Refractory Gluteal Pain In A Hypermobile Female Athlete

HISTORY: A 27 year-old female former competitive gymnast presented with 18 months of left hip pain. Her pain was primarily located in the gluteal region. She also noted occasional deep anterior and lateral hip pain. She had episodic flares of pain and stiffness associated with increased physical activity such as hiking, running and yoga. Hip MRI showed a labral tear and mild greater trochanteric bursitis; trochanteric bursa and intra-articular hip joint injections followed by a course of physical therapy without significant relief. Lumbosacral and pelvic MRI were unremarkable. Then SI joint injection was provided with no benefit. Family history notable for multiple autoimmune conditions. PHYSICAL EXAM: Hypermobility in hands, wrists, elbow, knees, and hips. Beighton score 9/9. Tenderness to palpation over the left gluteal muscles. No greater trochanter or piriformis tenderness. Logroll, Stinchfield, FABER and FADIR were negative. SI joint distraction and compression were positive. Positive Fortin finger test. Negative facet loading. Full strength. Symmetric reflexes. DIFFERENTIAL DIAGNOSIS: -Intra vs extraarticular hip etiology: labral tear, trochanteric bursitis, gluteal tendinopathy. -Spine referred etiology: facet arthropathy, sacroiliac joint dysfunction. -Hip synovitis, arthritis, tendinitis due to autoimmune, inflammatory or crystalline arthritis. TESTS AND RESULTS: -Screening rheumatologic lab work up notable for positive ANA 1:160. -Referred to rheumatology due to inadequate response to usual treatment for mechanical conditions and positive ANA. Full panel rheumatologic autoantibody work up was negative. -Point of care left hip ultrasound demonstrated focal calcifications of iliopsoas, gluteus medius, piriformis and within the sacroiliac joint which clinically corresponded to patient identified sites of pain. FINAL WORKING DIAGNOSIS: Basic calcium phosphate deposition disease TREATMENT AND OUTCOMES: Patient was treated with 7 sessions of extracorporeal shockwave therapy and was referred to physical therapy for hip girdle and core strengthening. Follow up left hip ultrasound at 3 months showed significant reduction in calcifications in all prior identified locations. At 7 month follow up, patient reported 90% improvement in symptoms and return to previous level of activity.