Leg Pain in an Adolescent Female - Basketball

Abstract

HISTORY: A 13-year old female basketball player presented with a 3-month history of progressive left lateral leg pain. She had sprained her left ankle 1 year earlier, though this had resolved with 1 month of relative rest. Her more recent leg pain began insidiously as she began the subsequent basketball season. She described throbbing pain, localized diffusely over the lateral lower leg. Pain was worse with walking, but was present even when not weightbearing. Concurrent symptoms included intermittent swelling and purplish mottling of the leg, as well as occasional toe numbness. She was initially treated with a 3-week trial of relative rest and a walking boot, but her leg pain continued to worsen. PHYSICAL EXAMINATION: Initial examination revealed an obese, otherwise healthy appearing adolescent female with normal gait. The left ankle was slightly edematous, and mild purplish mottling of the left leg was noted. She was diffusely tender to palpation over the left lateral calf and fibula. Left ankle ROM was normal. Strength was normal, but her pain was exacerbated with activation of the left ankle evertors and plantarflexors. In a subsequent examination, the slump test and left straight leg raise both reproduced her left lateral leg pain. Neurologic testing was otherwise unremarkable. DIFFERENTIAL DIAGNOSIS: Fibular stress fracture Calf muscle strain Deep vein thrombosis Complex regional pain syndrome Lumbosacral radiculopathy TESTING: Left tibia/fibula radiographs: No fracture. Lower leg MRI: No fracture or stress reaction. Increased T2 signal throughout left extensor digitorum, gastrocnemius, and soleus, suggestive of muscle strain. Similar, less severe findings in right leg. Left leg ultrasound: No venous thrombosis. Lumbar spine MRI: Left paracentral disc protrusion at L4-L5, impinging the traversing L5 nerve root. Congenitally narrow spinal canal. FINAL DIAGNOSIS: Left L5 radiculopathy TREATMENT AND OUTCOMES: 1. Physical therapy - dynamic lumbar stabilization program. 2. Gabapentin titrated to 300 mg three times daily. NSAIDs used as needed. 3. At 6 months, resumed strength training and low-impact endurance exercise. 4. Leg pain improved, but intermittent flare-ups continued. Refused epidural steroid injection. 5. At 1 year, still unable to return to competitive basketball.