Femoral neck stress fracture presenting as gluteal pain in a marathon runner: case report

Treatment and Rehabilitation Approaches for Stress Fractures in Long-Distance Runners: A Literature Review

Stress fractures (SFs) result from repetitive mechanical stress on bones, leading to an imbalance in osseous tissue adaptation and resulting in cortical fractures. The majority of SFs occur in the lower limb due to excessive mechanical loads. Long-distance runners are highly susceptible to SFs, especially when there is a significant increase in the load or intensity of their activity. Various intrinsic and extrinsic factors contribute to the development of SFs. Common SF locations in long-distance runners include the tibial shaft, femur, metatarsal, and pelvic region. Diagnosis may be delayed due to mild symptoms and unremarkable imaging tests. However, the chronicity and recurrence of misdiagnosed SFs may lead to debilitating complete fractures that are even more challenging to treat. In this review, we present data revealed from published case reports and case series studies obtained through PubMed and Embase databases focusing on the management of SFs in long-distance runners and correlate treatment outcomes with rehabilitation and return to high-level athletic performance.

Femoral Neck Stress Fracture of a Male, Healthy Marathon Runner - Case Report and Literature Review

In the present report, a case of a healthy, 38-year-old male recreational marathon runner who presented in the emergency department is discussed. He was diagnosed with a stress fracture of the femoral neck and treated surgically using a dynamic hip screw (DHS). One year after surgery, the patient was able to return to most of his previous sports activities. In the present report, the existing literature on the subject is exhibited and the points of interest in terms of incidence, risk factors, diagnosis, classification, treatment, and long-term outcome are analyzed. We suggest operative treatment of stress fractures of the femoral neck even in cases of complete undisplaced ones. This way, the risk of a displacement is counteracted, and patients can quickly return to daily activities without having to withstand long-term immobilization.

Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature

Femoral neck stress fractures (FNSFs) in healthy young subjects are uncommon and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders followed by amenorrhea and osteoporosis. This case report describes four young and middle-aged, active female recreational runners who developed stress fractures of the femoral neck. In three of them, with a clinical history of persistent pain in the groin region, which worsened during training, early diagnosis by MRI was considered essential in detecting the fractures. The patients were clinically, metabolically and radiographically evaluated; they were then treated and followed-up at our institution. Only one case was treated conservatively, while the others underwent surgical internal fixation using a screw-plate (DHS®). All of them returned to sport physical activity after a recovery period. Regarding the challenging management of FNSFs, our report highlights the importance of groin pain, especially in athletic females, an early diagnosis by MRI, and a proper classification of these injuries for a correct choice of treatment in order to prevent further dislocation and avoid avascular necrosis of the femoral head. (www.actabiomedica.it)

Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature

Femoral neck stress fractures (FNSFs) in healthy young subjects are uncommon and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders followed by amenorrhea and osteoporosis. This case report describes four young and middle-aged, active female recreational runners who developed stress fractures of the femoral neck. In three of them, with a clinical history of persistent pain in the groin region, which worsened during training, early diagnosis by MRI was considered essential in detecting the fractures. The patients were clinically, metabolically and radiographically evaluated; they were then treated and followed-up at our institution. Only one case was treated conservatively, while the others underwent surgical internal fixation using a screw-plate (DHS®). All of them returned to sport physical activity after a recovery period. Regarding the challenging management of FNSFs, our report highlights the importance of groin pain, especially in athletic females, an early diagnosis by MRI, and a proper classification of these injuries for a correct choice of treatment in order to prevent further dislocation and avoid avascular necrosis of the femoral head.

Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature

Femoral neck stress fractures (FNSFs) in healthy young subjects are uncommon and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders followed by amenorrhea and osteoporosis. This case report describes four young and middle-aged, active female recreational runners who developed stress fractures of the femoral neck. In three of them, with a clinical history of persistent pain in the groin region, which worsened during training, early diagnosis by MRI was considered essential in detecting the fractures. The patients were clinically, metabolically and radiographically evaluated; they were then treated and followed-up at our institution. Only one case was treated conservatively, while the others underwent surgical internal fixation using a screw-plate (DHS®). All of them returned to sport physical activity after a recovery period. Regarding the challenging management of FNSFs, our report highlights the importance of groin pain, especially in athletic females, an early diagnosis by MRI, and a proper classification of these injuries for a correct choice of treatment in order to prevent further dislocation and avoid avascular necrosis of the femoral head.

Lower limb stress fractures in sport: Optimising their management and outcome

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Femoral Neck Stress Fractures in Sport: A Current Concepts Review

Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. The commonest causative sports are marathon and long-distance running.

