The subject of this case report and her parents were informed that the data concerning the case would be submitted for publication and provided consent. A 15-year-old United States of America Gymnastics (USAG) level 9 gymnast presented with right hamstring pain after regular practice. She had been diagnosed with isolated GHD at age 4 and treated with growth hormone replacement therapy until age 14. After cessation of the HGH intervention, she continued to have normal physical growth, as indicated by records from her pediatric endocrinologist. She had delayed menarche at 16 years and had a history of secondary amenorrhea despite normal weight for her age.
Six months before presentation, she experienced the insidious onset of dull, aching pain in her right hamstring, near the junction of the thigh and buttocks, that was believed to be the result of a chronic hamstring strain. The pain increased gradually over a year and was relieved with rest, massage, and dry needling. Two days before presentation, she felt a "snap" and pain while performing a switch leap during regular practice. She had sharp localized pain in the proximal hamstring with walking and sitting.
Upon physical examination, the subject had tenderness over the ischial tuberosity and painful restriction of right hip flexion, especially with knee extension in this position. Although radiographs were normal, computed tomography showed an asymmetric 6-mm widening in the right ischial tuberosity epiphysis compared with the other side (Figure 1). Magnetic resonance imaging of the pelvis showed edema of the ischium near the origin of the hamstring tendon at the fracture site (Figure 2). She was diagnosed with a Type 2 avulsion fracture of the ischial tuberosity (displacement of 0-2 cm) according to the classification system proposed by McKinney et al. She chose nonoperative treatment and was subsequently treated with rest, ice, and non-weightbearing ambulation with crutches. Her serum growth hormone level (327 pmol/L) was within normal range. Radiography indicated a bone age of 13 years, but her chronologic age was 15 years 4 months.
The subject was advised to continue to be non-weightbearing until she was pain-free with radiographic fracture healing, which occurred three months after the injury.
The subject underwent rehabilitation with the athletic trainer. Starting three months post injury, her rehabilitation was focused on gaining hip range of motion for two weeks followed by strengthening of hip, lower extremity and core muscles, and gait training. Patient also underwent training for proprioception, running, and sprinting. She was then allowed to begin vault training at four months, and running at five months, after her injury. She could perform switch leaps and splits seven months after injury. She participated in a USAG level 9 competition 12 months after the initial injury. At a three-year follow-up, she continued to practice gymnastics and compete in level 10 USGA competitions without any symptoms related to her avulsion fracture of the ischial tuberosity.