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Typical evaluation and treatment of an adult with a sacral stress fracture. *Findings are typically unremarkable. Abbreviations: FABER, Flexion Abduction External Rotation; NSAID, nonsteroidal anti-inflammatory drug.
Source publication
Sacral stress fractures are uncommon injuries that are associated with repetitive load-bearing activities. The authors describe a 23-year-old male cross-country runner who presented with low back and buttocks pain. Radiographic findings were unremarkable, but a hop test identified a sacral stress fracture. The patient was instructed to stop running...
Citations
... Sacral and iliac insufficiency fractures are specific stress fractures caused by persistent and continuous stress from physiological loading on the sacrum and ilium in daily living. 22,23 The common causes of pelvic insufficiency fractures include severe OP, radiotherapy of the pelvis, 24 long-term immobilization in bed, long-term use of glucocorticoids, 25 vitamin deficiency, 26,27 and long segmental fixation of lumbar vertebrae. 28,29 FFP in the Elderly Fragility fractures result from mechanical forces that would not ordinarily result in fracture, known as low energy trauma. ...
Background:
Fragility fractures of the pelvis (FFPs) are osteoporotic pelvic fractures or insufficiency pelvic fractures caused by the low energy injury or stress fracture in daily livings in the elderly more than 60 years, which the incidence is increasing with the aging population in our country. FFPs result in considerable morbidity and mortality and as well as massive financial burden on the already strained health systems throughout the world.
Methods:
This clinical guideline was initiated by the Trauma Orthopedic Branch of Chinese Orthopedic Association; the External Fixation and Limb Reconstruction Branch of Chinese Orthopedic Association; the National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation; Senior Department of Orthopedics of Chinese PLA general hospital; the Third Hospital of Hebei Medical University. The grading of recommendations assessment, development and evaluation (GRADE) approach and the reporting items for practice guidelines in healthcare (RIGHT) checklist were adopted.
Results:
22 evidence based recommendations were formulated based on 22 most concerned clinical problems among orthopedic surgeons in China.
Conclusion:
Understanding these trends through this guideline will facilitate better clinical care of FFP patients by medical providers and better allocation of resources by policy makers.
... Sacral stress fractures (SSF) are rare injuries in athletes involved in sports like running, badminton, soccer, and volleyball; mostly being reported as isolated case reports in females [4][5][6][7][8]. It is still rarer in long distance runners especially in males, with only a few case reports available in published literature, so far [4,7,[9][10][11][12][13][14]. ...
... Volpin et al first reported SSF in three military recruits with sacral wing stress injuries [16]. They usually present as insidious onset of low back and buttock pain towards the end of the workout [4][5][6][7][8][9][10][11][12][13][14]. There is usually a delay in diagnosis, as SSFs are uncommon and hence not usually in the top differential. ...
... The vague, non-specific low back ache worsening with activity is often misdiagnosed as lumbar strain, disc disease, tendinopathies or sacroiliitis due to overlapping symptomatology. SSF are usually diagnosed on MRI, which is done due to non-responsive treatment aimed at other pathologies as mentioned before [7,9,11]. ...
Stress fractures are common overuse injuries in athletic population. They contribute to 15-20% of all cases in a sports medicine clinic [1,2]. These injuries occurs when a normal bone is exposed to excessive, repetitive forces leading to altered bone homeostasis with predominant osteoclastic function with osseous breakdown leading to micro fractures in the bone which may progress to a frank fracture line in the setting of continued exposure[3].
... The most commonly reported symptoms of sacral stress fractures include buttock or lower back pain [5]. These symptoms are not specific, and the differential diagnoses are extensive and include intervertebral disk pathologies [43], osteoid osteoma [45], strain [15], sprain [53], SIJ pathologies and stress fracture of femur neck [8]. ...
