OVERUSE SYNDROME-CROSS-COUNTRY

Abstract

1274 HISTORY -- 18 y.o. WF college freshman cross-country runner who presented to the Team Physician with the complaint of pain in her right hip, knees, shins and back of heel pain bilaterally. She had been a very successful high school cross-country runner but now in college her training program was much more intense. Her pain had increased steadily since she had started her freshman year two months prior and now she had both walking pain and a mild limp. She denied swelling, bruising, or acute traumatic injury. Her training shoes were three months old. She had hyper-pronation of the feet for which she wore orthotics which were less than a year old. She ran 40 miles per week in practice and did strength-training in the gym. PMH: “Loose joints.” Six year h/o B/L shoulder dislocations (over 25 times.) Shoulders had “come out” as often as 3x/basketball game and she had reduced them voluntarily. Ankle dislocations- 10x on R and 6x on L before ankle surgery. Right hip “pops in and out” during exercise and running. Easy bruisability, Asthma, Exercise-induced anaphylaxis, Allergic rhinitis, Nasal fx. PSH: Elbow fx & ORIF, R ankle stabilization (personeal tendon transfer) two years prior. Family Hx: Father had dislocations of R shoulder, Aunt diagnosed with “loose joints.” Allergies: NKDA. Meds: Hismanal, Proventil, Intal, Epi-Pen. ROS: Denies CP, SOB, Rashes, Swollen joints PHYSICAL EXAM: GEN: 18yo in NAD, slender VSS: HT-5'7” Wt-144 lbs. BP-94/62 CV: RRR no m,r,g SKIN: hyper-elastic (stretched to 3.5 cm at elblow), no cigarette-paper scar tissue. UPPER EXTREMITY: Elbows hyperextended to -20 °. Shoulders had forward flexion to 240 °, Abduction to 220 °, external rotation to 151 °, internal rotation to 160 °. Her wrists flexed to 125 °, extended to 115 °, & supinated to 170 °. Her 2nd finger at the MTP had -105 ° of extension. 5/5 overall strength. No arachnodactyly. LOWER EXTREMITY: Hips extended to 80 °, ext. rotated to 89°, int. rotated to 74 °, R Hip tender over Greater Trochanter, (+) Sartorius tenderness in Patrick's position. Knees extended to -10°, nl meniscal exam, +1 laxity of ligaments w/o pain, B/L (+) Clarkes, (+) Patellar grind, (+) RPT, AQ angle 20 °, (+) Obers (R only). Ankles dorsiflexed to 45 °, plantar flexed to 85 °, Achilles tendons & retrocalcaneal bursas - tender. B/L post. med. tibial tenderness (dist. 1/3). GAIT: B/L genu varum & recurvatum, hyperpronation, rear foot valgus& pes planus DIFFERENTIAL DIAGNOSIS: Overuse Syndrome-Multiple Joints B/L Shoulder instability R trochanteric bursitis B/L Medial tibial stress syndrome B/L achilles tendonitis/bursitis R Iliotibial band syndrome R sartorius strain B/L Patellofemoral Pain Syndrome Marfan's Syndrome Ehlers-Danlos Syndrome TEST AND RESULTS: Echo: Trace tricuspid regurgitation, (-) MVP, NL LV Function. No aortic aneurysm X-ray: B/L leg films- no stress fractures. Developmental Evaluation: Johns Hopkins University, Moore Clinic was positive for Ehlers-Danlos Type III (Benign Hypermobility.) FINAL/WORKING DIAGNOSIS: Ehlers-Danlos Type III presenting as an overuse syndrome of the lower extremities in a female cross-country runner. TREATMENT: JHU recommended non-weight bearing sports and exercise activities. The patient was started in formal P.T. on a dynamic stabilization program to emphasize muscle strengthening around her unstable joints. She received new orthotics after a detailed gait evaluation by a sports podiatrist and slowly returned to running. She returned to the cross country team near the end of the season but never realized her full potential. One year later she had given up running for roller-blading and body-shaping.