Working Diagnosis:
Left femoral neck stress fracture, compression side.

Outcome:
The patient had no significant post-operative complications and is currently undergoing a post-operative course. Post-surgically, the patient was placed on crutches with toe-touch weight-bearing for a total of 4 weeks. At this time she is only experiencing mild pain and is in the process of weaning from the crutches. She is able to ride a stationary bike, but is still refraining from an impact activity including running. She has not yet been cleared for full activity.

Author's Comments:
Femoral neck stress fracture is a relatively infrequent injury in runners, an incidence reported by Fullerton and Snowdy as 5% of 1049 stress fractures of all types in athletes over a 4 year prospective study (2).
There are 2 different types of stress fractures within the femoral neck:
Tensile forces occur at the superior aspect of the femoral neck (tension-sided)
Compressive forces occur at the inferior aspect (1) (compression-sided)
For compression-sided stress fractures, as in our case, with a fatigue line less than 50% of the width of the femoral neck, conservative treatment is typically recommended which includes strict maintenance of non-weight-bearing status until asymptomatic, followed by an additional 4-6 weeks of activity restriction until return to full activity (1,3).
Given the severity of the consequences if the fracture progresses to a complete fracture including nonunion, varus malunion, osteonecrosis, and subsequent arthritic changes, it can be justified to surgically fix this type of femoral neck stress fracture (3,4) Surgical intervention (percutaneous screw fixation) is usually reserved for those stress fractures that comprise greater than 50% of the width of the femoral neck(3)).
After a discussion with our patient, she elected for surgical fixation to help prevent the above consequences from occurring Case Photo #3 . She wanted to remain very active in the future, including continuing recreational running and possibly running marathons.
This is an important discussion to have with the patient so that an informed decision can be made on the treatment plan. In either case, complete healing of the fracture, both on imaging and clinical examination, followed by a full progressive return to running rehabilitation program should be achieved prior to allowing full return to activity (4).

Editor's Comments:
Consider elements of female athletic triad when diagnosing stress reactions/stress fractures. Her BMI was 18.8 in this case and low normal. initial hip pain in runner with low BMI should trigger further diet, menstrual, and bone questions.

A prospective meta-analysis noted a single risk factor verses combined risk factor significantly increases chance bone stress injury (restrictive diet, low BMD, hormonal changes).

Barrack MT et al. Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med. 2014 Apr;42(4):949-58.

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