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Left Gluteal Pain And Leg Weakness In A High School Football Player - Page #1
 

Author: Janine Wong, DO, MS
Senior Editor: Justin Mark Young, MD
Editor: Anthony Kwon, MD

Patient Presentation:
The patient is a 15 year old male with no significant past medical history who presented to the pediatric emergency department with a complaint of left gluteal pain and left leg weakness.

History:
The patient was playing in a junior varsity football game for his high school and was blocking when he had an acute onset of left gluteal pain and leg weakness. The patient was pulled from the game and reported difficulty walking and dorsiflexing his left foot which prompted further evaluation in the emergency department. He denied any trauma to his low back or left leg, but reported that he is very active and often lifts heavy weights. He denied any bladder or bowel incontinence. Notably, he reported that for a few weeks prior, he had muscle pain in his left gluteus, which was manageable with Tylenol, Ibuprofen, and stretches. He denied any leg weakness prior to the football game or constitutional symptoms.

Physical Exam:
The patient was in no acute distress. There was no tenderness to palpation along lumbar spinous processes or paraspinal muscles bilaterally. Range of motion of hip flexion and hip abduction were limited due to pain in gluteus. Decreased sensation was noted in left anterior shin and foot. There was 3/5 strength with left foot dorsiflexion, 5/5 strength with plantarflexion bilaterally, and 5/5 strength with straight leg knee extension bilaterally. The remainder of his exam was otherwise unremarkable.

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NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.
 

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