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Femoral Neck Stress Fracture Clinical Presentation

  • Author: Scott D Flinn, MD; Chief Editor: Sherwin SW Ho, MD  more...
Updated: May 12, 2014


Runners and military trainees develop stress fractures as the duration, frequency, and intensity of weight-bearing activities is increased. Furthermore, changes in running surfaces, such as from a flat surface to hills, or carrying a pack may increase the risk of stress fractures.

The patient reports a gradually worsening deep, achy pain in the hip, groin, or thigh.

Usually, pain initially occurs after an activity. As the stress of training continues, pain occurs during training and becomes more intense.

Unless the form of the activity is modified, the pain gradually worsens over a few weeks to the point where the patient is unable to walk without pain.

Continued activity will probably result in completion of the stress fracture.



Physical examination reveals the patient to have an antalgic gait.

Unlike many other stress fractures, it is not possible to palpate the femoral neck and determine the presence of the usual bony tenderness of a stress fracture. However, hip palpation may suggest another diagnosis, such as a hip flexor strain, if pain is present at the anterior inferior iliac spine and upon hip flexion. It is difficult to determine if anterior hip pain is due to a hip flexor strain or an FNSF by examination alone. Other possible diagnoses include greater trochanteric bursitis, adductor strain, or a pubic ramus stress fracture. (See also the articles Trochanteric Bursitis [in the Sports Medicine section], Adductor Strain [in the Physical Rehabilitation and Medicine section], and Pelvic Fractures [in the Orthopedic Surgery section].)

Pain at the extremes of passive range of motion (ROM), especially external and internal rotation, is the most sensitive sign for stress fractures.

Pain that is associated with log rolling, axially loading a supine patient (heel tap), and with single-leg standing or hopping also suggests a stress fracture. (Note: Performing a single-leg hopping test in a patient with a potential FNSF is risky and may cause completion of the stress fracture; this practice is not advised.)



Improper training is the most obvious cause for a stress fracture. Increasing the duration, frequency, and/or intensity of training too quickly does not allow for proper bone and supporting muscle adaptation, resulting in microscopic damage to the bone, which cannot be healed quickly.

In the military population, trainees who have initially lower levels of fitness and higher body mass indexes are at an increased risk of stress fractures.[1] A history of a previous stress fracture is also a risk factor for a recurrence. In addition, coxa vara has been associated with an increased risk of FNSF.[10] Finally, a study on male US Marine Corps recruits showed a higher risk of stress fracture with low body weight and small femoral diaphysis.[11]

Other hypothesized risk factors for FNSF include improper footwear, leg-length discrepancies, and a change of the running surface.

Females with the female athlete triad (ie, disordered eating, menstrual dysfunction, premature osteoporosis) are also at increased risk for stress fractures. (See also the article Female Athlete Triad.)

Young women who perform weightbearing exercise regularly can increase the bone density of their femoral neck.[12]

Plebes undergoing training at the US Naval Academy who had significant weight loss and smaller muscle mass were associated with a much higher incidence of stress fracture than their fitness-matched cohorts.[3]

Contributor Information and Disclosures

Scott D Flinn, MD Medical Director, Arch Health Partners

Scott D Flinn, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

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Radiograph showing a tension-side, completed femoral neck stress fracture.
Radiograph showing sclerosis on the compression side of the femoral neck.
Radiographs are often initially negative for stress fractures, including femoral neck stress fractures. Repeating x-ray films in 2 weeks may show the changes of a stress fracture, but approximately 20% of cases do not. Bone scanning or magnetic resonance imaging may be necessary to rule out a stress fracture. In the x-ray film for this patient, no changes were seen, but a bone scan showed an obvious compression stress fracture of the right femoral neck.
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