Let’s Talk About Stress

Abstract

HISTORY: A 32 year old Female nurse presented to the sports medicine clinic with complaint of left hip pain after she was lifting a patient and twisted her left hip internally. She felt sudden sharp pain over the lateral and anterior hip that radiated into the groin. Pain was made worse with movement and improved with rest and she rated the pain as 7 out of 10 after the injury. Her symptoms continued with little improvement over a few weeks resulting in a antalgic gait favoring the left side. She rates her pain as 6 out of 10 on VAS at presentation. She tried ibuprofen with little relief, has had no imaging or treatment. She runs 3 miles 3 to 5 times per week prior to the injury. She had a history of irregular menses for many years. PHYSICAL EXAMINATION: Examination in the clinic revealed a slim female with no swelling or bruising over the left hip. She had tenderness to palpation over the anterior groin and greater trochanter on the left side. She had limited internal rotation of the hip and preserved external rotation. Her strength was preserved and she was neurovascularly intact. She had positive log roll, FADIR and negative FABER. She had an antalgic gait favoring the left side. DIFFERENTIAL DIAGNOSIS: 1.Labral Tear 2.Femoroacetabular impingement (FAI) 3.Stress fracture of the femoral neck 4.Hip flexor strain 5.Female athlete triad TEST AND RESULTS: Left hip xrays: 1.Preserved joint space with mild pincer deformity suggesting FAI. No fractures or dislocations noted. MRI Arthrogram of Left Hip: 1.Significant marrow edema and contusion involving a large portion of the femoral neck with a non-displaced stress fracture involving the medial left femoral neck. 2.No labral tear noted. Left Hip Xray 1 week post operatively 1.Three compression screws in the femoral head and neck with adequate alignment and no signs of migration or loosening of the screws. FINAL/WORKING DIAGNOSIS: Left femoral neck non-displaced stress fracture with workup for female athlete triad TREATMENT AND OUTCOMES: 1. Patient made non weight bearing with crutches 2. Patient was given options of surgical or conservative management of her compression-sided fracture and chose to pursue surgical route given the fracture extended approx. 50% across the femoral neck and her level of activity prior to the fracture. 3. Closed reduction with percutaneous pinning of the left hip 4. Using a walker for immobilization she was made 25% weight bearing 5. 1 week post operatively her pain was improving and she was compliant with weight bearing status, 6. 2 weeks post operatively she continues to improve, she is advanced to 50% weight bearing status using walker and starting physical therapy. She remains off of work as a nurse. 7. Plan to return to work three to four months post operatively.