This 16-year old female soccer athlete experienced hip pain and audible snapping of the right and left hips with exercise. She failed over three years of physical therapy, activity modification, and anti-inflammatory agents.
The athlete suffered from constant anterior hip pain. She had pain when she sat, stood, walked, or climbed stairs. There was pain with active hip flexion as well as audible snapping. She also experienced some radiating pain in the anterior thigh with local parathesia. She suffered from low back pain begining in October, 1997. The back pain was present in conjunction with the hip pain and located over the lumbar spine at the L3-4 and 4-5 area. There was tenderness over the sciatic notch more on the right than the left. She also had persistent headaches.
The differentail diagnosis includes: snapping of the iliopectineal bursa, labrum injury, entrapment or irritation of lateral femoral cutaneous nerve, referred pathology from low back, femoral hernias, fibromyalgia or reflex neurovascular dystrophy.
MRI on the spine- normal; bone scan of hips- negative; plain films of spine- normal; plain films of hips- normal; MRI of hip and pelvis- nondiagnostic; ultrasound- shows iliopsoas snapping on both right and left sides; blood tests- normal; MR arthrography under x-ray guidance on right hip- ruled out labral tear; and evaluation for fibromyalgia negative.
Resticted activity in soccer as well as physical education which was followed by periods of rest. No improvement was noted through this period of restricted activity. Patient referred to a physical therapist where she received a biomechanical gait analysis and was constructed orthotics. She received ultrasound, massage therapy and stretched. Condition improved to the point where she could run cross country, but pain increased with runing and all activity was stopped. Oruvail prescribed. Tried deep massage, mild strengthening programs, long stretches and pressure-point therapy. Tried Nortriptyline, Prednisone, Neurontin, and Imitrex and Prozac (for migranes). Diagnosis is contracted (snapping) bilateral iliopsoas tendons. In December of 1998, patient underwent right iliopsoas release. Improvement in headaches, back pain, and hip pain slightly decreased; snapping continued. She experienced some numbness in her thigh and lower leg that did not disappear within 11 months. Persistent snapping in both right and left. In November of 1999, she underwent bilateral iliopsoas releases. Patient experiences numbness in left thigh as well. Return to physical therapy recommended six weeks after most recent surgery. Hopeful result is a full return to normal activities and the reduction or elimination of iliopsoas snapping.
This is unusual because the cause of this hip pain has been reported only sporadically, usually affecting young and active patients. The nature of abnormality is uncertain but may relate to the size of the iliopectineal ridge. The surgical treatment of this syndrome is not widely known.