Hip, Groin & Thigh Pain In A Semi-professional Football Player

Abstract

HISTORY: A 24-year-old football player presented to clinic on crutches with 6 weeks of left hip pain starting 2 days post-game. Pain was dull, constant, intensity 6-10/10, radiating to knee, worse with walking, better supine. Refractory to Naproxen. Denied trauma, bowel/bladder change. Had 20 lb. weight loss, night sweats, fever, "knot" in left low back. Daily cigarettes, occasional alcohol, no injection drugs. Epidural injection worsened pain; leg "locked up," could not walk. Spine surgeon found spondylosis, referred for pelvis evaluation. PHYSICAL EXAMINATION: Unable to bear weight, FABER positive, hip rotation painful. Tender spinous processes, paraspinal muscles, femur, but no mass or skin change. Healed abscess at knee joint line. Abscess right arm. Wasting thigh muscle. Tender groin node. DIFFERENTIAL DIAGNOSIS: 1. sacroiliitis, bursitis, tendonitis, synovitis, capsulitis, iliotibial band syndrome, lumbar plexitis, Reiter's syndrome, ankylosing spondylitis, Lyme disease, food poisoning, inflammatory bowel disease, rheumatoid arthritis, eosinophilic granuloma, osteomyelitis. 2. radiculopathy, piriformis syndrome, hernia, meralgia paresthetica, facet syndrome, vertebral diskitis, nephrolithiasis, epididymitis. 3. fracture, contusion, sprain, strain, labral tear, femoroacetabular impingement, osteoarthritis. 4. Ewing's sarcoma, osteosarcoma, lymphoma, costochondroma, metastasis. 5. osteonecrosis, sickle cell disease. 6. chondrocalcinosis, pseudogout. 7. athletic pubalgia. TEST AND RESULTS: MRI: L5-S1 spondylosis, left proximal femur marrow edema in muscles, superficial femoral vessels, sciatic nerve, T2 hyperintense femoral diaphyseal lesion with small soft tissue mass. Xray: 14 cm destructive lesion posteromedial proximal femur with periosteal reaction, malignancy v. infection v. tumor. CT: no metastases. WBC 4.3, Hgb 10.1, Plt 200, ESR 42, CRP 6.1. Blood cultures: negative. Echocardiogram: No vegetations. CT-guided bone biopsy: acute osteomyelitis. FNA soft tissue: MRSA. FINAL/WORKING DIAGNOSIS: MRSA osteomyelitis. TREATMENT AND OUTCOMES: Irrigation and debridement. Infectious disease consult: antibiotics 3 months. Physical Therapy. Return to activity by week: 6: toe touch. 13: weight bear as tolerated & return to work. 25: run. 36: football.