Author: Brett Bentley, MD
Co Author #1: James B. Robinson

Patient Presentation:
This is an incoming freshman track athlete who presented to our office for a pre-participation exam.

History:
A hammer thrower accepted a scholarship to throw collegiately. In the fall of his senior year of high school, he began to note vague right knee and thigh pain. Initially, he shrugged this off as expected musculoskeletal pain related to his heavy load of weight-lifting and the sequelae from a sport that requires significant rotational torque on his right lower extremity - in this case, his plant leg.
As the months passed, the pain intensified. Cyclical in nature, he would experience 5 days of excruciating thigh and knee pain that would respond to rest, ice, NSAIDs, and a neoprene sleeve. The pain would then subside for 2-3 weeks but would inevitably return. Initially this pain was aggravated only by activities that required significant quadriceps activation - most notably knee flexion past 90 degrees on squats and deadlifts - but eventually this pain would present even during everyday activities such as rising from a seated position and ascending stairs. He also noted swelling in his lower thigh - initially described as "fullness" in his quadriceps, later as a "golf ball-sized knob." The area of swelling was often warm to the touch as well.
When the symptoms continued to recur, he sought the attention of two sports medicine physicians, a chiropractor and a physical therapist, and received an array of possible diagnoses. During the subsequent months, he would undergo multi-modal physical therapy. He also had three x-rays of his knee and received two intra-articular corticosteroid injections. His pain would respond briefly to these treatments but his symptoms would invariably return.

Physical Exam:
Vitals: within normal limits
General: Well-nourished, in no acute distress.
Cardiopulmonary: Regular rate and rhythm, no murmur, lungs clear bilaterally.
Abdominal: Soft, nontender. Positive bowel sounds.
Extremities: Full ROM and 5/5 strength bilaterally throughout. Mass palpated beneath the vastus medialis oblique. Warm to the touch. Pain with deep knee flexion.
Neurological: Alert and oriented x 3. No focal deficits.
Psychiatric: Appropriate mood and affect.

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