Introduction
- Bryan C. Heiderscheit, PT, PhD
- Geoffrey S. Baer, MD, PhD
Epidemiology
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Femoral neck stress fractures account for approximately 11% of stress fractures in athletes; the incidence of stress fractures in the femoral shaft has been reported as approximately 3.5%, but is suspected to be as high as 20% in athletes.
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They are most commonly associated with vigorous weight-bearing activities, such as running, gymnastics, dancing, and marching.
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Females appear to be more prone to this injury.
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The role of age as an independent risk factor is inconclusive, as secondary factors such as training volume and intensity are typically not controlled.
- •
In athletes, femoral shaft stress fractures are more common in the mid-medial or posteromedial cortex
Pathophysiology
Intrinsic Factors
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Previous stress fracture or family history of stress fracture
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Low bone mineral density
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In women, low aerobic fitness, menstrual dysfunction during the prior year and small calf girth
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Bisphosphonate use in older athletes, most often female
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Poor nutritional status, including low vitamin D status
- •
Lower extremity alignment, such as rigid medial longitudinal arch of the foot, leg length inequality, and excessive forefoot varus
- •
Acetabular retroversion
Extrinsic Factors
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A rapid or substantial increase in training volume (i.e., frequency, duration, intensity) with inadequate rest days
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Greater vertical ground reaction force loading rate during running
Classic Pathological Findings
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Periosteal resorption occurs at a faster rate than bone formation, resulting in the cortex becoming weakened and fractured.
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The balance between resorption and bone formation is influenced by the extrinsic and intrinsic risk factors.
Clinical Presentation
History
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Pain is typically nonspecific, insidious, and related to activity.
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Anterior hip, inguinal, and groin pain is common for femoral neck involvement, with diffuse thigh or possibly knee pain if the femoral shaft is involved.
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Pain often persists during rest, particularly with more severe injuries.
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Increased pain with impact type activity
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Increased pain with continued activity
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Patient frequently reports a recent increase in activity level.
Physical Examination
Abnormal Findings
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Antalgic gait may be present
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Fulcrum test can be used to identify femoral shaft stress fractures, which involves the patient being seated with examiner’s arm under the involved distal thigh and applying gentle pressure over the knee directed toward the floor. The arm under the thigh is progressively moved from distal to proximal, with pressure applied at each position, until deep pain is felt by the patient indicating a positive test ( Figure 27-1 ).
FIGURE 27-1
Fulcrum test.
- •
Patrick’s test (hip flexion, abduction, and external rotation) or extremes of passive range of motion may provoke pain with involvement of the femoral neck or proximal shaft.
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Hopping on the involved side may elicit pain, although not specific for a femoral stress fracture.
Pertinent Normal Findings
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Bone tenderness may be absent because of the depth of the involved bones.
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Joint range of motion is usually normal, except if the femoral neck is involved.
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Strength is generally normal unless pain is provoked.
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Normal reflexes
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No referred symptoms during testing of lumbar spine
Imaging
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Plain radiographs have poor sensitivity but high specificity. Abnormalities are unlikely unless symptoms have been present for at least 2 to 3 weeks.
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If radiographs show new periosteal bone formation, a visible area of sclerosis, the presence of a callus, or a visible fracture line, the diagnosis of stress fracture is confirmed.
- •
If radiographs are negative but suspicion of a femoral stress fracture remains, a bone scan or magnetic resonance imaging (MRI) is indicated, with magnetic resonance imaging being the better modality to diagnose femoral neck stress fractures ( Figure 27-2 ).
FIGURE 27-2
Femoral neck stress fracture negative on ( A ) radiograph but positive on ( B ) magnetic resonance imaging.
