Hip Stress Fracture in Runners: Symptoms, Recovery Timeline & Prevention
If you picture an elderly person falling when you hear “hip fracture” it might be confusing to think of it as a running related injury. Distance runners are not likely to have an acute hip fracture from a fall, but they are at much higher risk than the average person to get a stress fracture from the repetitive stress of running.
Hip stress fractures in runners can be very complicated and unstable injuries that if left untreated can cause severe damage, so it’s important for runners to educate themselves on what these injuries are and what symptoms to look out for.
What Is a Hip Stress Fracture?
Stress fractures are repetitive stress injuries. When you run, your bones experience small amounts of damage called microdamage just like your muscles and tendons do. When you have sufficient recovery, your bones repair that damage and return to their baseline if not even a little stronger and more dense.
When your training load exceeds your recovery, bones can start to accumulate this microdamage. When you accumulate enough microdamage with insufficient recovery, you get a bone stress injury (BSI). These injuries can range from some mild swelling only visible on MRI, to a fracture visible on x-ray.
Femoral neck anatomy
Put your hand on the bony bump on the side of your hip. That's your greater trochanter. Now picture a short bridge of bone running from that bump up and inward toward the ball that sits in your hip socket. That bridge is the femoral neck, and it's where hip stress fractures almost always show up.
Compression-side vs. tension-side fractures: why the distinction changes everything
Think about snapping a stick. The side you bend away from gets pulled apart (tension side). The side you bend toward gets squeezed together (compression side). Your femoral neck does the same thing when you stand on one leg: the underside gets squeezed, the top side gets pulled.
Bone can heal when the broken edges are pressed together. It does not heal well when they're being pulled apart. Compression-side stress fractures can sometimes heal without surgery so long as they don’t span > 50% of the femoral neck. Tension-side fractures almost always require surgery even if they’re small. (1)
Why Runners Get Hip Stress Fractures
Spikes in training volume or intensity
Nothing increases risk of developing a stress fracture more than spikes in training volume or intensity. With that said, here are some other factors that may contribute to an increased risk of sustaining a stress fracture in the hip from running:
Poor core strength and/or pelvic stability
Underlying bone mineral density deficits related to nutrition, medication, or hormonal changes following childbirth and/or perimenopause
Low cadence running. For every step/min increase in cadence, there is a 5% decrease risk of bone stress injury. (2)
Symptoms & Early Warning Signs
Many of the symptoms of a stress fracture in the hip might mimic the symptoms of a hip flexor strain or gluteal tendinopathy. Generalized pain on the outside of the hip, front of the hip, or groin are common.
However, there are two characteristics of hip stress fractures that are unique and unlikely to be caused by a soft tissue injury:
Pain with weightbearing (walking or standing) that eases with sitting or lying down
Pain when switching from standing on the affected side to the unaffected side.
The risk of missing these injuries is so high that anyone who has even slight suspicion that they have a hip stress fracture should seek medical attention immediately. Continuing to run to “test it” can cause an acute hip fracture which is a medical emergency and would require emergency surgery.
Don’t do it.
How It's Diagnosed
Hip stress fractures are not common in non-distance runners, so health care providers that aren’t as familiar with common running related injuries might miss some of the signs.
The average delay between a runner’s symptoms starting to getting an accurate diagnosis is 14 weeks. (3)
Here’s why:
The runner has to decide whether their symptoms are worth getting evaluated. Many runners wait too long before asking for help. +2 weeks
They finally decide to get help, so they schedule a visit at their primary care or an urgent care. Because these practitioners don’t specialize in running related injuries, they might assume the runner’s symptoms to be muscle or tendon related after looking at a clean x-ray (which can miss stress fractures). +1 week
The primary care doc sends the runner to physical therapy where it takes 3 weeks to get an appointment (not the case at Alterra by the way). +3 weeks
The runner starts physical therapy, but their therapist doesn’t often treat running related injuries, so they assume the pain is coming from somewhere else. +6 weeks
3 months after that first call was made to the primary care doctor, the runner made a little progress but then tried returning to running and they had a flare up. They finally get in to see an orthopedist who specializes in running related injuries who immediately orders an MRI and tells the runner to use crutches until the results come back. +2 weeks
14 weeks later, the runner finally gets an accurate diagnosis- femoral neck stress fracture. The treatment might be 6 weeks of non-weightbearing. Had the runner gotten an accurate diagnosis sooner, they might be ready to start gradually returning to normal activities by now.
Bone stress injuries often take longer to diagnose because they aren’t as common in non-running populations. I had a bone stress injury in my foot last year that took 6 months to get an accurate diagnosis…now imagine if I WASN’T a PT specializing in running related injuries!
If you’re a runner in Boston dealing with hip pain, book a free discovery call with me. If it sounds to me like you might have a stress fracture in your hip, I’ll connect you to a running specialist orthopedist to make sure we get an accurate diagnosis ASAP.
Recovery Timeline: A Week-by-Week Return-to-Running Protocol
Some stress fractures of the hip, tension sided or any fracture that spans > 50% of the femoral neck, require surgery to recover.
Other stress fractures of the hip can recover with conservative (non-surgical) treatment through a phased treatment approach:
Phase 1: Non-weight-bearing for 6 weeks. This is the standard protocol for conservative treatment of a stress fracture of the hip.(3)
Phase 2: Return to activities of daily living like participating in work, school, and household activities
Phase 3: Begin structured rehabilitation exercises under the supervision of a physical therapist
Phase 4: Introduce Plyometric Exercises (jumping)
Phase 5: Return to running with supervised return to training and racing
One of the many challenges with rehabilitating these injuries is that there needs to be zero pain during the rehab process. To progress, the runner has to be able to do everything in a phase without pain. That means that just because a certain amount of time has passed does not mean that the runner is ready to move on to the next phase. This progression can be messy and setbacks are relatively common, so it’s important to work with a trusted physical therapist who can help you navigate this recovery process.
