Leg PainMarathon Runner

Abstract

HISTORY: A 28 year old marathon runner presented with 1 year history of bilateral leg pain. Prior to the insidious onset of pain, he reported no changes in his running routine, surfaces, or shoes. He described 3 distinct types of pain. The first pain was a “muscular pain” in his bilateral thighs that occurred while sleeping or lying prone. The second pain was a stinging pain that extended from his hips distally into his medial thighs and medial calves that worsened with sitting, computer work, or exercise. The third pain was aching pain in his thighs and calves that worsened with running or walking long distances, but improved with swimming or rest. In addition to pain, he also noted weakness with stair climbing. He denied numbness, weakness, bowel or bladder changes. He denied family history of neuromuscular, rheumatologic, or myopathic disease. Past medical history is significant for hypotestosteronism (treated with testosterone supplementation) and migraine headaches. Prior evaluation included MRI of the brain, cervical spine, lumbar spine, and pelvis, all of which were normal. Plain film radiographs of the hips were normal. PHYSICAL EXAMINATION: Normal vital signs. Normal gait, normal toe-walking and heel-walking. Normal skin and vascular examination. Normal manual muscle testing of C5-T1 and L2-S2 myotomes, but decreased strength in single leg squat bilaterally, with normal proximal upper limb strength. Normal light touch sensation, decreased pin prick sensation along lateral foot bilaterally. 2+ knee, medial hamstring, and ankle reflex. No clonus, downgoing Babinski, no Hoffman's sign. Hip examination (IR, ER, scour, FABER) normal. Straight leg raise, slump sit normal. DIFFERENTIAL DIAGNOSIS: Myopathy Peripheral neuropathy Lumbosacral plexopathy or radiculopathy Endocrine abnormality CNS process (e.g., multiple sclerosis, syrinx) Rheumatologic disease TESTS AND RESULTS: Electrodiagnostics: normal NCS, EMG demonstrated decreased activation in left gastrocnemius consistent with central process Thoracic spine MRI revealed T6-T9 syrinx FINAL/WORKING DIAGNOSIS: Thoracic syrinx TREATMENT AND OUTCOMES: Pregabalin 50mg PO tid, titrated to 150mg PO tid with some relief Neurosurgical consult, initially managed non-operatively Has resumed swimming, not currently running