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A 23-year-old female presented to physical therapy via direct access with acute right groin pain during half-marathon training. Primary complaints included pain with walking (rated 8/10), doffing shoes, and running. She denied all red flag questioning, but her BMI was 18.6 kg/m2 and her past medical history was significant for anorexia.
Physical evaluation revealed moderate hip weakness, limited hip internal rotation range of motion (ROM), and tenderness to palpation along the pubic ramus. Neurological examination, lumbar spine and sacroiliac joint screening were all unremarkable. She was initially treated with manual therapy, hip ROM exercises, and isometric gluteal exercises.
One week later, she reported continued pain with attempted running and palpation to the pubic ramus. The patellar-pubic percussion test (PPPT) revealed a dull and dissipated sound on her symptomatic side, when compared to the asymptomatic side. Due to concerns of a femoral stress fracture, she was referred for radiographic imaging that revealed linear lucency, but no fracture. Symptoms remained unchanged following another week of conservative management. Despite negative radiographic evidence, her lack of improvement, weight bearing sensitivity, low BMI, recent training changes, and history of anorexia prompted referral back to an orthopedist.
Questions for thought
What is your differential diagnosis at this point?
Would you refer, treat and refer, or treat only?
How would you continue this patient if you keep treating?
I will send the diagnosis and image after everyone has responded.
Articles:
Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice
A. Wright
https://pubmed.ncbi.nlm.nih.gov/25805712/Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture
L. Borgerding
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565630/ -
Hey Kyle!
Some other differentials on my list are athletic pubalgia, or moderate-severe FAI, however, femoral neck stress fracture is highest on my list. Based on the lack of improvement, weight bearing sensitivity, low BMI, recent training changes, history of anorexia, and positive PPPT, I would not treat this patient until after an additional follow up is completed with the orthopedist, despite negative radiographs. We also know that not all radiographs pick up on stress fractures, and the positive PPPT with other factors would spark enough concern for to not feel comfortable continuing to treat her at this time until further imaging such as an MRI was performed to rule out the presence of a fracture more accurately. If she were my patient, I would educate on symptom monitoring and activity modifications in the meantime while she is waiting for further testing/direction from the orthopedist.
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