Don’t miss Femoral Stress Fractures in the Female Runner!

Don’t miss Femoral Stress Fractures in the Female Runner!

Don’t miss Femoral Stress Fractures in The Female Runner!

Case Study:

A 28-year-old woman presents to the physiotherapy clinic with a 3-week history of left groin and anterior thigh pain that has progressively worsened while training for her first half-marathon. She has reduced her training schedule to two sessions a week due to her pain and is currently unable to run beyond 15 minutes.

What is the ONE condition that you don’t want to miss in this runner?

A stress fracture is caused by repeated sub-optimal loading on a bone over time as opposed to a single severe impact. Stress fractures in the hip and pelvis region (femoral neck, pubis, sacrum, and ischium) are more common in female runners and should not be missed, as a possible differential diagnosis of hip and groin pain. Femoral stress fractures account for around 11% of all stress fractures in the athletic population.


Risk Factors

There are multiple risk factors for the development of stress fractures within the athletic population. The key risk factors for stress fractures are highlighted below, as a checklist.

Stress Fracture Checklist


Clinical Presentation

In female runners, a history comprising of amenorrhea reduced calorie intake, and previous bone stress injuries should raise the suspicion of a stress fracture (Lodge et al. 2021).  Most runners usually present with vague symptoms about the hip and groin region.  Typically, the pain is diffuse around the groin, anterior hip and can radiate to the proximal thigh region. Tenderness is rarely elicited, even with severe stress fractures. The pain typically worsens with impact activities and worsens over time. In advanced cases, it may progress to night pain and even limping during walking (Petrin et al. 2016).

Femoral neck stress fractures are more concerning due to the risk of complete fracture, specifically for tension-type fractures on the superior neck. Compression fractures on the inferior neck are considered to be at much less risk of progression to complete fracture.

The risk of developing avascular necrosis following a displaced femoral neck fracture can be as high as 45% (Bachiller et al. 2002) and therefore, early recognition and management are crucial in the running population.


Physical Tests:

The single-leg hop test is sensitive for a stress fracture, although it should be used cautiously in runners with severe symptoms. Two useful tests which I use with runners in the clinic, with suspected femoral stress fractures are the fulcrum test and patellar percussion test, which are described below.


Fulcrum Test

Patella Percussion Test



A plain radiograph cannot reliably exclude a stress fracture. Also, plain radiograph often appears normal in the initial stages despite clinical signs and symptoms suggestive of a stress fracture (Groves et al. 2005).

MRI is the gold standard for confirmation of a stress fracture. The advantage of MRI is that it can detect ‘bone stress response’ often weeks, before visible changes are noted on radiographs (Pegrum et al. 2012), thereby enabling early intervention. Alternative imaging modalities for the diagnosis of stress fractures include bone scintigraphy.



Female runners are at increased risk for stress fractures in and around the hip. Clinicians should have a high index of suspicion for stress fractures as the cause of hip and groin pain in the long-distance female runner. Insidious onset of a vague, poorly localized pain is particularly concerning.  A positive hop test combined with no specific tenderness raises particular concern for a stress fracture, which must be ruled out with imaging. Plain film X-rays are insufficient for early diagnosis and MRI imaging is recommended. Worsening hip pain in a runner and inability to bear weight should raise concern for serious hip pathology and prompt an urgent orthopedic referral.


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This blog article is taken from our Running Rehab - From Pain to Performance Online Course. To learn more about the management of runners with injuries, including initial rehab, load management, strength training, and running re-training, check our comprehensive online Running Rehab Course with access to all information related to the rehab of running injuries.

Thanks a lot for reading! 


Benoy Mathew,

Lower Limb Specialist Physio

Creator (Running Rehab Course)



Bachiller FG, Caballer AP, Portal LF. Avascular necrosis of the femoral head after femoral neck fracture. Clinical Orthopaedics and Related Research®. 2002 Jun 1;399:87-109.

Groves AM, Cheow HK, Balan KK, Housden BA, Bearcroft PW, Dixon AK. 16-Detector multislice CT in the detection of stress fractures: a comparison with skeletal scintigraphy. Clinical radiology. 2005 Oct 1;60(10):1100-5.

Lodge CJ, Sha S, Yousef AS, MacEachern C. Stress fractures in the young adult hip. Orthopaedics and Trauma. 2020 Apr 1;34(2):95-100.

Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. Bmj. 2012 Apr 24;344.

