Hip Pain In A Cross Country Runner

Abstract

HISTORY: An 18 year-old female cross-country runner presented with 6 weeks of left posterolateral hip pain of insidious onset. She initially had pain with running only but now has pain with ambulation. She denies back pain, radiation of her pain, numbness, tingling, or weakness in her hip or leg. She denies prior hip pain or injury. She reports secondary amenorrhea for 5 years. She denies sexual activity, acne, hursutism, anemia, disordered eating behaviors, and reports she is happy with her weight. She has a history of bilateral medial tibial stress syndrome but no known history of a stress fracture. PHYSICAL EXAMINATION: Her examination revealed a height of 5'3", weight of 98 pounds, BMI of 17, pulse of 60, and blood pressure of 98/86. She had no acne or signs of hursutism. Her back exam revealed a straight spine with no midline tenderness and full range of motion, and negative straight leg raise and FABER tests. She was tender over her left piriformis, proximal iliotibial band and lateral iliac crest. She had full range of motion of the left hip with no pain. Her hip and leg strength was 5/5 and she was neurovascularly intact. She had a negative fulcrum test but pain in her left hip with hopping on one leg. DIFFERENTIAL DIAGNOSIS: Piriformis syndrome Gluteus medius strain Stress fracture Labral tear/hip impingement Avulsion fracture Hip pointer Lumbar radiculopathy SI dysfunction Gluteal bursitis TEST AND RESULTS: • Laboratory evaluation: -Estradiol low at <12 and luteinizing hormone low at 0.9, both in prepubertal range. Free T3 index low at 75. -Normal hemoglobin, ferritin, thyroid-stimulating hormone, follice-stimulating hormone, and prolactin. Urine pregnancy test negative Left hip radiographs: normal; growth plates still open. MRI left hip: left iliac crest apophyseal avulsion CT pelvis without contrast: subacute left iliac crest apophyseal avulsion injury DXA scan: spine Z-score -2.4 FINAL WORKING DIAGNOSIS: 1. Left hip iliac crest apophyseal avulsion fracture 2. Functional hypothalamic secondary amenorrhea 3. Osteoporosis 4. Low T3 syndrome TREATMENT AND OUTCOMES: 1. Non-weight-bearing until no pain with ambulation. 2. Slow gradual return to activity. 3. Referral to registered dietitian. 4. Calcium and vitamin D supplementation. 5. Decision made to medically red-shirt her freshman year.