Differential Diagnosis
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Groin pain: likely to provoke pain with strength testing and palpation
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Hip flexor strain: likely to provoke pain with strength testing and palpation
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Hip osteoarthritis: more gradual onset
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Hip labral tear or femoroacetabular impingement (FAI): MRI demonstrates labral tear or FAI without evidence of femoral neck involvement
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Sports hernia: MRI findings are often normal
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Avascular necrosis: gradual onset with pain in groin, thigh or buttock
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Greater trochanteric pain syndrome: superficial pain with palpation
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Osteosarcoma: swelling and tenderness; unexpected weight loss
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Osteoid osteoma: presence of night pain that can be initially relieved with over-the-counter pain medication; well-demarcated lytic lesion on imaging
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Lumbar spine involvement (i.e., radiculopathy, spinal stenosis, herniated disc, facet syndrome, spondylosis): positive lumbar spine physical exam
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Sacroiliac joint dysfunction: positive sacroiliac joint exam
Treatment
Nonoperative Management
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For nondisplaced compression stress reactions involving the femoral shaft, a 1- to 4-week period of limited weight bearing followed by a gradual, progressive return to activity is sufficient for recovery.
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For nondisplaced compression stress fractures involving the femoral shaft, a 4- to 6-week period of limited weight bearing followed by a gradual, progressive return to activity is sufficient for recovery.
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For nondisplaced stress fractures involving the inferior aspect of the femoral neck, a 4- to 6-week period of non–weight bearing is recommended. Radiographic evidence of healing should be evident before beginning a progressive return to weight bearing and activity.
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The gradual return to activity should include exercises to address strength, flexibility, and postural control deficits.
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An analysis of the individual’s sports mechanics (i.e., running, gymnastics, dance) should be performed to identify and correct any pathomechanics that may have contributed to the original injury or resulted from it.
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A nutritional assessment should be performed to ensure adequate caloric intake and appropriate vitamins and minerals to maintain adequate bone density.
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Calcium and vitamin D supplementation should be considered, especially for competitive athletes.
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If a metabolic disorder or hormonal imbalance is suspected to contribute to the stress fracture, a more detailed medical evaluation is required.
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Use of an electrical bone stimulator may be considered with stress fractures showing delayed healing or nonunion.
Guidelines for Choosing Among Nonoperative Treatments
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The location (shaft vs neck; compression-sided vs tension-sided) and severity (displaced vs nondisplaced) of the stress fracture determines the extent and duration of non–weight bearing.
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Prolonged non–weight bearing may be recommended if the individual has low bone mineral density.
Surgical Indications
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Displaced fracture ( Figures 27-3 and 27-4 )
FIGURE 27-3
Radiograph of right femoral neck stress fracture with displacement.
FIGURE 27-4
Postoperative radiographs following closed reduction and internal fixation of displaced right femoral neck fracture shown in Figure 27-3 . Minimal healing was evident at ( A ) 1 month postsurgery, with progressive healing present at ( B ) 7 months, ( C ) 14 months, and ( D ) 19 months postsurgery.
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Tension-sided stress fracture
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Subtrochanteric stress fracture
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Extension of fracture line of compression side femoral neck beyond 50%
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Failure of nonoperative management
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Malunion or nonunion
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Failure of prior fixation
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History of multiple stress fractures (relative)
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Low bone mineral density (relative)
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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Location of fracture established through physical examination and imaging
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History of multiple stress fractures
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Vitamin D deficiency (serum 25[OH]D status less than 10 ng/ml severe; 10 to 29 ng/ml mild/moderate; 30 to 80 ng/ml optimum; greater than 80 ng/ml toxicity possible) with goal of 60 ng/ml in athletes with stress fractures
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Low bone mineral density
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Patient’s relative activity level, more aggressive with more activity (e.g., competitive runner)
Aspects of Clinical Decision Making When Surgery Is Indicated
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Displaced femoral neck fractures often require emergent anatomical open reduction and fixation.
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Dynamic hip screw of fixed angle plate is often required for stable fixation.
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Osteotomy may be required for varus angulation in malunion or nonunion cases.
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Subtrochanteric fractures can often be treated with intermedullary nails or fixed angle plates.
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Nondisplaced tension-sided (superior) femoral neck stress fractures can be treated with percutaneous fixation.
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Compression-sided femoral neck stress fracture that extend beyond 50% can be treated with percutaneous fixation.
Evidence
Multiple Choice Questions
- QUESTION 1.
Which of the following athletes is at the greatest risk for a femoral shaft stress fracture?
- A.
Female softball player
- B.
