In this Ask Dr. Geier column, I answer the question from a reader in Baton Rouge, Louisiana who asks about hip and groin pain. While the discussion here centers on an uncommon injury, it is certainly one of the more problematic injuries, especially for a runner. Should she get an MRI for a femoral neck stress fracture?

Bekah asks on Twitter:

@drdavidgeier I’m a runner & DNF Boston due to severe groin pain. It’s better, but hurts down thigh, outside hip & butt. Should I get MRI? Stress fracture is my nightmare. Heard they rarely shows on x-ray. I got ART for strained adductor but pain has worsened.

Bekah, that is a great question. Before I get to causes for the type of pain you describe, let me explain one common misconception with hip and groin injuries in athletes. When different people tell me that they have hip pain, they often mean very different things. The hip joint (the ball-and-socket joint of the femur and acetabulum) causes pain typically felt in the groin. Pain felt mainly on the lateral side of the hip, especially at the bony prominence felt directly on the outside of the upper thigh, is usually caused by trochanteric bursitis. Buttock pain is very likely caused by a lumbar spine (lower back) or nerve issue instead of a problem within the hip joint.

What are some common causes of groin pain in an athlete?

As for causes of groin pain in an athlete, there are many potential causes, such as labral tears, hip osteoarthritis, adductor strains, and athletic pubalgia (sports hernias). While they are all possible in runners, the one that would most concern me would be a femoral neck stress fracture.

Should a female runner with groin pain get an MRI for a femoral neck stress fracture?
A female runner with groin pain that isn’t resolving should see a doctor to evaluate for a femoral neck stress fracture.

What is a femoral neck stress fracture?

A femoral neck stress fracture is an overuse injury to the upper part of the femur just below the femoral head (the ball of the ball-and-socket joint). Unlike many of the injuries listed above, this one does not often have a specific event that incited the pain. A runner will usually say that the groin pain starts to come on toward the end of runs and goes away relatively quickly. Over time, the pain comes on earlier and earlier and takes longer to resolve.

Do you need an MRI for a femoral neck stress fracture?

Diagnosis starts with the orthopaedic surgeon taking x-rays to look for abnormalities. While it is true that stress fractures often do not appear for six weeks or longer after symptoms begin, the x-rays are necessary to also rule out other potential causes of the pain. If the x-ray is negative but the surgeon has a high suspicion for a stress fracture, an MRI for a femoral neck stress fracture is a reasonable next step.

Stress fractures of the femoral neck concern surgeons because that area of the hip is subject to tremendous forces on certain parts of the femur. If a runner decides to continue running in spite of a stress fracture or runs through the pain without being examined (and thus unknowingly running on a stress fracture), there is a good chance of the fracture not healing. The blood supply to that part of the hip can be compromised as it runs through that area, creating significant long-term problems.

What is the treatment for a femoral neck stress fracture?

Sports medicine surgeons take these problems very seriously. Depending specifically on which part of the femoral neck has the injury, treatment can either involve the athlete eliminating all stress on the bone or undergoing surgery. In all circumstances, the runner must stop running and use crutches to walk without putting weight on the leg. If surgery is necessary, the surgeon places three or four screws across the bone through a small incision on the outside of the thigh. Running is withheld until the fracture has healed, regardless of treatment method.

The other point I would like to stress involves prevention. These are essentially overuse injuries, so it is critical that if pain with running is not going away, the runner should have it evaluated early in the process. Also, this injury commonly occurs in perimenopausal women and in female athletes in their teens and twenties. Osteoporosis or more mild bone loss (and subsequently stress fractures of many bones) is not uncommon in these age groups, so alterations in menstrual cycles or any issues with eating disorders need to be treated by their primary care doctors. If there is any question about bone quality or if any of these risk factors exist, undergoing a bone density study is important.

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