1. Unravelling posterior hip pain
Dr Leesa Huguenin
MP Sports Physicians

2. Anatomy 101 For a bear of simple brain 3 layers Extensors
Lateral stabilisers
External rotators

3. Figure 1The gluteal triangle
Figure 1The gluteal triangle. G Max, gluteus maximus; G Med, gluteus medius; P, piriformis; QF, quadratus femoris; SM, semimembranosus; ST, semitendinosus; BF, biceps femoris; VL, vastus lateralis.

4. The ischial tuberosity clock face
The ischial tuberosity clock face. ST, semitendinosus; BF, biceps femoris; QF, quadratus femoris; P, piriformis; G Med, Gluteus medius.

5. Diagnostic hints Pain location relative to gluteal triangle Medial SIJ
Superior
Muscle/ tendon/ enthesis
Lateral
Hip/ acetabulum
Within
Piriformis/ sciatic nerve

6. Medial differentials
SIJ/ L5 S1 facet
Sacral stress fracture
Superior gluteal artery entrapment
Posterior compartment syndrome

7. Superior differentials
Gluteus medius tendinopathy
Ilio lumbar ligament
Myofascial pain

8. Lateral Differentials
(Anterior also)
Trochanteric bursitis
TFL
Femoral stress fracture
LCNT

9. Piriformis syndrome A real pain in the bum………. or is it?
Many years after first described, debate rages over whether this is a true diagnosis
Sciatic nerve runs above, below or through piriformis.
Theory is that tightness/ scarring + adhesions of the muscle lead to sciatic nerve entrapment and referred hamstring pain

10. First line therapy Piriformis syndrome
I rarely see priformis overactivity in isolation
Usually secondary to SIJ instability/ lumbar pathology
I do not diagnose this condition, but I do address piriformis/ external rotator tightness
First line therapy

11. Ischiofemoral Impingement
Normal space between ischium and lesser trochanter of femur is 20mm in full ER and abduction
Narrow space increases risk (Bony or QF space)
Narrowing Congenital
Acquired Intertrochanteric fractures
direct trauma
fibrosis/ bursitis if persistent impingement

12. Ischiofemoral Impingement
Narrow space is 17mm
Need to exclude all other causes of referred pain – lumbar especially
Axial MRI will diagnose

13. QF space extends along intertrochanteric line posteriorly

15. Posterior gluteal eye pain!!!

16. THANK YOU