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Forum Name: Bone trauma and fractures

Question: Possible SCFE???


 Erin-Michelle - Sun Dec 26, 2004 8:45 pm

Hey!

I promise I've been to the doctor, but he's being extremely optimistic and perhaps a little oblivious. I'm glad to have found this site, though.

Now for my problem to see if anyone has an idea! These details are relevant: I'm a 16 year old girl, I weigh about 120 pounds, I'm 5'7" or 5'8", eight inches of that height was acquired over the course of three years (12/00 to 12/03), and I still have open growth plates. Anyway, in mid-October, I was walking around in school and suddenly an excruciating pain made itself known in the side of my left hip. For the rest of that day I was forced to use crutches because it hurt too much to use that leg. The pain was gone the next day, and started to disappear and reappear on an every-other-day basis for the next two weeks. I saw my orthopedic doctor (who also happens to be a hip specialist) after about 5 days of it because it was rather painful and annoying. He did ROM tests and found nothing wrong. About six weeks later I convinced my mom to take me in for another appointment. This time he took X-rays that he interpreted as "perfectly normal," told me it was probably inflammation, and diagnosed snapping hip syndrome. I was sent to physical therapy for the next two weeks to try to work out my issues via strengthening and the ASTYM system. Since about the 16th of November, I have been moving around outside my home on crutches. When I don't use them I get a "catching" feeling in my hip joints. My PT diagnosed me as having iliotibial band syndrome (almost "textbook", according to her), which accounted for the recent pain on the sides of my thighs that had developed in the last day or so, but on my second appointment, I puzzled her by expressing the fact that certain movements caused pain when I guess they shouldn't have (squeezing a partially inflated ball between my knees caused groin pain). On my follow-up appointment with my doctor, I relayed to him all the different movements that cause pain. Hugging my thighs with knees bent up to my chest, hopping on one foot, and lying supine and making a "4" with my legs all hurt. The pain is bilateral, too. He sent me to have an MRI done the next day, and I have an appointment with him tomorrow to look at the results. The funny thing about the MRI (it took about 45 minutes) is that when it was done, and I tried to get up, my hips were so stiff that I had trouble moving them without pain for a couple minutes. Also, the same cycle of symptoms (sharp pain, on-off catching, two or three days of muscular soreness, and finally daily pain) began in my right hip in late November. Now I just hop around on my crutches.

The pain that I feel is rather nondescript and hard to pinpoint. It moves up and down the front of my thighs and sometimes goes to my knees, I have groin pain, and sometimes it's just a very annoying ache that is just "in my hips." It's only a burning pain on the outside of my hips because I have bursitis there since my PT got a little overzealous with the ASTYM. Because I have been slow to mature, I'm wondering if, even at my age, I have developed an early stage of Slipped Capital Femoral Epiphysis. All my symptoms seem to match according to what I can find online, and the only areas that I don't fit the profile in are the facts that I'm not a boy, I'm older than most girls who develop that problem and have begun menstruating, and I'm about the furthest thing from obese. Obviously, though, I also had my growth spurt later than most girls do. I ride horseback, and over the summer I did have a bit of an accident. The horse reared and threw itself down onto the ground while I was still mounted. The girl who was watching said that for an instant he was lying on my leg; I was focusing on my head as it hit the ground and didn't notice that part of it! :lol My question is this: is there anyone here who could tell me if what I'm feeling sounds right for SCFE? Another thing, too. I looked up info about the possibility of iliopsoas/iliopectineal bursitis as a possible cause of my groin pain, and some sources said that Thomas' test was always positive in that case. I did it, and my knees were nice and flat.


Thanks for your time,
Erin-Michelle
 Theresa Jones, RN - Mon Dec 27, 2004 8:17 am

User avatar Hi Erin-Michelle,
The hip is a ball and socket joint. The ball is connected to the femur (thigh bone) by a growth plate. As the growth of the femur slows down, the ball can slip. If this occurs it can cause the leg to turn outwards by changing the shape of the top of the femur. SCFE causes severe pain. It affects both boys and girls. There may be a link between increased weight,(of course not in your case), the shape and position of the femur(thigh bone) (called retroversion) and the hormones of puberty. Have anomolies in the shape/structure been ruled out? Without treatment, SCFE worsens and may cause arthritis in the hip. Keep in mind that sudden growth spurts may also cause severe upper leg and hip pain. Also a condition called iliopsoas syndrome may make one have pain in the hip and thigh region, as well as hip stiffness and in some cases a clicking or snapping hip. A physiotherapist should be able to diagnose the condition through manual tests, but it can be confirmed by an ultrasound or MRI scan. Treatment for this syndrome is to allow the condition to settle down and pain to decrease through rest, electrotherapy and anti-inflammatory medications. Once achieved, a 6 week program of flexibility and strengthening exercises for muscles around the hip can begin. In my opinion taking into consideration your injury, I would give more consideration to iliopsoas syndrome. I'm certainly glad to hear that your condition is being evaluated with testing and I hope all turns out well.
Sincerely,
Rntdj
 Erin-Michelle - Sat Jan 01, 2005 2:37 pm

