Trainees With Displaced Hip Fractures Present to Physical Therapy With Primary Complaint of Knee Pain

Stress fractures of the femoral neck are career-threatening and life-altering injuries that occur frequently in Initial Entry Training (IET) Soldiers. Because of the severity of these injuries, military clinics that serve IET Soldiers have implemented guidelines to direct providers in the management of Soldiers with signs of symptoms of stress fracture. These guidelines focus on Soldiers presenting with a primary complaint of hip pain. The cases described here show two Soldiers who had displaced hip fractures despite having primary complaints of knee pain and no self-reported hip pain. In the first case, the patient was ambulatory with a slight limp and lateral knee pain that he rated as 3 out of 10. His physical therapist noted a significant gross leg length discrepancy on physical examination. Leg length X-rays identified a displaced fracture of the femoral neck. In the second case, the Soldier had severe (7/10) lateral knee pain with no complaints of hip pain. He presented to the Emergency Department where he received knee X-rays, which were normal. The next day in physical therapy, he continued to complain of severe knee pain. A femur X-ray demonstrated that he had a displaced hip fracture. Throughout their examination and diagnostic workup, neither of these patients ever experienced any hip pain. The implication of these cases is that clinicians must remain vigilant in examining the joints above and below the primary complaint. This may be more important when evaluating trainees who have a uniquely high risk of severe bone stress injury. Clinicians who work primarily with trainees should consider updating clinical management guidelines to include basic hip screening on patients who present with primary complaints of knee pain. Because of cases like these and the known connection between knee pain and hip pathology, we recommend that clinicians in IET clinics consider screening procedures to rule out hip pathology in trainees with primary complaints of knee pain.