Thigh Pain In A Division 1 Runner - Page #4
 

Working Diagnosis:
Femoral shaft stress fracture, secondary amenorrhea, grief reaction with acute adjustment disorder.

Treatment:
Removed from running in order to decrease energy use and protect injury.

Nutritional consult and reviewed daily food journals to increase energy intake.

Behavioral psychology consult. Close weekly check in with student athlete in training room.

Outcome:
After first three weeks patient improved with absence of pain with walking. Fulcrum and hop test negative at 3 weeks. Increased energy intake confirmed. Patient continued to need psychologic support and to adjust collegiate academic load do to loss of best friend. Eventually allowed to aqua jog and bike. Return to cross country after 12 week protocol expected.


The patient had stabilization of energy balance, CBT for life stresses, and normalization of menses. Patient progressed through a return to play protocol through 4 phases of care for femoral stress fracture.

Author's Comments:
Femoral shaft stress fractures are rare.

Stress fractures of the femoral shaft in athletes occur most commonly in the proximal third of the femur. They can, however, also be found in the mid- or distal third.

Stress fractures are more common in female athletes with menstrual disturbances.

Bone density in runners ought to be above those of their non-running pears.

Editor's Comments:
Dr. Sedgley does a great job of illustrating the importance of involving a multidisciplinary team for patients with elements of the female athletic triad. The female athletic triad was classically described as amenorrhea, disordered eating and osteoporosis. However, each component is now recognized as part of a spectrum with oligomenorrhea, energy imbalance and osteopenia representing the milder forms of the respective components. This patient experienced amenorrhea and an insufficiency fracture. She likely had insufficient caloric intake as well. She was treated by a mulitidisciplinary team that included sports medicine, nutrition and psychology

References:
Stress fractures of the femoral shaft in women's college lacrosse: a report of seven cases and a review of the literature, Kang, L. et al., Br J Sports Med. 2005 December; 39(12): 902–906.

Femoral shaft stress fractures in athletes.
Hershaman, E., Bergfeld, et al., Clin Sports Med. 1990 Jan;9(1):111-9.

Bone health in endurance athletes: runners, cyclists and swimmers., Scofield KL, Hecht S., Curr Sports Med Rep. 2012 Nov-Dec;11(6):328-34.

Stress fractures of the femoral shaft in athletes: a new treatment algorithm, A Ivkovic, et al., Br J Sports Med. 2006 June; 40(6): 518–520.

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