Femoral Neck Stress Fracture

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Written by: Dr Jeremy Steinberg – created: 5 June 2022; last modified: 5 June 2022

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Compression stress fracture of the left femoral head in a 25 year old runner on coronal PD FS
Femoral Neck Stress Fracture
Epidemiology 3% of sport-related stress fractures, most common in female long-distance runners.
Pathophysiology Fatigue loading of the femoral neck where loading exceeds metabolic repair potential. For tension fractures there is additional component of hip abductor fatigue.
Clinical Features Exercise induced anterior groin pain, pain at extreme range of motion.
Tests Plain films, but MRI gold standard.
Treatment Incomplete compression fractures - conservative. Complete compression, incomplete tension, and displaced - surgical.
Prognosis Incomplete compression good prognosis.

Femoral neck stress fractures are a rare sport-related stress fracture, most commonly seen in long distance runners.


It is most commonly seen in female long distance runners with a poor baseline level of fitness. This is due to repetitive submaximal loading in combination with relative energy deficiency.[1] They account for 3% of all sport-related stress fractures.

Clinical Features

Patients report a gradual onset poorly localised hip or groin pain that is exacerbated with weight-bearing exercise. The most consistent examination finding is pain at extreme end range of motion, particularly internal rotation.[1]


Originally Fullerton & Snowdy with several modifications:

  • Type I: Tension sided: supero-lateral femoral neck with vertical fracture line
  • Type II: Compression sided: infero-medial femoral neck with oblique fracture line
    • Further divided into those where fracture line less than 50% of femoral neck width vs greater than 50%
  • Type III: Displaced
  • Type IV: Atypical superiorly based incomplete tension

Femoral neck stress fracture classification.jpg

Differential Diagnosis

Differential Diagnosis


Plain films are usually taken first. But quite often MRI is needed for definitive diagnosis.

MRI features include: periosteal oedema and fractur line.

Classification system by Arendt and Griffiths.[2]
Grade Features
grade 1 signals changes only on STIR
grade 2 changes on STIR and T2
grade 3 changes on STIR, T1, and T2 with no fracture line present
grade 4 changes on STIR, T1, and T2 with a fracture line present


Compression sided fractures are usually treated conservatively with activity modification. Tension sided fractures may need surgery to reduce the risk of fracture completion and osteonecrosis.


Papers of particular interest have been highlighted as: ◆ of special interest ◆◆ of outstanding interest

  1. 1.0 1.1 ◆◆ open accessRobertson, Greg A.; Wood, Alexander M. (2017-02). "Femoral Neck Stress Fractures in Sport: A Current Concepts Review". Sports Medicine International Open. 1 (2): E58–E68. doi:10.1055/s-0043-103946. ISSN 2367-1890. PMC 6226070. PMID 30539087. Check date values in: |date= (help)
  2. Arendt, E. A.; Griffiths, H. J. (1997-04). "The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes". Clinics in Sports Medicine. 16 (2): 291–306. doi:10.1016/s0278-5919(05)70023-5. ISSN 0278-5919. PMID 9238311. Check date values in: |date= (help)

Literature Review