HIP PAIN IN A HOCKEY PLAYER

HISTORY: An 11 year old boy presented with a one year history of right hip pain. He first complained of pain after competing in a long jump event. For the following year, he has had worsening limp and pain with running and walking. He is able to play hockey with only mild discomfort. His mother noted that he was “the fastest kid in the class but now is slower”. The patient had no constitutional symptoms. His past medical history is unremarkable. His medications included nasal corticosteroids for seasonal rhinitis. PHYSICAL EXAMINATION: The patient was appropriately developed for his stated age. Lower extremities alignment showed genu valgus. There was an apparent pelvic obliquity and leg length discrepancy in the standing position. Leg length measurements were 77 cm on right, and 76.3 cm on left from ASIS to medial malleolus. Examination of the spine showed very slight spinal asymmetry of the thoracic spine to the right and the lumbar spine to the left. The right posterior superior iliac spine was higher on the right than the left on standing and was slightly was tender on direct palpation. On examination of the hips, he had tenderness over the right inguinal and femoral triangle area. ROM hips right IR 15 degrees, ER 30 degrees, left IR 50 degrees, ER 45 degrees. There was a palpable clunk of the iliopsoas tendon with flexion and extension of the right hip. Neurological exam revealed 4+/5 strength on the right extensor hallucis longus and extensor digitorum. Quadriceps, hamstring and hip flexor strength was normal. Sensation was decreased to pinprick from the right ankle down throughout the foot. On gait exam, the patient had no pain but circumducted the right pelvis and hip. DIFFERENTIAL DIAGNOSIS: Right Slipped Capital Femoral Epiphysis Legg-Calves-Perthes Disease Hip flexor tendinopathy Sacroiliac joint dysfunction Sacroilitis Artbritis Mass lesion pelvis or spine EXAMINATIONS: X-ray Pelvis and Hips - No bony abnormality, no SCFE, no LCPD. Bone Scan - Pelvis and hips within normal limits. X-rays Scoliosis Views- 7 degree curve. Blood work WBC 4.3, Plt 287, ESR 4, RF 3, ANA negative, Lyme disease negative CT Pelvis - no pelvic mass MRI Spine - no spinal cord lesion/mass MRI hips - right-sided hip effusion with some edema and cortical irregularity FINAL/WORKING DIAGNOSIS: Jurvenile Rheumatoid Arthritis TREATMENT: Initial course - physical therapy, patient allowed to play hockey but avoided painful activities including running Referred for manual therapy. Referred to Orthopedics and Rheumatology. Physical therapy remains focus of treatment plan.

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