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Sacral Stress Fracture

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Other Names

  • Sacral Stress Fracture
  • Sacrum Stress Fracture

Background

  • This page refers to stress fractures of the Sacrum

History

Epidemiology

  • Incidence is unknown
  • Literature is primarily limited to case reports

Pathophysiology

  • General: Stress Fractures (Main)
  • The majority of cases are seen in runners
    • Considered fatigue-type stress fracture
  • Challenging diagnosis, often mimics other causes of back pain
  • Etiology
    • Somewhat controversial, no widely accepted theory
    • One theory: concentration of vertical body forces dissipated from spine to sacrum and sacral ala
    • Leg length discrepancy has also been postulated[1]
    • Insufficiency or weakness in supporting muscles

Pathoanatomy


Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • Insidious onset of pain
    • Typically complains of lower back pain, less commonly gluteal pain
    • May radiate into leg, groin, buttocks or thigh
    • Neurological symptoms are typically absent
  • Physical Exam: Physical Exam Back
    • Tenderness along the sacrum or SI joint
  • Special Tests
    • FABER Test: Flexion, abduction and external rotation with stabilization of contralateral ASIS, ipsilateral knee
    • Flamingo Test
    • Gaenslens Test: Flex contralateral hip to chest, extend ipsilateral hip and apply pressure
    • Squish Test: Apply inward pressure on ASIS and compare mobility of affected and unaffected side

Evaluation

Radiographs

MRI

  • Gold standard for evaluating suspected stress fractures
  • Sensitivity 42%, specificity 100% for pelvic stress fractures
    • Sensitivity much lower than other stress fractures[6]

CT

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

Bone Scan

  • Has fallen out of favor for MRI due to poor specificity

Classification

Denis Classification

  • Not specific to stress fractures, originally designed for traumatic fractures[7]
  • Zone 1: Involves sacral wing
  • Zone 2: Involve sacral foramina, excluding sacral canal
  • Zone 3: Involve the body and canal of sacrum

Management

Prognosis

  • Diagnosis is often missed or delayed
  • Johnson reported average time to pain free was 6.6 months, with 8 month return to pre-injury activity level[8]

Nonoperative

Operative

  • Rare, only indicated if if significantly displaced full cortical break

Rehab and Return to Play

Rehabilitation

  • Conditioning exercises
  • Performed in pool or under supervision of physical therapist

Return to Play

  • Most patients are able to return to normal activity in 4-6 weeks[9]
  • Return to sport is gradual and based on tolerance
  • Proposed by Knoboloch et al[10]
    • Early: low impact physical activity, such as Walking and Nordic pole walking, for gradual increase of load
    • 2 Weeks: variations of physical activity with daily cycling and cross-training
    • 4 weeks: walking, strength training
    • 7 weeks: return to running

Complications

  • Full cortical break
  • Inability to return to sport
  • Recurrance

See Also


References


  1. Atwell EA, Jackson D. Stress fractures of the sacrum in runners: Two case reports. Am J Sports Med 1991; 19: 531–3.
  2. Southam, Jodi D., Matthew L. Silvis, and Kevin P. Black. "Sacral stress fracture in a professional hockey player." Orthopedics 33.11 (2010).
  3. 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.
  4. 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.
  5. 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.
  6. 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
  7. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.
  8. Johnson AW, Weiss CB, Stento K, Wheeler DL (2001) Stress fractures of the sacrum— an atypical cause of low back pain in the female athlete. Am J Sport Med 29(4):498–508
  9. Major NM, Helms CA. Sacral stress fractures in long-distance runners. AJR Am J Roentgenol. 2000;174(3):727-729.
  10. Knobloch K, Schreibmueller L, Jagodzinski M, Zeichen J, Krettek C. Rapid rehabilitation programme following sacral stress fracture in a long-distance running female athlete. Arch Orthop Trauma Surg. 2007;127(9):809-813.
Created by:
John Kiel on 5 July 2019 08:29:54
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Last edited:
23 November 2020 15:32:47
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