Programming Exercise for Femoral Neck Stress Fractures

Femoral neck stress fractures (FNSF) are challenging to treat.

They’re easily misdiagnosed and rarely prescribed a specific rehab plan considering the uniqueness of this injury. Runners are often left with a laundry list of basic exercises and an off-the-shelf return-to-run program. This leaves runners confused, apprehensive, and often lacking the confidence to stress their hip and their body ever again. We can do better than that!

Let’s go through four fundamental principles that are crucial to consider when designing efficient FNSF rehab programs.
Then, let’s cover how to implement effective exercise programs with actual people.

Principle One: Every Exercise is an Experiment

Every exercise during stress fracture rehab is an experiment. An isometric contraction, a balance exercise, and a kettlebell deadlift all stress the fracture site as an opportunity to assess for pain or apprehension. If an intervention aggravates a runner’s symptoms, it tells you they aren’t ready for that specific exercise. Testing the affected area with exercise is crucial to check if we are on the right course.

If every exercise is an experiment, the experiments should get more challenging over time.

Principle Two: Progressive Overload

Stronger, denser bones are less likely to break. Unfortunately, running alone isn’t great at building strong, dense bones1. Lack of strong bones can play a big role in developing a FNSF.

Prioritizing activities that build a resilient skeleton is essential to stress fracture rehab. A 10% increase in bone density can show a 107x increase in fracture resistance1. Even small changes give you massive benefits. Since our bones adapt in a site-specific manner, you must stress the fracture site and surrounding structures during rehab.

Progressive overload says you have to gradually increase the stress on your body for it to improve certain qualities (strength, endurance, etc.). Your body and your bones get bored quickly. If you perform the same set of sets, reps, and weight indefinitely, your skeleton sees no reason to get stronger.
Whatever exercise plan you have at the start of the rehab has to progress over time.

Here’s a sample progression of exercises I often use with runners returning from a FNSF. Once we progress to the third exercise of each progression, we continue to add weight or speed to the movements.

Principle Three: Bone Adapts in a Direction-Specific Manner

Hart et al states “Bone routinely withstands pulling, pushing, and tear forces in multiple planes of movement. At any given time, bone will experience all three forms of strain at various locations and magnitudes”2,3.

The hip is an incredibly dynamic joint and structure. The hip joint (and the femoral neck) moves in three planes: forward and back, side-to-side, and rotating in and out. Your skeleton needs to handle these tri-planar forces with running and life. This has direct implications on how to design a quality rehab program.

You want movements in three different directions in your rehab plan. Here are a few practical examples.

Anterior – Posterior (Forward and Back)

Medial – Lateral (Side to Side)

Hip Rotation

Practically, I’ll often plan out a sample week of exercise like this ⬇️.

Principle Four: Engage in Flight

One of the best ways to stronger bones is by including plyometrics in your training regimen. Running is inherently a plyometric activity but doesn’t have the same type of loading as jumping. 

Jumping (and landing) drives large forces through your skeleton, forcing them to adapt. Scheduling plyometrics around running can be tricky! Plyometric sessions should be short in duration with plenty of recovery between sessions. It’s helpful to schedule these around 3 hours before or after any running and keep them on non-workout days4,5.

Some runners have more control over their schedule and life than others. Navigating everyone’s unique schedule without overloading the athlete is crucial. My goals when combining running, lifting, and plyometrics are:

  • Keep workouts and lifting + plyometrics on separate days
  • Keep a few hours between lifting and running sessions
  • Keep at least one day with no ballistic activities (running or jumping)

Practically, this is how I regularly lay out a runner’s week if the goal is to return to higher levels of performance.

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References:

  1. Warden S, Davis I, and Fredericson M. Management and Prevention of Bone Stress Injuries in Long-Distance Runners. JOSPT. 2014. 44 (10). 749-765.
  2. Hart N, Nimphius S, Rantalainen. Mechanical basis of bone strength: influence of bone material, bone structure and muscle action. J Musculoskelet Neuronal Interact 2017; 17(3):114-139
  3. Hart N, Newton R, Tan J. Biological basis of bone strength: anatomy, physiology and measurement. J Musculoskelet Neuronal Interact 2020; 20(3):347-371
  4. Robling A, Hinant F, Burr D. Improved Bone Structure and Strength After Long-Term Mechanical Loading is Greaterst if Loading is Separated into Short Bouts. Journal of Bone and Mineral Research. 17 (8). 2002.
  5. Umemura Y, Ishiko T, Yamauchi T. Five Jumps per Day Increase Bone Mass and Breaking Force in Rats. Journal of Bone and Mineral Research. 12 (9). 1997

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