Hip Injury - Soccer

Abstract

HISTORY: 16 year-old male competitive soccer player with insidious onset of right hip pain since soccer pre-season conditioning two years ago. The pain is located over the right anterior inferior iliac spine (AIIS). Described as "pulling" and dull in nature, worse with running and especially kicking. Denies paresthesia or radiating pain. Denies inciting events or history of trauma. He has been unable to sustain sports activities due to the pain. He has undergone several work-ups and conservative treatment without resolution of symptoms. PHYSICAL EXAMINATION: Normal inspection, without discoloration, deformity, or asymmetry. Mild tenderness over right AIIS area. Mild pain with active and passive motion of the right hip, notably with active flexion and passive extension. No tenderness of Anterior Superior Iliac Spine. Range of motion within normal limits. Strength and sensation intact. Normal gait. DIFFERENTIAL DIAGNOSIS: 1. Chronic Rectus femoris tendinosis 2. Apophysitis 3. AIIS avulsion fracture 4. Osteitis Condensans Ilii 5. Lower Thoracic Entrapment Neuropathy TEST AND RESULTS: Serum Phosphate, Alkaline Phosphatase, Erythrocyte Sedimentation Rate - normal AP Pelvis and Frog-Leg views -No fractures, normal bone mineralization 1st MRI of Hip (7 months from symptom onset) -Musculature and soft tissues within normal limits 2nd MRI Hip (22 months from symptom onset) - Minimal asymmetric irregular signal in the Right AIIS likely very mild chronic avulsive changes. Ultrasound (US) Right Hip - Small discontinuous cortical irregularity of the chronic avulsion changes of AIIS FINAL WORKING DIAGNOSIS: Chronic Avulsion Fracture of Right AIIS TREATMENT AND OUTCOMES: 1. Oral NSAID treatment provides no relief. 2. Several week cessation of impact activity provides temporary relief. 3. Physical Therapy focused on strengthening/flexibility provides minor improvement. 4. Orthopedic consult decided no indication for surgery. 5. Steroid injection at tendon-bone interface at AIIS under US guidance resulted in minimal response at 4 weeks. 6. Prolotherapy with 50% dextrose injected to the tendon-bone interface at AIIS under US guidance repeated at 2 and 4 weeks resulted in improvement of the symptoms on 3-week and 6-week follow-up. 7. Resume sports specific activities as tolerated and full return to play.