Medicine & Science in Sports & Exercise:
May 2006 - Volume 38 - Issue 5 - p S129-S130
Presidential Closing Remarks 12:05 PM - 12:15 PM: Immediately Following President's Lectures ROOM: Ballroom 2/3 and Ballroom 1: A-22 Clinical Case Slide - Pediatric Issues: WEDNESDAY, MAY 31, 2006 9:30 AM - 11:30 AM: ROOM: 709
HISTORY: C.D. is an 18 y.o. male who presents with a 3 month history of right knee pain. He denies any history of trauma or previous injury. He played organized sports in high school, and currently plays pick-up games of basketball and baseball with friends. He localizes the pain to the anterior aspect of his knee, medial to the patella. He can't pinpoint an area of maximal tenderness. He denies mechanical symptoms, but does state the knee occasionally gives way when he's walking. He has pain at night, occasionally waking him from sleep, but denies any constitutional symptoms. He has a positive theater sign, and states the pain worsens with climbing stairs. He has no neurologic complaints.
One Primary Care Physician and two Orthopedic Surgeons evaluated C.D. prior to his presentation in our clinic. He followed a prescribed physical therapy regimen for patellofemoral dysfunction for 1 month with no change in function or pain. Previous radiographs of the knee were normal, and an MRI showed only slight patellar chondromalacia. Blood work, including CBC, ESR, CRP, Rh factor, ANA and uric acid, was normal.
PHYSICAL EXAMINATION: No swelling, erythema or discoloration. Tenderness to palpation is present over the medial and superior-lateral aspect of right knee. All ligamentous and mensical testing is normal. Flexibility testing significant for 100 degree popliteal angle bilaterally. Functional testing normal. Hip range of motion showed 5 degrees of internal rotation on the right, 40 degrees on the left, with external rotation 60 degrees bilaterally.
DIFFERENTIAL DIAGNOSIS:
1. Patellofemoral dysfunction
2. Avulsion fracture of the lesser trochanter
3. Labral tear of hip
4. Slipped Capital Femoral Epiphysis
5. Malignancy in hip
TEST AND RESULTS: Hip and femur radiographs:
- Focal calcification anterior to the trochanteric region of the proximal right femur, with no specific osseous abnormality of the underlying femur
- Area of myositis ossificans measures 8.4 cm in vertical axis and 2.6 cm in horizontal axis
FINAL/WORKING DIAGNOSIS:
Right Patellofemoral Dysfunction secondary to decreased internal rotation of the hip as a result of myositis ossificans
TREATMENT AND OUTCOMES:
1. Held from sports
2. Started on diclofenac for pain control
3. Physical therapy to increase range of motion of hip
4. Follow-up four weeks after diagnosis showed a 5 degree improvement in internal rotation of hip, with a 80-90% decrease in.