has anyone had a femoral neck stress fracture?

Question

if you are a runner or have been in the military and had a femoral neck stress fracture, can you tell me how you got better or if you still have problems with it.

Answer 1

I am an MD, also former military(USAF). I would think that they would "board you out" as medically unqualified for a combat ready force if you have had a fracture such as that. I am sure you will at least have to have a waiver to stay in, signed by a General. At the very least you will need to do things to strengthen your bones, including prescription drugs. Good luck.

Answer 2

Femoral Neck Stress Fracture Recovery

Answer 3

Most ladies have it

Answer 4

Stress fractures are a common problem in various populations, including runners and military trainees. Stress fractures can be very mild and cause only minimal changes to the bone, which eventually heal, or they may progress to a complete fracture that requires surgical fixation. Although rare, poor outcomes may occur in the form of nonunions or avascular necrosis. Certain stress fractures have a higher risk of poor outcome, including anterior tibial and femoral neck stress fractures (FNSFs).

FNSFs are some of the most difficult injuries to diagnose. The pain associated with a femoral neck stress fracture may be poorly localized in the hip and may be referred to the thigh or back. Physical examination findings are not very specific for this injury, and diagnostic radiographs in the form of x-ray films, bone scan, and/or MRI often are necessary. Failure to diagnose this injury may lead to catastrophic consequences, including avascular necrosis of the femoral head and need for a hip replacement in otherwise healthy young individuals. A high index of suspicion in the appropriate risk populations is the key to diagnosing and treating FNSFs.

Frequency
United States
Stress fractures may develop in up to 15% of runners and military trainees. Of those patients who develop stress fractures, about 5-10% are in the femoral neck. Stress fractures on the compression side (inferior aspect) of the neck are more common than stress fractures on the tension side (the superior aspect).

Functional Anatomy
The femoral neck lies between the femoral head and femoral shaft, demarcated by the greater and lesser trochanters. Weight-bearing forces from the trunk cause a compressive force on the inferior aspect of the femoral neck, whereas the superior aspect is subject to tensile forces. The blood supply to the femoral head runs through the femoral neck; thus, a femoral neck stress fracture may disrupt the blood supply to the femoral head and cause avascular necrosis of the femoral head.

Sport Specific Biomechanics
The load of the runner's body weight is transmitted down the lower extremities through the bones and may exceed 3-5 times the body weight in the femoral neck during running. Muscles help absorb forces and distribute load, especially the gluteus medius. The weight of the trunk and upper extremities applies compressive forces to the inferior aspect of the femoral neck. Conversely, tensile forces act upon the superior aspect of the femoral neck. These forces become important in prognosis and management of the stress fracture. A sudden reduction in weight and lower muscle mass combined with daily training has been associated with an increased risk of FNSF in US Naval Academy plebes.
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.

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

Continued activity probably will 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 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. Other possible diagnoses include greater trochanteric bursitis, adductor strain, or a pubic ramus stress fracture.

Pain at the extremes of passive range of motion, especially external and internal rotation, is the most sensitive sign.

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

Causes

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 proper bone and supporting muscle adaptation and results in microscopic damage to the bone, which cannot be healed quickly enough.


In the military population, trainees with lower initial levels of fitness and higher body mass indexes have been associated with stress fractures. A history of a previous stress fracture is a risk factor. Coxa vara has recently been associated with an increased risk of FNSF.

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

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

Young women who exercise regularly can increase their femoral neck bone density.

Recently, 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 fitness-matched cohorts.
Rehabilitation Program
Physical Therapy
Follow the acute treatment principles of protection, rest, ice, compression, elevation, medication, and modalities (PRICEMM). This treatment regimen is most appropriate for compression (as opposed to tension) fractures. Patient compliance is important.


Protection - Crutches with non–weight-bearing ambulation until relief of pain at rest


Rest - Non-weight bearing if pain at rest; may do alternative exercises (eg, swim, upper extremity Exercycle) to maintain cardiovascular conditioning


Ice - To assist with pain reduction


Elevation - Usually difficult


Medication - Consider low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief, or narcotics if severe pain


Modalities - Not much help acutely

Medical Issues/Complications
If the fracture is on the compression side and is not displaced, patients usually do well with conservative management of non-weight bearing on crutches and gradually progress to touchdown weight bearing, partial weight bearing, and, then, no crutches in 4-6 weeks, depending upon clinical response. Tension-side fracture treatment is somewhat controversial, with some physicians advocating surgical pinning (even for nondisplaced fractures) and others advocating conservative treatment such as for compression-side fractures. In a compliant patient who will maintain non–weight-bearing on crutches, a trial of conservative treatment with non–weight-bearing on crutches is recommended for both types of fracture unless displacement is present. If displacement is present, urgent referral for operative evaluation and fixation is indicated.



Treatment of the tension side is based on the completeness of the fracture (ie, unicortical versus bicortical) based on a classification scheme. In general, bicortical tension-side fractures are treated surgically.

