Lower Extremity Pain And Weakness In A Recreational Runner

HISTORY: This patient is a 22 year old F recreational runner with PMH significant for L lateral meniscectomy 3 months prior to presentation. She was originally referred by PCP for continued management of a grade 1 stress injury of the L tibia. Her tibial pain improved with 8 weeks of immobilization and rest however she subsequently developed pain in her quadriceps that worsened when she was going up stairs, squatting and standing. Her symptoms did not improve with 8 weeks of physical therapy and reportedly progressed to L sided low back pain, pain in her medial calf and weakness with knee flexion. PHYSICAL EXAMINATION: Initial exam revealed no tenderness to palpation and full, painless range of motion at the hip and spine with negative straight leg testing. Significant findings include 3/5 strength with hip flexion. DIFFERENTIAL DIAGNOSIS: Lumbar Radiculopathy, Obturator Nerve Entrapment, Femoral Stress Fracture TEST AND RESULTS: MRI of the L-spine revealed spondylolysis and annular bulging at the L3-L4 and L4-L5 level with lobular masses in the bilateral L5, S1 and S2 nerve roots with extension into the presacral space suggestive of giant Tarlov Cysts. The mass involving the left L5 nerve root measured at least 2.0 x 2.8 cm. FINAL/WORKING DIAGNOSIS: Lumbar Radiculopathy TREATMENT AND OUTCOMES: • Her symptoms did not respond to a 5 day course of prednisone so she was referred to Neurosurgery who did not recommend any surgical interventions of the Tarlov cysts. She was referred to Pain Management for a left-sided L4-L5 transforaminal injection. She ultimately, she elected to pursue less invasive management. Her pain and weakness began to improve significantly when she started aquatherapy and she was able to reduce her pain while returning to a baseline level of strength.