Working Diagnosis:
Right Distal Femur and Proximal Tibia Stress Fractures

Treatment:
Crutches were provided at the initial visit to use as needed while she rested from sport and waited to obtain her MRI. Once diagnosed with her stress injuries, she was provided a hinged knee brace, referred to sports nutrition, and labs ordered. DEXA scan recommended but never obtained. She was started on vitamin D supplementation. After 6 weeks of rest, she then started physical therapy.

Outcome:
Strength and flexibility deficits were addressed in physical therapy over 4 weeks. She then started on a supervised running progression. A gait analysis was performed and biomechanical issues were addressed. She completed her progression over the next 5 weeks and was discharged once she returned to competitive running. There has been no report of recurrent symptoms.

Author's Comments:
Stress fractures are common overuse injuries in athletes that typically result from a combination of increased repetition and load. Risk factors for bone stress injuries include prior stress fracture, inadequate vitamin D and calcium, disordered eating, decreased bone density, running biomechanics, and non-modifiable factors such as female gender. After a thorough history and physical exam, the first step in diagnostics is plain radiographs. Often they demonstrate poor sensitivity and the best test becomes MRI, although other modalities can be used, such as bone scan and ultrasound. While stress fractures are common, the simultaneous presentation of both a femur and tibia stress fracture is not typical.

Editor's Comments:
Bone stress injuries require a high index of suspicion; particularly when they are in uncommon areas, such as the distal femur and proximal tibia. Stress fractures as mentioned by the authors are difficult to observe on plain radiographs and often require advanced imaging. A thorough and comprehensive approach is required to elucidate the underlying cause for this injury which may have components concerning for relative energy deficiency syndrome (RED-S). In this case, given her recent compression fractures, age, and current injuries, inquiries into her menstrual history, nutrition/eating habits, and level of activity to rule out RED-S as a multidisciplinary etiology would be essential for an optimal outcome and prevention of future injuries.

References:
1. deWeber K. Overview of stress fractures. UpToDate. Accessed on November 11, 2021 at https://www.uptodate.com/contents/overview-of-stress-fractures.
2. Jackson J. Femoral stress fractures in adults. Accessed on November 11, 2021 at https://www.uptodate.com/contents/femoral-stress-fractures-in-adults?search=tibia%20stress%20fracture&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5.
3. Fields K. Stress fractures of the tibia and fibula. UpToDate. Accessed on November 11, 2021 at https://www.uptodate.com/contents/stress-fractures-of-the-tibia-and-fibula?search=tibia%20stress%20fracture&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

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