12 year old boy is brought to your office for evaluation of limping for one month. His parents cannot recall a specific episode of trauma. With further questioning, he admits to falling from his scooter at home.
His left distal thigh near his knee is sore with prolonged walking. He cannot run or jump without severe medial left knee pain. He has difficulty squatting or rising from a deep chair. Previous examinations of his knee by another physician were reportedly normal. He has been taking ibuprofen for a “bursitis” without improvement. His limp is getting worse.
PMH is significant for asthma, sleep apnea and severe obesity.
ROS: He denies any radiation of pain below the knee, paresthesias or tingling in the feet, back pain, morning stiffness, swollen joints, fevers, chills or recent infection. He has no symptoms of endocrine abnormalities or hypothyroidism.
FH: Significant for multiple individuals with severe obesity.
Medications: Albuterol HFA, 2 puffs q 4, PRN, cough, SOB, wheezing
Pulmacort turbohaler, 1-2 puffs BID
Weight: 169# (76.8 kg) Height: 55 1/2 “ T: 36.8C P: 80 RR: 24 BP 130/76
General: Extremely obese, no significant distress.
Musculoskeletal: Positive difficulty standing with both feet together; prefers to externally rotate his left foot. Gait is notable for his left foot turned outward. Positive truncal sway to the left side with the swing phase of his right foot. Cannot squat. Negative Adam’s forward bend test. Knee examination is normal bilaterally. His left hip flexion is decreased to 40 degrees. He has obligate external rotation of the hip with attempted flexion. Internal rotation causes severe thigh pain. Internal rotation is essentially zero degrees.
Neurologic: CN II-XII intact. Brisk and bilaterally equal popliteal and ankle reflexes.
Circulation: Full and symmetric.