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Sacral Stress Fracture
From WikiSM
Contents
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
- Female
- Amenorrhea or oligomenorrhea
- Mostly attributed to Relative Energy Deficiency In Sport
- Military service
- Sports
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
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
- Region: Standard Radiographs Lumboacral Spine, also consider Standard Radiographs Pelvis
- XR has low sensitivity early in disease process
- Additionally, fecal mater, vascular calcification, bowel gas may overshadow the fracture line
- Findings when abnormal
- Periosteal elevation
- Cortical thickening
- Sclerosis
- Fracture line
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
- See: General Stress Fracture Management
- No best practice guidelines for sacral stress fractures
- Relative Rest
- Typically 4-8 weeks
- Analgesic medications as needed
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
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ Atwell EA, Jackson D. Stress fractures of the sacrum in runners: Two case reports. Am J Sports Med 1991; 19: 531–3.
- ↑ Southam, Jodi D., Matthew L. Silvis, and Kevin P. Black. "Sacral stress fracture in a professional hockey player." Orthopedics 33.11 (2010).
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.
- ↑ 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
- ↑ Major NM, Helms CA. Sacral stress fractures in long-distance runners. AJR Am J Roentgenol. 2000;174(3):727-729.
- ↑ 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.