This is exceedingly frustrating. The MRI came back completely normal--indicating that I do not have bursitis in any form around any area of my hips. The only finding was that of some excess fluid around the hip joints which was ruled to be normal. Unfortunately, my physical therapist has informed me that by now they should be seeing results (after 5+ sessions), and if after the two sessions that I have this week there aren't any results, we should discontinue therapy because it will not help. My older sister suggested the shoes I wear on occasion as the cause of my misery, and I will admit that I do wear boots with 3-inch heels. So lately I have refrained from wearing the boots and have either walked around barefoot or in flat-soled shoes. Yesterday I took a "test drive" on my legs with flat shoes in several stores. Within 10 minutes of walking I was in pain, and about a half hour later my left hip developed the "catching" sensation that I know only too well. It is painful and causes me to straighten the leg that feels that way and walk with it turned out. Since last night, I have been experiencing intense pain around the left iliac crest upon flexion and walking--and it kills!!!!. I'm not sure what is going on, and as my doctor does not know either, and my mother has decided to "let it go for several months", I am willing to look elsewhere for advice. The next medical step that we have set up is to obtain a third opinion from my orthopedic doctor's colleague. Any other ideas?

Erin-Michelle :?
 Dr. A. Saif - Sun Jan 02, 2005 11:35 am

User avatar Dear Erin,

Sorry to hear of your discomfort...I take it from the signature, that you are a keen rider? I have daughters who are mad on the critters themselves, and have been driven to poverty by the animals.

Judging by your story, I reckon SCFE is probably unlikley. SCFE pain is typically in the groin, although occasionally it is referred to the knee. It may on the late stages make you wake with your leg turned outwards, as you describe, but by this time it is usually obvious on X-rays. Diffuse pain is possible with this as well, and the pain up and down the thigh is again atypical. Certainly and MRI would be diagnostic, a bone scan, although less specific would certainly be able to identify the actual site of the problem.

Problems such as labral tears (damage to the lip of the socket of the hip joint), can cause clicking in the hip joint, and an MRI can sometimes pick this up. It is also rare. Personally I guess the problem most likely is as your specialist and your PT (AKA physio-terrorists) suspects. Both the Ilio-tibial band syndrome and the "snapping hip syndrome" are similar conditions. This is more common in females (wider hips, you see). The Iliotibial band is a strong tissue, like a ligament, extending from your Iliac Crest to just below you knee. The snapping is induced by a thickened part part of this band flicking over the greater trochanter (GT), the prominence of your femur at your hip. This thickening can be natural, but the flicking that occurs over the GT causes more fibrosis, and more thickening, exaggerating the symptoms. PT helps by stertching the tissues, and also local interferential treatment may reduce the local inflammatory thickening. If this and other conservative measures fail we can always operate...the procedure is a Z-plasty of the IT band which reduces the tightness of the tissue. The procedure works in about 80% of the patients who have it and there is a chance of recurrence despite surgery, so I would think your orthopaedic surgeon is quite right not to jump to it straight away.

You are right that all the features are not entirely consistent with this diagnosis, but most of what you say seems to point in this direction.

Hope this helps, Erin, and good luck!

Saif
 Erin-Michelle - Mon Jan 03, 2005 8:20 pm

Thanks, Dr. Saif, for your concern :) , and, yes, I am horse crazy. I'm going to keep posting even if you all become bored in reading it so that maybe if anyone else comes along with my same symptoms then there will be an answer (or a possible rebuttal to accusations of hypochondria! :lol: ).

My physical therapy is almost over but not because I'm graduating; rather, I am being "kicked out" because there has been no improvement in my symptoms besides removing the fibrosis in my thighs with the ASTYM. I guess that after this coming Thursday, I will be immediately referred to the pediatric orthopedic specialist of whom I spoke earlier. Looking back, I was a little scatterbrained in describing my symptoms; those weren't all of them. Most of the pain that I do have is in my hips, mainly along the junction of my hips and legs (groin, I think? :shock: ), and sometimes higher. The thigh thing was probably what I was feeling at the time. There is a definite, without-a-doubt connection between walking and the symptoms.
Oh dear, I''m repeating myself; sorry. The tendon that causes the snapping is not the ilio-tibial band; it's one that's on the inside of my hips around the inferior pubic ramus (i'll pretend I know what I'm talking about). It makes racket or moves around when I abduct my hips, and that same area hurts when I adduct them. It feels like something is being squished in my groin when I flex my hips. My physio-terrorist :lol: tested the psoas muscle today to see if it is too tight; it isn't...yay!! Everyone who is working with me says that I don't really have any issues with the ilio-tibial band besides tightness (no syndrome), so, besides that, is there any possible explanation except hypochondria? :lol:

Later,
Erin
 Dr. A. Saif - Thu Jan 06, 2005 2:39 pm

User avatar Dera Erin,

It is fair to say that by the end of your research into your condition you may well be qualified to give instructions to me about peculiar hip pains...

As before, a bit tricky to daignose without you in front of me...but if the pain is on the inner side of the thigh, then clearly ITS and SHS are unlikely. Groin pains can be due to adductor tendinitis, once we have decided that there is no joint pathology (which we seem to have done). This would make it difficult to squeeze a ball between your legs. It is aggravated by moving the legs away from the center, and resisted adduction, (e.g. squeezing something between your legs) would increase pain. The cause is an inflammation of the tendon of the muscles that normally bring your legs together, the adductors. This tendon attaches itself roughly to the area you seem to be describing.

Adductor tendinitis can be picked up on MRI, but the scans need to be directed with this in mind. It may respond to interferential treatment to this area, by your physiotherapist, but sadly it appears that he/she is about to give up on you...oh well. Intervention in the way of a local injection of steroids may also help.

Regards

Saif

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