13 yo M presenting with worsening left low back pain. Two weeks ago, he was lifting a heavy tire in football practice and felt like something “pulled” in his back. 5 days ago, he presented to the ED with continued back pain and new fever, cough, and blood-tinged post-tussive emesis. CXR and UA at that time were negative. Found to be flu+ and discharged home with supportive care. Since then, back pain has extended to left hip and groin.  Fever and emesis have resolved but he continues to have persistent cough. Denies testicular pain, dysuria, or hematuria. Denies prior injuries, incontinence, numbness, paresthesias, or weakness in his legs.

T 38.6, HR 101, BP 135/98, RR 20, SpO2 98%, Weight 133.9 kg

PE:

General: Alert. Obese male.  

Skin: Warm. Dry. Pink 

HEENT: Normocephalic. PERRL. EOM intact. Normal conjunctiva.    

CV: RRR. No murmurs. Normal peripheral perfusion 

Resp: CTAB. Non-labored. BS equal.  

Abd: Soft. Nontender. Nondistended.   

GU: Normal genitalia for age. No tenderness. No testicular edema or erythema.

Back: Nontender. Normal ROM. Normal alignment   

MSK: No swelling or deformity. Moving all extremities. Tenderness to palpation over left hip . No pain with hip flexion.  

Neuro: No focal neurologic deficit. Normal strength and sensation. Normal reflexes. Normal gait.  

XR L hip: No evidence of underlying fracture/dislocation or osseous lesion

Patients fever and pain responded to ibuprofen. Pain well controlled and patient ambulating. Discharged with referral to sports medicine.

Nine days later pt returns to ED and reports pain has gotten worse and is extending down into his left thigh, knee, and calf.  He states that he is most comfortable with his leg everted or when he is lying on his hip.  Pain worsens significantly with movement.  Patient states pain is significantly worse with walking. He denies fever, chest pain, or shortness of breath. Continues to have cough. Mother states cough has been ongoing x2 months and is concerned that patient has lost 34 pounds in 2 months.

T37.1, HR 112, BP 106/69, RR 16, SpO2 97%

Exam unchanged from prior except: Left hip held in external rotation while lying on back. Tenderness to palpation to left hip, posterior thigh, posterior knee, and calf. Left calf feels more taught and larger than R calf. No overlying erythema or warmth. Pain with all ROM of left hip but no limitation with passive ROM of hip and knee. FROM of left ankle and toes.  Sensation intact distally. Distal pulses 2+ and equal. Unable to ambulate at this time secondary to pain.