PurposeFatigue stress fractures are a common overuse injury, frequently associated with high load-bearing endurance activities such as running, military training and aerobic exercise. While these fractures can arise at any site, sacral stress fractures are poorly studied with evidence consisting mainly of case reports and limited case series. This review aims to analyze and summarize all reports published to date describing cases of sacral stress fracture in athletes.Methods
PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on Stress Fractures of the Sacrum. Insufficiency fractures of the elderly were excluded.ResultsThe literature review revealed 49 studies reporting on 124 cases of sacral stress fractures. Seventy-six patients (61%) were professional or collegiate level athletes, and 37 (30%) were military recruits or police officers in training. Seventeen female athletes were identified as suffering from low bone mineral density (25%), 9 of which reported menstrual irregularities. Thirteen female patients (19%) had a history of eating disorders.Conclusion
While most sacral stress fractures occur in normal bones exposed to abnormal repetitive loads, the high percentage of lower bone mineral density can blur the lines between fatigue fractures and insufficiency fractures. The causes of these fractures are multifactorial. High endurance sports and the features of the female athlete triad were found in high percentage of the cases. Conservative treatment is the mainstay of treatment, consisting of ceasing of training and a period of rehabilitation and gradual return to training and competition.
... Therefore, it is proposed that the athlete should have no pain and have sufficient motor control when performing these tests, as defined by good qualitative form. Kahanov et al. suggest the hop test as a physical test to support the diagnosis of stress fractures, as it recreates the load-bearing forces of running [73]. There are different modifications of hop tests, which may include the single hop for distance, the triple hop, timed hop, counter-movement vertical hop, and the medial hop. ...
Running injuries are very common, and there are well-established protocols for clinicians to manage specific musculoskeletal conditions in runners. However, competitive and elite runners may experience different injuries than the average recreational runner, due to differences in training load, biomechanics, and running experience. Additionally, injury-specific rehabilitation protocols do not consider the broader goal of return to competitive running, including the unique psychosocial and cardiorespiratory fitness needs of elite athletes. This review aims to suggest a guideline for running-specific progression as part of a comprehensive rehabilitation program for injured competitive runners. Tools to evaluate an athlete’s psychosocial preparedness to return to competition are presented. Recommendations are also provided for monitoring cardiorespiratory fitness of injured runners, including the nuances of interpreting these data. Finally, a six-phase training paradigm is proposed to guide clinicians as they help competitive runners transition from the early stages of injury through a full return to competition.
... These type of fractures typically involve the bones of lower extremities such as, femur, tibia, fibula, metatarsal bones, or spine. The sacrum is an uncommon location for a stress fracture [2]. Therefore, sacral stress fractures are rare injuries among athletes. ...
... Therefore, sacral stress fractures are rare injuries among athletes. The few cases of sacral stress fractures that have been reported in the literature involve long-distancee runners [2,3], football [4], basketball [5], volleyball [6], tenis [7], badminton [8], hockey [9], and rugby [10] players. The largest case series of sacral stress fractures in the literature has been published by Vajapey et al. with five athletes [11]. ...
... According to the literature, the incidence of the symptoms is influenced by the sport, sex, age, training intensity, and frequency. High-intensity training and/or rapid changes in the training program are common predisposing factors [2][3][4][5][6][7][8][9][10]. ...
Sacral stress fractures are rare injuries among professional and amateur athletes and are considered to be an uncommon source of low back pain. These type of fractures are mainly seen in competitive, high-impact sports, most commonly in long-distance runners. Sacral stress fractures are usually overlooked in young patients presenting with low back pain without any trauma history. Diagnosis of sacral stress fractures is often delayed because the history and physical examination of these patients are not specific and conventional radiographic images are frequently inadequate. A high index of clinical suspicion and further radiologic imaging such as MRI utilization can provide the accurate diagnosis. The treatment mainly includes rest, pain control, nutritional support, and biomechanical optimization.
Herein, we report the case of a woman amateur golf player with a sacral stress fracture who complained of aggravating low back pain. To the best of our knowledge, this appears to be the first report of a sacral stress fracture in a golf player and also the first case of this pathology in low-impact sports. Therefore, physicians should keep in mind that stress fractures can also be seen in low-impact sports. We recommend considering stress fractures in the differential diagnosis of non-traumatic, aggravating low back pain in golfers.
... 1,2,6-10 These injuries occur from a variety of sports, from running to badminton to weightlifting. 6,7,10 These injuries can occur in both female and male athletes and military recruits. 8 Rarely, they may also occur in young females in the peripartum period. ...
