Long Stride Walking Test | Ischiofemoral Hip Impingement (IFI)

Posterior hip pain remains a challenge for clinicians. The following graphic from a paper by Gomez-Hoyos et al. (2018) shows an overview of possible competing diagnoses:

As you can see, differential diagnosis in the posterolateral hip region is not that straightforward.

In 1977 ischiofemoral impingement, abbreviated as IFI, was first described by Johnson and still remains a disputed entity. Unlike femoroacetabular impingement that you know from the CAM and pincer deformity, IFI is an extraarticular form of impingement.  Torriani et al. (2009) defined the syndrome as a decrease in ischiofemoral space between the lateral ischium and the minor trochanter and a decreased quadratus femoris space between the minor trochanter and the proximal hamstring tendons.

Patients often complain about long-stride walking pain. The pain is felt lateral to the ischium during the toe-off/preswing phase of gait with the hip in terminal extension in which position the lesser trochanter rubs the lateral border of the ischium or the semimembranosus tendon origin. Some patients also complain about radiating pain down the ipsilateral leg which could be elicited when the sciatic nerve becomes entrapped in the ischiofemoral space.

Gómez-Hoyos et al. (2016) evaluated the accuracy of the Long stride walking test and found a sensitivity of 95% and a specificity of 84% to diagnose ischiofemoral impingement. The gold standard they used was a combination of posterior hip pain, abnormal MRI findings including a reduced ischiofemoral space or quadratus femoris space, as well as at least 60% pain relief after decompression surgery. This is the only study so far and it was done in a retrospective study design which might have missed patients who did not undergo injection or surgery. Additionally, the study did not determine the intra- or interobserver reliability of this test. For this reason, the clinical value of this test remains questionable for now.

To perform the test have the patient walk with longer strides.  The long stride is expected to provoke impingement between the lesser trochanter and lateral ischium in terminal hip extension. Afterward, the patient is asked to walk again with shorter strides to avoid maximal hip extension. The findings of this test are considered positive if the posterior pain is reproduced lateral to the ischium during extension with long strides whereas pain is alleviated when walking with short strides.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Another orthopedic test that assesses for ischiofemoral hip impingement is the ischiofemoral impingement test.

Gómez-Hoyos, J., Martin, R. L., Schröder, R., Palmer, I. J., & Martin, H. D. (2016). Accuracy of 2 clinical tests for ischiofemoral impingement in patients with posterior hip pain and endoscopically confirmed diagnosis. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(7), 1279-1284.

Johnson, K. A. (1977). Impingement of the lesser trochanter on the ischial ramus after total hip arthroplasty. Report of three cases. JBJS, 59(2), 268-269.

Gómez-Hoyos, J., Martin, R. L., & Martin, H. D. (2018). Current concepts review: evaluation and management of posterior hip pain. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 26(17), 597-609.

Torriani, M., Souto, S. C., Thomas, B. J., Ouellette, H., & Bredella, M. A. (2009). Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. American journal of roentgenology, 193(1), 186-190.

Martin, H. D., Khoury, A., Schröder, R., & Palmer, I. J. (2016). Ischiofemoral impingement and hamstring syndrome as causes of posterior hip pain: where do we go next?. Clinics in Sports Medicine, 35(3), 469-486.