Preventing Future Hip Stress Fractures
While it is not possible to 100% prevent ANY injury, there are things that runners can do to reduce their risk of developing stress fractures in the hip.
Training load management: Following a well established protocol or working with a coach can help to avoid big spikes in training load. Weekly mileage matters, but the change week over week in your longest or hardest run of the week may matter more.
Strength training: Heavy resistance training has been shown to improve bone mineral density across multiple age groups, and is one of the best ways to maintain good bone health while running long distance.
Cross training: Mixing in low impact cardio can be a great way for more beginner runners to ease into higher volume training without beating up their legs.
Nutrition: insufficient fueling whether intentional or unintentional is one of the most important risk factors to manage for stress fracture risk reduction. Adequate carbohydrate intake specifically reduces risk of bone stress injuries. (4)
Bone Health, Nutrition & Relative Energy Deficiency Syndrome (RED-S) in Runners
Bones are dynamic structures that are heavily affected by what is going on in the rest of the body. Specifically, nutrition and hormone function have a massive impact on bone health.
Runners are especially susceptible to underfueling because of the high caloric demand of their sport. Additionally, many people get into running partially because they hope it will help them lose weight, and so they bring with them a nutritional strategy that is focused on weight loss rather than health and performance.
Not to mention, running as a sport has a notorious body image problem where many elite runners are extremely lean, creating a narrative that lean = speed.
Runners in a chronic state of underfueling will likely identify with some or all of the characteristics of RED-S: (5)
Endocrine/Reproductive: loss of menstruation in females or low sex drive in males along with decreased function of hormones that help the body recover from injury.
Musculoskeletal: Decreased bone mineral density and increased frequency of musculoskeletal injuries.
Cardiovascular: Impaired cardiovascular health and function
Immune: frequent illness and/or difficulty fighting off infections.
Hematological: Impaired iron management
Gastrointestinal: GI disturbances like constipation or diarrhea
Runners should have a basic understanding of running nutrition and an awareness of some of the signs of underfueling so that they know when to ask for help from a registered dietitian. I send most of my athletes to KC Stockholm at Truly Fueled Nutrition who has been an incredibly valuable member of the rehab team for my runners navigating injuries.
Hip Stress Fractures in Runners: Final Thoughts
If you've already been diagnosed, the next few months are going to be a grind, and doing it alone is extremely hard. If you're still in the "I don't know what this is" phase, that's the more urgent problem. Either way, if you’re a runner in Boston dealing with hip pain, book a free discovery call and we'll figure out where you actually are.
FAQ
What is the fastest way to heal a stress fracture?
The fastest way to heal a stress fracture is to connect with a healthcare provider who specializes in treating them. There are no shortcuts to healing from a stress fracture and trying to find one often makes the process take even longer.
How long does a stress fracture take to heal?
Stress fracture healing times can vary pretty vastly. A mild (grade 1) bone stress injury in the tibia might heal within 4-6 weeks, while a stress fracture in a high risk location like the femoral neck or navicular could take 3-6 months before returning to running.
Do stress fractures heal on their own?
It depends. Many stress fractures will experience bony healing during the offloading period that can be observed on follow up imaging, however some high risk stress fractures that occur in areas of poor blood supply require surgical management. With that said, ALL stress fractures will require rehabilitation to return to prior levels of function.
Can you run through a hip stress fracture?
It would be extremely difficult and painful to run through a hip stress fracture and the risks of doing so are severe. Running through a stress fracture in the hip could lead to a full fracture of the femoral neck which would require emergency surgery. Once you’ve been diagnosed with a stress fracture in your hip, you should be advised to stop running until cleared by a medical professional. The tricky period is when you know you’re injured, but it hasn’t been diagnosed yet. If you can’t walk without pain, you shouldn’t be running.
Common stress fractures in runners
Tibia (shin bone), metatarsals (foot bones), navicular (foot bone), femoral shaft (thigh), femoral neck (hip), sacrum (near tailbone).
Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
Sources
Harris JD, Chahal J. Femoral Neck Stress Fractures. Operative Techniques in Sports Medicine. 2015;23:241-247. doi:10.1053/j.otsm.2015.07.001
Kliethermes S, Stiffler-Joachim M, Wille CM, Sanfilippo JL, Zavala P, Heiderscheit B. Lower Step Rate is Associated with a Higher Risk of Bone Stress Injury: A Prospective Study of Collegiate Cross Country Runners. British journal of sports medicine. 2021;55:851 - 856. doi:10.1136/bjsports-2020-103833
Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress fractures of the femoral neck in athletes. The American Journal of Sports Medicine. 1990;18:524 - 528. doi:10.1177/036354659001800514
Fensham NC, Heikura IA, McKay AKA, Tee N, Ackerman KE, Burke LM. Short-Term Carbohydrate Restriction Impairs Bone Formation at Rest and During Prolonged Exercise to a Greater Degree than Low Energy Availability. J Bone Miner Res. 2022;37(10):1915-1925. doi:10.1002/jbmr.4658
Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine. 2023;57:1073 - 1097. doi:10.1136/bjsports-2023-106994
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