Preemptive analgesia in hip arthroscopy: intra-articular bupivacaine does not improve pain control after preoperative peri-acetabular blockade.

INTRODUCTION: Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures. METHODS: 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively. RESULTS: Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, p = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period. CONCLUSIONS: This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.

Iliopsoas Muscle/Tendon Proportions at Three Levels of Described Arthroscopic Tenotomy: An Anatomic Study in Fresh Cadaveric Specimens.

PURPOSE: To calculate the iliopsoas muscle/tendon ratio at 3 levels of arthroscopic iliopsoas tenotomy sites in fresh cadaveric specimens. METHODS: An anatomic study design was performed using 16 iliopsoas musculotendinous units from the level of the hip joint to their insertion on the lesser trochanter. All specimens came from 16 fresh cadaveric specimens (10 male, 6 female), with a median age of 41 years (range 31-55.25 years). Circumferential measurements of the composite musculotendinous unit and the iliopsoas tendon were then made at the lesser trochanter insertion, the site of transcapsular tenotomy, and the site of tenotomy at the level of the labrum. Anatomical variance of the iliopsoas tendon at the insertion on the lesser trochanter and muscular extension below the lesser trochanter level also were described. The difference between the median circumference of the iliopsoas musculotendinous units or the isolated tendons at the 3 levels was calculated. RESULTS: The median circumference of the iliopsoas musculotendinous unit at the level of the labrum, orbicularis zone (transcapsular tenotomy site), and the lesser trochanter was 140.9 mm (range 137.9-148.9), 136.7 mm (range 132.9-140), and 99.5 mm (range 96.5-104.8), respectively. The median circumference of the iliopsoas tendon at these same levels was 25.6 mm (range 22.7-33.7), 28.9 mm (range 25.1-32.2), and 30.9 mm (range 27.9-36.1), respectively. Accordingly, the proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site, and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively. CONCLUSIONS: The proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively. The distal muscular projection below the tendinous insertion on the lesser trochanter may maintain the functional connection of the iliopsoas between origin and insertion even after releasing the tendon. CLINICAL RELEVANCE: This finding may have implications for a new understanding of arthroscopic tenotomy of the iliopsoas around the hip, as previously described muscle/tendon proportions were not calculated in fresh cadavers.

Pain management practice patterns after hip arthroscopy: an international survey.

Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons' responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.

A MECHANISM FOR LIGAMENTUM TERES INJURIES IN FEMOROACETABULAR IMPINGEMENT: AN ANATOMICAL STUDY.

BACKGROUND: Femoroacetabular impingement can produce abnormal biomechanics that lead to compensatory injuries around the hip and pelvis. Ligamentum teres pathologies are commonly associated with these bony deformities but a mechanism for injury has not been described in the literature. PURPOSE: The purpose of this study was to describe a potential mechanism behind ligamentum teres injury and impingement between the femoral neck and acetabulum. STUDY DESIGN: Laboratory controlled cadaveric study. METHODS: Twenty-six hips from 15 embalmed cadavers (8 male; 7 female) with lifespans between 55-93 years were skeletonized. The hip was placed in 90 ° flexion and 0 ° abduction/adduction and internally rotated until the femoral head neck contacted the acetabulum. This position of impingement with respect to internal rotation was recorded with a goniometer. The hip was then further internally rotated until end range of motion was achieved and again the position of internal rotation recorded with a goniometer. RESULTS: The positions of internal rotation at which impingement occurred (mean 9 °; SD 4.2; Range -2 ° to 15 °) when compared to end range (mean 21 °; SD 5.7; Range 5 ° to 27 °) were significantly different (p<0.005; t = 14.8). In all the hips, after impingement occurred the site of bony contact between the femoral neck and acetabulum acted as a pivot point. The femoral head was levered inferiorly with a loss of the rotational center within the acetabulum, as internal rotation continued. This movement of the femoral head caused the ligamentum teres to tighten and restricted further movement. Movement into internal rotation beyond this end position caused rupture of the ligamentum teres. CONCLUSION: Internal rotation range of motion can occur beyond the position of impingement and resulted in abnormal inferior movement of the femoral head and tightening of the ligament teres. This study provides cadaveric evidence for the mechanism of ligamentum teres injury in those with who engage in activities that required motion beyond the point of impingement.