Female cross country runner
- C.
Male cross country runner
- D.
Female basketball player
- A.
- QUESTION 2.
Which of the following is not an intrinsic risk factor for a femoral stress fracture?
- A.
Poor nutritional status
- B.
High medial longitudinal arch of the foot
- C.
Prior stress fracture
- D.
Rapid or substantial increase in training volume
- A.
- QUESTION 3.
Which clinical test may be useful in detecting a stress fracture of the femoral shaft?
- A.
Ober’s test
- B.
Fulcrum test
- C.
Straight leg raise test
- D.
Scour test
- A.
- QUESTION 4.
To confirm the diagnosis of stress fracture from radiographs, which of the following should be observed?
- A.
New periosteal bone formation
- B.
Visible area of sclerosis
- C.
Visible fracture line
- D.
Any of the above
- A.
- QUESTION 5.
Which of the following is recommended as part of the recovery process for a nondisplaced, compression-sided femoral shaft stress fracture?
- A.
Limited weight bearing for 1 to 4 weeks
- B.
Exercises to address strength, flexibility, and postural control deficits
- C.
Nutritional assessment
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Epidemiology )
- QUESTION 2.
Correct answer: D (see Pathophysiology )
- QUESTION 3.
Correct answer: B (see Clinical Presentation— Abnormal Findings )
- QUESTION 4.
Correct answer: D (see Clinical Presentation— Imaging )
- QUESTION 5.
Correct answer: D (see Treatment )
Nonoperative Rehabilitation of Stress Fractures of the Femoral Neck and Shaft
- Bryan C. Heiderscheit, PT, PhD
- Geoffrey S. Baer, MD, PhD
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Protection to site of injury to prevent fracture propagation
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Progressive loading to promote bone regeneration
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Maintenance of muscle strength
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This rehabilitation program is designed for nonoperative management of nondisplaced femoral neck and shaft stress fractures.
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Because of risk for significant complications, most tension-sided femoral neck stress fractures are managed surgically. This rehabilitation program is not appropriate for postoperative management because additional restrictions may apply.
Phase I (weeks 1 to 4–6) : Limited Weight Bearing
Protection
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Crutches
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Femoral shaft
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Toe-touch weight bearing with progression to weight bearing as tolerated over a 1- to 4-week period
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Femoral neck
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Non–weight bearing until pain free with radiographic evidence of healing, often 4 to 6 weeks
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| PHASE I (weeks 1 to 4 to 6) | PHASE II (weeks 4 to 6 to 8) | PHASE III (weeks 8 to 12) |
|---|---|---|
|
|
|
Techniques for Progressive Increase in Range of Motion
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Femoral neck stress fracture may display limited hip range of motion primarily owing to muscle guarding. Soft tissue mobilization may prove useful in resolving the muscle guarding; however non–weight bearing and activity restriction often produce the same effect.
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Joint mobilization techniques should not be performed with femoral neck stress fractures as they are typically unnecessary and could compromise the fracture healing. Hip range of motion is rarely affected as a result of femoral shaft stress fractures.
Soft Tissue Techniques
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Deep tissue massage, trigger point release and augmented soft tissue mobilization may be considered to resolve associated muscle guarding (gluteals, adductors, quadriceps, hamstrings)
Stretching and Flexibility Techniques for the Musculotendinous Unit
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Gentle to moderate intensity stretching to hamstrings, quadriceps, hip flexors, adductors, and plantar flexors.
Other Therapeutic Exercises
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Easy freestyle swimming
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Deep water running with a flotation belt
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Seated cycling with low to moderate resistance
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Total arm strengthening
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Core stability, as appropriate given limited weight-bearing status
Activation of Primary Muscles Involved
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Vastus medialis and adductor brevis attach at a common site for femoral shaft stress fractures (junction of proximal and middle thirds). Therefore selected exercises should minimize the force production required of these muscles.
Techniques to Increase Muscle Strength, Power, and Endurance
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For femoral shaft stress fractures:
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Side-lying hip abduction, 2 × 15
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Bent knee hip extension in quadruped, 2 × 15 each side ( Figure 27-5 )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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