Clinical Decision Making for Femoral Neck Bone Stress Injuries

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses femoral neck bone stress injuries, including referral for diagnosis, potential treatment options, and rehabilitation & return to running.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

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EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Jaina.

MEGAN PEACH This is your PT on ICE, the daily show. brought to you by the Institute of Clinical Excellence. My name is Megan Peach. I am one of the lead faculty for Rehabilitation of the Injured Runner online and live. And today I'm gonna talk to you about, no surprises here, bone stress injuries. But specifically I wanna talk to you about femoral neck bone stress injuries and what to do once you expect that your patient has a possibility of even having a femoral neck bone stress injury. because sometimes that decision on what to do might be a little daunting. And so I'm going to present this information in a bit of an algorithm format. And I'm not the biggest fan of algorithms because our patients don't often fit perfectly into the algorithm boxes that we need them to fit in to in order to progress along that algorithm route. But this one I actually think makes a lot of sense and I think it's pretty straightforward so hopefully it will be helpful for you in your clinical decision-making process. So I'm also going to make some assumptions that you have already done your subjective exam, you've already done your objective exam as well, and you are ready to make some decisions and you've decided that your patient has potentially a femoral neck bone stress injury. Now that part is really important because if you are even suspecting a femoral neck bone stress injury, then you need to consider it a femoral neck bone stress injury until it's proven otherwise. And that's important because as physios, we can't tell if that's a high risk or a low risk femoral neck bone stress injury. All we know is that there's potential there and one, they're treated differently, but two, the high risk can progress on to be a more serious injury. And so it's really important that we treat them as femoral neck bone stress injuries until that condition is proven otherwise, or it's proven as a femoral neck bone stress injury, and then we can move on in that treatment algorithm. So once you have made that decision, this person sitting in front of me is potentially a femoral neck bone stress injury or has one. The first thing we're going to do is refer them out to an orthopedist. They need additional imaging. And again, that's because we really need to determine one, if this is a femoral neck bone stress injury, and two, if this is a high risk or low risk, because again, they're treated a little bit differently. And so that referral to the ortho is going to jumpstart that part of the process where they can then get additional imaging. MRI is the gold standard to diagnose bone stress injuries. You could also refer them to their primary care provider. Their primary care provider can certainly refer them for an MRI, but ultimately they're going to go and see an orthopedist. And so it's nice to just take out that middle appointment and you can always communicate this information to their primary care provider, especially if they were the ones that referred them to you in the first place. Okay, so all of the patients are going to start out with their referral to the ortho, and then hopefully go for an MRI. Now the results of the MRI are really important because they're going to dictate at what path in this algorithm they're going to take. So I'm gonna give you three different scenarios based on the results of this initial MRI. The first scenario is that the MRI is positive for only bone marrow edema. It is a femoral neck bone stress injury, but it's only bone marrow edema. There's no fracture line. So this patient is then going to do six weeks of non-weight-bearing. Kind of a bummer, a hard conversation to have, especially if there's no distinct fracture line, but they still need six weeks of non-weight-bearing to prevent further progression of this injury. After the six weeks, whether or not they get a follow-up MRI is really dictated by that orthopedist and their experiences. Typically they don't if it is bone marrow edema only, And so at this point, they would likely begin a weight-bearing progression. And that weight-bearing progression is going to be gradual, likely over the course of a couple of weeks. After they are able to weight-bear normally, they're going to then start into a normal walking program and a formal rehabilitation program. With that being said, during that six-week period of non-weight-bearing, certainly they could do formal physiotherapy, but you could also send them home with exercises they can do on their own to prevent atrophy, to maintain the strength that they do have and the muscle mass that they do have. That, of course, is a conversation between you and the patient and the orthopedist on where they want to spend their time, potentially money, potentially number of visits for physio, because you know they're going to need them once they start that weight-bearing progression. I'm not going to talk a lot about the details of that weight-bearing progression because I want to stick to this clinical decision algorithm, but in that weight-bearing progression, it would then work itself into also a return to sport progression as well, but that's where it starts. Okay, so to summarize that first scenario, you have your patient, You have differentially diagnosed them with a potential femoral neck bone stress injury. You referred them out to an orthopedist. They had an initial MRI, which was positive for bone marrow edema. Then they did six weeks of non-weight bearing, and then they progressed into a loading program to get them to load normally and walk normally, ultimately probably run normally, and get back into the sports and the activities that they want to do. Okay, so the second scenario, we're going back to that first MRI. They come in with their results. Their results say that they now have a stress fracture, okay? And so this is a totally different scenario than the first scenario with bone marrow edema only. Now, the location of a femoral neck stress fracture is really, really important because that's going to determine whether or not this is a high-risk or a low-risk bone stress injury. So if the fracture is on the underside of the femoral neck, it is deemed a compression-type fracture, and it is going to be more low-risk. If the fracture is on the superior aspect of the femoral neck, it is deemed a tension-type injury, and that is going to heal a lot more slowly with a lot more difficulty. It is deemed a high-risk bone stress injury, and it's treated very differently from the low-risk or compression type fracture. So the MRI is going to describe the location of that fracture as well as occasionally the severity. If that person presents with a compression type fracture, so on the underside of that femur, and it is 50% or less of the width of the femoral neck, they are going to then, surprise, do six weeks of non-weight bearing, okay? And so they have a fracture line, but we're still going to