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Femoral shaft bone stress injuries occur at an incidence of ~20% in military recruits & collegiate athletes. They can be tricky to diagnose and may be misdiagnosed as a quad strain due to the location of discomfort. Most of them occur on the upper part of the bone, while distal femoral shaft BSIs are relatively uncommon though possible. 

Signs & symptoms include:

  • Vague anterior thigh pain

  • Insidious/gradual onset

  • Initially during activity; may progress to following

  • Do not typically have swelling, limited ROM, tenderness to touch

  • + Fulcrum test

  • + Single leg hop test

Initial management depends on the severity of the injury, determined by both imaging and the individual's pain levels with daily activity. Often activity modification including a period of time off from running is indicated, prior to a gradual return to regular activities. Typical return to sport after this injury is around 8-12 weeks following diagnosis. 

A treatment algorithm was developed by Ivkovic et al. 2006 to help guide treatment for this specific injury, and is shown below. 

This algorithm proposes 4, 3-week phases of rehab. At the end of each phase, the athlete completes the single leg hop and fulcrum tests. The athlete is progressed to the next phase as long as these tests do not reproduce pain. If pain is reproduced, the athlete starts the prior phase of rehab over. 

As you can see, each phase in this algorithm consists of specific suggestions for weight-bearing and exercise, and each phase includes progressively higher amounts of loading to match the bone healing timeline. This can be a useful starting point for femoral shaft stress fracture rehab, but will still need to be individualized to the specific athlete. 

Questions about bone stress injury rehab? Contact me!


Ivkovic, A., Bojanic, I., & Pecina, M. (2006). Stress fractures of the femoral shaft in athletes: a new treatment algorithm. British journal of sports medicine, 40(6), 518.

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