Right Leg Spasms And Fasciculations - Slide Tackle During A Soccer Match

HISTORY: 15-year-old female, competitive high school soccer player with no prior PMH, presented to our clinic with intermittent, spontaneous sharp pains and aching of her right “hamstrings”, tremoring of her right “quadriceps”, right knee buckling, lower back pain with movement, and headaches. 4 months prior, she initially overextended her right leg while performing a slide tackle during a soccer match. 5 weeks later and 2 weeks into PT for the initial injury, she felt a “pulling sensation” in her hamstring while bending over to pick up her younger brother of 25 pounds. Patient saw multiple specialists at several different institutions before coming to our clinic initially and after, many of whom associated her symptoms with depression/somatization. PHYSICAL EXAMINATION: Lower back appeared symmetrical without significant curvature. No vertebral point tenderness. No SI joint tenderness. Negative straight leg tests. Left quadriceps strength 5/5, right quadriceps strength 4/5 with flexion spasticity. Right quadriceps also exhibited clonus with rhythmic contraction about every 3-5 seconds, worsened with intention. Right knee extension strength 4/5. Strength of adductors, hamstrings, and iliopsoas 5/5 bilaterally. DTRs left patellar/Achilles 2+, DTRs right patellar/Achilles 4+/3+. Sensorium grossly intact. DIFFERENTIAL DIAGNOSIS: 1. Femoral nerve adhesion 2. Functional movement disorder 3. MS 4. Neuroforaminal stenosis 5. Somatization TEST AND RESULTS: MRI right femur w/o contrast —unremarkable MRI lumbar spine w/o contrast —minimal disc bulging at L3-L4 CT brain —unremarkable MRI brain, cervical spine, thoracic spine, hips/pelvis w and w/o contrast —unremarkable EMG/NCS —spontaneous activity on right lumbar paraspinal muscles LP/CSF fluid studies —normal opening pressure, negative ab tests FINAL WORKING DIAGNOSIS: CRPS TREATMENT AND OUTCOMES: 1. Office U/S revealed right vastus intermedius twitching 2. PT 5 days/week worsened right quad tremor 3. U/S guided femoral nerve hydrodissection reduced right leg twitching for a day 4. CRPS diagnosed at another facility after further review of history and U/S procedure result 5. Gabapentin titrated up to 900 mg TID, symptoms gradually improved over several months 6. By 17 y.o., patient returned to play and signed LOI to play collegiate soccer