Surgical Management of Deep Gluteal Syndrome Causing Sciatic Nerve Entrapment: A Systematic Review.

PURPOSE: To assess the causes, surgical indications, patient-reported clinical outcomes, and complications in patients with deep gluteal syndrome causing sciatic nerve entrapment. METHODS: Three databases (PubMed, Ovid [MEDLINE], and Embase) were searched by 2 reviewers independently from database inception until September 7, 2016. The inclusion criteria were studies reporting on both arthroscopic and open surgery and those with Level I to IV evidence. Systematic reviews, conference abstracts, book chapters, and technical reports with no outcome data were excluded. The methodologic quality of the studies was assessed with the MINORS (Methodological Index for Non-randomized Studies) tool. RESULTS: The search identified 1,539 studies, of which 28 (481 patients; mean age, 48 years) were included for assessment. Of the studies, 24 were graded as Level IV, 3 as Level III, and 1 as Level II. The most commonly identified causes were iatrogenic (30%), piriformis syndrome (26%), trauma (15%), and non-piriformis (hamstring, obturator internus) muscle pathology (14%). The decision to pursue surgical management was made based on clinical findings and diagnostic investigations alone in 50% of studies, whereas surgical release was attempted only after failed conservative management in the other 50%. Outcomes were positive, with an improvement in pain at final follow-up (mean, 23 months) reported in all 28 studies. The incidence of complications from these procedures was low: Fewer than 1% and 8% of open surgical procedures and 0% and fewer than 1% of endoscopic procedures resulted in major (deep wound infection) and minor complications, respectively. CONCLUSIONS: Although most of the studies identified were case series and reports, the results consistently showed improvement in pain and a low incidence of complications, particularly for endoscopic procedures. These findings lend credence to surgical management as a viable option for buttock pain caused by deep gluteal syndrome and warrant further investigation. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Influence of Aging on Microvascular Supply of the Gluteus Medius Tendon: A Cadaveric and Histologic Study.

PURPOSE: The purpose of this cadaveric study was to assess the relation between age and microvascular supply of 3 areas of the gluteus medius tendon using a previously validated CD31 immunohistochemistry staining technique. METHODS: Twenty-four fresh-frozen gluteus medius specimens were obtained through a posterolateral approach to the hip. Specimens aged 18 years or older, of either sex, and of any race were considered for this study. The average age of donors was 47.3 years (range, 18-68 years). Each sample was divided into 3 portions: musculotendinous, tendinous, and tendon-bone junction. H&E staining was used for qualitative structural analysis, and then all samples underwent staining with CD31 immunohistochemistry for quantitative assessment of vessels per square millimeter. A comparison of the microvessel density between zones according to age was performed by an analysis of variance. To evaluate the relation between microvessel supply and age, a regression model with curvilinear estimation was used. The data were fitted to a quadratic model. RESULTS: Vascular supply in transversal and longitudinal cuts regardless of the zone was, on average, 53.9 ± 32.1 vessels/mm2 and 51.1 ± 19.3 vessels/mm2, respectively. All the areas of the tendon showed a strength of relation (R) ranging from 0.41 to 0.76 between age and vascular supply. In addition, the proportion of vascular supply change explained by age (R2) was significant in most cases (ranging from 0.17 to 0.56, with P < .05). CONCLUSIONS: There is a chronological relation between aging and microvascular supply of the gluteus medius tendon, in which an initial increase occurs from 18 years of age to 30 to 40 years of age, with a progressive decrease after 50 years of age. CLINICAL RELEVANCE: The findings of our study may have implications for increased vulnerability of the gluteus medius tendon and decreased healing potential.

