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European Spine Journal

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01-01-2022 | Eating Disorder | Review Article

Sacral stress fractures in athletes

Authors: Eran Beit Ner, Oded Rabau, Saad Dosani, Uri Hazan, Yoram Anekstein, Yossi Smorgick

Published in: European Spine Journal | Issue 1/2022

Abstract

Purpose

Fatigue 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.

Results

The 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.

Kahanov L, Eberman LE, Games KE, Wasik M (2015) Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med 6:87–95CrossRef

Bennell K, Matheson G, Meeuwisse W, Brukner P (1999) Risk factors for stress fractures. Sports Med 28:91–122. https://doi.org/10.2165/00007256-199928020-00004CrossRefPubMed

Fredericson M, Jennings F, Beaulieu C, Matheson GO (2006) Stress fractures in athletes. Top Magn Reson Imaging 17:309–325. https://doi.org/10.1097/RMR.0b013e3180421c8cCrossRefPubMed

Fredericson M, Salamancha L, Beaulieu C (2003) Sacral stress fractures: tracking down nonspecific pain in distance runners. Phys Sportsmed 31:31–42. https://doi.org/10.3810/psm.2003.02.189CrossRefPubMed

Vasudevan JM, Smuck M, Fredericson M (2012) Evaluation of the athlete with buttock pain. Curr Sports Med Rep 11:35–42. https://doi.org/10.1249/JSR.0b013e3182423d71CrossRefPubMed

Ahovuo JA, Kiuru MJ, Visuri T (2004) Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol 14:500–505. https://doi.org/10.1007/s00330-003-1989-2CrossRefPubMed

Abel MS (1985) Jogger’s fracture and other stress fractures of the lumbo-sacral spine. Skelet Radiol 13:221–227. https://doi.org/10.1007/BF00350578CrossRef

Kahanov L, Eberman L, Alvey T et al (2011) Sacral stress fracture in a distance runner. J Am Osteopath Assoc 111:585–591PubMed

Kaneko T, Kono N, Mochizuki Y et al (2017) Bi-cruciate substituting total knee arthroplasty improved medio-lateral instability in mid-flexion range. J Orthop 14:201–206. https://doi.org/10.1016/j.jor.2016.12.005CrossRefPubMedPubMedCentral

10.

Alsobrook J, Simons SM (2007) Sacral stress fracture in a marathon runner. Curr Sports Med Rep 6:39–42. https://doi.org/10.1007/s11932-007-0010-2CrossRefPubMed

11.

Kavukcu E, Akdeniz M (2020) Sacral stress fracture in an amateur golf player: a case report and literature review. Phys Sportsmed. https://doi.org/10.1080/00913847.2020.1773746CrossRefPubMed

12.

Atwell EA, Jackson DW (1991) Stress fractures of the sacrum in runners. Two case reports. Am J Sports Med 19:531–533. https://doi.org/10.1177/036354659101900523CrossRefPubMed

13.

Kendall J, Eckner JT (2013) Sacral stress fracture in a young healthy athlete. Am J Phys Med Rehabil 92:1120. https://doi.org/10.1097/PHM.0b013e31825f1c20CrossRefPubMed

14.

Battaglia M, Guaraldi F, Vannini F et al (2012) Unusual supero-medial iliac fatigue stress fracture. Skeletal Radiol 41:103–106. https://doi.org/10.1007/s00256-011-1244-xCrossRefPubMed

15.

Klossner D (2000) Sacral stress fracture in a female collegiate distance runner: a case report. J Athl Train 35:453–457PubMedPubMedCentral

16.

Bednar DA, Almansoori K (2015) Sacral stress fracture mimicking lumbar radiculopathy in a mounted police officer: case report and literature review. Global Spine J 5:e69–e73. https://doi.org/10.1055/s-0035-1546955CrossRefPubMedPubMedCentral

17.

