Sacral Stress Fractures in Long-Distance Runners

Differential Diagnosis of a Sacral Stress Fracture

“…Table 2 summarizes the symptoms and signs reported in published sacral stress fracture case reports. Of those noted, only localized pain, 1,10,14,19,39 tenderness with palpation, 1,6,8,12,14,15,19,33 normal lumbar spine ROM, 1,6,10,12,14,19,39 normal hip ROM, 1,6,12,14,19 and a normal neurovascular status 1,12,33 were consistently reported in these cases. The patient in this resident's case problem complained of localized sacral pain and tenderness over the area with palpation.…”

“…41 Extrinsic risk factors associated with stress fractures include a sudden change in the training regimen, improper footwear, and alterations in the training surface. 1,12,15,19,41 This patient presented with both intrinsic and extrinsic risk factors, which included female sex, a recent rapid increase in training intensity, and questionable footwear, as she wasn't wearing the recommended sole insert in her left shoe. In addition, she had just recently recovered from a stress fracture in the same area, albeit in the opposite side.…”

“…1,6,8,10,12,14,15,19,33,39 Although plain film radiography is the initial test for most patients with low back pain, the sacrum is a challenge to image definitively on plain films secondary to the overlying soft tissues and bowel gas. 12,33 Plain films detecting a stress fracture are also dependant upon the time frame between injury and the imaging examination. 9 Holtzhausen 19 suggested a lag period of 2 to 12 weeks from the onset of pain to the presence of positive findings on plain radiographs.…”

“…9 Fatigue stress fractures are commonly observed in athletes as well as military recruits and account for 5% to 6% of overuse injuries. 1,6,[8][9][10]12,14,15,20,22,30,31,[33][34][35]37,39,40 Based on an extensive review of the literature, Daffner and Pavlov 9 correlated the location of various fatigue stress fractures with the causative activity ( Table 1). Even though stress fractures do occur with greater frequency in the lower extremities than in the upper extremities, fatigue fractures are not thought to be common in the sacrum.…”

“…Although case reports regarding sacral stress fractures do exist, 1,6,8,10,12,14,15,30,31,33,37,38 few provide a comprehensive discussion of the differential diagnostic process. 10,41 Because stress fractures are a component of the very broad ''overuse syndrome'' category and can be confused with many other medical conditions, physical therapists should have a thorough understanding of the etiology, clinical manifestations, and diagnosis of stress fractures.…”