Persistent Thigh Pain Misdiagnosed as a Spinal Problem — Atypical Femoral Fracture Associated with Long-Term Osteoporosis Treatment

by Son’s Rehabilitation Medicine & Chiropractic Clinic in Seoul

Today’s case is about an 80-year-old female patient who had visited several clinics for thigh and hip pain.
She was repeatedly told that the cause was lumbar disc herniation or spinal stenosis, and received multiple spinal and gluteal injections without much relief.

She came to our clinic after being referred by another patient who had been under my care.
Given the findings, I referred her to a university hospital for further imaging and management.

👩‍⚕️ Case Summary

  • 80-year-old female

  • Long history of osteoporosis medication; currently on Denosumab (Prolia) injections

  • Complained of bilateral thigh pain worsening over several weeks

  • Previous  lumbar disc  and spinal stenosis, but pain persisted despite injections

🔍 X-ray Findings

Radiographs of the entire femur revealed cortical thickening (beaking) and transverse lucent lines along the anterolateral cortex of both femurs.

These findings are consistent with a pre-fracture stage of Atypical Femoral Fracture (AFF) —
a stress-related fracture associated with long-term anti-resorptive therapy, rather than a nerve-related pain from the spine.

⚠️ What Is an Atypical Femoral Fracture (AFF)?

An atypical femoral fracture occurs when the natural bone remodeling process is suppressed by long-term use of anti-resorptive medications such as bisphosphonates or Denosumab (Prolia).
The bone becomes more brittle over time, and small cracks form on the outer cortex of the femur, even without trauma or falls.

Typical features include:

  • Minimal or no trauma

  • Transverse or short-oblique fracture line on the lateral cortex

  • May appear bilaterally

  • Prodromal thigh pain weeks or months before a complete fracture

🧠 Clinical Significance

In many cases, patients with AFF are misdiagnosed with lumbar radiculopathy or spinal stenosis,
since the early symptom is vague, dull pain radiating to the thigh or hip.

However, in this patient:

  • Long-term Denosumab therapy had suppressed bone remodeling

  • Stress changes appeared in both femurs, suggesting systemic effect

  • She was immediately referred for MRI and bone scan to assess marrow edema and fracture stage

⚕️ Management Principles

  1. Medication Review

    • Denosumab should not be abruptly discontinued due to rebound fracture risk.

    • Transition therapy with Teriparatide (PTH analog) is recommended in consultation with an endocrinologist.

  2. Weight-Bearing Precautions

    • Use of cane or walker to reduce load on the femur.

    • In progressing cases, prophylactic nailing can prevent a complete fracture.

  3. Regular Follow-Up

    • Bilateral monitoring is essential, as the contralateral side may develop similar lesions.

💬 Dr. Son’s Commentary

When an elderly patient with long-term osteoporosis medication complains of thigh pain,
physicians should not immediately assume it’s a spinal problem.

Atypical femoral fracture (AFF) can develop silently and be mistaken for back pain or sciatica.
Early detection through a simple femur X-ray can prevent major surgery and restore mobility safely.

At Dr. Son Rehabilitation & Chiropractic Clinic, we focus on uncovering the true origin of pain —
integrating musculoskeletal structure, metabolic health, and medication history into one diagnostic view.

📘 Medical References

  1. Shane E, et al. Atypical Subtrochanteric and Diaphyseal Femoral Fractures: Second Report of a Task Force of the ASBMR. N Engl J Med. 2014;370:1728–37.

  2. Dell RM, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res. 2012;27(12):2544–50.

  3. Anastasilakis AD, et al. Rebound-associated vertebral fractures after discontinuation of denosumab therapy. Eur J Endocrinol. 2017;176(6):L1–L3.


“Not All Thigh Pain Comes from the Spine.”

If you’ve been on osteoporosis medication for years
and experience persistent outer thigh pain without trauma,
it could be an early sign of stress fracture.

🦴 A simple X-ray can detect it before a major fracture occurs.

👉 Don’t ignore thigh pain — early diagnosis can save your bone.

Dr. Son Cheol-Ho Rehabilitation Medicine & Chiropractic Clinic
Integrative musculoskeletal medicine combining structure, function, and healing.

👍Consultation and Appointment Information

Son PMR & Chiropractic Clinic( 2nd floor, 229-1 Gucheonmyun-Ro, Gangdongu, Seoul, South Korea) 

by  Dr Son MD & DC 
Contact: 02-482-8875 in Seoul( +82-2-482-8875)

chson@daum.net



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