Working Diagnosis:
Idiopathic Femoral Neck Stress Fracture

Treatment:
He was treated with a course of 6 weeks of non-weight-bearing with crutches, 4 weeks of partial weight-bearing with crutches, and 2 weeks of walk-through gait pattern with crutches. He started physical therapy at 12 weeks from diagnosis with focus on pelvis, gluteal, and core stabilization/strengthening. He was recommended a gradual return to plyometrics and sport.

Outcome:
Interval imaging at 4 months with repeat MRI of the hip showed resolution of the femoral neck stress fracture and stress reaction. He returned to full activity at 16 weeks without complications.

Author's Comments:
Femoral neck stress fractures are very rare in children under 10 years of age, with only 15 cases previously reported. Stress fractures in adults are often associated with acute strenuous activity, but in children, significant changes in activity level do not usually precede injury. Most present with antalgic gait, but diagnosis is challenging due to subtle physical exam findings and broad differential diagnosis. Pathogenesis is likely related to increase in activity level, subtle bone microstructure abnormality, or combination of muscle fatigue and compensatory gait alterations. Cross-sectional imaging is recommended to confirm the diagnosis, as well as a complete metabolic bone evaluation.

Editor's Comments:
This rare case of femoral neck stress fracture highlights two things. First, children are not little adults and can present differently than adults for a a similar condition. My experience is that kids can sometimes have little complaints and listening to parental concerns is paramount to making the correct diagnosis. Secondly, when initial labs and x-rays are negative for typical hip complaints, only advanced imaging can help nail the diagnosis. This of course, is predicated on the first point - having a high index of suspicion and listening to the parents concern.

References:
1. Hoenig T, Ackerman KE, Beck BR, et al. Bone stress injuries. Nat Rev Dis Primers. 2022;8(1):26. Published 2022 Apr 28. doi:10.1038/s41572-022-00352-y
2. Boyle MJ, Hogue GD, Heyworth BE, Ackerman K, Quinn B, Yen YM. Femoral Neck Stress Fractures in Children Younger Than 10 Years of Age. J Pediatr Orthop. 2017;37(2):e96-e99. doi:10.1097/BPO.0000000000000739
3. Palocaren T. Femoral Neck Fractures in Children: A Review. Indian J Orthop. 2018;52(5):501-506. doi:10.4103/ortho.IJOrtho_404_17
4. Er MS, Eroglu M, Altinel L. Femoral neck stress fracture in children: a case report, up-to-date review, and diagnostic algorithm. J Pediatr Orthop B. 2014;23(2):117-121. doi:10.1097/BPB.0000000000000003
5. Jones T and Tarazona D. Femoral Neck Stress Fractures. August 11, 2025. Accessed February 8, 2026. https://www.orthobullets.com/knee-and-sports/3110/femoral-neck-stress-fractures

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