Missed Avulsion Fracture of the Ischial Tuberosity in an Adolescent Competitive Athlete: Case Report and Literature Review

Abstract

Although the majority of these cases are muscle strains taking place most of the times in the musculotendinous junction [2], it is noticeable that a 12% of hamstring injuries may involve a tear or avulsion of the proximal hamstring origin and that another 9% represents complete avulsions [3]. Despite these well-documented cases of avulsions in the literature, there remains a diagnostic difficulty in differentiating a simple muscle strain from an avulsion. Therefore, patients continue to present late in the therapist for definitive treatment. Prompt diagnosis and subsequent treatment of ischial tuberosity avulsions are crucial, because the outcome in non-properly treated cases is a persistent and residual loss of muscle power. Case Presentation A 17-year-old soccer player referred to our clinic, due to persistent pain located at his right hip and at the posterior aspect of his thigh, 7 months after the initial injury. The trauma was elicited while he was performing a free kick, and he was immediately withdrawn from the match. The team physicians diagnosed initially hamstrings muscle strain and the patient was submitted in a course of physical therapy and rest for ten days. Afterwards, he was impelled to return to his previous sporting activities, but he was unable to follow the team’s training program, as he continued to feel disabling pain every time he was flexing his hip with the knee in extension. The same physicians decided that he should undergo a new course of rest and physical therapy for a further period of two weeks. One and a half month after the initial injury, he returned to the training program, with his symptoms partly relieved. For the next four months, he was partially participating to the team’s program with intervals of rest, as he still had pain in the back of his thigh, even in mild activities (e.g. running). Due to the persistence of symptoms, his therapist decided an MRI scan of his thigh, in order to exclude any other pathology besides trauma. The MRI scans revealed areas of edema and hemorrhage, between obturator externus and ischial tuberosity, as well as around the sciatic nerve (Figure 1). The patient was then referred to our department, with the possible diagnosis of a neoplasm surrounding the sciatic nerve.