Overview
A 40-year-old female marathon trainee presented with progressive anterior hip and groin pain. Following clinical assessment and risk factor review, a neck of femur (NOF) stress fracture was diagnosed, highlighting the importance of considering bone stress injuries over common musculoskeletal diagnoses in at-risk patients.
Subjective History
- 40-year-old woman with right anterior groin pain starting 3 weeks ago after long run.
- Symptoms worsen with increased running duration and frequency; now experiencing night pain that interrupts sleep.
- Past medical history: ex-smoker, low BMI, early menopause.
- Recent significant increase in running activity due to marathon training started 3 months ago.
- Previous private physiotherapist suspected hip flexor tightness.
Objective Examination
- Painful, antalgic gait; patient avoids loading right leg.
- Full, pain-free lumbar spine movement.
- Right hip: reduced flexion (100°), reduced internal rotation (10°); both painful on active and passive movement.
- Global hip weakness (4/5 on Oxford scale), likely due to pain, not true weakness.
- Single-leg stand on right is slightly painful; hopping is significantly painful in anterior hip/groin.
- Positive FADIR test (flexion, adduction, internal rotation).
Clinical Reasoning and Diagnosis
- Hip flexor issues are often overdiagnosed in runners; extensors play a more dominant role in running.
- Key considerations for bone stress injuries include sudden increase in activity and presence of bone health risk factors.
- Night pain suggests more serious underlying pathology (e.g., fracture, malignancy).
- Risk factors: ex-smoking, low BMI, early menopause—all increase susceptibility to bone stress injuries.
- Diagnosis: Neck of femur (NOF) stress fracture is suspected based on combined history, risk factors, and examination findings.
Management and Next Steps
- Immediate referral for imaging (MRI) to confirm or rule out NOF stress fracture.
- Early and accurate diagnosis is crucial; refer without delay if bone stress injury is suspected.
- If NOF stress fracture is ruled out, standard physiotherapy management can proceed.
Recommendations / Advice
- Consider bone stress injuries over common muscular diagnoses in runners with risk factors and escalating pain, especially with night symptoms.
- Hip flexor diagnoses in runners should be an exclusion diagnosis, not primary.
- Prompt imaging and specialist referral are advised when stress fracture is suspected.