Running Into Trouble: Diagnosing Hip Pain In The Marathoner

HISTORY: A 51-year-old male with no significant past medical history presents with 2 years of left gluteal and hamstring pain without an inciting event. The patient is an avid runner training for a marathon, but the pain limits his ability to run, particularly after fast runs or long distances. Despite reducing weekly mileage from 40-80 miles to complete rest for 2 months following a marathon, the pain persisted. Physical therapy and dry needling provided no relief, though NSAIDs offered mild improvement. The pain is absent at rest but triggered by ankle plantar flexion or hamstring contraction. The pain severity has fluctuated over 2 years but worsened recently with marathon training. PHYSICAL EXAMINATION: No skin changes or deformity in the left lower extremity. No tenderness on palpation of the hip, including AIIS, ASIS, ischium, piriformis, proximal hamstring, or IT band. The patient has full active and passive range of motion in the left hip, though active internal rotation recreates the pain. Strength is 5/5 in hip flexion, extension, abduction, and adduction. Sensation is intact bilaterally. Positive FADIR on the left hip. Normal gait. DIFFERENTIAL DIAGNOSIS: Proximal hamstring tendinopathy, iliopsoas bursitis, lumbosacral radiculopathy, sacroiliac joint dysfunction, femoroacetabular impingement, ischiofemoral ligament sprain TEST AND RESULTS: Left hip and pelvis radiographs: No acute fractures or dislocations. Joint spaces preserved. Alignment satisfactory. MRI left hip (without contrast): Edema in quadratus femoris within the ischiofemoral space, small bursal collection at the lesser trochanter (possible adventitious bursitis), mild tendinosis, and low-grade partial tearing of left hamstring origins. FINAL WORKING DIAGNOSIS: Ischiofemoral impingement syndrome TREATMENT AND OUTCOMES: After discussion with the patient, who was concerned about training interruptions, he opted for an ultrasound-guided lidocaine/triamcinolone injection into the ischiofemoral space. The patient resumed running as usual and reported no pain during or after runs. He returned to full training and completed a marathon 4 months post-injection.