Hip Pain - Cross Country

Abstract

HISTORY A 17 year old male cross country runner presented with acute onset of left hip pain without antecedent trauma. Pain localized to the lateral aspect of the hip with radiation to the groin, but no further. This was worse with running, and occasionally walking. Onset of the pain began shortly after the conclusion of a running camp, where he rapidly increased his mileage to 54 miles over one week from a previous 20–35 mile per week average. Camp consisted mostly of distance running, with a number of hills, trails, and uneven terrain. His past history is notable for polyostotic fibrous dysplasia of the left leg and a pathological midshaft femur fracture that was treated nonoperatively at age 6. PHYSICAL EXAMINATION Weight stable at 125 pounds. Non-tender to palpation over the hip and groin. Full range of motion and normal strength. Pain elicited passively only with hip internal rotation. Positive Faber and Stinchfield Tests. Reflexes, sensation and pulses in the legs were all normal. Seated straight leg raising negative, and knee/back exams within normal limits. DIFFERENTIAL DIAGNOSIS Femoral neck stress fracture “Snapping hip” of the illiopsoas tendon, or illiotibial band Trochanteric bursitis, Tensor fascia lata strain Arthritis Transient synovitis Slipped capital femoral epiphysis TEST AND RESULTS Plain radiographs Fibrous dysplasia involving the proximal 3/4 femur, incomplete pathologic fracture through the medial half of the femoral neck. MRI hip and pelvis Polyostotic Fibrous dysplasia and fracture involving the medial aspect of the femoral neck. Bone scan for other areas of active pathology Foci of increased uptake throughout much of the left femur, the mid right tibial diaphysis, talus, second metatarsal, and second toe. CT scan to determine the extent of the bony abnormality Nondisplaced, minimally comminuted, pathologic fracture of the medial left femoral neck involving 1/2 the diameter of the femur. FINAL WORKING DIAGNOSIS Incomplete femoral neck stress fracture (compression side) in the setting of polyostotic fibrous dysplasia. TREATMENT AND OUTCOMES Recommended operative fixation vs. conservative treatment of the fracture with non- weight bearing. Surgical intervention chosen to stabilize the fracture, thus reducing the risk of extension to completion, minimizing complications such as avascular necrosis. In addition, fixation would speed the healing process, and return the patient to normal activity quicker. Hip screw and plate with four cortical screws. Crutches and partial weight bearing post-op. Discontinued crutches and cleared to bike and swim at 1 month. Return to light impact activities at 2 months.