Author: Faustine Ramirez, MD
Co Author #1: Alan Zhang
Co Author #2: Celina de Borja
Senior Editor: Justin Mark Young, MD
Editor: Shaheen Jadidi, DO

Patient Presentation:
A 14-year-old female soccer player and track sprinter presents with right hip pain for 6 weeks.

History:
The patient's right hip pain began while passing the ball during a soccer game 6 weeks prior to consultation. She denied any popping or snapping sensation during the injury. She was able to finish the game and continue participating in sporting activities afterward, but her pain worsened while sprinting during a subsequent track meet as the beginning of her track season overlapped with her soccer season. Her hip pain was anteromedial, and described as intermittent and sharp. She could ambulate without pain, but her pain was aggravated by running and kicking which improved with rest. Prior to consultation, she had been resting for 2 weeks during which time she participated in at-home quadriceps stretching and strengthening exercises. Her home exercise program led to an improvement in symptoms, but her pain immediately recurred upon return to playing soccer. She also reported weakness affecting her speed and kicking. On review of systems, she denied a lump, swelling or bruising over the painful area, limping, lower extremity radiating pain, numbness, tingling, weakness, bowel/bladder incontinence, or nighttime pain. She had a well-balanced diet and denied any dietary restrictions or special dietary practices. At the initial visit, radiographs showed a normal skeletally immature pelvis with no evidence of avulsion fractures Case Photo #1 . She initiated formal physical therapy and activity modifications (light jogging, soccer drills) for 4 more weeks and experienced improvement in her pain during this period to a point that she was able to return to playing soccer competitively. However, her symptoms recurred upon return to sports, where she was able to play an entire game but only at 30% of her usual performance.

Physical Exam:
Inspection of the right hip and lower extremity revealed no gross deformities, muscle asymmetries, masses, swelling, bruising, or discoloration. There was tenderness to palpation over the medial aspect of the proximal quadriceps, with no palpable defect or mass in the muscle belly. There was no tenderness to palpation over the bony prominences of the pelvis. She had full range of motion at the hip, with pain on passive hip flexion. On provocative testing, she had pain with the Stinchfield and Ludloff maneuvers, and negative log roll, FABER, FADIR, and Scour tests. Her gait was normal and non-antalgic. On functional testing, she had pain with a single leg hop, as well as pain and weakness with a single leg squat.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.