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Pelvic Stress Fracture

From WikiSM

Other Names

  • Pubic Ramus Stress Fracture
  • Inferior Pubic Rami Stress Fracture
  • Pelvic Stress Fracture
  • Pelvic Stress Injury
  • Pubic Symphysis Stress Injury
  • Sacral Stress Fracture
  • Iliac Wing Stress Fracture
  • Acetabular Stress Fracture
  • Ischial Stress Fracture

Background

  • This page refers to stress fractures of the Pelvis, most commonly the Pubic Rami, often referred to as pelvic stress fracture

History

  • Described in military recruits as early as 1937[1]

Epidemiology

  • Represent only 1.6% - 5.6% of lower extremity stress fractures[2][3]
  • More common in women[4]

Introduction

Bones of the pelvic girdle[5]
Pelvic stress fracture (arrow) in a 40-year-old distance runner[6]

General

  • Rare cause of pelvic pain or type of stress fracture
  • Difficult to diagnosis due to low sensitivity of imaging and broad differential
  • More common in women, presenting with pain in the inguinal, perineal and adductor region
  • Treatment is activity cessation with a typically prolonged recovery

Etiology

  • Thought to be due to the repetitive pull of the Adductor Muscles on the pubic rami[7]
  • Most commonly seen in long distance runners
  • Most commonly occur at the inferior pubic ramus

Pathophysiology

  • Most commonly occur at the intersection of the ischium and inferior pubic ramus[8]

Anatomy of the Pelvis

Associated Conditions

Location

  • Pubic Ramus
    • Most common
    • Often seen in runners, military recruits
  • Sacrum
    • Pain is more posterior/ lower back
    • Often seen in elderly patients with insufficiency fracture
  • Iliac wing Fracture
  • Acetabular Stress Fracture
  • Ischial Stress Fracture
    • Can be seen in activities with repetitive hamstring contraction

Risk Factors

  • Female
  • Military service
  • Sports
  • Additional considerations
    • Training errors
    • Use of improper equipment
    • Nutritional/ hormonal deficiencies

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Groin Pain

Clinical Features

Positioning for the single leg hop test[13]

History

  • Onset of pain is insidious
  • Training is typically only with activity, then typically occurs with rest too
  • Reports pain in the hip, groin, inguinal, perineal or adductor region
  • Worse with kicking, running and pivoting[14]
  • History often includes a sudden increase in training regimen

Physical Exam: Physical Exam Hip

  • Sacral: tenderness along the sacrum or SI joint
  • Gait may be antalgic
  • Point tenderness over the pubic ramus

Special Tests

  • Hop Test: Patient hops on ipsilateral leg
  • Standing Sign: inability to stand unsupported on affected leg[15]

Evaluation

Stress fractures of the pelvis. (a, b) Multiple stress fractures of the pelvis in a 61-year-old female runner[16]
CT demonstrating stress fracture of the let iliac wing (white arrow)[17]
MRI of the pelvis (a T1 coronal image) demonstrates an iliac stress fracture (top arrow) and surrounding bone edema (bottom arrow).[18]
Magnetic resonance image of the pelvis. Note the line of the stress fracture (arrow).[19]

Radiographs

MRI

  • Gold standard for evaluating suspected stress fractures
  • Findings
    • Bone edema (increased signal on T2 weighted images)
  • Sensitivity 42%, specificity 100% for pelvic stress fractures
    • Sensitivity much lower than other stress fractures[20]

CT

  • More useful for pelvis given low sensitivity of MRI
  • Helpful for surgical planning

Bone Scintigraphy

  • Has fallen out of favor for MRI due to poor specificity
  • Will demonstrate increased uptake at the site of bone turnover

Laboratory

  • No specific tests for pelvic stress fracture
  • If recurrent, a metabolic evaluation may be indicated

Classification

  • N/A

Management

Nonoperative

  • Patients require rest
    • Relative rest may be insufficient due to prolonged recovery times
    • May require non-weight bearing status
  • Take longer than other stress fractures
    • Licata reports most patients will be asymptomatic at 6-12 weeks[21]
    • Another study found longer durations of 6-8 months
  • Therapeutic Ultrasound
    • Some studies have shown promise, not widely adopted

Prevention

  • Training errors are frequently encountered as a cause of stress fractures
    • Must avoid increase in training regimen that exceeds rate of bone repair
    • Cyclical rather than progressive training can help
  • For runners, mileage increase should be gradual[22]
  • Proper shock absorbing shoe wear
  • Any nutritional or eating disorders should be addressed

Rehab and Return to Play

Proposed 3 Phase Rehabilitation Protocol[23]

  • Phase 1
    • Cessation of all painful activity
    • If weight bearing is painful, activity that minimize weight bearing can be considered
    • Once pain free for 3-5 days, move to phase 2
  • Phase 2
    • Light weight exercises, non-impact loading activities
    • Goal is to recover strength, correct imbalances
    • Sport specific muscle rehabilitation can be initiated
  • Phase 3
    • Gradual re-entry into athlete's sport specific activity
    • Progression to a normal load for sport
    • This phase can vary from 3 to 18 weeks

