Painful Hip Snapping In A 15 Year Old Female Soccer Player

Abstract

HISTORY: A 15 y/o girl with history of bilateral iliotibial band (ITB) lengthening was referred to sports medicine clinic for diagnostic ultrasound of the right anterior hip due to painful snapping in the groin. Pain was exacerbated by kicking a ball. Sonographic examination demonstrated snapping iliacus and psoas major tendons with reproduction of groin pain. Physical therapy (PT) focusing on iliopsoas stretch was ineffective; she underwent iliopsoas tendon lengthening and synovectomy with complete resolution of pain. Five months following iliopsoas tendon lengthening, she returned with a new painful grinding sensation in the right buttock. Pain was exacerbated by walking, specifically at toe-off. Pain was sharp, episodic, and debilitating. She denied groin pain or pain with hip flexion. She denied neurologic deficits PHYSICAL EXAMINATION: Gen: No acute distress Neuro: Audible clunk with ambulation. Non-focal sensory, motor, and reflex examination of the RLE MSK: No visible defect of right buttock. Nontender over the gluteal region and ischial tuberosity. Pain reproduced with passive external hip rotation. Negative FABER, FAIR, log roll, Stinchfield, Ober, and scour DIFFERENTIAL DIAGNOSIS: 1. Ischiofemoral impingement 2. Hip labral/intraarticular pathology 3. Snapping gluteus maximus tendon/muscle 4. Recurrent iliotibial band snapping TEST AND RESULTS: MRI arthrogram: minimal labral fraying. Minimal symptom improvement with intraarticular steroid. Diagnostic ultrasound: hypertrophy of the right quadratus femoris (QF) (2.51cm right vs 1.54cm left) with dyskinetic motion of the QF between the ischial tuberosity and lesser trochanter during external hip rotation. Dyskinesis was more pronounced with standing and walking. Contralateral QF was void of dyskinetic movement. She underwent injection of lidocaine and triamcinolone into the right QF under sonographic guidance FINAL WORKING DIAGNOSIS: Ischiofemoral impingement 2/2 hypertrophied QF TREATMENT AND OUTCOMES: 1. Sonographically guided injection of lidocaine/corticosteroid resulted in diagnostic block from lidocaine component only 2. Discussed repeat injection vs debulking operation vs trial of botulinum toxin injection to the QF 3. Referred to PT for hip stretching and pelvic stabilization exercises