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Maryland Orthopedic Specialists
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Hip

Hip Stress Fracture (Femoral Neck Stress Fracture)

Femoral neck stress fractures are among the most consequential injuries in endurance athletics and military training, and one of the few orthopedic conditions where delayed diagnosis can be catastrophic. At Maryland Orthopedic Specialists, we treat these injuries with urgency, using MRI for early detection and decisive management to protect the femoral head and get patients back to full function safely.

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What is hip stress fracture (femoral neck stress fracture)?

A stress fracture develops when repetitive cyclic loading produces cumulative bone microdamage faster than the body can repair it. In the femoral neck, this occurs in two distinct patterns with very different prognoses: Compression-side (inferior femoral neck): The inferior cortex is under compressive forces.

A stress fracture develops when repetitive cyclic loading produces cumulative bone microdamage faster than the body can repair it. In the femoral neck, this occurs in two distinct patterns with very different prognoses:

Compression-side (inferior femoral neck): The inferior cortex is under compressive forces. Fractures here are more stable and typically managed non-operatively with protected weight-bearing. Lower immediate risk of complete fracture or femoral head avascular necrosis.

Tension-side (superior femoral neck): The superior cortex experiences tensile (pulling) forces, which bone resists poorly. Tension-side fractures are inherently unstable and can propagate to a complete displaced fracture, a surgical emergency. Displaced femoral neck fractures carry up to a 30% risk of avascular necrosis of the femoral head. Tension-side stress fractures require urgent surgical fixation.

Who is at risk:

  • Distance runners (particularly women — female athlete triad: low energy availability, menstrual dysfunction, low bone density)
  • Military recruits in basic training
  • Patients with osteoporosis or vitamin D deficiency
  • Athletes rapidly increasing training volume ("too much, too fast")

Symptoms — do you recognize these?

  • Groin pain or anterior hip pain that develops gradually with increasing activity
  • Pain worsens with running and weight-bearing; initially resolves with rest, then becomes persistent
  • Antalgic gait in more advanced cases
  • Tenderness over the anterior hip (femoral neck region)
  • Positive "hop test": Pain with single-leg hopping on the affected side is highly sensitive for femoral neck stress fracture
  • Fulcrum test: pain when the examiner applies a fulcrum force to the mid-thigh with the patient seated

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

How we diagnose it

MRI is the gold standard for early diagnosis of femoral neck stress fractures (sensitivity and specificity >95%). It identifies:

  • Periosteal edema and endosteal edema before X-ray changes appear
  • Precise location (compression vs. tension side)
  • Grade of injury (trabecular vs. cortical involvement)
  • Associated conditions (bone marrow edema, early AVN)

X-rays are often normal in early stress fractures. In more advanced cases, a sclerotic line, periosteal reaction, or cortical break may be visible. Normal X-rays do not exclude the diagnosis. MRI must be obtained if clinical suspicion is high.

CT scan provides excellent cortical detail once a fracture line is identified, useful for surgical planning.

Bone density (DEXA scan) should be ordered in all patients, particularly women with stress fractures, to assess for underlying osteoporosis and guide metabolic treatment.

Recovery & rehabilitation

  • Compression-side (non-op): Return to running 3–4 months; full return to training 4–6 months with graduated program
  • Tension-side (surgical fixation): Weight-bearing within days; return to running 3–6 months; full sport 6–9 months

Long-term management must address the underlying cause (training errors, nutritional deficiencies, bone density) to prevent recurrence.

Frequently Asked Questions

How is a femoral neck stress fracture different from a regular hip fracture?
A traumatic hip fracture occurs in an instant from a fall. A stress fracture develops gradually from repetitive loading without acute trauma. Both involve the femoral neck, but stress fractures occur in younger, often active individuals and have different management priorities.
Can I keep training with a stress fracture?
No. Running or high-impact activity on a femoral neck stress fracture risks complete displacement. This is a surgical emergency that can cause permanent damage to the femoral head. You must stop running and seek immediate evaluation.
Why do women get these more often?
The female athlete triad (low energy availability, menstrual irregularities, low bone density) significantly increases stress fracture risk. Estrogen plays a key role in bone remodeling, and low estrogen states from excessive training and caloric deficit impair bone repair.
What is the treatment for a femoral neck stress fracture, and will I need surgery?
Treatment depends on the location and type of the stress fracture. Compression-side fractures (on the inner, lower part of the femoral neck) are lower risk and can often be treated with protected non-weight-bearing on crutches for six to twelve weeks, followed by a gradual return to activity. Tension-side fractures (on the outer, upper part of the neck) are at higher risk of completing into a full fracture and typically require surgical fixation with screws to prevent displacement. Your MOS surgeon will carefully classify your fracture on MRI and X-ray to determine the safest course of action.
When can I return to running after a femoral neck stress fracture?
Return to running after a femoral neck stress fracture is a gradual process that typically takes three to six months for compression-side injuries managed non-surgically, and four to six months or longer after surgical fixation. Bone healing must be confirmed on imaging before impact activity resumes. A structured return-to-run program beginning with walking, then walk-run intervals, is essential to allow the bone to adapt progressively. Addressing any nutritional deficiencies, hormonal factors, or training errors that contributed to the fracture is equally important to prevent recurrence.

Meet the specialists

John J. Christoforetti, MD

John J. Christoforetti, MD

Orthopedic Surgery · Sports Medicine · Hip, Knee & Shoulder Arthroscopy · Shoulder Replacement

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Medically reviewed by John J. Christoforetti, MD, FAAOS
Last reviewed May 1, 2026

References

  1. Johansson C, Ekenman I, Törnkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med. 1990;18(5):524–528. https://doi.org/10.1177/036354659001800512
  2. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344–353. https://doi.org/10.5435/00124635-200011000-00002
  3. Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867–1882. https://doi.org/10.1249/mss.0b013e318149f111
  4. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988;16(4):365–377. https://doi.org/10.1177/036354658801600409
  5. American Academy of Orthopaedic Surgeons. Stress Fractures of the Foot and Ankle. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures/
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