Persistent Lower Back Pain In A Gaelic Footballer: 714 May 30 3 55 PM - 4 15 PM

HISTORY: A 27 year old, male, high-level, Gaelic Football and Hurling player presented to the Sports Medicine Clinic with a 3-year history of gradually deteriorating lower back pain rated 6/10. The pain was exacerbated by activity and improved by rest. He denied any history of trauma. He denied any radiation or radicular symptoms. Three years prior to presentation MRI had demonstrated a Scheuermann’s kyphosis involving T12 with associated disc space narrowing at the T12-L1 level in addition to a transitional S1 vertebra. PHYSICAL EXAM: Visual inspection was unremarkable. There was no pain on palpation over lumbar spine or paraspinal musculature. Lumbar flexion, extension and lateral side flexion were pain free and range of motion was within normal limits. Straight Leg Rise, Schobers and the Femoral Nerve Tension Test were normal. Examination of the hips revealed pain free but restricted internal and external rotation on the right but was otherwise normal. Neurovascular exam of lower limbs was normal. DIFFERENTIAL DIAGNOSIS: 1)Degenerative disc disease. 2)Lumber disc prolapse. 3)Spondylolisthesis. 4)Fracture of a lumbar vertebral body. 5)Hip pathology. 6)Inflammatory arthritis. 7) Seronegative spondyloarthropathy. 8)Infection. TESTS AND RESULTS: Bloods were analysed to out rule inflammation or infection. MRI lumbar-sacral spine demonstrated L2-L3 facet joint hypertrophy but no significant thecal sac or nerve root compression and no evidence of sacroiliitis. X-ray of right hip showed significant acetabular dysplagia with uncovering of the femoral head. MRI right hip revealed oedema and multiple small cysts in the right femoral head with remodelling and fragmentation, features consistent with avascular necrosis. FINAL/WORKING DIAGNOSIS: Idiopathic Avascular Necrosis of the Femoral Head. TREATMENT AND OUTCOMES: The patient was advised to abstain from training and competition. NSAIDs were prescribed for pain and Alendronate 70mg once weekly was initiated to inhibit osteoclastic activity and reduce the risk of femoral head collapse. The patient was referred for an orthopaedic opinion where options included, observation, femoral head core decompression, non-vascularized bone grafting and hip arthroplasty. The decision was ultimately made to pursue a conservative medical approach as outlined above.