On-again off-again hip pain

Stuck at home during the COVID-19 pandemic, the patient — who was 18 at the time — would often work out with her friends over FaceTime. At first, the patient wondered if the hip pain she was experiencing was the result of a pulled muscle. It was a dull pain that came on slowly when she laid in bed, but would disappear by the time she woke up.

After weeks of the pain coming and going, the patient mentioned it to her parents, both of whom are doctors. They suggested it was some sort of muscle injury and recommended she take a few days off from exercising, which she did.

However, the pain continued coming at night, which ultimately led the patient to try physical therapy. Unfortunately, that didn't help, and while the pain didn't come every night, it came often, but still never in the daytime.

In the fall, as she started college, she didn't experience much pain until right after Halloween when the pain returned at night. The patient signed up for more physical therapy, but that didn't work. Just before Thanksgiving, she had a visit with her pediatrician who ordered an X-ray that came back normal, leading the doctor to encourage the patient to continue with physical therapy.

By the springtime, the patient's pain started arriving during the day, and it was more intense than before. Not only that, the pain was spreading, moving from her hip down her thigh and to her knee, sometimes going as low as her foot. The only thing that would help the pain was walking or taking ibuprofen.

During breaks in school, the patient's parents took her to see her pediatrician and a number of physical therapy appointments but none of it helped. Eventually, on the recommendation of a friend, the patient went to see Samantha Smith, a sports-medicine doctor at Yale New Haven Hospital.

A revealing blood test

Smith noticed the patient had tenderness at the top of her thigh bone and down the side of her thigh, called the IT band. She tested the patient's hips and legs and found that, while her right leg was entirely normal, there was a subtle weakness on the left.

When Smith asked the patient to do a squat only using her right leg, she had no problem, but she struggled to do the same with her left. Smith then prescribed a series of exercises designed to strengthen the muscles that were weak in her left leg and told her to come back in a month.

After a month, Smith found the patient's muscles were stronger, but the pain hadn't changed. That's when the patient's mother mentioned there was an abnormality in one of the patient's blood tests done at the start of the pain.

Specifically, the test found an inflammation of a C-reactive protein, also known as CRP. CRP can spike because of physical trauma or a minor infection, but consistently high CRP is sometimes seen in autoimmune disease, chronic infections, and even cancer, Sanders writes.

Smith ordered a new X-ray and a new blood test. The X-ray came back normal, but the blood test came back with CRP levels elevated three times what they were before, leading Smith to recommend an MRI of the patient's hip.

The MRI revealed a tumor in the patient's hip, and a CT scan confirmed the patient had an osteoid osteoma — an inflammatory tumor that can occur in patients her age. These tumors are often referred to as "the great mimicker," as they can look like many other possibilities that are more common or more dangerous, Sanders writes.

While osteoid osteoma tumors often resolve on their own after several years, most patients get them removed. During surgery, a small catheter is placed into the skin to the tumor which then allows a probe to blast the tumor with heat.

By the winter, the patient went in for surgery to have the tumor removed. The pain recovering from the surgery for the first week was intense, but by the second week, she was fine, Sanders writes. (Sanders, New York Times Magazine, 8/17)

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