Let me start off by saying I have the privilege to assess and treat many avid runners on a weekly basis.  Some of them are triathletes and others just dedicated runners.  While the age and experience level varies, I see more female runners in all.


Recently, a woman in her mid thirties came in for PT after being referred by a physician’s assistant (PA) with a working diagnosis of hip flexor tendinitis.  She had developed pain running in the past few weeks.  It was now at a level preventing her from running despite using NSAIDS to reduce inflammation.

Specifically, she complained of increased pain with figure 4 sitting, difficulty and pain getting up from a chair, and increased pain with running.  Her pain level at the eval was 2/10 but went as high as 9/10 with running. Lots of things can cause pain in the hip joint.


Summary of clinical findings:

  • Poor single leg stance on the involved hip with mild pain
  • No leg length discrepancy
  • Subtle antalgic gait
  • AROM for hip and L-spine are within normal limits
  • No pain with quad or hip flexor stretching
  • Manual muscle testing reveals 5/5 strength for hip flexion (SLR and seated), abduction and adduction
  • Pain with FABER  testing
  • Positive hip impingement sign
  • Pain with deep squat

So, it doesn’t really seem like hip flexor tendinitis does it?  In fact, I initially thought she had strong signs of a labral tear and perhaps FAI based on her history, exam and other runners I have seen with similar symptoms.  Not to mention the fact FAI is commonly misdiagnosed as hip flexor tendinitis.  Click here to read an earlier post on FAI.

My initial treatment focused on joint mobilization, stretching, core strengthening and hip work (emphasis on gluteus medius) all in an unloaded position given she had pain in weight bearing.  She tolerated all treatment without c/o.  The patient liked to work out at the gym, cycle and do Yoga in addition to her running.  I advised her to hold all squats and lunges and minimize activities that provoked her pain so we could get her inflammation to calm down.

Unfortunately, I do not think the patient felt she had a serious hip problem.  Inherently, I could sense she doubted my assessment.  She returned for her next appointment limping far worse than before.  She acknowledged that she went to the gym and did quite a few lunges and squats despite what I told her.  I never quite understand why people come for professional help and then decide not to follow the advice I offer.

Upon re-evaluation her FABER and hip impingement signs are still positive.  I had arranged for her to follow up with our hip specialist in a few weeks.  We had one more appointment scheduled, but she called and canceled it a few days later.  After 2 weeks passed, I followed up with her.

She had chosen to get a second opinion with another MD.  I knew we needed more information, so I was actually glad she sought additional medical advice.  Then came the big news.  She told me they had ordered an MRI (which I felt she needed) and it actually revealed a 50% femoral neck stress fracture.  Note: the MRI image below is not my patient’s hip.


Now we finally had a true diagnosis.  Per the doctor, she would be on crutches for at least 3 weeks.   The initial x-ray did not reveal a fracture – the PA did not see one nor did I when I reviewed her films.  While her IR was not limited, it is still possible to have FAI or a labral tear.  The pain with special tests, sitting and squatting all are indicative of impingement, which is why my initial line of thinking went there.  However, the other thing you have to keep in mind is that with a stress fracture, the hip will be irritable with the same provocative testing and of course direct loading.

From the outset I knew she had an intra-articular issue, but the PA and I had missed the target on this one.  In retrospect, the key factor I did not weigh heavily enough was the fact that female runners are much more likely to have a stress fracture than males.

Assessing the hip is certainly a complex proposition.  Many things cause pain in the hip including (but not limited to):

  • Muscle strains/tears
  • Osteitis pubis
  • FAI
  • Labral tears
  • Apophysitis
  • Athletic pubalgia
  • SCFE
  • Arthritis
  • Iliopsoas bursitis
  • IT band syndrome
  • Pifirormis syndrome
  • Femur fractures

So, the takeaways from this case study are:

  1. Remember that early stress fractures will not show up on x-ray for up to 3 weeks
  2. Suspect a stress fracture in female runners with symptoms worsening in a short time period (esp. when worse with weight bearing activity)
  3. Know that an irritable hip can give you false positives with clinical testing
  4. Obtaining additional imaging beyond x-ray is often needed to rule out other differential diagnoses

In the end, I did not pin down the exact diagnosis, but fortunately my exam and critical thinking caused me to question the PA’s diagnosis.  My discussion with the patient then prompted her to seek another opinion and get additional imaging.  While I was naturally disappointed that my diagnosis was not accurate, I know that my questions/conversation with the runner probably prevented a full fracture (and subsequent surgery) as she may have kept trying to workout and run.

I have learned a lot from this case, and I am not one who is afraid to admit it when I get it wrong.  🙂  In life, I believe we often learn more from our missteps based on my experience than we do from our triumphs.  When viewed correctly, we gain better perspective and are more prepared to succeed in the future.  I hope this information adds to your knowledge base and helps you or someone you know personally or professionally moving forward.