Thigh Pain - Olympic Triathlete

HISTORY: A 30-year-old female Olympic Triathlete presents with right thigh pain for two months. She denies specific injury but was training after a period off following a recent left femoral neck stress reaction. The patient reports insidious onset and worsening of symptoms with weightbearing activities, progressing to pain during daily activities. Denies groin pain and low back pain. Numbness, tingling, and swelling are denied, but weakness and loss of power are noted. In addition, she reports loss of menstrual cycle for over a year and no OCPs or HRTs. She denies history of eating disorder. PE: The right thigh shows no gross deformity, swelling, or redness. Full ROM of the hip and knee, no groin pain during flexion/internal rotation and no anterior impingement. There is no tenderness in the anterior thigh, and the fulcrum test is negative. Examination of the right knee shows no effusion, medial or lateral joint line tenderness, or instability with varus or valgus stress. (+) distal femur pain with hop test. Strength is 5/5 in both lower extremities, and sensation is intact to light touch throughout. Dorsalis pedis and posterior tibial pulses are 2+ bilaterally. DDX1.Distal femur stress fracture 2.Lumbar radiculopathy 3.Quadriceps tendinopathy TEST/RESULTS: MRI confirmed a Grade 4 stress fracture in the posterior lateral cortex of the right distal femoral diaphysis. Additional findings included minor marrow signal abnormalities in the left femoral neck, and a chondral labral junction tear in both hips. FINAL/WORKING DIAGNOSIS: Grade 4 distal femur stress fracture + REDs TREATMENT/OUTCOMES: 1.Crutches with non-weightbearing restrictions x6 weeks. 2.Maintaining swimming followed by progression to cycling with parameters of 0/10 pain. 3.Weightbearing at 6 weeks without symptom exacerbation to allow for pain-free walking with another 6 weeks of avoiding high-impact activities. 4.She was referred to a registered dietician and Endocrinology and started on an estrogen patch. 5.A follow-up MRI at 12 weeks from the date of initial diagnosis showed healing of the stress fracture with near complete resolution of bone marrow edema. 6.After the MRI, she performed impact testing and was cleared to begin a return to run progression.7.She returned to competition at 5-6 months with continued multidisciplinary management of REDs.