Return to Play

  • Guided by pain

Prognosis and Complications

Prognosis

  • Most pelvic stress fractures will be successfully treated with stress and activity modification
  • Pelvic stress fractures take 6-12 months of recovery, which is substantially longer than the 2-3 months required by stress fractures at other sites[24]
  • In cases of delayed union, conservative management was eventually successful and patients returned to normal activity

Complications

  • Inability to return to sport
  • Delayed union

See Also

Internal

External

References

  1. ↑ . Wachsmuth W: Zur atlologtc der schleichenden frakturen. Der Chirung 1937; 9: 16-24.
  2. ↑ Wentz, Laurel, et al. "Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review." Military medicine 176.4 (2011): 420-430.
  3. ↑ Matheson, G. O., et al. "Stress fractures in athletes: a study of 320 cases." The American journal of sports medicine 15.1 (1987): 46-58.
  4. ↑ Miller, Christine, Nancy Major, and Alison Toth. "Pelvic stress injuries in the athlete: management and prevention." Sports medicine 33 (2003): 1003-1012.
  5. ↑ Image courtesy of https://www.britannica.com/science/pelvis
  6. ↑ Behrens, Steve B., et al. "Stress fractures of the pelvis and legs in athletes: a review." Sports health 5.2 (2013): 165-174.
  7. ↑ Ha KI, Hahn SH, Chung MY, et al. A clinical study of stress fractures in sports activities. Orthopedics 1991;14(10):1089–95.
  8. ↑ Pavlov, Helene, et al. "The roentgen examination of runners' injuries." Radiographics 1.1 (1981): 17-34.
  9. ↑ Southam, Jodi D., Matthew L. Silvis, and Kevin P. Black. "Sacral stress fracture in a professional hockey player." Orthopedics 33.11 (2010).
  10. ↑ Crockett, Heber C., et al. "Sacral stress fracture in an elite college basketball player after the use of a jumping machine." The American journal of sports medicine 27.4 (1999): 526-528.
  11. ↑ Silva, R. T., et al. "Sacral stress fracture: an unusual cause of low back pain in an amateur tennis player." British journal of sports medicine 40.5 (2006): 460-461.
  12. ↑ Shah, Mrugeshkumar K., and Gregory W. Stewart. "Sacral stress fractures: an unusual cause of low back pain in an athlete." Spine 27.4 (2002): E104-E108.
  13. ↑ Miller, Timothy L., and Thomas M. Best. "Taking a holistic approach to managing difficult stress fractures." Journal of orthopaedic surgery and research 11.1 (2016): 1-8.
  14. ↑ Wiley, James J. "Traumatic osteitis pubis: the gracilis syndrome." The American journal of sports medicine 11.5 (1983): 360-363.
  15. ↑ Noakes, Timothy D., et al. "Pelvic stress fractures in long distance runners." The American Journal of Sports Medicine 13.2 (1985): 120-123.
  16. ↑ Mann, Gideon, et al. "Stress Fractures: Specific Site Involvement, Prevention, and the Role of Female Recruits in Military Service." Sports Injuries: Prevention, Diagnosis, Treatment and Rehabilitation (2015): 2067-89.
  17. ↑ Touhy, John, and Aurelia Nattiv. "Iliac stress fracture in a male collegiate track athlete." Current sports medicine reports 7.5 (2008): 252-254.
  18. ↑ Touhy, John, and Aurelia Nattiv. "Iliac stress fracture in a male collegiate track athlete." Current sports medicine reports 7.5 (2008): 252-254.
  19. ↑ Silva, R. T., et al. "Sacral stress fracture: an unusual cause of low back pain in an amateur tennis player." British Journal of Sports Medicine 40.5 (2006): 460-461.
  20. ↑ Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity: the importance of increasing awareness amongst radiologists. Eur J Radiol. 2007;62(1):16-26
  21. ↑ Licata, ANGELO A. "Stress fractures in young athletic women: case reports of unsuspected cortisol-induced osteoporosis." Medicine and science in sports and exercise 24.9 (1992): 955-957.
  22. ↑ Eren, O. T., and R. Holtby. "Straddle pelvic stress fracture in a female marathon runner. A case report." The American Journal of Sports Medicine 26.6 (1998): 850-851.
  23. ↑ Arendt, Elizabeth A., and Harry J. Griffiths. "The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes." Clinics in sports medicine 16.2 (1997): 291-306.
  24. ↑ Matheson GO, Clement DB, McKenzie JE, et al: Stress fractures in athletes: a study of 320 cases. Am J Sports Med 1987; 15: 46-58.
Created by:
John Kiel on 6 July 2020 15:39:45
Authors:
Last edited:
2 June 2025 13:13:40
Categories:
Lower Extremity | Groin | Hip | Fractures | Overuse
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