Hip Stress Fracture

author : AMSSM

comments : 2

Type of stress fracture dictates treatment and possibility of return to sport

Hip Stress Fracture: Question from trichickdd2013

"I was just diagnosed with a stress fracture in my hip, underside of the trochanter, compression. What should I expect from the recovery process?

For this year, I was aiming for Haines City 70.3 in May and IMFL as my first full iron in Nov. Haines is out of the question and it seems that IMFL is a wild card.

I had a bone density test which showed me as being in the healthy zone which is great given that I'm 40-something. It's going to be tough to change up the run as that's my favorite stress relief. "

Answer by Dusty Marie Narducci, M.D.,
Member AMSSM

A stress fracture is a partial or complete bone fracture caused by repetitive stress. This stress is applied at an intensity less than that required to fracture a bone in a single injury. Stress fractures of the lower extremity are common injuries in athletes. Since it is a commonly undiagnosed condition it is difficult to determine its true incidence. It has been predicted that 50 percent of runners will have a stress fracture at some point during their running career.

Stress fractures are generally divided into two categories; insufficiency fractures and fatigue fractures. Insufficiency type stress fractures occur when normal activity causes an already unhealthy bone to fracture. A fatigue stress fracture occurs when excessive repetitive stress is placed on normal bone. Prior stress fractures, hormonal abnormalities, leg length discrepancy, nutritional deficits, poor biomechanics as well as decreased strength and endurance are risk factors for the development of stress fractures. Training patterns of high intensity, large volume, that abruptly increase and consist of higher weekly running mileage have a greater incidence of stress fractures. Activities on uneven surfaces can result in muscle fatigue with subsequent excessive load being placed on the bone. Inappropriate footwear including worn-out shoes can make athletes more prone to stress fractures. For unknown reasons, women are up to 10 times more likely to develop fatigue fractures than men. Hormonal changes and a higher incidence of disordered eating patterns in female athletes may play a role. The declining levels of physical fitness that occurs during the aging process makes stress fractures more common in older athletes.

Stress fractures will often cause localized pain that is related to activity (more intense activity will cause more pain). If untreated, this pain will occur with less strenuous activity and even sometimes with walking or at rest. There may be point tenderness over the injury site in addition to swelling and mild redness. The most common location to have a stress fracture is in the lower limb including the thigh, shin, and foot bones. Although rare it is possible to get stress fractures in the upper extremities as well as the spine and ribs.

Femoral Stress Fractures:

Femoral stress fractures are common in athletes who participate in long-distance running, jumping, and triathlons. The femur also known as your thighbone is the longest and strongest bone in the human body. Anatomically, the femur has a body (shaft) with two ends called epiphyses. One end articulates with the hip and the other with the knee. The head of the femur unites with the hip or more specifically the acetabulum of the pelvic bone. The head of the femur attaches to the body of the femur by an area of the bone called the neck. The underside of the femur neck is called the compression side and the upper side is called the tension side.

Femoral neck fractures are typically divided into three categories: tension sided, compression sided and displaced. Tension side (upper side) femoral neck stress fractures have a higher risk of complications compared to those occurring on the compression side. Displaced fractures occur when the bone cracks all the way through and there is no longer normal alignment between the cracked bone. All stress fractures of the femur are dangerous but the tension type is more likely to become a displaced stress fractures. Displaced fracture can compromise the blood supply to the femur. When there is limited or absence of blood to the femur a very serious complication called avascular necrosis (AVN) of the hip can occur. Non-union healing and AVN can result in long-term functional deficits. Stress fractures of the femur can also occur in the shaft (body), the greater trochanter (large bump below the neck of the femur) and the pelvis bone.

Symptoms & Diagnosis:

Although femoral stress fractures can be challenging to diagnosis, a change in the way you walk or run due to pain is a concerning sign. Most athletes with stress fractures of the femur feel vague pain at the front of the groin or anterior thigh usually related to activity. Stress fractures, including those located at the femoral neck, often require a MRI for diagnosis because plain radiographs regularly fail to demonstrate the fracture site during early stages. Depending on the situation other tests such as a three-phase bone scan, SPECT or CT scan may be necessary for diagnostic purposes.

Management:

In general stress fractures are managed with rest and activity modification. Some stress fracture sites are less likely to heal and therefore are consider high-risk. High-risk stress fractures require more strict treatment and sometimes even surgery. Low-risk sites are often treated with protection of the fracture site, reduced or avoidance of painful weight bearing, activity modification and rehabilitation. Early intervention of stress fractures is essential to prevent further damage.

Compression-type femoral neck stress fractures are usually treated without surgery. Resting the hip for 6-12 weeks along with appropriate rehab is most commonly recommended. The progression of rehabilitation should be influenced by symptoms and exam findings. Once pain free, the aggravating activity can be resumed and increased slowly. Generally, the volume of exercise should be increased by 10 % or less per week. Some literature supports non-impact exercise beginning as early as the first few weeks of recovery if the individual is pain free during standing and walking. These activities include cycling, freestyle swimming, and pool running (using a floatation belt). This type of cross-training should be guided by an experienced medical team. In addition, rehabilitation, focusing on improving strength and flexibility in the hip, abdomen, back, quadriceps and hamstrings is essential.

The management of tension-type stress fractures is highly debated among medical professionals. Tension-type stress fractures at risk of displacing are often treated with surgery. Non-surgical treatment of this type requires that the athlete avoids placing weight onto the injured leg (this is called non-weight bearing) for an extended period of time. Depending on the type of fracture crutches may be necessary. At the appropriate time, rehab should be initiated with close instruction and monitoring.

The majority of stress fractures will heal routinely with return to sport within 6-12 weeks. The healing of femoral neck stress fractures can be challenging with recovery delays up to 50%. Successful treatment is profoundly dependent on compliance. The duration of recovery relies heavily on the individual athlete. It is critical to resume exercise at a frequency and intensity well below the level that produced the symptoms. With appropriate management, successful return to sport is achievable.

References:

1. Ramey, Mclnnis, Palmer. Femoral Neck Stress Fracture: Can MRI Grade Help Predict Return-to-Running Time? Am J Sports Med.2016 Aug; 44 (8): 2122-9

2. Diehl J.J, Best TM, Kaeding CC. Classification and Return to Play Considerations for Stress Fractures. Clinics in Sports Medicine. 2006 Jan 25 (1) :17-28

3. DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med. 2006 Jan. 25(1):89-103, ix

4. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. 2006 Jan. 34(1):108-15.

5. Kahanov L, Eberman LE, Games KE, et al: Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med 2015;6:87-95.

Dusty Marie Narducci, M.D.

Board Certified Family Medicine, Sports Medicine

Assistant Professor Morsani College of Medicine

Department of Family Medicine & Orthopedics/Sports Medicine USF Health Team Physician for the Department of Athletics at the University of South Florida

Team Physician for Saint Leo's University

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date: January 30, 2018