Ischiofemoral impingement: defining the lesser trochanter-ischial space.

PURPOSE: The purpose of this study was to define changes in the ischial-lesser trochanteric space associated with medial and lateral hip rotation in neutral and 10° of extension and adduction. METHODS: Twenty-five hip joints from 14 embalmed cadavers (7 males and 7 females) were used for this study. The pelvic region of each cadaver was skeletonized, and the hip capsule released distally. With the hip joint in 0° flexion-extension/abduction-adduction, the distance between the lesser trochanter and ischium was measured in: neutral rotation, 40° medial rotation, and 60° lateral rotation. A one-way ANOVA with post hoc analysis determined the difference in the ischiofemoral space in these three positions. An additional position was then tested by laterally rotating the femur with the hip joint positioned in 10° extension and adduction. RESULTS: The average distance between the lesser trochanter and ischium was different (p < .0005) in neutral rotation, 40° medial rotation, and 60° lateral rotation at 2.8 cm (SD 1.1), 4.3 cm (SD 1.2), and 1.4 cm (SD 0.7), respectively. With the hip joint laterally rotated from a starting position of 10° extension and adduction, 21 of 25 (84 %) hips made contact between the lesser trochanter and ischium at an average position of 29° (SD 20) of lateral rotation. CONCLUSIONS: The lesser trochanter is closest to the ischium in lateral rotation and is furthest away in medial rotation when the hip is in neutral flexion-extension/abduction-adduction. The lesser trochanter approximates the ischium when the hip is laterally rotated in 10° extension and adduction. The information gained through this investigation helps to define the pathomechanics associated with ischiofemoral impingement and validate clinical tests to diagnose ischiofemoral impingement.

The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints.

PURPOSE: To assess the relation between ischiofemoral impingement (IFI) and lumbar facet joint load during hip extension in cadavers. METHODS: Twelve hips in 6 fresh T1-to-toes cadaveric specimens were tested. A complete pretesting imaging evaluation was performed using computed tomography scan. Cadavers were positioned in lateral decubitus and fixed to a dissection table. Both legs were placed on a frame in a simulated walking position. Through a posterior lumbar spine approach L3-4 and L4-5 facet joints were dissected bilaterally. In addition, through a posterolateral approach to the hip, the space between the ischium and the lesser trochanter was dissected and measured. Ultrasensitive, and previously validated, piezoresistive force sensors were placed in lumbar facet joints of L3-4 and L4-5. Lumbar facet loads during hip extension were measured in native hip conditions and after simulating IFI by performing lesser trochanter osteotomy and lengthening. Four paired t-tests were performed comparing normal and simulated IFI on the L3-L4 and L4-L5 facet joint loads. RESULTS: After simulating IFI, mean absolute differences of facet joint load were 10.8 N (standard error of the mean [SEM] ±4.53, P = .036) for L3-4 at 10° of hip extension, 13.71 N (SEM ±4.53, P = .012) for L3-4 at 20° of hip extension, 11.49 N (SEM ±4.33, P = .024) for L4-5 at 10° of hip extension, and 6.67 N (SEM ±5.43, P = .245) for L4-5 at 20° of hip extension. A statistically significant increase in L3-4 and L4-5 lumbar facet joint loads of 30.81% was found in the IFI state as compared with the native state during terminal hip extension. CONCLUSIONS: Limited terminal hip extension due to simulated IFI significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-IFI native hips. CLINICAL RELEVANCE: This biomechanical study directly links IFI to increased lumbar facet loads and supports the clinical findings of IFI causing lumbar pathology. Assessing and treating (open or endoscopic) hip disorders that limit extension could have benefit in patients with concomitant lower back symptoms.

Contribution of the Pubofemoral Ligament to Hip Stability: A Biomechanical Study.

