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Hip pain in runners can have many causes, but when someone schedules a consult with me saying they have “hip flexor strain” or “hip tightness” along with deep groin pain, I listen very carefully. I want to make sure we’re not dealing with something more serious, like a femoral neck stress fracture, a type of bone stress injury that affects the upper part of the thigh bone near the hip joint.

Often, runners describe a similar story.

It starts with a vague pain in the groin after a run. The hip feels sore and tight, so they do what they can to loosen it up. They foam roll and stretch. Maybe they take a few days off. Or they try to push through it and keep training. But instead of improving, the pain worsens. It lingers after runs, is present with walking, and eventually progresses to the point where they are unable to fully weight-bear on that side and begin to limp. In scenarios like this, we start to think about a potential bone stress injury.

A bone stress injury is an overuse injury to the bone, caused by repetitive loading without enough recovery. Over time, this leads to a buildup of micro-damage that exceeds the bone’s ability to repair itself. These injuries exist on a continuum. They begin as bone stress reactions, essentially bone swelling, and can progress to a stress fracture or, in more severe cases, a complete fracture.¹

Femoral neck stress fractures are less common than tibial or metatarsal stress fractures, but they’re especially important to catch early. If they’re missed, they can lead to serious complications, including fracture displacement or, in some cases, avascular necrosis, which is a loss of blood supply to the bone. Not to be alarmist, but early diagnosis and prompt, appropriate management are key to a safe and successful return to running.³

How does it present?

Runners usually describe vague, deep groin pain, sometimes traveling down the thigh, that feels worse with weight-bearing activities. This differs from hip impingement or labral tear pain, which is more commonly triggered by specific movements or positions of the hip.

Lifting the leg straight up is often painful. One finding that can feel counterintuitive is pain with unloading the injured leg. For example, when weight is taken off the affected side, symptoms can actually increase.

Who is at higher risk?

You may be at higher risk if you are female, have a history of prior bone stress injuries, are under-fueling, intentionally or unintentionally, have menstrual irregularities, or have low bone density. These injuries also tend to occur during periods of high training load, especially in the weeks leading up to a race.²

How is it diagnosed?

MRI is the standard for confirming bone stress injuries at the hip and determining their severity. X-rays are often normal, especially in the early stages.³

There are two main types of femoral neck stress injuries. Compression-side injuries, which occur on the inner, lower part of the femoral neck, are more common and are usually managed with a period of non-weight-bearing followed by a gradual return to running. Tension-side injuries, located on the outer, upper part of the femoral neck, are less common but high risk and require surgical management.³

A note on pain medications

Pain medications should be used with caution. While they may take the edge off, they can also mask symptoms and allow activity to progress faster than is safe for recovery. Using NSAIDs, like ibuprofen or naproxen, for extended periods may also slow bone healing, which is why they’re generally not recommended during recovery from a bone stress injury.¹

I hope this post helps you better understand bone stress injuries in the hip and make sensible decisions about your training. Paying attention to early signs and listening to your gut when something doesn’t feel right can help you catch issues early. Early assessment may help prevent bigger problems and support long-term running health.

In Brooklyn and unsure about hip or groin pain? Reach out or connect to get assessed.

Dominika Piestrak is a physical therapist, running coach, and trainer based in New York City. You can learn more about her here.

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References

1. Tenforde AS, Fredericson M. Bone Stress Injuries: Diagnosis, Treatment, and Prevention. Springer; 2022.
2. Miller TL, Kaeding CC. Stress fractures in athletes. Am J Sports Med. 2012;40(3):661–670.
3. Robertson G, Wood A. Femoral neck stress fractures in sport: a current concepts review. Sports Med Int Open. 2017;1:E58–E68.