Hi

Possibly my first presentation of Quadratus Femoris

apart from the other ones that I have missed ……

Clinical Presentation

51 year old male commercial painter with 2/7 Hx of pain. Not sure about cause of onset but had been painting a residential home (ladders, squatting, awkward positions) , plus moving around furniture day prior. Went to bed okay, slight sore in AM that increased as day progressed. Pain developed slowly and was described as a strong ache in R lumbar, lateral buttock with radiation to lateral thigh and hadn’t gone in the past 2/7. No PNN sensations.

Over 24 Hr supine was fine, sidelying either side increased pain, walking was fine, but sit to stand or sitting increased painHad tried voltaren with no effect.

On objective assessment NRPS 5/10, lumbar movements were full and neural provocation tests were negative, which for me immediately implicates the gluteals as a prime source.

Passive hip movements were pain limited into flexion and increased with added adduction (20 degrees cf 40) or external rotation (30 degrees cf 50). Internal rotation was fine, as was quadrant testing. Isometrics all directions at 90 degrees hip flexion fine.

Palpation he was slightly sore over his L45 and L23 centrally and was painful posterior and distal to greater trochanter about 5cm (see green crosses on picture). The gluteal region and piriformis were fine.

The bit of the clinical picture that was unusual from my experience, was the painful restriction of adduction and external rotation – haven’t noted this before in this situation.

Intervention

This involved the insertion of one 0.25 * 40mm Seirin with him in contralateral side lying, hip flexed and adducted (positional stretch)into the green crosses and fanned vertically. A strong local twitch was elicited 35 mm deep. The client was warned about single legged activity and taught appropriate hip stretches.

On review 2 days later, he had no pain and was comfortable in all ADLs. In addition to his stretches I started him on single leg squat, bridging and a couple of single leg balance drills with the aim of him progressing these over the next 6 – 8/52s.

Anatomy

The quadratus femoris is a rectangular muscle with parallel fibers that attach medially to the anterolateral surface of the ischium, caudad to the inferior gemellus and posterior to the obturator externus. Laterally, it attaches to the femur on the quadrate tubercle and along the intertrochanteric crest (see green crosses), which extends vertically about halfway between the greater and lesser trochanters. It is innervated by the quadratus femoris nerve that rises from the ventral roots of the L4, L5 and S1 nerves in 79.4% of patients. In adults, the myotendinous junction is the most vulnerable location for injury.

Background

Agreed upon by researchers as an uncommon MS condition, quadratus femoris strain/rupture it is usually diagnosed by MRI (except we don’t have one in Esperance, but we do have running water and electricity and the best beaches in the world). The review papers highlight high female to male ratio, often non traumatic, and delay to diagnosis of 1 day to 5 months. Clinically pain ranged from groin, lateral thigh and posterior thigh. Pain increased with squatting and sitting. No PNN. No benefit from NSAIDs when noted.

In regards to reported passive movements and isometric testing; pain on flexion, adduction and internal rotation (not mentioned but I would guess at 90 degrees flexion) and weak external rotation. I didn’t have this complete pattern. Quadratus femoris is classically described as an external rotator and adductor so my findings are unusual.

So there you have it. I certainly learnt some interesting features from this clinical presentation, and hope that in putting this together you also did. As a result of this experience quadratus femoris will now be included in our AAP Education Advanced Lower Limb Dry Needling Course. We have one place still available in the February course. If you a comment or have been lucky enough to have already experienced a couple of these, would love to hear your clinical story.

Other Readings

Travell & Simons are pretty quiet on quadratus femoris in Vol II (Lower Extremities). You can however review a series of MRI case histories of quadratus femoris tears by O’Brien & Bui-Mansfield: MRI of Quadratus Femoris Muscle Tear: Another Cause of Hip Pain and a chronic presentation of sciatica that was due to quadratus femoris rupture Bano et al.: Persistent sciatica induced by quadratus femoris muscle tear and treated by surgical decompression: a case report. Journal of Medical Case Reports 2010 4:236 and surgically corrected.

Happy Australia Day!!

All the best,

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

email: doug@aapeducation.com.au

ph/fx: 08 90715055

Receive a FREE Information Report

Choose The Top 5 Manual Therapy Apps or Infection Control & Needling (V2)

Along with the report you'll also get a complimentary subscription to "Clinical Kit" our regular eZine (email newsletter) and Free Bronze Membership. You'll get ideas, information, insight and inspiration on a regular basis, plus access to our Resource Library, helping you unravel those clinical conundrums appearing every day.

You are free to use material from the Blog in whole or in part, as long as you include complete attribution, including live website link. Please also notify me where the material will appear. The attribution should read: "By Doug Cary FACP of AAP Education. Please visit our website at www.aapeducation.com.au for additional clinical articles and resources on post graduate education for health professionals" (Please make sure the link is live if placed in an eZine or in a web site.)