5 Early radiographs of the hip failed to identify stress fractures in 30–70% of cases. 9 other symptoms, such as an antalgic gait and limited range of motion are also commonly reported and lower limb shortening is typically encountered in displaced fractures. Tenderness to palpation is not common, but pain with extremes of internal and external rotation may elicit some discomfort. 7, 8 Patients with femoral neck stress fracture typically present with anterior groin pain and inability to bear weight. Extrinsic factors include training errors (overuse, lack of cross-training, lack of conditioning, sudden increases in training intensity and duration, poor technique), environmental challenges (nonabsorbent training surface, banked track), and improper equipment (inappropriate footwear, prolonged use of footwear, non–gender-specific training equipment). Intrinsic factors include biomechanics (malalignment, gait abnormality, muscle imbalance, and small tibia diameter) and biochemical issues (hormonal imbalance, low bone mineral density, bone disease, and nutritional deficits). 6 Both intrinsic and extrinsic risk factors have been implicated in the etiology of stress fractures. 5 Women are 3.5 times more likely to sustain a stress fracture than men and are more prone to femoral stress fractures. Stress fractures caused by sports activities predominantly represent the fatigue type and are located almost exclusively in the lower extremity. Failure can occur in a normal bone exposed to abnormal stress (fatigue fractures) or in abnormal bone that cannot compensate normal stress loading (insufficiency fractures). Stress fractures are defined as the mechanical failure of bone due to repetitive loading, which exceeds its structural strength. A consultation from the orthopedics department recommended surgery but the patient refused and she stopped coming to the clinic for further treatment. Lab results showed nothing abnormal with all values within the range. Laboratory testing included a complete blood cell count, a chemistry panel, serum 25-hydroxyvitamin D levels, parathyroid hormone levels, and thyroid-stimulating hormone with reflex thyroxine levels. Later on, a hip MRI ( Figure 2) showed a left femoral neck fracture. However, her symptoms showed no sign of improvement. She was advised to rest and NSAIDs were prescribed for pain relief. Pelvic AP X-Ray was ordered but no signs of fracture or other acute lesions were identified in the x-rays ( Figure 1). The affected limb was well perfused, with normal peripheral pulses and normal motor and sensory function. Both active and passive range-of-motion in the left hip was with mild discomfort on the extremes of the range of motion. In physical examination, no deformities were noticed. Her height was 165cm and she weighed 55 kg, and her body mass index (BMI) is 20.20kg/ m2. There was no significant feature in her family history. There was no history of trauma and nutritional deficit, steroid use, menstrual abnormality, metabolic disorder, and any other relevant illnesses. The patient was not a professional athlete and said she was walking just for physical activity. A 21-year-old young female patient presented with left hip pain after a strenuous walking exercise, in which she walked nearly 10km every day.
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