In July 2018, a 14-year and 9-month-old Caucasian male patient, in good general health, presented with an onset of acute pain while attempting a kick with his contralateral leg during an amateur football match. He, also, noticed that an ecchymosis in the dorsal aspect of the left thigh formed shortly after the traumatic event. He presumed, with no medical consultation, that the acute event was a muscle tear of the hamstrings and dealt with it as such.
In September 2018, he consulted an orthopedic surgeon complaining of pain in the dorsal aspect of the left thigh and buttock for 3 months and difficulty walking, resulting in a slight limp. The pain worsened during exercise and an extended period of walking and radiated to the groin area and toward the dorsal and lateral periphery of the left buttock and thigh during physical activity. During clinical examination, range of motion of the left hip is slightly impaired due to pain with particular exacerbation during flexion. Straight leg rise was about 70 , 15 lower compared to the right hip. Neither neurological and vascular symptoms or signs nor involvement of other musculoskeletal components were detected. The patient underwent frontal radiographic examination of the pelvis and hip (Fig. 1a) that showed irregularity of the inferior margin of the left ischial tuberosity with fragmentation and avulsion of the apophysis and also ultrasonography of the area that was normal. A tumor could not be excluded from the differential diagnosis yet, so follow-up was crucial.
After about 9 months, later than the follow-up that was advised, in which the patient was prescribed with rest and painkillers and saw great improvement, he underwent full investigation that included another radiographic examination (Fig. 1b) that was unchanged compared to the previous one, computed tomography (CT) (Fig. 2), MRI (Fig. 3), Technetium99 scintigraphic scan (Fig. 4), and blood analysis. The CT scan (bony window) confirmed the diagnosis as apophysitis of the ischial tuberosity, as it showed enlargement of the left ischial tuberosity with irregularity of its inferior margin and focal sclerosis. The MRI showed apophyseal avulsion with marrow edema and widening of the apophysis and focal edema of the insertion of the hamstrings. Blood analysis had no pathological findings (white blood count 6350 with neutrophil 57%, erythrocyte sedimentation rate 4, and alkaline phosphatase 187 IU/l). Finally, in the bone scintigraphic scan, there was an increased blood flow in the ischial tuberosity, compatible with the diagnosis, and a slight increase of the bone metabolism in the left ischial body (posterior view) and the anterior-lateral aspect of the left femoral diaphysis due to a known non-ossifying fibroma.
With the entire investigation concluded, the diagnosis is confirmed as an apophysitis of the ischial tuberosity. The patient is treated with rest, physical therapy, and painkillers.