ITBS, Hamstring Tear or Stress Fracture….Make the Call
History: A patient training for his 4th marathon presented complaining of pain in his lateral, posterior thigh that gets progressively worse while running and seems to be accompanied by groin pain on the same side. He stated that the pain began 3 weeks ago and increases with mileage. The conditions I wanted to eliminate as possible diagnosis were Iliotibial Band Syndrome (ITBS), Hamstring Tear and Stress Fracture.
Manual testing: The patient was instructed to run on the treadmill and point to the painful spot. The pain began immediately and he pointed to his posterior lateral left thigh. He was then instructed to jump up and down landing hard on the involved leg. When he jumped he experienced pain in his posterior lateral left thigh. At this point I could eliminate ITBS as a diagnosis because ITBS causes pain on the lateral thigh near where the tendon inserts on the tibia. In this case the patient was clearly pointing to his lateral posterior thigh in the vicinity of his hamstring muscle called the Biceps Femoris. I instructed the patient to lie down on the table and began to manually stress his hamstring with muscle testing. He was able to maximally contract his hamstring muscle without any pain in addition there was no pain in the muscle with maximal stretching. He was able to both stretch and contract the hamstring without pain which eliminated a hamstring tear as a possible diagnosis.
The Diagnosis: Because the patient originally described pain while running in the vicinity of the lateral leg the 3 most likely diagnosis were originally considered. Once the patient was able to accurately point to the pain it was easy to eliminate ITBS as that condition typically affects a specific portion of the leg at the lateral knee. This leaves us with 2 possibilities, a hamstring tear or a stress fracture in the femur. Stress fractures in runners often masquerade as muscle injuries to those less skilled in diagnostics. In this case I decided to use provocative testing to differentiate a muscle injury from a bone injury. Because the patient was able to both stretch and contract the muscle maximally without any pain it was extremely unlikely that it could be a hamstring injury. Couple that finding with the fact that the patient’s thigh had pain during the impact phase of jumping (positive jump sign) and we are left with the diagnosis of stress fracture. Because the patient is a competitive runner currently training for one of the USA Major’s we agreed that we would order an MRI to ensure the diagnosis was 100% accurate and that there was not an overlapping diagnosis or a complicating factor. The MRI would also show us the severity of the fracture which will help guide us in predicting a length of time the patient will be unable to run.
The Treatment: We will begin training on the Altered Gravity Treadmill at approximately 60% of full body weight. This
reduced body weight will not provide enough impact to provoke the fracture but will allow him to continue running keeping his running muscles strong and maintaining his cardiovascular capability. As the bone injury heals body weight will be added back during running sessions so that as he approaches full recovery he is running as close to 100% of his body weight as possible. During the rehabilitation the patient will also perform cross-training exercises such as cycling, swimming and lower body strength and conditioning.