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A 23-year-old female presented to physical therapy via direct access with acute right groin pain. She is currently training for her first half-marathon. Primary complaints included pain with walking (worse with longer distances, up to 8/10), tying her shoes, and running (unable to perform any running without pain). Her BMI was 18.6 kg/m2 and her past medical history was significant for anorexia. She also had a 2nd metatarsal stress frx in high school when racing for the indoor track team.
Physical evaluation revealed moderate hip abductor weakness, painful and 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 open chain gluteal strengthening.
One week later, she experienced pain with attempted running and demonstrated worse tenderness to palpation along 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. She was referred for radiographic imaging that revealed linear lucency along the femoral head, but no fracture. Symptoms remained unchanged following another week of conservative management.
Initial question:
Please list your initial differential diagnosis list and RANK from most likely to least likely, with relevant subjective and objective signs/symptoms listed for each. You can also add in subjective questions or objective testing you would include to help narrow down your list.
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Given the background, history of anorexia, and presentation, a stress fracture of the femoral neck or head would remain at the top of my list, and I would continue conservative care.
Other causes of this imaging finding and hip pain may include avascular necrosis, which would be more likely if the patient is a heavy drinker, using corticosteroids, biphosphonates or certain antiviral drugs or if the patient is suffering from lupus, HIV, pancreatitis, or certain types of cancer.
Pubic ramus stress fracture would also be a consideration. This would also initially be noticed during or after provocative activities and worsen over a period of weeks following, with pain over the fracture site.
Labrum injury or FAI could lead to similar pain location and behavior, though this would typically be more with the sporting activities and positions of increased flexion or adduction, and there is often an associated clicking or popping sensation.
Inquiry into any past episodes of similar pain, any trauma or even minor injury, clicking pr popping, substance abuse, steroid use, medications undisclosed medical conditions, or other potential diseases that may sway the differential list would be helpful. Repeat imaging (MRI) should be recommended if symptoms persist, given the history of anorexia increasing potential for reduced bone density and high risk site for stress fracture.
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Nice!
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