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Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 172-174

Bilateral stress fracture femur presenting with thigh pain

1 Department of Orthopaedics, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
2 Department of Orthopaedics, Srinivas Institute of Medical Sciences and Research Centre Mukka, Surathkal, Mangalore, India
3 Hardikar Orthopaedic Hospital, Pune, Maharastra, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Bahubali Aski
House Number: 407, Staff Residence, SIMS&RC Campus, Mukka, Surathkal, Mangalore - 574 146
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-6308.142423

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Stress fractures are relatively common in runners and must be diagnosed early to prevent serious potential complications. A 25-year-old male patient, Borderline Security Force (BSF) trainee by occupation, with complaints of pain in the bilateral thigh with no history of trauma. On evaluation found to have bilateral stress fracture of proximal femur. The systematic protocol in treatment results in favorable outcome.

  Abstract in Arabic 

الكسر الإجهادي الثنائي المصحوب بألم حاد في عظم الفخذ
تصف هذه المقالة حالة مريض ذكر يبلغ من العمر 25عاما يعمل متدربا في قوة حرس الحدود جاء يشكو من ألم في جانبي وسط الفخذ ألأعلى دون أن يكون قد تعرض لرضخ سابق. وعند تقييم حالته اتضح أنه مصاب بكسر إجهادي في جانبي الفخذ الأدنى. ومن المعروف أن الكسور الإجهادية شائعة نسبيا عند العدائين ن ولابد من تشخيصها مبكرا لمنع المضاعفات الخطيرة المحتملة.

Keywords: Borderline security force, runner, stress fracture

How to cite this article:
Manojkumar H V, Aski B, Bhatnagar A, Savadi V. Bilateral stress fracture femur presenting with thigh pain . Saudi J Sports Med 2014;14:172-4

How to cite this URL:
Manojkumar H V, Aski B, Bhatnagar A, Savadi V. Bilateral stress fracture femur presenting with thigh pain . Saudi J Sports Med [serial online] 2014 [cited 2023 Dec 8];14:172-4. Available from: https://www.sjosm.org/text.asp?2014/14/2/172/142423

  Introduction Top

Stress fractures are relatively common in runners and must be ruled out early to prevent serious potential complications. The hip and thigh pain is a common complaint in runners. Femoral stress fracture should always be in the differential diagnosis. Bilateral femoral stress fractures are extremely uncommon, and in this case the etiology seemed to be overload of normal bone from significantly increased running mileage over a short interval. Femoral shaft stress fractures are stable stress fractures that can be treated with a progressive rehabilitation program as discussed here. The conservative treatment is generally successful.

  Case report Top

A 25-year-old male, Borderline Security Force (BSF) trainee by occupation came with complaints of pain in the bilateral upper medial thigh with no history of trauma. Training pattern was 15 km running twice a day (morning and evening) with jumping tasks in between over the poles. Trainee has to finish in prescribed time of 2 hours.

Patient started having pain in the upper medial and anterior thigh 2 months after starting of training. However, he could undergo training with pain for 15 more days when he presented to us. On examination, patient had tenderness over the medial thigh. No crepitus and no abnormal mobility with no distal neurovascular deficits. The fulcrum and hop test both were positive. X-ray pelvis with bilateral hip and proximal femur taken which showed bilateral unicortical upper femoral stress fracture with abundant callus formation. with abundant callus formation [Figure 1].
Figure 1: X-ray showing bilateral symmetrical femoral stress fracture

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Metabolic conditions which affect the bone were ruled out. Investigations: Complete blood count (CBC), erythrocyte sedimentation rate (ESR), electrolytes, serum phosphorus, and calcium levels within normal limits. Thyroid profile normal.

In literature, there is mention about different patterns of stress fractures, that is, bilateral femoral shaft fracture (complete), bilateral femoral neck fractures, and bilateral which were diagnosed on bone scan. However, our case is unique where we have unicortical (posteromedial) bilateral upper femoral shaft fracture with abundant callous formation which was diagnosed on X-ray.

The patient was advised to refrain from training, he was asked to progressively increase his activities, initially for the first 15 days to only perform activities of daily living. For the next 1 month he underwent physiotherapy and brisk walking for an hour a day. Subsequently for the next months advised 10 min of walking followed by 5 min of running for an hour in the morning and same such cycles for an hour in the evening. For the next month advised to run 5 km in the morning and 5 km in the evening. From next month patient is advised to continue the training; however, for some personal reason he discontinued.

