hey everyone we've got another fabulous case study for you this patient has hip pain can you work out the diagnosis can you work out what's going on we're going to guide you through everything in this video about this case including the assessment and the diagnosis so if you're ready to learn and put yourself to the test let's dive in hey everyone Khid here welcome back to Clinical Physio let's take a look at this case study starting with the subjective history so today we have a 40-year-old woman presenting to our clinic with right-sided anterior groin pain they feel that their symptoms started about 3 weeks ago which they first noticed towards the end of a long run and indeed they are doing long runs at the moment because they're training for a marathon and they started training for their marathon approximately 3 months ago so they've seen a private physiootherapist who has assessed the patient and has suggested that they have a hip flexor tightness which is causing the symptoms in their hip so what does the patient present with well they have a dull aching pain around the anterior hip and the anterior thigh when they're walking but it's worse when they're running and they've specifically noticed that as they run further the pain tends to get worse so if they're doing a longer run the pain gets worse as they continue running or if they do more running during the week than the previous week the pain will also get worse she feels that her symptoms have generally been getting worse over the course of the last 3 weeks to the extent that she has now been experiencing discomfort and pain at night which she feels is waking her up regularly during the night and as for past medical history this patient is an ex-smoker she has a relatively low BMI considering her height and she is a patient who has gone through the menopause slightly earlier than you may imagine in other women so next let's look at the objective examination first of all we do our gate assessment we can see that this patient walks with a painful or antalgic gate and in particular they don't like spending time on their right leg during stance phase it's clear that they don't like loading the right leg as much and they're clearly limping on their right leg as a result trying to get onto their left leg as quickly as they can we have a look at the lumbar spine to clear this area and we find that the patient has no pain at all on lumbar spine range of movement testing full active range of movement of the lumbar spine with no pain at all however when it comes to the right hip it is evident that there are restrictions first of all we can see that they have reduced hip flexion to only 100° and they clearly have reduced internal rotation to only 10° both of these movements are painful and it's evident that they are painful on both active range of movement and passive range of movement and in fact we saw that the restrictions we see for active are the same for passive as well we then look at strength testing for the patient and it seems globally a little bit weaker around the hip as a whole where we look at all the different movements and we can see that it brings up a four out of five level of strength on the Oxford scale however because of the pain that the patient's having we feel that this is the main restriction to them being able to do a five out of five rather than a true muscle weakness so therefore we go on to do some additional special tests starting with a single leg stand on one leg which on the right side is a little bit painful but then when we ask the patient to hop on their right leg it's significantly painful around the anterior hip and groin and then we also do a feder test flexion adduction internal rotation all combined and we find that this is also positive for the patient so with these thoughts in mind this is your opportunity to think about what you think is going on with this patient so write down your thoughts and join us again to find out the answer okay everyone time's up let's take a look at the answer to this patient's case study unfortunately we were concerned that this patient had a relatively serious issue going on in which that we suspected that this patient had a necur stress fracture this is a incredibly significant injury for runners and therefore it's something that has to be investigated quickly but the first thing to mention is not about the neca stress fracture but actually about the previous thought from the private physio that this patient may have had hip flexor tightness what we actually find in clinical practice is that hip flexor issues are really heavily overly diagnosed and therefore what we should be doing is thinking about a hip flexor problem as a diagnosis of exclusion looking at other conditions first why is this well when you think about runners how much do they actually use their hip flexors when they run when we're running we actually use more of our extensor muscles to push ourselves from one step to the other such as our gastromus muscles maybe our quadriceps muscles and our hip extensors our glutial muscles to actually propel us forwards we don't drive our legs significantly forwards and when you look at people who are running you'll find that actually they don't move that much into hip flexion when they're running instead it's more of the extensor muscles that are doing the work therefore this is just one reason why hip flexor issues are heavily overdiagnosed in these patients and we should be looking at other conditions that may cause this anterior hip and groin pain and thigh pain first rather than a hip flexor problem so therefore we might be thinking about a necope femur stress fracture like this patient has femorro acetabular impinchment or even something like osteoarthritis in its early stages rather than diving straight into a hip flexor problem that is one key learning that we will take from this patient okay so we've moved the hip flexor issues to the back of our thinking what has brought the neca stress fracture to the front of our thinking well actually it's a lot of the clues in the subjective history that has pointed us in this direction and this is one condition where it's really important to be aware of the key subjective signs surrounding the diagnosis so the first most pertinent thing is this increase in activity which is a really common story for bone stress injuries like a neca stress fracture the thought process is that when patients have been used to a low level of activity and then suddenly have increased their activity levels particularly with impact or loading exercises like running you're suddenly putting a lot more stress through the bone that it was previously coping with so for this particular lady she hasn't been doing much running and then suddenly 3 months ago she started doing this longer distance running because she's training for her marathon the increase in impact and increasing load in that short period of time will put pressure on the bone tissue especially when it's not used to it so therefore the fact that her pain in her hip and anterior thighs started and was getting worse as her running was progressing is a clear sign that it could be a bone stress injury that is causing her symptoms secondly the fact that she's been experiencing night pain night pain makes us think of more significant pathologies like something like cancer avascular necrosis or a potential fracture and therefore we should always be alert to patients who have night pain but then it's probably this final thought that has been perhaps the kicker in thinking that we need to look further to think that this patient has a stress fracture and that is her bone health risk factors we noticed in her past medical history that she's an ex-smoker which will have an effect on the health of bone tissue the fact that she has a low BMI this suggests that there may be reduced nutrition within her body over a long period of time and therefore less nutrition to the bones which also may reduce the health of the bones in general and the fact that she is a female who has gone through the early menopause we know that as ladies go through the menopausal change hormonal changes take place in their body and therefore the reduced hormones that support bone health means that the bones are more likely to be vulnerable to injury so we have this misbalance with regards to this patient we have lots of increased activity and we have significantly increased risk factors towards a bone stress injury which is the key reasons why the initial thinking would be a nec stress fracture it was therefore that the objective assessment in terms of the reduced range of movement the gate disturbance but most importantly the pain with the single leg hop test that made me think right I think this is likely to be a bone stress injury i need to proceed as if it is before I do anything else and therefore how would this patient have been managed they would have been referred immediately for investigations most likely in the form of an MRI scan in order to diagnose the necur stress fracture or indeed rule it out even ruling it out allows us to proceed with physiootherapy as normal but if you think this might be going on diagnosis is key and so get your patients referred on if you suspect a bone stress injury so everyone I really hope you enjoyed this video if you have please support us by smashing that like button it's the number one thing you can do to help our channel and if you want more resources for physiootherapists do check out our Instagram account clinical physio give us a follow there for some brilliant resources for physiootherapists now if case studies is the way that you like to learn make sure you check out our membership channel member.clinicalphysio.com as a part of membership you'll get access to the case study club the case study club is a brilliant resource where we have different expert clinicians come in to describe patient cases and to describe the key clinical reasoning as to how they came up with their diagnosis for that particular patient so if you like case studies check out membership a great way to learn for your clinical practice my name's Khaled thank you so much for watching see you soon here on Clinical Physio