PURPOSE: To determine the isolated function of the pubofemoral ligament of the hip capsule and its contribution to hip stability in external/internal rotational motion during flexion greater than 30° and abduction. METHODS: Thirteen hips from 7 fresh-frozen pelvis-to-toe cadavers were skeletonized from the lumbar spine to the distal femur with the capsular ligaments intact. Computed tomographic imaging was performed to ensure no occult pathological state existed, and assess bony anatomy. Specimens were placed on a surgical table in supine position with lower extremities resting on a custom-designed polyvinylchloride frame. Hip internal and external rotation was measured with the hip placed into a combination of the following motions: 30°, 60°, 110° hip flexion and 0°, 20°, 40° abduction. Testing positions were randomized. The pubofemoral ligament was released and measurements were repeated, followed by releasing the ligamentum teres. RESULTS: Analysis of the 2,106 measurements recorded demonstrates the pubofemoral ligament as a main controller of hip internal rotation during hip flexion beyond 30° and abduction. Hip internal rotation was increased up to 438.9% (P < .001) when the pubofemoral ligament was released and 412.9% (P < .001) when both the pubofemoral and teres ligament were released, compared with the native state. CONCLUSIONS: The hypothesis of the pubofemoral ligament as one of the contributing factors of anterior inferior hip stability by controlling external rotation of the hip in flexion beyond 30° and abduction was disproved. The pubofemoral ligament maintains a key function in limiting internal rotation in the position of increasing hip flexion beyond 30° and abduction. This cadaveric study concludes previous attempts at understanding the anatomical and biomechanical function of the capsular ligaments and their role in hip stability. CLINICAL RELEVANCE: The present study contributes to the understanding of hip stability and biomechanical function of the pubofemoral ligament.

Endoscopy-Assisted Periacetabular Osteotomy.

Minimizing soft tissue dissection and improving visualization of vital structures during periacetabular osteotomy (PAO) is of paramount importance to improve patient outcome and minimize complications. The endoscopy-assisted PAO was introduced to accomplish this objective. It involves an initial hip arthroscopy, for treatment of central compartment pathology, followed by a mini-open Bernese periacetabular osteotomy under fluoroscopic and endoscopic guidance, and completed by final dynamic hip arthroscopy to assess acetabular reorientation and fixation and to perform femoroplasty in relation to the new acetabular rim position, if needed. Endoscopy-assisted PAO is used to treat dysplasia or acetabular retroversion in a minimally invasive fashion.

Capsulotomy Size Affects Hip Joint Kinematic Stability.

PURPOSE: To evaluate the effect of capsulotomy size and subsequent repair on the biomechanical stability of hip joint kinematics through external rotation of a cadaveric hip in neutral flexion. METHODS: Eight fresh-frozen cadaveric hip specimens were used in this study. Each hip was tested under torsional loads of 6 N·m applied by a servohydraulic frame and transmitted by a pulley system. The test conditions were (1) neutral flexion with the capsule intact, (2) neutral flexion with a 4-cm interportal capsulotomy, (3) neutral flexion with a 6-cm capsulotomy, and (4) neutral flexion with capsulotomy repair. Soft tissue was retained during all interventions. Measures indicating joint kinematics (range of motion [ROM], hysteresis area [HA], and neutral zone [NZ]) were obtained for each condition. RESULTS: For all hip specimens, the average ROM, HA, and NZ were calculated relative to the intact capsular state (100%) and expressed in terms of percentage (± SD). The findings for ROM were as follows: intact, 100%; 4 cm, 107.42% ± 5.69%; 6 cm, 113.40% ± 7.92%; and repair, 99.78% ± 3.77%. The findings for HA were as follows: intact, 100%; 4 cm, 108.30% ± 9.30%; 6 cm, 115.30% ± 13.92%; and repair, 99.47% ± 4.12%. The findings for NZ were as follows: intact, 100%; 4 cm, 139.61% ± 62.35%; 6 cm, 169.25% ± 78.19%; and repair, 132.03% ± 64.38%. Statistically significant differences in ROM existed between the intact and 4-cm conditions (P = .039), the intact and 6-cm conditions (P < .0001), the 4-cm and repair conditions (P = .033), and the 6-cm and repair conditions (P < .0001). There was no statistically significant difference between the intact and repair conditions (P > .99) or between the 4- and 6-cm conditions (P = .126). CONCLUSIONS: Under laboratory-based conditions, larger-sized capsulotomies were accompanied by increases in all 3 measures of joint mobility: ROM, HA, and NZ at time zero. Complete capsular closure effectively restored these measures when compared with the intact condition. CLINICAL RELEVANCE: Cadaveric models consisting of the hip joint with surrounding soft tissue were used under laboratory testing conditions to investigate potential iatrogenic joint instability resulting from expansive capsulotomies, showing that complete capsular closure leads to reconstitution of original joint stability properties at time zero.

