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Femoral Shaft Stress Fracture

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Other Names

  • FSSF


  • This page refers to stress fractures of the mid-shaft of the Femur



  • 80-90% of all stress fractures occur in the lower extremities[1]
    • Femoral stress fractures make up about 6.6% of all lower extremity stress fractures[2]
  • Stress fractures represent between 0.7% and 20% of all sports medicine injuries[3]
    • In runners, stress fractures represent 16% of all injuries
  • Most commonly seen in young, athletic individuals


  • General: Stress Fractures (Main)
    • Occur as a result of repetitive submaximal mechanical load across the femur
    • As with all stress fractures, this occurs when the bone absorption exceeds mechanical repair during remodeling
    • Vast majority of cases occur in individuals with normal bone and excessive forces
    • Starts with a "crack" but can propagate with inadequate healing time
  • Early detection is important
    • Increased awareness has been shown to improve early detection

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • There is typically no acute trauma
    • Athletes will most frequently endorse an increase in training duration or intensity
    • Often associated with inadequate recovery as well
    • Pain will initially only occur at the end of physical activity
    • Later on in the disease course, it may start early during exercise or even at rest
  • Physical Exam: Physical Exam Hip
    • Often point tenderness over a the shaft of the femur
    • Swelling may or may not be present
  • Special Tests
    • Fulcrum Test: Arm is placed under affected femur and used as a fulcrum to recreate pain
    • Hop Test: Patient jumps up and down on affected limb to recreate pain


Bilateral femur XR showing a linear fracture line with lateral cortex thickening in right mid shaft is suggestive of stress fracture. Only lateral cortex thickening is seen on the left side.[4]


  • Standard Radiographs Femur
  • Often normal early in the disease process
  • Abnormal findings, if present
    • Periosteal reaction
    • Endosteal, cortical thickening
    • Linear cortical radiolucency


  • Gold standard and preferred imaging modality in suspected stress fractures
  • Findings: increased signal intensity, bone edema, soft tissue edema
  • Sensitivity, specificity and accuracy rated as high as 100%[5]

Bone Scan

  • Technetium Tc 99m bone scan falling out of favor for MRI


  • Not typically indicated
  • May demonstrate cortical lucency and periosteal reaction



  • N/A




  • Indications
    • Most FSSF
  • Technique
    • Relative rest
    • Discontinue offending activities
    • Protected weight bearing
    • Should use Crutches if painful on ambulation, typically for 2-4 weeks


  • Indications
    • Full cortical break or displacement
    • Patients with low bone mass or over 60 may get prophylactic treatment
  • Technique
    • Intramedullary nail

Rehab and Return to Play


  • Symptomatic (Weeks 0-3)
    • While symptomatic, patient should be kept non-weight bearing with Crutches
  • Asymptomatic (Weeks 3-6)
    • Patient can discontinue crutches when they can walk pain-free
    • Can begin swimming, resistance training on unaffected limb
    • No strength training on affected leg, no impact activities
  • Basic Rehab (Weeks 6-9)
    • Athlete may begin advancing training on affected limb
    • This includes light weights only, light running in a straight line
    • Volume should remain low, controlled and supervised if possible
  • Advanced rehab (Weeks 9-12)
    • Continued gradual return to longer distance and sports-specific activities
  • Additional points
    • The Hop Test and Fulcrum Test can be used to guide decision to advance athlete to next stage
    • If tests are still positive, athlete should not advance to next stage

Return to Play

  • Radiographs
    • Should be checked every 3-4 weeks during rehabilitation
  • Criteria
    • Athlete must be pain free
    • Graded return to activity
    • Typical time frame is 3-4 months


  • Full cortical break
  • Re-fracture
  • Inability to return to sport

See Also


  1. Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med. 2013;6(2):173–181.
  2. Kahanov, Leamor, et al. "Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners." Open access journal of sports medicine 6 (2015): 87.
  3. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–481.
  4. Jo, Yil Ryun, et al. "A case report of long-term bisphosphonate therapy and atypical stress fracture of bilateral femur." Annals of Rehabilitation Medicine 37.3 (2013): 430.
  5. Shin A Y, Morin W D, Gorman J D, Jones S B, Lapinsky A S. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24:168–176
Created by:
John Kiel on 5 July 2019 08:29:47
Last edited:
10 April 2022 08:25:53
Lower Extremity | Hip | Thigh | Fractures | Overuse