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Maximizing Readiness Through Improved Health and Performance
Increasingly Common and
Incredibly Challenging
Femoral Neck Stress Injuries
• The views expressed in
these slides and in today’s
discussion are my own
• My views may not be the
same as Auburn University
or the United States
Military
• Participants must use
discretion when using the
information contained in
this presentation
http://ww w.auburntigers.com
Experienced sports
medicine professionals
develop great instincts
to identify
musculoskeletal
injuries (MSI) when
they see/hear
common symptoms
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
My goal today is just
to make sure
somewhere in the
back of your head you
consider FNSF an
option….
www.ccsu.edu
Anatomy Review
Why do I care about FNSFs?
• Typically we think of these injuries in post- menopausal women
• Then I started working with the military……
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
Sample of yearly FNSFs in 2 brigades
• One year I had 85 FNSFs
in one training location
• Months of missed
training
• Often end of career
• FNSF costs $85K - $150K
• Army owns these
Soldiers for the rest of
their lives
• We developed screening,
changes in training, and
new diagnosis protocols
Another Soldier on Sticks?
• Soldiers come in unfit
• Nutrition is poor
• Poor diet impacts bone density and calcium levels
• Unaccustomed to physical activity/movement
• Rapid increase in physical activity
• Extensive daily ‘foot time’
192d Prevention Initiative
• Reduce unnecessary time standing, especially in IBA
• Integrate PRT with foot marches, combatives, and other physical events
• Use transport to when possible
• Execute PRT with precision, progression, and integration with proper form
and pace.
• Utilize approved corrective action, and repetitions/time-directed
exercises prescribed
• Maintain foot march pace no faster than 3 mph for red, white, and blue
phase, no faster than 3.5 mph for gold and black phases of IN OSUT.
• Use flat terrain when possible and emphasize finishing as a team.
• Minimum of seven hours of sleep/night in garrison.
• Consider increased injury rates caused by striving to exceed or maximize
APFT scores
• Emphasize 4 for the Core and Hip Stability Drill to strengthen hip and core
muscles and minimize injury.
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
FNSFs in Athletes
• Becoming more common in collegiate sports
• AU Team Physician sees 3-5/year now
• 2 women’s cross country
• 1 men’s cross country
• 1 women’s BB
• Commonalities with other types of Stress Injuries
• Often long distance athletes
• Tall, lanky Soldiers and athletes more susceptible
• Females, especially if not fueling properly are
vulnerable
• Rapid increases in training
• Unfit athletes training too much
• Poor lifetime nutrition
https://www.google.com/search?q=ccsu+athlete&source=lnms&tbm=isch
&sa=X&ved=0ahUKEwiq84u95bzZAhVohOAKHXmHAeUQ_AUICigB&biw=128
0&bih=907#imgrc=ltKKxKmzDom6LM:
FNSFs in Athletes
• 5% of all SFs
1
• May see comorbid with SF of the femoral head
or pelvis
• May be bilateral
• Delay in DX leads to high complication
2,3
• 8-14 week delay common
• Difficult to DX
• 60% of athletes that suffer complications
never return to preinjury activity level
1
Femoral Neck Stress Fracture
Fracture due to repetitive bending
load (stress) on bone angle over
time
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
• If injury is caught early,
non-weight bearing rest
followed by rehabilitation
can be effective
• If not, surgery and pinning
may be required
Femoral Neck Stress Fracture
Femoral Neck Hip Stress Fracture
Typically surgical FNSFs result in hip replacement (20 yrs)
Femoral Neck Stress Fractures/Injury (FNSF)
• Are wickedly tricky
• They hide
• There may be no pain with an almost
through/through injury
• They mimic other common injuries
• Impossible to predict, hard to prevent
• Can occur as rapidly as 1-2 weeks of training
• Common symptoms
3
• Low back pain
• Knee pain
4
• Lateral thigh pain
• Glute pain, running down to the knee
• Inner thigh pain
5
• Or no pain at all
www.ccsu.edu
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
www.ccsu.edu
• Signs/Symptoms
1
• Antalgic gait
• Pain
• Deep-achy or sharp shooting
• Pain occurs with activity, slowly becomes continuous
• Often progresses to night pain
• Esp. when log rolls onto involved side
6
• Decreased weight bearing
• Decreased stride length
• Decreased strength
• Decreased/painful ROM
• Missed FNSF can become emergency
(femoral artery)
Assessment
• Complete your normal assessment
• It may not be obvious that it’s a hip
problem. If findings are inconclusive, clear
the hip.