Defining the greater trochanter-ischial space: a potential source of extra-articular impingement in the posterior hip region.

The purpose of this study was to describe greater trochanteric-ischial impingement and the relative position of the hip joint where impingement occurs. Twenty-three hips from 13 embalmed cadavers (seven males and six females) with a lifespan ranging between 46 and 91 years were used for this study. The pelvic region of each cadaver was skeletonized leaving only the hip capsule and the sciatic nerve. From 90° of flexion, the hip was extended while maintaining a position of 30° abduction and 60° external rotation. The position of hip flexion was recorded when there was contact between the greater trochanter and the ischium. The procedure was repeated in 0° abduction. A Flexion-Abduction-External Rotation (FABER) test was then performed on all specimens with a positive finding defined as contact between the greater trochanter and the ischium. In 30° abduction, contact of the ischium and the greater trochanter occurred in 87% (20/23) of the hips at an average of 47° of flexion (SD 10; range 20-60°). In 0° abduction, a positive finding was noted in 39% (9/23) of hips at an average of 59° flexion (SD 6; range 52-70°). A positive finding in the FABER test position was noted in 96% (22/23) of hips. The greater trochanter can impinge on the ischium when the hip is extended from 90° flexion in a 60° externally rotated position. This impingement occurred more commonly when the hip was in 30° abduction compared with neutral abduction. The FABER test position consistently created greater trochanteric-ischial impingement.

Dry Endoscopic-Assisted Mini-Open Approach With Neuromonitoring for Chronic Hamstring Avulsions and Ischial Tunnel Syndrome.

Chronic hamstring origin avulsions and ischial tunnel syndrome are common causes of posterior hip pain. Although physical therapy has shown benefits in some cases, recent evidence has reported better outcomes with surgical treatment in appropriately selected patients. The full-open approach has been the classic procedure to address this problem. However, the complications related to extensive tissue exposure and the proximity of the incision to the perianal zone have led to the description of full-endoscopic techniques. Achieving an accurate hamstring repair could be technically demanding with a full-endoscopic procedure. Accurate reattachment is crucial in hamstring repair because of the functional demand of the muscles crossing of 2 major joints (hip and knee). This surgical note describes a mixed technique including a mini-open approach, neuromonitoring, and dry endoscopic-assisted repair of the hamstring origin as an alternative for treating patients with chronic hamstring avulsions and ischial tunnel syndrome that remain symptomatic despite nonoperative treatment.

Function of the ligamentum teres in limiting hip rotation: a cadaveric study.