Knobloch K, Schreibmueller L, Jagodzinski M et al (2007) Rapid rehabilitation programme following sacral stress fracture in a long-distance running female athlete. Arch Orthop Trauma Surg 127:809–813. https://doi.org/10.1007/s00402-006-0201-yCrossRefPubMed

18.

Boissonnault WG, Thein-Nissenbaum JM (2002) Differential diagnosis of a sacral stress fracture. J Orthop Sports Phys Ther 32:613–621. https://doi.org/10.2519/jospt.2002.32.12.613CrossRefPubMed

19.

Kojima K, Asamoto S (2017) Bilateral fracture of the superior articular process of S1—an unusual fracture seen in a speed skater. Br J Neurosurg 31:273–274. https://doi.org/10.3109/02688697.2015.1122174CrossRefPubMed

20.

Bottomley MB (1990) Sacral stress fracture in a runner. Br J Sports Med 24:243–244. https://doi.org/10.1136/bjsm.24.4.243CrossRefPubMedPubMedCentral

21.

Leary PF (2001) Sacral stress fracture-crew. Med Sci Sports Exerc 33:S190CrossRef

22.

Burgess MD, Johnston MJ, Silverman ED (2017) Sacral fatigue fracture in a military recruit. Clin Nucl Med 42:e319–e321. https://doi.org/10.1097/RLU.0000000000001666CrossRefPubMed

23.

Major NM, Helms CA (2000) Sacral stress fractures in long-distance runners. AJR Am J Roentgenol 174:727–729. https://doi.org/10.2214/ajr.174.3.1740727CrossRefPubMed

24.

Carlson SF, McCracken W, Hecht S (2015) Sacral stress fracture in a collegiate distance runner. Med Sci Sports Exerc 47:205–206

25.

Marchinkow A, Mallinson PI, Coupal T et al (2014) Sacral stress fractures in a sprint and throw athlete—a case report. Curr Sports Med Rep 13:297–298. https://doi.org/10.1249/JSR.0000000000000082CrossRefPubMed

26.

Connolly LP, Drubach LA, Connolly SA, Treves ST (2004) Young athletes with low back pain: skeletal scintigraphy of conditions other than pars interarticularis stress. Clin Nucl Med 29:689–693. https://doi.org/10.1097/00003072-200411000-00003CrossRefPubMed

27.

McFarland EG, Giangarra C (1996) Sacral stress fractures in athletes. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-199608000-00030CrossRefPubMed

28.

Creighton A, Holtzman G, Ziegler C, Prather H (2019) Sacral pedicle stress fracture in an adolescent competitive basketball and track and field athlete with a prior femoral physeal injury: a case report. PM R 11:657–660. https://doi.org/10.1002/pmrj.12119CrossRefPubMed

29.

Miletic D, Sestan B, Pusic M et al (2012) Unusual consecutive sacral stress fractures in a female distant runner: a case report. Eur J Phys Rehabil Med 48:283–287PubMed

30.

Crockett HC, Wright JM, Madsen MW et al (1999) Sacral stress fracture in an elite college basketball player after the use of a jumping machine. Am J Sports Med 27:526–528. https://doi.org/10.1177/03635465990270042001CrossRefPubMed

31.

Milgrom C (2000) Sacral stress fracture in an elite college basketball player after the use of a jumping machine. Am J Sports Med 28:133CrossRef

32.

Delvaux K, Lysens R (2001) Lumbosacral pain in an athlete. Am J Phys Med Rehabil 80:388–391. https://doi.org/10.1097/00002060-200105000-00016CrossRefPubMed

33.

Nusselt T, Klinger H-M, Schultz W, Baums MH (2010) Fatigue stress fractures of the pelvis: a rare cause of low back pain in female athletes. Acta Orthop Belg 76:838–843PubMed

34.

Eller DJ, Katz DS, Bergman AG et al (1997) Sacral stress fractures in long-distance runners. Clin J Sport Med 7:222–225. https://doi.org/10.1097/00042752-199707000-00014CrossRefPubMed

35.