Surgical Intervention
Surgical intervention is dependent upon the type of fracture. Compression-side fractures can be treated with conservative therapy. Nondisplaced tension-side treatment is controversial, with some physicians advocating prophylactic surgical fixation and others advocating a trial of conservative therapy in compliant patients. Urgently refer the patient for evaluation for surgical fixation in displaced fractures.

Consultations
Regardless of displacement, tension-side stress fractures of the femoral neck should be managed in coordination with an orthopedist.

Other Treatment
Review the patient's diet and ensure adequate calcium and vitamin D intake and supplement as needed. Consider oral contraceptives for amenorrheic women. Oral contraceptives may aid in the recovery of bone mass in these women. Athletes with eating disorders may need psychological and nutritional support.

Recovery Phase
Rehabilitation Program
Physical Therapy
As the patient’s pain decreases, gradually increase from non-weight bearing to touchdown weight bearing to partial weight bearing and eventual discontinuation of crutches. This usually takes 4-6 weeks. Coordinate rehabilitation with orthopedics for patients with hips that have surgical pinning. After the patient is able to walk 1.5 miles without pain (usually in 8-12 weeks, but sometimes longer), begin a gradual return to a running program. Usually, it takes approximately 2.5 months to be able to run 3 miles pain free. If pain returns during rehabilitation, decrease the patient's activity until walking is pain free again.

Non–weight-bearing training also can play a role. Activities such as running in water with an appropriate floatation vest can be helpful. Upper extremity resistance and aerobic training can be used.


Medical Issues/Complications
A very mild pain may return briefly when first attempting to run. If the pain is more than a very mild intensity, consider that the stress fracture is not healed completely and needs additional rest. If pain is severe, perform another x-ray film to check for displacement. Avascular necrosis, nonunion, malunion, and eventual hip replacement may result from complications of the femoral neck stress fracture that are not diagnosed in time or are rehabilitated too quickly.

Surgical Intervention
If pain persists for longer than 2 weeks, despite true compliance with non–weight-bearing status on a tension-side, nondisplaced stress fracture, consider surgical fixation if not already performed.

Consultations
Consult orthopedics if the patient is not progressing adequately.

Other Treatment (Injection, manipulation, etc.)
Ensure adequate calcium and vitamin D intake. If an eating disorder is present, monitor treatment and recovery of proper dietary and weight management habits.

Maintenance Phase
Rehabilitation Program
Physical Therapy
Monitor activity to ensure that the same training errors that initially resulted in the fracture are not committed again. Gradual increases in mileage (£10%/wk) generally are accepted as safe and effective. Likewise, intensity of workouts should increase gradually and not dramatically.

Medical Issues/Complications
Recurrence of the same type of pain should warrant a return visit to check for a recurrent stress fracture.

Surgical Intervention
If the femoral neck was surgically fixated, consult orthopedics regarding when (if ever) the pins should be removed.

Consultations
Obtain an orthopedic consult if the patient is not progressing adequately.

Other Treatment
Continue calcium supplementation if necessary. Monitor for recurrence of an eating disorder if appropriate.

Return to Play
Once the athlete has completed the walk/run program and is able to run 3 miles without pain, gradually increase mileage (no more than 10% per week) until the goal level is obtained. Gradual sport-specific drills and higher-intensity training is accomplished over a few weeks.

Complications
Complications include recurrence of stress fracture and avascular necrosis of the femoral head.

Prevention
Prevention includes gradual increase of training, halting/decreasing training upon return of symptoms, and reevaluating for recurrence, adequate calcium intake, and further treatment of eating disorder (if appropriate).

Prognosis
Compression-side fractures have an excellent prognosis. Usually, if the injury is diagnosed early and the patient does not return to training too rapidly, tension-side fractures also do well. However, up to 25% of patients may have residual hip pain, discomfort, and gait problems 5-7 years after treatment.

Displaced fractures have a guarded prognosis until after surgical fixation and evaluation for 4-6 weeks. Even after surgical fixation, displaced FNSFs have a high prevalence of avascular necrosis, with one case series reporting a rate of 24%. Persistent pain and a poor outcome occurred in 19% of the 42 patients in that series
FNSFs are difficult to diagnose upon examination. History and physical examination findings indicative of pain upon internal and/or external rotation of the hip or pain upon single-leg standing or hopping should arouse clinical suspicion. Single-leg hopping may complete the fracture and should be discouraged. The patient should be restricted to crutches, non–weight-bearing or touchdown weight-bearing, if it causes no pain. Perform further investigation, including radiography, bone scanning, and/or MRI. Obviously, a missed femoral neck stress fracture originally diagnosed as bursitis or tendonitis and allowing the patient to return to sport, only to have the patient snap the femoral neck and eventually require an artificial hip, is not a good outcome. A completed displaced femoral neck stress fracture has about a 20% chance of having a poor outcome even with surgical fixation; thus, diagnosing these injuries prior to completion of the fracture is essential.