What is the cause of persistent pain in a patient with a history of closed femur (thigh bone) fracture, and what treatment can provide relief, given that exercises currently alleviate the pain?

From the Guidelines

The patient's pain after a femur fracture repair is likely due to post-traumatic arthritis, hardware irritation, or muscle imbalances, and I recommend a comprehensive approach starting with physical therapy focusing on quadriceps and hamstring strengthening, hip stabilization, and range of motion exercises 2-3 times weekly for 6-8 weeks. For pain management, begin with acetaminophen 500-1000mg every 6 hours or NSAIDs like ibuprofen 400-600mg three times daily with food (if no contraindications) 1. Topical agents such as diclofenic gel 1% applied to the painful area 3-4 times daily may provide localized relief with fewer systemic effects. If hardware is suspected of causing irritation, orthopedic consultation for potential removal should be considered. Heat therapy for 15-20 minutes before exercise and cold therapy for 15-20 minutes after activity can help manage pain. Since exercise already provides some relief, a structured program will likely enhance benefits by improving muscle support around the healed fracture, increasing joint stability, and promoting better biomechanics.

Key Considerations

• The most recent and highest quality study 1 suggests that exercise is strongly recommended for all osteoarthritis (OA) patients, and there is considerably more evidence for the use of exercise in the treatment of knee and hip OA.
• A comprehensive approach to pain management should include education, physical activity, and exercise, as well as pharmacological and joint-specific treatment options 1.
• Patient preferences, access, and affordability should be considered when developing an exercise program, and supervised exercise programs are often more effective than those performed by the patient alone 1.
• If pain persists despite these interventions, further evaluation with imaging may be warranted to rule out hardware complications or secondary issues.

Treatment Options

• Physical therapy: focusing on quadriceps and hamstring strengthening, hip stabilization, and range of motion exercises 2-3 times weekly for 6-8 weeks.
• Pain management: acetaminophen 500-1000mg every 6 hours or NSAIDs like ibuprofen 400-600mg three times daily with food (if no contraindications).
• Topical agents: diclofenic gel 1% applied to the painful area 3-4 times daily.
• Orthopedic consultation: for potential removal of hardware if suspected of causing irritation.
• Heat and cold therapy: to help manage pain before and after exercise.

From the Research

Causes of Persistent Pain

• Persistent pain in a patient with a history of closed femur (thigh bone) fracture can be caused by various factors, including changes in peripheral tissues and nociceptors, neuropathic pain signs and symptoms, reduced central inhibition and enhanced central excitability, psychosocial factors, and alterations of the movement system 2
• The pain mechanisms can be categorized into nociceptive, central, neuropathic, psychosocial, and movement system, and several different mechanisms can simultaneously contribute to a patient's pain 2

Treatment Options

• Exercises can provide relief for patients with persistent pain, and common physical therapist interventions such as education, exercise, manual therapy, and transcutaneous electrical nerve stimulation can be used to target specific pain mechanisms 2
• A study on subacromial impingement syndrome found that exercise therapy (ET) alone and in combination with platelet-rich plasma (PRP) injections can be effective in reducing pain and improving functionality and quality of life 3
• Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain, and recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications 4
• Exercise-induced hypoalgesia (EIH) is a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward, and it is considered an important component of effective chronic pain management 5
• Nonpharmacologic and rehabilitative strategies such as physical therapy, occupational therapy, and multidisciplinary care can be effective in addressing chronic pain, and exercises including aerobic, strengthening, and flexibility exercises can be beneficial for pain-related outcomes 6

Specific Treatment Recommendations

• For patients with persistent pain due to a history of closed femur fracture, exercises that target specific pain mechanisms can be recommended, and the use of platelet-rich plasma (PRP) injections in combination with exercise therapy may be considered 3
• A multidisciplinary approach that includes physical therapy, occupational therapy, and other nonpharmacologic interventions can be effective in managing chronic musculoskeletal pain 4, 6