History:
A 27-year-old male presented with left anteromedial hip/groin pain for 2 weeks. He competes
in a dodgeball league and plays occasional racquetball as well. After a dodgeball game, he
noted onset of hip and groin pain, which became progressively severe, and went to a local
Emergency Department. He had x-rays and were told they were normal, however he had
significant pain even with weightbearing at this point. No past history of hip dysplasia,
dislocation, hip surgery.
Physical Examination:
Hip flexion was 110°, internal rotation 20°, external rotation 60°, abduction 45°; significant pain
with flexion, adduction, and internal rotation, and positive FABER. He was able to ambulate
without assistance.
Differential Diagnosis:
• Labral tear
• Femoroacetabular impingement
• Femoral neck stress fracture
• Loose body
• Chondral defect
• Athletic pubalgia
Tests and results:
X-rays were obtained and suggested minimal left femoral head collapse, and did suggest mild
right femoral head sclerosis; an MRI showed large areas of grade 2 avascular necrosis
bilaterally. The left had a joint effusion, edema in addition to necrotic fatty signal in the femoral
head compatible with early collapse.
Final/Working Diagnosis:
Bilateral hip avascular necrosis with early left collapse.
Treatment/Outcome:
- Internal Medicine and Rheumatology referral for serological work up.
- Referred to Orthopedic Surgeon; recommended toe-touch weightbearing, counseled on
risk of progression. Alendronate was considered as with precollapse Ficat stages 0-II.
- At 8 months, left hip pain was progressing, and noted onset of right hip pain. X-rays
showed visible left AVN on the entire weightbearing surface with collapse and flattening
of the superior articular surface; right hip now showed subtle sclerosis.
- His only pertinent history included a brief course of oral corticosteroids when he got his
wisdom teeth removed, which he did not initially disclose. This case reports an unusual
etiology of an avascular necrosis after taking a short-term dose of corticosteroids. Case
raises awareness to counsel health providers about collaborating to provide patients
with optimal care and avoid potential serious side effects.