Reis Rodrigues LM, Ueno FH, Valesin Filho ES et al (2009) Sacral stress fracture in a runner: a case report. Clinics 64:1127–1129

36.

Featherstone T (1999) Magnetic resonance imaging in the diagnosis of sacral stress fracture. Br J Sports Med 33:276–277. https://doi.org/10.1136/bjsm.33.4.276CrossRefPubMedPubMedCentral

37.

Schils J, Hauzeur JP (1992) Stress fracture of the sacrum. Am J Sports Med 20:769–770. https://doi.org/10.1177/036354659202000623CrossRefPubMed

38.

Ficek K, Cyganik P, Rajca J et al (2020) Stress fractures in uncommon location: six case reports and review of the literature. WJCC 8:4135–4150. https://doi.org/10.12998/wjcc.v8.i18.4135CrossRefPubMedPubMedCentral

39.

Shah MK, Stewart GW (2002) Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine (Phila Pa 1976) 27:E104–E108. https://doi.org/10.1097/00007632-200202150-00023CrossRef

40.

Fredericson M, Moore W, Biswal S (2007) Sacral stress fractures: magnetic resonance imaging not always definitive for early stage injuries: a report of 2 cases. Am J Sports Med 35:835–839. https://doi.org/10.1177/0363546506296519CrossRefPubMed

41.

Silva RT, De Bortoli A, Laurino CFS et al (2006) Sacral stress fracture: an unusual cause of low back pain in an amateur tennis player. Br J Sports Med 40:460–461. https://doi.org/10.1136/bjsm.2005.023473CrossRefPubMedPubMedCentral

42.

Slipman CW, Gilchrist RV, Isaac Z et al (2003) Sacral stress fracture in a female field hockey player. Am J Phys Med Rehabil 82:893–896. https://doi.org/10.1097/01.PHM.0000091987.99243.5DCrossRefPubMed

43.

Gerrard DF, Doyle TC (1998) Lumbosacral pain in an athlete: an unusual site for stress fracture. Clin J Sport Med 8:59–61. https://doi.org/10.1097/00042752-199801000-00014CrossRefPubMed

44.

Southam JD, Silvis ML, Black KP (2010) Sacral stress fracture in a professional hockey player: a case report. Orthopedics 33:846. https://doi.org/10.3928/01477447-20100924-23CrossRefPubMed

45.

Haasbeek JF, Green NE (1994) Adolescent stress fractures of the sacrum: two case reports. J Pediatr Orthop 14:336–338. https://doi.org/10.1097/01241398-199405000-00011CrossRefPubMed

46.

Takahashi Y, Kobayashi T, Miyakoshi N et al (2016) Sacral stress fracture in an amateur rugby player: a case report. J Med Case Rep 10:327. https://doi.org/10.1186/s13256-016-1120-3CrossRefPubMedPubMedCentral

47.

Hameed F, McInnis KC (2011) Sacral stress fracture causing radiculopathy in a female runner: a case report. PM R 3:489–491. https://doi.org/10.1016/j.pmrj.2010.10.009CrossRefPubMed

48.

Tzoanos G, Tsavalas N, Manidakis N, Karantanas A (2013) Sacral fatigue fracture in an amateur soccer player. Case Rep Med 2013:985310. https://doi.org/10.1155/2013/985310CrossRefPubMedPubMedCentral

49.

Haun DW, Kettner NW, Yochum TR, Green RL (2007) Sacral fatigue fracture in a female runner: a case report. J Manip Physiol Ther 30:228–233. https://doi.org/10.1016/j.jmpt.2007.01.007CrossRef

50.

Vajapey S, Matic G, Hartz C, Miller TL (2019) Sacral stress fractures: a rare but curable cause of back pain in athletes. Sports Health 11:446–452. https://doi.org/10.1177/1941738119854763CrossRefPubMedPubMedCentral

51.

Hearn DW, Humphrey DW (2015) Stress fracture of the sacrum. J Orthop Sports Phys Ther 45:965. https://doi.org/10.2519/jospt.2015.0411CrossRefPubMed

52.

