July 14, 2020 at 8:36 am #8683
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.
July 15, 2020 at 10:03 am #8690
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
July 15, 2020 at 5:18 pm #8693helenrshepParticipant
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.
July 16, 2020 at 6:51 am #8696
July 18, 2020 at 4:42 pm #8700
Here was the result of this case:
Computed tomography identified a non-displaced transverse fracture of the midportion of the right inferior pubic ramus.
Conservative management continued over the next 8 weeks, emphasizing pain-free ROM and progressive weight-bearing exercise with running return at 12 weeks.
Attached are the images.
July 19, 2020 at 4:02 pm #8708awilson12Participant
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?
July 21, 2020 at 8:06 am #8713
July 26, 2020 at 9:23 pm #8717Taylor BlattenbergerParticipant
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?
August 10, 2020 at 9:25 pm #8719
Great questions Anna and Taylor
I used the Bringham and Womans return to running program from Harvard (attached below)
I also like this other article about runners and bone stress.
The patient presented like a combination of athletic pubalgia and a stress fracture of the femoral neck due to WB and load severity, but also the positive tests for atheletic publaglia.
Looking back, it makes sense that both were positive because there was a fracture in a load bearing aspect of the pelvis and the adductors attach to where the fracture was present.
With the anorexia, I was very clear on the importance of the triad in the initial evaluation and she was very open. She opened up about what her issues were and I addressed her need to load with nutrients and 5-6 small meals a day during recovery.
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