P3.249: Pursuit of a Full Night’s Sleep

Introduction: As hip pain increases in pediatric athletes, it’s essential to maintain a wide differential. With consideration of impingement, necrosis, tears, or even neoplasm, workup and management of hip pain is vast, sometimes without improvement. Knowing specific, distinguishing symptoms can help pinpoint a diagnosis.

Case Description: A 12-year-old female presents to the Sports Medicine Clinic for left hip pain. Pain of the anterior hip began 8 months prior as an insidious onset ache that radiates distally. Despite 2 months of physical therapy prior to clinic visit, no improvement is seen. The 8/10 pain worsens with prolonged sitting and activity and has a mild response to NSAIDs. She maintains full weight bearing status. No fevers, weight loss, or abnormal bruising, are noted, however pain wakes her from sleep nightly. No pertinent medical or family history. She participates in volleyball and running.

Physical exam shows a healthy female with antalgic gait pattern of left lower extremity. Tenderness to palpation over left anterior superior iliac spine. Full active and passive flexion and extension. Significant limitations of internal rotation and external rotation of the left hip compared to right hip. Left lower extremity strength 4/5. Lateral weight shift to right lower extremity for running, jumping, and squatting. Positive Trendelenburg, Faber, and Ely’s testing.

Initial outside hip x-ray read as no acute bone abnormality. Secondary x-ray in clinic reads as possible left greater than right acetabular impingement. CT reads as osseous lesion and sclerosis in lateral aspect of left acetabulum. MRI reads as extensive bone marrow edema with rounded lesion throughout left ileum. Findings most compatible with 0.4 cm osteoid osteoma.

Discussion: Pediatric hip osteoid osteomas rarely present, but when they do, they are often misdiagnosed. Consequently, improper interventions are undergone, resulting in refractory pain. Osteoid osteomas present as nighttime pain relieved with NSAID use in 90% of cases. If these complaints occur in conjunction with exam findings, imaging is essential. CT scans can provide a definitive diagnosis, as specific sclerosis and cortical thickening of the acetabulum is seen. By obtaining imaging sooner, diagnosis of osteoid osteoma is streamlined, intervention is initiated, and return to activity occurs sooner.

Conclusion: After diagnosis, this athlete was referred to an oncologic orthopedic surgeon. She underwent a CT guided microwave ablation and biopsy to remove the benign lesion. Immediately after, she was full weight bearing, ambulating with minimal pain. Even more so, the patient slept incredibly well that night, without waking. It was the first time in 8 months this happened. A routine follow up was scheduled 4/7/25 to discuss return to activity.

Ultimately, this case highlights how to pinpoint an osteoid osteoma diagnosis. Osteoid osteomas should always be considered early so that months of activity and full nights of sleep are not lost.