Right Hip Pain in a 36 year old Ironman Athlete

Abstract

HISTORY: A 36 year old female long distance runner who was training for an Ironman that presented with a 1 week history of right hip pain. Onset of pain when standing up quickly from sitting position. Pain is reported laterally and worsening with activity. She said it is progressing to the point that it has disrupted sleep for the last 2 nights. Now she is unable to weight bear on her right leg. PHYSICAL EXAMINATION: Her hips were with no obvious deformity or effusion to inspection bilaterally. She exhibited normal ROM with severe pain with internal rotation. Strength 5/5 in hip bilaterally. Tenderness of the anterior aspect of the right hip. Pain elicited with resisted hip flexion. TEST AND RESULTS: Xray right hip revealed a large separated bony piece at the area of the anterior inferior iliac spine (AIIS) consistent with an avulsion, initially presumed as a chronic injury. Based on the severity and concern for stress fracture of the femoral neck she was placed on crutches with no weight bearing. MRI was ordered for further evaluation and she was informed to hold off all activity until results. MRI of right hip revealed acute-to-subacute avulsion fracture of the right anterior inferior iliac spine with associated partial tearing of the rectus femoris tendon, as well as mild edema in adjacent musculature and in fascial planes about the proximal rectus femoris muscle. FINAL WORKING DIAGNOSIS: acute-to-subacute avulsion fracture of the AIIS. TREATMENT AND OUTCOMES: Typically, in the adolescent population where these injuries are more commonly seen, the therapy consists of complete rest and non-weight bearing then progress with light activity and running at 8-10 weeks, with a goal to return to full activity in sports at 12 weeks following the injury. This patient followed a similar course of therapy but because of age and the idea was she would not need longer to heal based on her having a fused growth plate we were more aggressive with her return to running. Therefore, she was non-weight bearing and did core and hip strengthening for one month and then gradually progressed to running using AlterG at 4 weeks and typical road jogging in 6 weeks. After 3 months she had completed a 7 mile long run and had been able to start kicking and swimming. At 16 weeks from injury, she still reports little to no pain and is currently back to training for Ironman competitions.