduja V. Treatment strategies for ischiofemoral impingement: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2020 Sep;28(9):2772-2787. doi: 10.1007/s00167-018-5251-5. Epub 2018 Nov 13. PMID: 30426139; PMCID: PMC7471170.