Virtually all contemporary cementless femoral hip stems are designed with the goals of achieving immediate and long-term stability, restoring hip mechanics, and minimizing thigh pain. However, the incorporation of features specifically intended to minimize stress-mediated bone resorption (stress shielding) has been variable. Attempts to reduce bone loss through stem design have yielded inconsistent results and, in certain instances, early and catastrophic failure. Prior beliefs regarding the determinants of stress shielding were based upon the qualitative assessment of bone loss using plain radiographs. These are being challenged, particularly with regard to the role of porous coating level. This is in large part due to the refinement and widespread availability of dual-energy xray absorptiometry (DEXA), which allows quantitative assessment of bone mineral density both pre- and postoperatively. The available evidence indicates stem stiffness plays a dominant role. Progressive bone loss through stress shielding has potentially dire consequences. While such problems have not manifested as severe or widespread clinical issues, the preservation of femoral bone stock is an important and desirable goal.