Hijacking the Discussion Board early with another article; partially for the pictures (who doesn’t love a good hip fracture pic); but mainly for the what it adds to Kyle’s case, the sequelae of this patient’s management, not just regarding bone health, but multi system influences.

OK – start this discuss please.

Nice case Kyle

Diagnoses: primary – femoral stress fracture, differentials – hip flexor strain, pubic symphysis dysfunction, pelvic floor dysfunction, visceral referral (appendix, ovary)

Treat/refer: Refer and treat – may need an MRI, however, will a confirmatory diagnosis alter patient management? Unlikely to be displaced (probably not going in for surgery), so I would modify her activity and treat her like she has a stress fracture for a few weeks before really pushing for the MRI. I would also continue to treat with non weight bearing exercises to improve muscular strength of the hip girdle if indicated in assessment.

Continued treatment: pain free exercises for hip strengthening that are in a limited range of motion – progressive glute bridges, side planks. Discourage patient from running at this time. Lots of education, refer to RD for nutrition consult.

“It is imperative that clinicians consider the possibility of false-negative radiographic findings and treat suspected stress fractures as such until proven otherwise.”

The pictures in Eric’s article… super unfortunate injury. I would also question this patient on training during her adolescent years – as the article points out, if she had disordered eating and excessive running when she was younger, that could have set her up for low bone density currently.

What is pubic symphysis dysfunction?

Attached articles to review/discuss/add to library.

SIJ narrative one of my personal favorites in the past few years – discussed already.

What is your differential diagnosis at this point? pubic ramus stress fracture or avulsion fracture, adductor tendinopathy or strain, pelvic floor dysfunction

Would you refer, treat and refer, or treat only? With high suspicion of a fracture and no improvements with treatment seems like a refer to me. To help make this decision though a few things I would want to know- what her training looks like (has she stopped, continued, modified?), what specific manual therapy and exercise have been prescribed and why, history of orthopedic injury (especially other stress fractures), and progression of pain (worsening, getting a little better, no improvement at all?).

How would you continue this patient if you keep treating? Discussion about training load and nutrition is definitely warranted and further referral to other professionals as needed. For this runner I think that hip and core strengthening/NMR would be a good place to start.

Definitely an interesting case and good resources to read through and guide decision making and management!

Kyle I am assuming this was one of your patients- What did your education and return to running “protocol” look like? Were there other psychosocial factors that you picked up on associated with history of anorexia and if so how did you manage this?

Bone Stress Library builder (possible repost)

This was a very interesting case. Shows how a healthy amount of skepticism in the absence of a clear clinical pattern can help catch something that was missed.

It seems like a lot of the decision process was based on risk factors, MOI, lack of progress, and again a lack of a pattern. Were you able to reproduce symptoms in the clinical exam at all? Were there features to this case that made sense from the objective exam when reflecting on the ultimate diagnosis?