Distal Thigh Pain-Running

Abstract

HISTORY: A 29-year-old female presented with progressive right distal thigh pain. Her pain began gradually after increasing her mileage jogging approximately three months prior to presentation. Her pain was dull, non-radiating and worse at night as well as with running. She had no recent weight loss. There was no associated numbness or tingling. Her past medical history is significant for multiple miscarriages and infertility. PHYSICAL EXAMINATION: She had a non-antalgic gait. Inspection was negative for edema, masses, adenopathy or skin changes. There was pain with palpation of the supracondylar region of her medial right femur. Range of motion of bilateral hips and keens were full and pain free. Lower extremity strength was normal and symmetric. There was no laxity appreciated with varus/valgus stressing. Lachman and posterior drawer tests were negative. DIFFERENTIAL DIAGNOSIS: •Distal adductor tendinopathy •Femoral epicondyle stress fracture •MCL strain •Plica syndrome •Osteosarcoma TEST AND RESULTS: Knee Radiographs •Small eccentric lytic lesion in the distal right femoral diaphysis medially with associated indolent periosteal new bone formation and minimal surrounding sclerosis Femur MRI •Eccentric, T1 hypointense, T2 hyperintense 1.2 x 1.3 x 2.4 cm lytic mass right femoral with a thin rim of peripheral sclerosis and faint rim of T1 hyperintensity •Thinning of the lateral femoral cortex without definitive cortical breakthrough •Moderate surrounding marrow and periosteal edema •Mildly heterogeneous mass with peripherally located enhancement CT Guided Biopsy •Pathology positive for Langerhans cell histiocytosis FINAL/WORKING DIAGNOSIS: •Langerhans cell histiocytosis TREATMENT AND OUTCOMES: •Extended intralesional curettage for gross total resection with synthetic bone graft •Discharged home the next day with weight bearing as tolerated, walker and Aspirin 325mg BID for 4 weeks for DVT prophylaxis •Recovery complicated by soleal DVT and hematoma requiring aspiration •6 week post-op started full weight bearing and nonathletic activities •4 month follow up with stable x-rays, pain free and cleared to resume full activities •Plan for one year follow up with repeat radiographs and baseline MRI