Vague, Non-palpable Hip Pain In A Runner

Abstract

HISTORY: A 54-year-old female experienced runner presented to a sports medicine center with six months of insidious left anterior hip pain and hip weakness while training for a marathon. She had run 9 previous marathons but this was to be her first in 7 years. The pain was in the left anterolateral hip with occasional radiation into the left groin. She had noted some left hip weakness while hiking and also noticed a change in her running stride. She could not correlate any particular movement or activity with the pain but it was more noticeable while running. She denied any trauma, prior hip injury, back pain, numbness or tingling. PHYSICAL EXAMINATION: The patient had decreased single leg balance, left worse than right, and overall unsteadiness with deep squatting. She had mild tenderness to palpation along the left iliac crest and left sacroiliac joint. There was full painless range of motion of her lumbar spine, bilateral hips, knees and ankles. Manual muscle testing showed 4/5 right and 4-/5 left hip flexion strength but was otherwise 5/5 in the bilateral lower extremities. She had a positive left Ober's sign and positive left Thomas test. Reflexes were 2+ and symmetric in her lower extremities. Sensation to light touch was intact bilaterally. Her femoral and dorsalis pedis pulses were palpated bilaterally and were normal. Overall there was a noticeable inability to reproduce her pain on PHYSICAL EXAMINATION. DIFFERENTIAL DIAGNOSIS: 1. Iliopsoas strain/bursitis 2. Femoral stress fracture 3. Gluteal tendinopathy 4. Acetabular labral tear 5. Pelvic mass TEST AND RESULTS: X-rays of the pelvis and a pelvic MRI were ordered. X-rays showed mild degenerative changes of the pubic symphysis but were otherwise normal. Pelvis MRI found a large 23.6 × 13.4 × 20.7 cm cystic mass within the pelvic cavity. FINAL WORKING DIAGNOSIS: Benign serous cystadenoma TREATMENT AND OUTCOMES: 1. Gynecology referral. 2. Exploratory laparotomy and left salpingo-oophorectomy. 3. The pelvic mass was completely resected and the final pathology was consistent with a benign serous cystadenoma. 4. 2 months after resection the patient began a rehabilitation program with a clinical exercise physiologist focusing on core strengthening and pelvic stabilization exercises. 5. Resumed running and 4 months after resection completed 10K of the 2010 Chicago marathon.