  Discussion Top

Stress fractures are overuse injuries of bone, and may be defined as partial or complete fracture that results from repetitive application of stress of less strength than that required to fracture a bone in a single load. [1]

Previous reports of femoral shaft fractures have involved either military recruit during basic training or long distance runners. Since the 1970s, the nature of stress fractures has changed from being considered to be a ''military disease'' to being more commonly observed in athletes of all ages, sex, and sports. [2]

Stress fractures constitute about 10% of all sport related injuries, and the most common site is the tibia. [2],[3] Stress fractures of the femur are relatively uncommon, and data from the literature suggest that they constitute only 2.8-7% of all sport related stress fractures. [1] They do pose a great challenge for both diagnosis and treatment. [1]

The X-ray made the diagnosis that stress fractures occurred in both femurs, localized to both medial shafts. This area of the femur has been shown to have the greatest strain in the sagittal plane, but is also susceptible to stress fracture due to the origin of the vastus medialis and the insertion of the adductor brevis. [3]

About one-half of all femoral stress fractures occur in the femoral shaft, with the medial aspect of the proximal third of the femur being by far the most common location. Biomechanical studies have shown that the medial shaft of the femur undergoes a compression strain with weight bearing, with the greatest strain occurring proximally [3] as revealed by Koch's free body analysis of the femur. [4] This analysis shows that the junction of the proximal and middle third of the femur in the subtrochanteric region is particularly susceptible to repetitive submaximal stress. [1] This excessive compression in weight bearing, compounded by additional compressive loads from the adductors and vastus medialis, predisposes the medial aspect of the proximal femur to stress injury. [1],[4]

The examiner performs the fulcrum test by placing an arm under the symptomatic thigh of the seated patient then pushing down on the knee. In the hop test, the patient attempts to hop on the injured leg, inevitably reproducing pain if an undisplaced stress fracture is present. [1],[4] Thigh pain with the maneuver is a positive test. In our case, the hop test and the fulcrum test were positive. These tests are very sensitive and were also used during follow-up to determine the eligibility of the patient for transfer to the next phase of the treatment. [1]

The patient had medial thigh pain and tenderness over medial aspect of upper thigh. This case illustrates a number of important points in the evaluation of a trainee who is a military recruit. Thigh and hip pain from a femoral stress fracture is generally vague, and the location of the pain might not correlate with the location of the fracture. Clinical findings are also variable. [4] The physical findings of localized tenderness and swelling are notoriously absent from femoral shaft fractures. [2] The X-ray could diagnose the stress fracture in our case; however, initial radiograph findings are often normal. [4] Not surprisingly, plain radiographs are not always sensitive. Rather, in that case include the bone scan and the magnetic resonance imaging (MRI) in the work up of suspected femur fractures. [2]

Successful rehabilitation protocols have been discussed in the literature. In low-risk stable stress fractures, a progressive loading regimen can usually be followed as directed by symptoms. [3] The main treatment for femoral shaft stress fractures is rest from the offending athletic activity, a concept known as ''relative rest''. Furthermore, if not treated correctly, femoral shaft stress fractures are well-known for complications and difficulties, such as delayed healing, fracture displacement, and symptom recurrence. Nevertheless, the athlete returning to proper training must be cautioned to resume at a frequency and intensity well below the level that produced the symptoms. [1]

Rehabilitation and return to play after a femoral shaft stress fracture are guided by tolerance of pain free activity. Conservative therapy is uniformly successful provided the patient gets adequate rest, and factors promoting the initial injury are addressed. Return to play is guided, however, by the absence of clinical symptoms, and a follow-up MRI or bone scan is not necessary provided the athlete follows the expected course of improvement. [4]

A similar philosophy of low impact strength training and rest from running with a gradual return to activities was employed in our case. Reduced pain was used as a marker for improvement and progression of activity level. He did not at any time rest completely from all activities.

  References Top

Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: A new treatment algorithm. Br J Sports Med 2006;40:518-20.  Back to cited text no. 1
Kang L, Belcher D, Hulstyn MJ. Stress fractures of the femoral shaft in women's college lacrosse: A report of seven cases and a review of the literature. Br J Sports Med 2005;39:902-6.  Back to cited text no. 2
Weind KL, Amendola A. Rare bilateral femoral shaft stress fractures in a female long-distance runner: A case report. Iowa Orthop J 2005;25:157-9.  Back to cited text no. 3
O'Kane JW, Matsen LJ. Mid-third femoral stress fracture with hip pain. J Am Board Fam Pract 2001;14:64-7.  Back to cited text no. 4


  [Figure 1]


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