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1 · SNAPSHOT

Hip / Pelvic Stress Fracture (Femoral Neck / Pelvis) body chart — Illustrative, not diagnostic. Canva body chart for Hip / Pelvic Stress Fracture (Femoral Neck / Pelvis).

Who: Endurance athletes, military recruits, dancers. Load spike, low energy availability, menstrual disturbance, low BMI.
What: Bone stress injury of the femoral neck or pelvis.
How it behaves: Gradual groin, hip or deep pelvic pain with weight-bearing. Worse with running and loading, may progress to pain with walking or at rest. A "deep ache", an inability to continue running, sometimes night pain.

The one thing to take from this page:

Which side of the femoral neck decides everything — and you cannot tell clinically. The tension side is a surgical conversation; the compression side is still not a rehabilitate-through problem. That is why it gets imaged, not observed.

Tension side vs compression side

	Where	What it means
Tension side	Superolateral femoral neck	High risk. Displacement and non-union. Urgent surgical discussion
Compression side	Inferomedial femoral neck	Lower risk — still not a rehabilitate-through problem
Clinically	You cannot tell them apart	Which is why it gets imaged

⚠️ Displacement is documented. A completely displaced femoral neck stress fracture in a young soldier, and bilateral simultaneous fractures, both appear in the case literature. This is what "do not run through this" is protecting against.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages. This is an acute-risk presentation, so the order shifts: main problem → history and risk profile → body chart → behaviour → screening.

MAIN PROBLEM

"Deep in my groin, and it's there when I walk now."
"I had to stop mid-run and I couldn't finish."
"It aches at night."

HISTORY AND RISK PROFILE — take this first

The load spike. Volume, intensity, surface, a new programme, a camp, a recruit intake.
Energy availability. Ask directly. Eating patterns, deliberate restriction, weight change, appetite.
Menstrual history. Regularity, absence, contraceptive use, age at menarche.
Previous bone stress injury or fracture. The strongest history item there is.
Low BMI, endurance sport, dancer, military recruit.
Vitamin D, nutrition, and any eating-related concern.

BODY CHART

Deep groin, hip, or pelvis. Often poorly localised — patients cup rather than point.
Mark the pubis and ramus separately.
Anterior thigh or knee referral? Common with a hip source.
Not dermatomal, not neurological.

BEHAVIOUR

	Fits bone stress	Points elsewhere
Aggs	Weight-bearing. Running, then walking	Position-related pinch with FADIR → hip-related pain
Progression	Getting worse across sessions and then across days	Stable, load-related, able to hop → tendon entity
Rest	May ache at rest or at night	Settles fully with rest → tendon entity
Hop	Often unable	Able to hop comfortably → not this, usually
Neuro	Normal	Deficit → different problem

SPECIAL / SCREENING QUESTIONS

Can they hop? Will they let you ask them to?
Any night pain, weight loss, fever, cancer history?
Any sudden increase in pain, or a moment where it changed? That is the displacement question.
In an older adult with no load story — osteoporosis, steroid use, previous fragility fracture?

Assessing this region? Download the Hip & Groin assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Adductor- or pubic-related groin pain	Load-related but able to hop; tenderness at the tendon or symphysis rather than deep and axial.
Hip-related pain (FAI, labral)	Position-related pinch rather than weight-bearing pain. Can hop.
Proximal hamstring tendinopathy	Ischial tenderness, sitting pain, able to weight-bear.
Pelvic insufficiency fracture in an older adult	Same injury, different mechanism — osteoporosis rather than a load spike.
Lumbar referral	Neural behaviour, dermatomal pattern, and weight-bearing does not drive it.

The distinction that changes urgency

High-risk versus low-risk bone stress injury site. Femoral neck is a high-risk site, and factors associated with high-risk and low-risk bone stress injury in female runners have been examined [1]. That is what makes this different from a tibial or metatarsal stress injury — the consequence of getting it wrong is not a longer recovery, it is a displaced fracture.

The two that outrank everything

A tension-side femoral neck stress fracture. Urgent surgical discussion — and the case literature explains why: completely displaced femoral neck stress fracture in a young soldier [2], bilateral simultaneous femoral neck stress fracture in a military officer [3], and femoral neck stress fracture in a healthy marathon runner [4].

Malignancy or infection. Night pain, systemic symptoms, no load story.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated. This whole page is.

Finding	What it suggests	What you do
Groin or hip pain with inability to hop or weight-bear	Femoral neck stress fracture	Stop all impact. Urgent imaging (MRI). Consider non-weight-bearing
Pain now present at rest or at night	Advanced bone stress	Urgent imaging
Sudden increase in pain, or a moment where it changed	Displacement	EMERGENCY. Non-weight-bearing, urgent orthopaedic review
Low energy availability, menstrual disturbance, low BMI	REDs	Image, and refer for the medical and nutritional side
Previous bone stress injury	Recurrent bone stress	Low threshold to image
Older adult with no load story	Insufficiency fracture, malignancy	Image and medical review
Night pain, weight loss, fever, cancer history	Malignancy, infection	Medical review
A normal radiograph but the story fits	Radiographs are insensitive early	MRI anyway

The rule: there isn't one. Weight-bearing groin or hip pain in a high-risk athlete is a stress fracture until imaging says otherwise. This page has no "yours" column.