PURPOSE: The purpose of this cadaveric study was to evaluate the function of the ligamentum teres (LT) in limiting hip rotation in 18 distinct hip positions while preserving the capsular ligaments. METHODS: Twelve hips in 6 fresh-frozen pelvis-to-toes cadaveric specimens were skeletonized from the lumbar spine to the distal femur, preserving only the hip ligaments. Hip joints were arthroscopically accessed through a portal located between the pubofemoral and iliofemoral ligaments to confirm the integrity of the LT. Three independent measurements of hip internal and external rotation range of motion (ROM) were performed in 18 defined hip positions of combined extension-flexion and abduction-adduction. The LT was then arthroscopically sectioned and rotation ROM reassessed in the same positions. A paired sample t test was used to compare the average internal and external hip rotation ROM values in the intact LT versus resected conditions in each of the 18 positions. P < .0014 was considered significant. RESULTS: A statistically significant influence of the LT on internal or external rotation was found in 8 of the 18 hip positions tested (P < .0014). The major increases in internal and external rotation ROM occurred when the hip was in 90° or 120° of flexion. CONCLUSIONS: The major function of the LT is controlling hip rotation. The LT functions as an end-range stabilizer to hip rotation dominantly at 90° or greater of hip flexion, confirming its contribution to hip stability. CLINICAL RELEVANCE: Ruptures of the LT contribute to hip instability dominantly in flexed hip positions.

Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

Femoral retroversion is an uncommon cause of cam femoroacetabular impingement that may require surgical treatment beyond arthroscopic or open femoroplasty. We present the case of a young adult with bilateral severe femoral retroversion in whom such treatment failed. We discuss the rationale, surgical technique, and outcome of this patient, who underwent bilateral closed intramedullary derotational proximal femoral osteotomies and interlocked nailing with adjunctive pre- and post-osteotomy hip arthroscopies. Clinical improvement with normal foot progression angles, radiographic union, and resolution of bilateral cam femoroacetabular impingement from femoral retroversion was achieved. This surgery permits rapid institution of weight-bearing ambulation and an early rehabilitative program. Femoral retroversion may be an underappreciated and insufficiently treated cause of cam femoroacetabular impingement that may be readily detected and successfully remedied with this less invasive procedure.

Ischiofemoral space decompression through posterolateral approach: cutting block technique.

Ischiofemoral space impingement has become an increasingly recognized extracapsular cause of atypical hip, deep gluteal, and groin pain that can be treated endoscopically. We present a minimally invasive posterolateral technique that preserves the attachment of the iliopsoas tendon and quadratus femoris insertion while decompressing the ischiofemoral space by resecting the lesser trochanter. Furthermore, we present tips to perform this technique in a manner that minimizes the potential for damage to the sciatic nerve. This technique also allows the surgeon to treat concurrent hip pathology arthroscopically.

Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region.

PURPOSE: The purpose of this study was to determine the diagnostic accuracy of the straight leg raise (SLR), active piriformis, and seated piriformis stretch tests in identifying individuals with sciatic nerve entrapment. METHODS: Thirty-three individuals (female = 25 and male = 8) with a mean age of 43 years (range 15-64; SD ± 11 years) were included in the study. Twenty-three subjects had endoscopic findings of sciatic nerve entrapment. Ten subjects without entrapment during endoscopic assessment were used as a control group. The results of the SLR, active piriformis, and seated piriformis stretch tests were retrospectively reviewed for each subject and compared between both groups. The accuracy of these tests for the endoscopic finding of sciatic nerve entrapment was determined by calculating the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. RESULTS: The SLR had sensitivity of 0.15, specificity of 0.95, positive likelihood ratio of 3.20, negative likelihood ratio of 0.90, and diagnostic odds ratio of 3.59. The active piriformis test had sensitivity of 0.78, specificity of 0.80, positive likelihood ratio of 3.90, negative likelihood ratio of 0.27, and diagnostic odds ratio of 14.40. The seated piriformis stretch test had sensitivity of 0.52, specificity of 0.90, positive likelihood ratio of 5.22, negative likelihood ratio of 0.53, and diagnostic odds ratio of 9.82. The most accurate findings were obtained when the results of the active piriformis test and seated piriformis stretch test were combined, with sensitivity of 0.91, specificity of 0.80, positive likelihood ratio of 4.57, negative likelihood ratio of 0.11, and diagnostic odds ratio of 42.00. CONCLUSIONS: The active piriformis and seated piriformis stretch tests can be used to help identify patients with and without sciatic nerve entrapment in the deep gluteal region.