Lower Extremity Recurring Injuries In A Young Male Soccer Player

HISTORY:A 15-year-old male high school and club soccer player presented to clinic over 2 years with multiple leg injuries, none linked to a specific incident. He was initially seen for 2 weeks of right lateral leg pain and 6 months of right posterior hip pain. The hip pain improved with rest but returned a month before presentation to clinic with increased activity. Two weeks before presentation, the pain evolved to include his lateral leg. There was pain with walking, running, and at rest. PHYSICAL EXAMINATION: Examination revealed a BMI 19.58 kg/m2. He had tenderness with palpation over the ischial tuberosity and femur and a positive fulcrum test of the proximal femur. He had pain with single leg hop, and there was lateral thigh pain with passive logroll and FADIR. DIFFERENTIAL DIAGNOSIS: 1. Stress vs pathological fracture of femur, tibia, and fibula 2. Muscle strain 3. Apophysitis 4. Relative Energy Deficiency in Sport (REDS) vs Overtraining Syndrome TEST AND RESULTS: Pelvic and right femur radiographs-Skeletally immature, bone stress injury (BSI) of the mid femur, and stress at proximal hamstring insertion of the ischium. MRIs of right femur - Apophysitis, proximal hamstring partial tear, and acute on chronic BSI of the femur; improved on repeat MRI. MRIs of bilateral tibia/fibula - Bilateral tibia BSI; subsequent left tibial delayed healing; followed by recurrence of bilateral tibia BSI. DEXA Scan: normal bone density Vitamin D (VD):13 (Low); Parathyroid (PTH): 91 (High) ; CBC, Thyroid activity, and Ferritin normal FINAL WORKING DIAGNOSIS: BSI to Femur and Recurring BSI to Bilateral Tibia in the setting of possible REDS, VD Deficiency, and High PTH TREATMENT AND OUTCOMES:1.Initially non-weightbearing. Resolution of hip and leg pain by 3 months. 2.5 months after return to sport (RTS), lower leg pain and bilateral tibial BSI on MRI.3. REDS evaluation showed low VD and high PTH; calcium and VD prescribed, and a sports dietician was consulted. 4.3 months post second injury (PSI) and after RTS, left leg pain and delayed healing of left tibia on MRI; bone stimulator started. VD and PTH normalized. 5.8 months PSI, pain resolved. Patient returned to occasional running. 6.1 month after RTS, lower leg pain and recurrence of bilateral BSI on MRI; bone stimulator restarted; PT and endocrinology referral; Patient not currently playing soccer.