Cross-links: Adductor-related groin pain · Pubic-related groin pain · Femoroacetabular impingement · Proximal hamstring tendinopathy

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline.

Anchored to the 2023 IOC consensus statement on Relative Energy Deficiency in Sport (Mountjoy et al. 2023, PMID 37752011) for the risk profile the subjective questions already ask about, and to the bone stress injury literature in runners (Tenforde et al. 2016, PMID 26616181; Tenforde et al. 2024, PMID 38779133) for the high-risk versus low-risk site distinction.

PubMed Source

The IOC consensus is about relative energy deficiency, not about femoral neck stress fracture management — it supplies the risk framework, not the treatment. There is no validated return-to-running protocol for femoral neck stress fracture specifically, and the return-to-running work is a scoping review of criteria.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2024Tenforde et al. (2024). Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management. Orthopaedic journal of sports medicine, 12(5), 23259671241246227. https://doi.org/10.1177/23259671241246227
2023Alhawas et al. (2023). Completely Displaced Femoral Neck Stress Fracture in a Young Male Soldier With Almost No Functional Impact: A Case Report. Cureus, 15(1), e33629. https://doi.org/10.7759/cureus.33629
2024Khired (2024). A Case of a Young Military Officer with Bilateral Simultaneous Femoral Neck Stress Fracture. International medical case reports journal, 17, 131-135. https://doi.org/10.2147/IMCRJ.S411460
2022Weinrich et al. (2022). Femoral Neck Stress Fracture of a Male, Healthy Marathon Runner - Case Report and Literature Review. Zeitschrift fur Orthopadie und Unfallchirurgie, 160(5), 564-571. https://doi.org/10.1055/a-1401-0375
2026Rawal et al. (2026). Imaging of bone stress injury in runners. Skeletal radiology. https://doi.org/10.1007/s00256-026-05310-3
2024Foti et al. (2024). Diagnostic Accuracy of Dual-Energy CT for Bone Stress Injury of the Lower Limb. Radiology, 313(2), e232415. https://doi.org/10.1148/radiol.232415
2024Breighner (2024). Dixon Method in MRI and Virtual Noncalcium Imaging in Dual-Energy CT of Bone Stress Injury: Different Means to (Nearly) the Same Ends. Radiology, 313(2), e242970. https://doi.org/10.1148/radiol.242970
2026Kuwabara et al. (2026). Proposed Modified Bone Stress Injury Classification Score. Orthopaedic journal of sports medicine, 14(3), 23259671251399815. https://doi.org/10.1177/23259671251399815
2024Toresdahl et al. (2024). Serial Ultrasonography for the Assessment of Healing of Lower Extremity Bone Stress Injury and Correlation With Return to Sport/Exercise. Sports health, 16(5), 750-758. https://doi.org/10.1177/19417381241231590
2023Mountjoy et al. (2023). 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British journal of sports medicine, 57(17), 1073-1097. https://doi.org/10.1136/bjsports-2023-106994
2023Stellingwerff et al. (2023). Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs. British journal of sports medicine, 57(17), 1109-1118. https://doi.org/10.1136/bjsports-2023-106914
2023Burke et al. (2023). Mapping the complexities of Relative Energy Deficiency in Sport (REDs): development of a physiological model by a subgroup of the International Olympic Committee (IOC) Consensus on REDs. British journal of sports medicine, 57(17), 1098-1108. https://doi.org/10.1136/bjsports-2023-107335
2023Fredericson et al. (2023). Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners. BMJ open sport & exercise medicine, 9(2), e001545. https://doi.org/10.1136/bmjsem-2023-001545
2024George et al. (2024). Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports medicine (Auckland, N.Z.), 54(9), 2247-2265. https://doi.org/10.1007/s40279-024-02051-y
2023Yang et al. (2023). Femoral neck stress fracture return to activity and the effect of metabolic dysfunction on recovery: A systematic review. Journal of orthopaedics, 43, 79-92. https://doi.org/10.1016/j.jor.2023.07.023
2022Wilzman et al. (2022). Medical and Biomechanical Risk Factors for Incident Bone Stress Injury in Collegiate Runners: Can Plantar Pressure Predict Injury?. Orthopaedic journal of sports medicine, 10(6), 23259671221104793. https://doi.org/10.1177/23259671221104793
2025Stennett et al. (2025). Bone Stress Injury Epidemiology and Risk Factors in Female Off-Road Runners: A Systematic Review. Journal of sport rehabilitation, 34(5), 470-483. https://doi.org/10.1123/jsr.2024-0288
2022Tenforde et al. (2022). Prevalence and factors associated with bone stress injury in middle school runners. PM & R : the journal of injury, function, and rehabilitation, 14(9), 1056-1067. https://doi.org/10.1002/pmrj.12673
2016Tenforde et al. (2016). Bone Stress Injuries in Runners. Physical medicine and rehabilitation clinics of North America, 27(1), 139-49. https://doi.org/10.1016/j.pmr.2015.08.008
2025Malla et al. (2025). Undisplaced transcervical femoral neck stress fracture in a recreational runner: A case report. International journal of surgery case reports, 128, 111090. https://doi.org/10.1016/j.ijscr.2025.111090

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