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ABSTRACT
We present a distal femoral shaft fracture in a female collegiate cross-country athlete. The injury occurred during off-season training and presented initially as general knee soreness, followed by an acute onset of pain during a middle mileage run. Her rehabilitation program focused on progressive weight bearing after a 4-week aquatic therapy conditioning program. She began a running protocol, with half-mile runs 3 times per week increasing by half-mile increments weekly. After the patient was consistently pain-free with a 3-mile per day protocol for 2 weeks, she was cleared to participate in team practices. Most femoral stress fractures involve the femoral neck; however, in this case, it involved the distal one-third of the femoral shaft. Femoral stress fractures, regardless of location, need to be treated conservatively, including a period of nonweight bearing and nutritional, orthopedic, and possibly psychological treatment, and should progress based on the presence of symptoms.
Stress fractures are a common pathology seen predominately in military personnel and athletes, particularly middle- and long-distance runners1-4 and gymnasts.2 These injuries result when an imbalance between bone (Ca^sup 2+^) reabsorption and formation occurs, often due to prolonged, repetitive, or unaccustomed submaximal exercise.1,5-7 Stress fractures account for approximately 10% of all sports-related overuse injuries, 1,8 with the tibia, tarsals, and metatarsals accounting for the highest incidence.9,10 Most stress fractures afflicting the femur involve the femoral neck or head and rarely affect the femoral shaft, particularly the distal end.1,2,11,12 Previous accounts of femoral shaft fractures have predominately involved military recruits during basic training,3,6-9 whereas others have been reported in middle- and long-distance runners,1,2,4 ballet dancers,3 and female collegiate lacrosse players.2 Stress fractures involving the shaft can be classified as proximal, middle, or distal, with distal fractures being further classified as supracondylar, condylar, or subchondral.13,14
Diagnosis is often based on clinical findings and a detailed and thorough physical examination, and is confirmed with the use of multiple imaging techniques, such as plain radiograph, magnetic resonance imaging (MRI), or bone scan.13 Clinically, femoral stress fractures, specifically located within the femoral shaft, present with vague, nondistinct exercise-induced leg or knee pain with an insidious onset.1,5,13 In addition, localized tenderness and swelling may be present,15,16 along with palpable periosteal thickening and positive hop and fulcrum tests.1,2,13,15,16 Overtraining is most often thought...