treat them conservatively in this scenario. After the six weeks of non-weight bearing, typically they will have a second MRI or follow-up imaging. Occasionally that can be x-ray if they were able to visualize the fracture line on an initial x-ray. So a follow-up image, and based on the results of the follow-up image, they're going to be filtered into basically three different paths again. And so if that follow-up image says that they are making good progress and healing, so maybe we don't see a line anymore, maybe there's callus, maybe there's less bony edema, then we're going to filter them back into that progressive weight-bearing approach. And so the same thing that we use for scenario one, they're going to do a progressive loading program into full weight-bearing and then walking and then running and then return to sport, et cetera. Okay, that is if they were asymptomatic and they demonstrate healing on that follow-up image. If the follow-up image does not show any progress, it doesn't show any regression, it's just kind of stagnant, or the patient is still symptomatic, they're still having symptoms in that hip. Now, granted, they haven't been weight-bearing for six weeks. they're going to restart that six weeks weight-bearing. It is a tough, tough conversation, and nobody likes it. Not you, not the orthopedist, certainly not the patient. They're going to start that process over again, and they're gonna start back at the top of that six weeks non-weight-bearing, and then they'll likely have a repeat image at the end of that second six weeks of non-weight-bearing. I should mention here that I keep saying six weeks non-weight-bearing It's a start and I think it's important to educate our patients on that. It is just a start very often they will go into Longer durations of time non weight-bearing in order to treat this condition Okay, so the third scenario after the second image the follow-up image is that there is a regression and so this is not based on symptoms it is only based on that second image and this now shows a progression in the injury, maybe the fracture line increased, maybe the edema increased, but there's been some basically like regression in the issue. And so, or progression in the injury, however you want to take it. And so with this situation, unfortunately, they've now become a surgical candidate and they will likely stay under the care of that orthopedist. Okay. So to summarize that second scenario, They have come into your clinic, you suspect a femoral neck bone stress injury, you refer them out to an orthopedist, they come back with a positive MRI for a fracture line, but that fracture line is less than 50% of the width of the femoral neck and it is on the compression side or the underside of that femoral neck. They then do six weeks of non-weight bearing. They get a follow-up image. Based on that follow-up image, they will either continue in a progressive loading program in formal rehabilitation, repeat the six weeks non-weight bearing, and then do another follow-up image, or go on to be a surgical candidate, depending on the results of that second image. Okay, our third scenario. They come back with their first MRI, and the results show, again, a fracture line. This fracture line, though, is one of two scenarios. It is either a fracture line on the superior aspect of that femoral neck, which is a high-risk, tension-tight bone stress injury, or that fracture line is on the compression side, or the underside of that femoral neck, and it is greater than 50% of the width of that femoral neck. Either of these two situations, unfortunately, are going to necessitate, likely, a surgical intervention. So an open reduction, internal fixation, to stabilize that fracture and make sure that it doesn't progress into a more severe injury. The type of that ORIF is obviously very dependent on that surgeon as is the weight-bearing status post-operatively. So some will do non-weight-bearing for an additional six weeks, Some will do partial weight-bearing and then some will do full weight-bearing immediately after surgery. It is obviously just up to that orthopedist. And so that third scenario is quite short compared to the others. Your patient came in, you suspect ephemeral neck bone stress injury, you refer them out to the orthopedist, they come back with the MRI results with a positive for either a fracture line on the underside of that femoral neck on the compression side that is greater than 50% of the width of that femoral neck, or they have a fracture line on the tension side, the superior aspect of that femoral neck. Either of those two situations are then going to necessitate some kind of surgical fixation for that injury. Obviously, that is always a discussion between you and that patient and the orthopedist and whatever team they have around them in terms of if surgery is the appropriate intervention for them. Obviously, this is just a basic algorithm and then to help guide some of these clinical decision-making processes. Okay, so the themes in this algorithm that I want to highlight are regardless of what that initial MRI says, basically all roads lead to six weeks non-weight bearing. It's kind of an unfortunate part of this injury is that we definitely don't want this to progress from a low risk to a high risk bone stress injury. That's the worst case scenario because if we can prevent that in any way, even if it means six weeks non-weight bearing, we have to do that. So any roads, maybe with the exception of that third scenario where it just leads to surgery, all of the other paths essentially lead to that six weeks non-weight-bearing. So just know that that might be in their future. The other thing is, is that any progression that we do formally as informal rehabilitation after they've done their six weeks non-weight-bearing and they've been basically released to physiotherapy or released to progress to walking or weight-bearing, all of the progression has to be asymptomatic. Any progression that is symptomatic, creating symptoms in that hip, it must be backtracked. And so if they are initiating weight bearing and they are symptomatic, they're likely going to have to backtrack into a few weeks of non-weight bearing again. Really hard conversation again, but it's necessary in order to really prevent progression of this injury for obvious reasons. So the two themes, six weeks non-wavering and any progression must be asymptomatic. SUMMARY All right, that is the content I have for you today. Just want to make a couple of mentions of our upcoming Rehab of the Injured on our online course. We are currently in the middle of our, our current cohort is right in the middle of this session and All of the online cohorts this year have been on our new ICE app, which has been fantastic. It is really generating a great online community of therapists that are interested in treating endurance athletes. And so we've had some good discussions on there and it's really just fostering a great community. So if you haven't already taken Rehab of the Injured Runner online, I would definitely encourage you to do so. Our next cohort starts, I believe, in June. We will see you there. I can't wait to see you there. And have a great Friday and a great weekend.

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