Congenital Hip Abnormality Causing Micro-instability And Leading To A Stress Fracture In A Track Athlete

HISTORY: A 20-year-old female track athlete was evaluated in the training room for progressive right femur pain with running. She had been held out of her most recent event 3 weeks ago due to pain and has been completely non-weight bearing and ambulating with the use of crutches since that time. She has no history of stress fractures, eats a well-balanced diet, had no changes in her weight, and had a regular menstrual period. Her initial X-rays did not reveal any obvious fracture in her femur but did show incomplete ossification of her right inferior pubic ramus. PHYSICAL EXAMINATION: Vitals: Ht: 5'8" Wt: 140 lb BMI: 21.3 General: Well-appearing African American female MSK: Hips normal to inspection and palpation with full non-painful ROM. 5/5 strength with hip flexion, abduction, and adduction. FABIR/FADIR negative. Moderate tenderness to palpation antero-medial femur. Positive fulcrum test. Knees normal to inspection and palpation bilaterally with full ROM and 5/5 strength with knee flexion and extension. Neuro: Patellar and achilles reflexes 2+. Normal muscle tone, coordination, and sensation in lower extremities. Skin: warm and dry without rashes, erythema, or pallor. DIFFERENTIAL DIAGNOSIS: 1. Femoral Shaft Stress Fracture 2. Bone Stress Injury 3. Deep Vein Thrombosis TEST AND RESULTS: X-ray Femur Right AP/Lat Weight Bearing: No arthritis or fractures of the right hip or femur. Incomplete ossification of the right inferior pubic ramus. MRI Femur/Thigh W/O Contrast Right: Asymmetrical marrow edema proximal to mid right femoral diaphysis, most consistent with intramedullary stress fracture. FINAL/WORKING DIAGNOSIS: Right femoral stress fracture due to micro-instability and mechanical stress from the incomplete ossification of the ischiopubic synchondrosis. TREATMENT AND OUTCOMES: 1. Non-weightbearing with crutches for 7 weeks. 2. Advised on maintaining adequate levels of calcium and vitamin-D.3. Progressed slowly to weight bearing as tolerated and eventually light running over 6-8 weeks, once off the crutches.4. Underwent treatment with her athletic trainer focusing on hip adductor and hip flexion exercises to optimize the stability of her right hip.5. Return to unrestricted running in about 4 months with full strength and no pain.