Template:Case Study

  Ewing’s Sarcoma Case Study

Keywords

Fatigue, treatment, fever, bone pain, cancer, therapy, symptoms

Authors

Jack Tencza and Joseph Dorrell

Abstract

Ewing’s Sarcoma is the 2nd most commonly diagnosed form of primary bone cancer in children and young adults. In this example, a case study of an 18 year old Caucasian female gymnast is examined to help health care professionals identify a possible clinical case of Ewing’s Sarcoma.

Introduction

Ewing’s Sarcoma family of tumors are a group of small round cell tumors that include Ewing’s Sarcoma, Extraosseous Ewing Sarcoma, Askin Tumor, and Primitive Neuroectodermal Tumor. This cancer primarily affects children and adolescents, and most often affects soft tissue and bone. The most common sites for Ewing’s Sarcoma is the pelvis, hip, femur, tibia and fibula.

Case Presentation

Subjective :
Patient History: Pt. is an 18 year old Caucasian female who reports with a recent history of right hip pain of 5/10 during the day and 7/10 at night. She reports limping from a cartwheel at gymnastics 2 months ago. She reports that she has had night sweats with intermittent fever and general fatigue during the day. Pt. reports that she has had a recent physical examination 5 months ago with her GP who found that she was underweight. GP states this could be possibly due to female athlete triad. She notes that she has been more attentive with her diet and exercise since then. Pt. states her goal is to return to gymnastics pain free and as soon as possible.
Medical History: Unremarkable
Self Report Outcome Measures: Pain Diagram, Patient-Specific Functional Scale, Lower Extremity Functional Scale
Objective : Physical Examination Tests and Measures
Observation/ Palpation: Pt. has pinpoint tenderness around R ASIS, and notes pain with R weight shifting
ROM:
Lumbar ROM
Lumbar Flexion 65
Lumbar Extension 35
Lumbar Sidebend 20
Lumbar Rotation 30

Hip ROM Right Left
Hip Flexion 85 130
Hip Extension 15 30
Hip IR 20 40
Hip ER 25 40
Hip ABD 25 45
• MMT:
L Hip 5/5 in all planes
R Hip 4/5 in all planes (pain)
UE ROM: WNL
UE MMT: WNL
Neurovascular: decreased sensation along R lateral thigh
Special Tests:
FABER - Negative
Scour Test - Positive
Anterior Labral Tear - Negative
Impingement Test - Positive

Clinical Impression

Examination findings show decreased ROM and weakness of the R hip with palpable pinpoint pain, tenderness, and warmth. No other musculoskeletal abnormalities found to be present. Working diagnosis of female athlete triad and hip impingement. Targeted interventions include strengthening the R hip musculature, improving R hip ROM in all planes, manual therapy to decrease pain and improve function, and modalities for pain relief.

Intervention

Hip AROM/ PROM exercises
Standing hip flexion, extension, abduction, IR and ER resistance exercises
Wall slides & standing squats
Hip long axis traction

Outcomes

Over a period of 5 visits pt’s s/s did not improve. Pain intensified to a 7/10 during the day and an 8/10 at night. PT then determined that pt needed to be referred out for imaging of the hip. Pt went to MD and received X-Ray which indicated a possible tumor of the pelvis. Blood tests indicated elevated lactate dehydrogenase and red blood cell sedimentation rate. MD referred to Oncologist for biopsy which confirmed a Ewing’s Sarcoma of the pelvis. Pt received chemotherapy and radiation.

Discussion

Ewing’s Sarcoma is a malignant bone tumor which in this case affects a female, which is not as common as a male. In this case, the pt. demonstrated constitutional signs and symptoms including night sweats, weakness, fatigue, intermittent fever and increased pain at night which could indicate a systemic problem. Physical therapists should be aware that Ewing’s Sarcoma can mimic musculoskeletal signs and symptoms which can make it difficult to diagnosis. It is imperative to monitor the patient and refer out to patient’s MD when appropriate to prevent further metastasis of the tumor. The pelvic and hip region is the most common area affected by Ewing’s Sarcoma and can be difficult to observe and palpate due to its location. In this case the pt did not improve upon multiple visits which would indicate it is not a musculoskeletal pathology and the pt. was referred to her primary care provider for further testing.

Related Pages

Halwai MA, Mir BA, Wani MM, Bashir A, Hussain A. Ewing's sarcoma of the ilium mimicking inflammatory arthritis of the hip: a case report. Cases Journal. 2009;2(1):6487. doi:10.4076/1757-1626-2-6487. http://casesjournal.biomedcentral.com/articles/10.4076/1757-1626-2-6487