Thigh Pain In A Adoloscent Female Tri-athlete

Abstract

HISTORY: An 18 year old national female tri-athlete presented with gradual discomfort in the right gluteal and proximal thigh area, which was aggrevated by sitting and climbing stairs and exercises that include squatting. Neither distal paraesthesia nor weakness of the posterior thigh and calf or lower back pain was reported. During the past 2 years several stress fractures occured at multiple sites. During this period the athlete was treated for an ongoing hamstring problem on the right side. The athlete also experienced a low body mass, amenorrhea and decreased bone density. A previous resection of colon and small bowel was performed after the diagnosis of Crohn's disease.At the time of the visit loose and unformed stools were confirmed. PHYSICAL EXAMINATION: At the affected side, tenderness over the insertion of piriformis and reduced passive internal hip rotation could be clearly demonstarted. Pain occured with resisted abduction with the hip in adduction and flexion as well as in external rotation with the hip and knee flexed. No discomfort with deep palpitation over the area of the hamstring insertion could be demonstarted. There was discomfort on deep palpitation over the muscle belly of the proximal hamstring. With biofeedback evaluation, acceptable low threshold, but weak rotational core stability was confirmed. Abnormal neuromuscular firing with hip extension, on the affected side, was positive. Examination of the back was within normal limits. Skeletal point tenderness at several sites remained negative. DIFFERENTIAL DIAGNOSIS: Chronic Piriformis Strain, Piriformis Syndrome, Apophysitis, Avulsion Fracture, Stress Fracture TEST AND RESULTS: Ultrasound Thigh:Normal. Blood:Thyroid Antibodies, Hemoglobin, Thyroid Functions and Sexual Hormones were all normal. FINAL WORKING DIAGNOSIS: Chronic Piriformis Strain TREATMENT AND OUTCOMES: PHYSICAL THERAPY: Deep tissue mobilization. Restoration of neuromuscular firing pattern. Rotational core stability STRENGTH AND CONDITIONING: Strengthening of adductors and abductors Swimming and cycling DIETARY: Increase in body mass. Energy and water intake during intensive training and races. Controll of Crohn's disease and amenorrhea. Advice on safe participation