The main types of FNSF are compression-sided, tension-sided and displaced. The most common reported symptom is exercise-related groin pain. Radiographs form the first line of investigation, with MRI the second-line investigation.

The management of FNSFs is guided by the location and displacement of the fracture. Delay in diagnosis is common and increases the likelihood of fracture displacement. Sporting outcomes are considerably worse for displaced fractures. Education programmes and treatment protocols can reduce the rates of displaced FNSFs.

This article aims to provide a current concepts review on the topic of FNSFs in sport, assess the current evidence on the epidemiology and pathophysiology of these injuries, detail the current recommendations for their imaging and management, and review the recorded sporting outcomes for FNSFs in the existing literature.

From this study, we conclude that although FNSFs are a rare injury, they should be considered in all athletes presenting with exercise-related hip pain, because delay in diagnosis and subsequent fracture displacement can significantly impair future return to sport. However, when detected early, FNSFs show promising results in terms of return-to-sport rates and times.

Young man with sudden severe hip pain secondary to femoral neck stress fracture

Femoral neck stress fractures have been described in military recruits and athletes. Early recognition and aggressive treatment are important, as femoral neck stress fractures have a high potential for complications and even uncomplicated fractures require an extensive course of rehabilitation. Tension-side (superolateral) stress fractures of the femoral neck are at high risk for complications such as displacement, non-union and avascular necrosis, and need to be treated surgically, while compression-side (inferomedial) fractures can be treated conservatively. We describe a case illustrating a typical presentation of insidious hip pain culminating in sudden onset of severe hip pain in a healthy young man. We perform a literature review of studies showing epidemiology, treatment algorithms and rehabilitation.

Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners

Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.

Bilateral femoral neck stress fractures in a fire academy student

Unilateral femoral neck stress fractures are well documented in active patients; however, the risk of a subsequent contralateral stress fracture remains unknown in patients who continue to be active. This article describes a 24-year-old male fire academy student who sustained a left femoral neck stress fracture, followed approximately 11 months later by a right femoral neck stress fracture, both of which went on to completely displace. A review of the index radiographs of each hip from outside institutions revealed femoral neck stress fractures that went undiagnosed until they displaced. The patient was referred to our institution and underwent closed reduction and internal fixation using cannulated screws in both cases. A full endocrine evaluation was performed in the following weeks and proved unremarkable. Although it is difficult to extrapolate the results from 1 patient beyond the case studied, there is cause for concern in patients who remain active following femoral neck stress fractures. Our case highlights the significance of obtaining a complete and thorough medical history on physical examination and appropriately counseling patients regarding activity level. Until further research explores this possible relationship, physicians evaluating patients with a history of a stress fracture are encouraged to be vigilant of subsequent contralateral fractures and educate patients of this potentially avoidable injury.

Use of the patellar-pubic percussion test in the diagnosis and management of a patient with a non-displaced hip fracture

This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.

Differential diagnosis of a femoral neck/head stress fracture

STUDY DESIGN

Resident's case problem.

BACKGROUND

Identifying stress fractures of the hip can be a challenging differential diagnosis. Pain presentation is not always predictable and radiographs may not show the fracture, especially during its early stages. Hip stress fractures left untreated can displace and necessitate open reduction internal fixation or total hip arthroplasty.

DIAGNOSIS

A 70-year-old woman presented to the physical therapy clinic with complaints of right hip pain. She had been evaluated by a physician and radiographs of the hip, which revealed some arthritic changes, were otherwise normal. Upon examination, the physical therapist observed an antalgic gait, a noncapsular pattern of limitation of hip motion, an empty painful end feel at the end range of motion (ROM) for hip abduction, external rotation, and flexion, and extreme tenderness to palpation over the anterior hip region. The therapist suspected a more pernicious problem than osteoarthritis and discussed his suspicion with the physician. The physician subsequently requested an MRI that revealed a femoral neck and head stress fracture that was later confirmed with a bone scan. The patient was provided with a walker for ambulation with a non-weight-bearing status for 6 weeks, after which she returned to physical therapy for progressive weight bearing and strengthening. She was discharged with a relatively pain-free hip and was ambulating with a cane. A 2-month follow-up examination revealed a pain-free hip and a return to all premorbid activities, including ambulation without an assistive device.

DISCUSSION

The presence of a normal radiograph of the hip should not be considered conclusive in ruling out a stress fracture in the hip region. The current case demonstrates how careful evaluation can reveal occult pathologies and prevent potentially catastrophic morbidity.

Lumbosacral pain in an athlete

This report presents a case of a stress fracture in the sacrum. The diagnosis of a stress fracture in the sacrum is an uncommon localization and has been reported infrequently in the English literature. Association of this type of stress fracture with a pneumatocyst has not previously been reported.