• Specifically:
• Palpation
• FN is too deep to palpate, area around hip
joint may be tender, muscles may be tense
and splinting
• ROM
• PROM - Pain at extremes of external/internal
rotation
• RROM – often painful, can be weak
• Axially loading pain
• Supine, heel tap
• Functional
• Single leg standing (single leg hop can
create a through/through SF*)
Auburn.edu/athletics
Orthopedic Tests
• Complete your normal hip assessment
• FABER test often +
• Scour test – determine if hip involvement, rule
out labral tear
• Fulcrum test – more specific for femur SF
• https://youtu.be/96RqZTYuKrw
• Differential DX
1
• Hip flexor strain
• Greater trochanteric bursitis
• Adductor strain
• Pubic ramus SF
• Low back pathology
• Knee pathology
Auburn.edu/athletics
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
• Imaging
• Radiographs may be unremarkable (only 10%
+)
6
• Bone scan is positive in multiple locations if
the athlete is in intense training
• MRI is the gold standard
• Treatment/Rehabilitation
• Non-weight bearing rest
• Time depends on severity (4-6 weeks non-
surgical)
• Once physician approves return to activity
begin hip and core strengthening
• Alter-G treadmill
• Caution – may produce gait changes
• Pool PT
• Slow return to full weight bearing and
activity
https://www.google.com/search?q=au burn+f ootball&source =lnms&tbm=is ch&
sa=X&ved=0ahUKEwjq7uHv_bzZAhUkVt8 KHdmsCw0Q_ AUICigB&biw=128 0&bih=
907#imgrc=-ifwm xjxtPKnvM:
Take Home Points
• FNSFs occur in non-military athletes (5% of all SFs)
• Becoming more frequent
• FNSFs mimic other injuries
• They frequently are missed, causing serious complications
• A through/through FNSF is life threatening
• Consider FNSF if the injury just doesn’t make sense
• Fulcrum test, PROM/RROM, single-leg standing, axial loading
• MRI only conclusive DX
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
Thank you!
Questions?
1. Gurney B, Boissonnault WG, Andrews R. Differential diagnosis of a femoral
neck/head stress fracture. The Journal of orthopaedic and sports physical
therapy. 2006;36(2):80-88.
2. Clough TM. Femoral neck stress fracture: the importance of
clinical suspicion and early review. Br J Sports Med.
2002;36(4):308-309.
3. Johansson C, Ekenman I, Toernkvist H, Eriksson E. Stress fractures of
the femoral neck in athletes. The consequence of a delay in diagnosis.
American Journal of Sports Medicine. 1990;18(5):524-528.
4. Carow SD, Houser JD. Trainees With Displaced Hip Fractures Present to
Physical Therapy With Primary Complaint of Knee Pain. Military
medicine. 2017;182(11):e2095-e2098.
5. Rolf C. Pelvis and groin stress fractures: a cause of groin pain in
athletes. Sports Medicine & Arthroscopy Review. 1997;5(4):301-304.
6. Starkey C., Brown SD, Ryan J. Examination of Orthopedic and Athletic Injuries. 3
rd
Ed. F.A. Davis. 2008.
References
CCSU Sports Medicine Symposium 2018
Tuesday March 6, 2018
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