Bilateral Hip Pain - Cross Country Runner: 1138: 9:50 AM - 10:10 AM

HISTORY: An 18-year-old, college freshman cross-country runner presented to our office for a second opinion regarding management and treatment of her bilateral hip pain. She had been diagnosed with bilateral femoral neck stress fractures by an orthopedic surgeon in her college town.

In high school, she ran 25-30m/wk. Her hip pain developed when she began her preseason workouts for college. The workouts included a jump of her weekly mileage to a minimum of 40m/wk. Her pain intensified to the point where she was unable to run when the season began. Her initial diagnosis was tendonitis and she was sent to traditional physical therapy for modalities and range of motion. When her pain did not improve, a MRI was done and revealed bilateral femoral neck stress injuries.

Historically, her menses were slightly abnormal. Out of season, she menstruated every 1.5 months. When in training, her periods came every 2 months. She drank milk regularly and added a calcium supplement after starting college. Her mom felt the patient ate a fairly well-balanced diet. The patient was comfortable with her current weight. She denied a history of stress fractures

PHYSICAL EXAMINATION: Weight: 126lbs

Well developed, well nourished young woman. Tender to palpation over her anterior hip flexor and iliacus muscles and pubic symphysis. No pain when her hip joints were flexed to 90 degrees and axially loaded. There was superior rotation of her right anterior anominate and medial malleolus. Passive internal and external hip rotation was normal and symmetric. Passive piriformis stretch was painful and limited. There was also pain and restriction with joint play of her medial hip capsules.

DIFFERENTIAL DIAGNOSIS:

1. Borderline amenorrhea

2. Overuse syndrome

3. Variety of pelvic muscle/fascial imbalances

4. Leg length discrepancy: Functional or anatomic

TEST AND RESULTS:

MRI:

- Focal marrow edema involving medial aspect of the right femoral neck, compression type stress fracture

- Very minimal focal edema involving the inferior most aspect of the left femoral neck, may represent a stress reaction

DEXA Scan: Osteopenia

- Lumbar spine Tscore -1.01 (89th percentile)

- Left forearm Tscore-1.39 (88th percentile)

FINAL WORKING DIAGNOSIS:

Bilateral hip stress injuries with multifactorial cause

TREATMENT AND OUTCOMES:

1. Physical therapy with therapist skilled at myofascial release techniques and focused on core strengthening.

2. Non-weight bearing cardiovascular workouts including cycling and water running.

3. Hormonal therapy.

4. Calcium and vitamin D supplementation.

5. Correction of leg length discrepancy with myofascial release techniques.

6. Return to running program initiated.