Volpin G, Milgrom C, Goldsher D, Stein H (1989) Stress fractures of the sacrum following strenuous activity. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-198906000-00028CrossRefPubMed

53.

Johnson AW, Weiss CBJ, Stento K, Wheeler DL (2001) Stress fractures of the sacrum. An atypical cause of low back pain in the female athlete. Am J Sports Med 29:498–508. https://doi.org/10.1177/03635465010290042001CrossRefPubMed

54.

Linstrom NJ, Heiserman JE, Kortman KE et al (2009) Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine (Phila Pa 1976) 34:309–315. https://doi.org/10.1097/BRS.0b013e318191ea01CrossRef

55.

Backes A, Skejø SD, Gette P et al (2020) Predicting cumulative load during running using field-based measures. Scand J Med Sci Sports 30:2399–2407. https://doi.org/10.1111/sms.13796CrossRefPubMed

56.

Kiapour A, Joukar A, Elgafy H et al (2020) Biomechanics of the sacroiliac joint: anatomy, function, biomechanics, sexual dimorphism, and causes of pain. Int J Spine Surg 14:S3–S13CrossRef

57.

Chen Y-T, Tenforde AS, Fredericson M (2013) Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med 6:173–181. https://doi.org/10.1007/s12178-013-9167-xCrossRefPubMedPubMedCentral

58.

Drinkwater BL, Nilson K, Chesnut CH et al (1984) Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med 311:277–281. https://doi.org/10.1056/NEJM198408023110501CrossRefPubMed

59.

Cobb KL, Bachrach LK, Sowers M et al (2007) The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc 39:1464–1473. https://doi.org/10.1249/mss.0b013e318074e532CrossRefPubMed

60.

Bennell K, White S, Crossley K (1999) The oral contraceptive pill: a revolution for sportswomen? Br J Sports Med 33:231–238. https://doi.org/10.1136/bjsm.33.4.231CrossRefPubMedPubMedCentral

61.

Feingold D, Hame SL (2006) Female athlete triad and stress fractures. Orthop Clin North Am 37:575–583. https://doi.org/10.1016/j.ocl.2006.09.005CrossRefPubMed

62.

Yoder K, Bartsokas J, Averell K et al (2015) Risk factors associated with sacral stress fractures: a systematic review. J Man Manip Ther 23:84–92. https://doi.org/10.1179/2042618613Y.0000000055CrossRefPubMedPubMedCentral

63.

Wright AA, Hegedus EJ, Lenchik L et al (2016) Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures: a systematic review with evidence-based recommendations for clinical practice. Am J Sports Med 44:255–263. https://doi.org/10.1177/0363546515574066CrossRefPubMed

64.

Nye NS, Covey CJ, Sheldon L et al (2016) Improving diagnostic accuracy and efficiency of suspected bone stress injuries: algorithm and clinical prediction rule. Sports Health 8:278–283. https://doi.org/10.1177/1941738116635558CrossRefPubMedPubMedCentral

65.

Sofka CM (2006) Imaging of stress fractures. Clin Sports Med 25:53–62, viii. https://doi.org/10.1016/j.csm.2005.08.009CrossRefPubMed

66.

Ziltener J-L, Leal S, Fournier P-E (2010) Non-steroidal anti-inflammatory drugs for athletes: an update. Ann Phys Rehabil Med 53:278–288. https://doi.org/10.1016/j.rehab.2010.03.001CrossRefPubMed

Title: Sacral stress fractures in athletes
Authors: Eran Beit Ner
Oded Rabau
Saad Dosani
Uri Hazan
Yoram Anekstein
Yossi Smorgick
Publication date: 01-01-2022
Publisher: Springer Berlin Heidelberg
Keywords: Eating Disorder
Eating Disorder
Published in: European Spine Journal / Issue 1/2022
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-021-07043-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Sacral stress fractures in athletes

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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