Hip Pain In A Weightlifter

HISTORY: 72 year old male who presented with progressively worsening right hip pain that started 3 weeks prior without any trauma or injury. He is an active weightlifter and was planning to do a leg day after the appointment despite walking with a limp. His pain was located in the groin and worse with weight-bearing. Past medical history includes double lung transplant, on chronic prednisone for years, osteopenia, and CKD. He denied any low back pain, radicular pain, paresthesias, or other joint pain. PHYSICAL EXAMINATION: Right lower extremity - no skin lesions, erythema or ecchymosis. No clinical leg length discrepancy. Passive hip irritability predominantly with rotation. Positive FADIR test. Mildly positive Stinchfield's. Nontender at the greater trochanter. Negative logroll maneuver. Neutral mechanical alignment of the knee with no knee effusion. Motor and sensory intact distally. Right hip ambulates with slight antalgic gait favoring the right hip. BMI 24.21. DIFFERENTIAL DIAGNOSIS: 1. Osteoarthritis2. Trochanteric bursitis3. Femoral neck fracture4. Tendinopathy5. Metastatic disease6. Hip labral tear7. Avascular necrosis8. Femoroacetabular impingement TEST AND RESULTS: AP pelvis/frog leg lateral right hip x-ray:- no evidence of acute fracture, dislocation, lytic lesion, or cam or pincer osteophyte formation. MRI right hip: - clear marrow edema extending through femoral neck with nondisplaced fracture line that extends from superior cortex through femoral neck and exiting out of the inferior cortex on T2 images. Clear effusion. Edema within the femoral head. No changes consistent with osteonecrosis or chondromalacia. FINAL WORKING DIAGNOSIS: Right hip tension sided femoral neck stress fracture with moderate effusion. TREATMENT AND OUTCOMES:1. Strict nonweightbearing with crutches until orthopedic evaluation.2. Underwent close reduction and percutaneous pinning of the right femoral neck with Orthopedic surgery due to high-risk of displacement.3. Postprocedural therapy for range of motion and low-impact muscle strengthening.4. Three-month follow up noted improved activity and minimal sporadic pain. Returned to activity as comfortable.5. Follow-up x-rays at 5 months showed no appearance of osteonecrosis or fracture line.