Petrin Z, Sinha A, Gupta S, Patel MK. Young man with sudden severe hip pain secondary to femoral neck stress fracture. Case Reports. 2016 Oct 26;2016:bcr2016216820.


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Hip Pain in Runners

PT vs. Surgery for Rotator Cuff Tear

Major ? Alert!
A while back we posted about a randomized controlled trial comparing decompression surgery with physiotherapy in the case of lumbar spinal stenosis. The outcome: Physiotherapy yielded similar outcomes as surgery!
Inspired by these findings, I prepared an inservice during my last clinical rotation in the form of a critically appraised topic on the current evidence comparing surgical to conservative treatment of rotator cuff tears.

The results:

– A total of 3 RCTs were published between 2014 & 2015.
– Patientgroups amounted to 56 (1), 103 (3), and 180(2) Patients
– Follow-Up Evaluations at 1 (1) (2) and 5 (3) years

– No significant differences in age/gender across studies
– Symptoms since 1 (1) (3) and 2 (3) years
– Studies included degenerative, atraumatic ruptures (1) (2) (3) and traumatic ruptures (3)
– Affected tendons: Supraspinatus (2), supraspinatus + ≥1 additional (1) (3)

– Trauma as onset of symptoms (1) (2)
– local & systemic diseases (1) (2) (3)
– previously operated shoulder (1) (2) (3)
– cognitive impairments influencing participation (1) (2) (3)

– Surgical protocol:
Open/miniopen (1) (3) or arthroscopic (2) surgery followed by ≥12 weeks of Physiotherapy mostly identical to the conservative protocol

– Conservative protocol:
inconsistent description (2) (3)
4-6 weeks: Maintain Glenohumeral/Scapular Mobility
6-12 weeks: Stabilitytraining, Increase Strength

– Primary outcome across all studies:
Constant Murley Score: Combines Shoulderfunction (65 Points) with subjective evaluation of disabilites (35 Points)

– Secondary:
…MRT post (1) (3), VAS (1) (3), several questionnaires (1) (3), SF-36 (3), Costs (2),…

– Heerspink (2015) (1): No significant difference in the per-protocol analysis. Statistically significant difference in the intention-to-treat (Surgery better than Physiotherapy). Difference below Minimal Clinically Important DifferenceHeerspink et al

– Kukkonen (2015) (2): No significant difference

Kukkonen et al

– Moosmayer (2014): Statistically significant difference. Surgery better than Physiotherapy. Difference below Minimal Clinically Important Difference

Moosmayer et al


– Re-rupture rate 20-73% (1) (3)
– Rupture progression ≥5mm in 37% of conservative shoulders.
– Costs: 2417€ for Physiotherapy, 5709€ for surgery


– Patientgroups equal at baseline
– Appropriate randomization/blinding
– Intention-to-treat (1) (2) (3) and per-protocol analysis
– Subgroup analysis (intact vs. rerupture, rerupture vs. conservative)
– High follow up rate ≥95%

– Insufficient/inconsistent description of conservative Protocols (2) (3)
– Pragmatic Studies
– Cause and Extend of ruptures differ greatly
– Kukkonen (2015) (2): Included only well compensated, small, isolated ruptures. No info whether full-thickness or partial thickness tear. Patients had full ROM at inclusion => The CMS has great focus on ROM improvement. They have no follow-up MRI.

Clinical Bottom Line:
In practice, conservative protocols yield similar outcomes to surgical intervention. Patients with degenerative ruptures should be advised to start with a conservative treatment and only cross over to surgery if it doesn’t yield satisfactory results.
Concerning the re-rupture rate, further research should be done on prognostic factors indicating successful surgery.

This is again fairly recent evidence underlining the power of our profession. In the end, we CAN prevent surgery in many cases. Furthermore, patients received the same physiotherapy as their conservative counterpart. What made the improvement? Really the surgery? And once again, physiotherapy could save a tremendous amount of money. so #GetPT1st




Heerspink, F. O. L., van Raay, J. J., Koorevaar, R. C., van Eerden, P. J., Westerbeek, R. E., van’t Riet, E., … & Diercks, R. L. (2015). Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. Journal of Shoulder and Elbow Surgery, 24(8), 1274-1281.

Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K., Kauko, T., & Äärimaa, V. (2015). Treatment of Nontraumatic Rotator Cuff Tears.J Bone Joint Surg Am, 97(21), 1729-1737.

Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Smith, H. J. (2014). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears. J Bone Joint Surg Am, 96(18), 1504-1514.