Background
Stress fractures of the sacrum are an uncommon cause of low back and buttock pain in athletes. They have been described in few case reports with the injury occurring most often in female distance runners. Given the rarity of this condition, there is a general lack of awareness of this injury, which may lead to a missed or delayed diagnosis.
Study Design
Case series.
Level of Evidence
5.
Methods
The 5 cases were identified by performing a medical records search within the practices of the senior authors over a 3-year period from January 2016 to December 2018.
Results
Three of 5 patients (1 male, 2 female) returned to regular activity after diagnosis and treatment. Two (1 male, 1 female) have yet to return to regular activity. Magnetic resonance imaging was the key modality in all diagnoses. All 3 female patients had components of the female athlete triad—menstrual irregularity, disordered eating, and decreased bone mineral density.
Conclusion
A high index of suspicion is required to make the correct diagnosis and initiate treatment for this rare condition given its association with low body mass index, vitamin D insufficiency, disordered eating, and malabsorption disorders. Appropriate treatment includes rest from the causative activity, nutritional support, and biomechanical optimization. In severe, chronic, or recurrent cases, referral for nutritional counseling, hormonal replacement therapies, and mental health support may be necessary.
Clinical Relevance
Sacral stress fractures, though uncommon, should be included prominently in the differential diagnosis for runners with low back pain especially if the athlete has a history of prior stress fracture or the female athletic triad.
... Female athletes exhibiting the 'female athlete triad' of low energy availability (imbalance between nutrition intake and energy expenditure), amenorrhea/oligomenorrhoea and decreased bone mineral density are particularly susceptible [3,[5][6][7][8][9][13][14][15]. While stress fractures most commonly occur in the foot or lower leg, fractures of the femoral neck, pelvis and sacrum have all been described in the literature and must be included as potential causes of hip pain [16][17][18][19][20][21][22][23]. Timely diagnosis and treatment is crucial to avoid fracture propagation or development of symptomatic non-union [7,[23][24][25][26]. ...
... Of these, 40.3% were in the tibia [8].In the military recruit population, metatarsal stress fractures are more common [6]. Stress fractures have been described in the patellae, ribs, elbow, humerus, sacrum or iatrogenically after bone graft harvest [10,22,26,[33][34][35][36][37][38][39][40][41][42][43][44][45]. In the hip region, stress fractures can occur in the femoral neck, pelvis or sacrum. ...
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
... Die Stressfraktur des Kreuzbeins stellt eine schwere, bislang zu wenig beachtete und dadurch teilweise fehldiagnostizierte Verletzung des passiven Bewegungsapparates dar [5,19,22]. Mit dem vorliegenden Artikel soll einerseits auf diese Form der Ü berlastungsverletzung bei Sportlern aufmerksam gemacht und andererseits diskutiert werden, wie sich eine effiziente laufspezifische konservative Therapie mithilfe eines Teilschwerelosigkeitslaufbands gestalten lässt. Die mit einer sakralen Stressfraktur einhergehenden Beschwerden äußern sich in der Initialphase sehr unspezifisch und ähneln denen bekannterer Verletzungsformen des pelvitrochantären Muskel-Sehnen-Apparates. Sie werden häufig als zunächst nur latente, belastungsabhängig auftretende, ,,tiefsitzende'', ,,dumpfe bis stechende'', oftmals einseitige Schmerzen im Bereich LWS/ISG bzw. ...
... Gesäß/Hüfte/Becken beschrieben. Während Stressfrakturen (Synonym: Ermüdungsbrüche) der unteren Extremitäten, vor allem der Röhrenknochen wie Tibia, Ossa metatarsalia, Femur etc., hinlänglich bekannt sind und bei entsprechender Symptomatik schnell als (Verdachts-)Diagnose in Betracht kommen [34], werden Stressfrakturen des Kreuzbeins häufig zu spät oder gar nicht erkannt [5,19,22]. Vor dem Hintergrund mehrerer unlängst betroffener Spitzensportler, insbesondere im Langstreckenlauf, erlangt die sakrale Stressfraktur derzeit jedoch eine zunehmende Beachtung [4,13,23]. In der internationalen Fachliteratur finden sich seit der ersten Beschreibung durch Lourie 1982 einige Einzelfallbeschreibungen aus dem (Leistungs-)Sport (Shah et al. [5]). ...
Zusammenfassung
Die Stressfraktur des Kreuzbeins stellt eine oftmals fehldiagnostizierte Überlastungsverletzung bei Sportlern dar. Sie äußert sich in ihrer Initialphase latent und sehr unspezifisch als tiefsitzender, oftmals einseitiger Schmerz im LWS-/ISG- bzw. Gesäß-/Hüft-/Beckenbereich. Eine gesicherte Diagnose gelingt derzeit nur per MRT. Hierauf sowie auf ihre erfolgreiche konservative Therapie mittels Alternativtraining wird anhand zweier Kasuistiken aus dem Jahr 2016 (Elite-Langstreckenläufer und Amateur-Triathlet) eingegangen. Basierend auf einer verlaufsbegleitenden MRT-Diagnostik wird die radiologische Zeitskala der Knochenreparaturprozesse dargestellt und eine Halbwertszeit des ossären Ödemvolumens von 31 ± 7 Tagen abgeleitet. Aus therapeutischer Sicht wird insbesondere auf den Einsatz eines Teilschwerelosigkeitslaufbands (AlterG®) eingegangen. Ein Vergleich der unterschiedlichen individuellen Verläufe der beiden beschriebenen Fälle lässt vermuten, dass sich bei frühzeitiger Erkennung, adäquater Therapie und einem spezifischen Trainingswiedereinstieg die Heilungszeit verkürzen und der Trainingsrückstand deutlich reduzieren lassen können.
... Sacral stress fractures are rare among athletes. Previous reports have shown that the fractures most frequently occur in long distance runners [1,2]. Stress fractures of the sacrum have also been sporadically reported in a hockey player, tennis player, soccer player, and volleyball player [3][4][5][6]. ...
... A case of stress fracture of the second metacarpal bone has been reported in a badminton player [8]. Sacral stress fractures have been reported mostly in long distance runners and also in hockey, soccer, tennis, and volleyball players [1][2][3][4][5][6]. There has been no reported case of a badminton-related sacral stress fracture yet. ...
... In the current case, no underlying diseases affecting bone metabolism were evident. Kahanov and others reported a case of a sacral stress fracture in a distance runner who had tightness of the hamstrings when the intensity of training was increased [1]. Tzoanos and others reported that decreased shock absorption on an artificial surface in a middle-aged soccer player might have influenced the development of sacral fracture [4]. ...
Sacral stress fractures are rare among athletes but have been reported most frequently in long distance runners. We report herein the first case of a sacral stress fracture in an amateur badminton player. A 16-year-old, left-handed adolescent girl, who had just started to play badminton 3 months previously, complained of acute left buttock pain when she received a shuttlecock. Magnetic resonance imaging revealed a linear lesion of the left sacrum with low signal intensity on T1- and high signal intensity on T2-weighted images, which was consistent with a stress fracture. Conservative treatment with rest relieved her symptoms. Her fracture was considered to have occurred due to repetition of an exercise that caused excessive vertical power .
... Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] Stress fractures in the lower extremity account for 80%-90% of all stress fractures, representing between 0.7% and 20% of all sports medicine injuries. 3,6,9,16 Specifically, stress fracture incidence in runners approaches 16% of all injuries. ...
... 22,29,[62][63][64][65][66] Sacrum Sacral stress fractures are uncommon injuries characterized by low back and buttocks pain. 1,2,7,9,[11][12][13][14][15][16][17]19 Symptoms include low back and/or buttock pain typically exacerbated by single leg hopping. Sacral stress fractures are difficult to diagnose given the symptoms are representative of several injuries including low back, disk disease, sciatica, sacroiliac joint pathology, and piriformis syndrome. ...
... 14 Likewise, any return to participation should include modifications of potential risk factors such as biomechanical, nutrition, training, and equipment factors. Although the identification of risk factors are noted in the literature, 7,11,29,71,73,74 the usefulness of mitigating risk factors in the prevention of stress fractures is lacking, and thus recommendations for specific regimens are absent. 17 Individual assessment and reassessment to minimize the injury is therefore suggested. ...
Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.
