CASE REPORT
Sacral Stress Fractures in a Sprint and Throw Athlete V a Case Report Adam Marchinkow; Paul Ian Mallinson, MBChB; Tyler Coupal, BMSc; Donald Robertson Lloyd-Smith, MD; Peter Loren Munk, MD; and Hugue A. Ouellette, MD Introduction Sacral stress fractures in athletes are rare clinical diagnoses that are found most commonly in female long distance or marathon runners (5,6). Previous literature also has described these fractures in athletes involved in repetitive high-impact sports such as tennis, basketball, gymnastics, volleyball, and military training (5Y7). To the authors’ knowledge, however, sacral stress fractures have yet to be determined in the sprinting and throwing athlete. Given the scarce literature describing sacral stress fractures, the primary objective of this report was to outline their clinical and radiological characteristics to aid diagnosis. The secondary objective was to provide continued awareness surrounding the incidence of sacral stress fractures in high-performance athletes. Case Report A 20-year-old male varsity sprint and throw (javelin) athlete presented with a 2-year history of worsening lower lumbar back pain. The patient has no significant medical history, particularly no previous back trauma or sportsrelated injuries. His training regimen consisted of two practices a day, Monday through Saturday. These workouts consisted of a 45-min warm-up, 2 h of track workouts, and 1 h of weight training and core strengthening. At the start of fall training, the patient was asymptomatic and underwent a preseason physical examination and was cleared medically. This included functional movement screening, a series of seven movements, which generates a score based on how fluid and symmetrical the body movements are. The patient scored 19/21 with no apparent asymmetry and therefore was deemed not to be at excessive risk of injury. Four weeks into the season, the patient began to experience frequent lumbar muscular spasm with constant mild pain. The athletic physical therapy team assessed him, and he was diagnosed initially with paraspinal muscular tension and strain. Regular massage treatments immediately following training provided short-term pain relief Address for correspondence: Paul Ian Mallinson, MBChB, University of British Columbia/Vancouver General Hospital, Vancouver, British Columbia, Canada; E-mail: [email protected]. 1537-890X/1305/297Y298 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
throughout his first track season, but a sustained response was not accomplished. The lumbar back pain progressed, and halfway through his second season, he reported significant increase in sharp back pain following exercise activity and dull ache at rest. The athletic physical therapy team continued to perform massage, ultrasound, and transcutaneous electrical nerve stimulation (TENS) therapy; however this now provided no pain relief. The pain had progressed to the point where lumbar rotation and extension now were restricted significantly. In particular, exercises involving axial loading and back extension were most painful. Repeat assessment revealed the patient to be in perfect health, with the exception of the lumbar back pain. This pain and the tenderness were limited to the paraspinal muscles and lower back. There were no radiating pain, leg numbness, tingling, weakness, bladder/bowel control issues, or loss of muscular strength globally. He had negative slump and straight leg raise tests but tender paralumbar musculature. The active range of external rotation, flexion, and extension of the hips was decreased bilaterally, although no neurovascular compromise was found. There was no clear diagnosis for his progressively debilitating back pain. As a result of the increased back pain, the athlete required significant decreases in workout intensity, which provided mild relief of his lumbar symptoms. The patient’s family physician ordered anteroposterior (AP) and lateral radiographs of the lumbar spine, which were normal and did not yield a diagnostic result. Upon consultation with a medical specialist, a lumbosacral magnetic resonance imaging (MRI) was ordered for further investigation. MRI of the L1 to S5 region showed abnormalities in the partially imaged superior aspect of both sacral alas, which was suggestive of bilateral superior sacral stress fractures (Fig. 1). A subsequent focused dual-energy computed tomography (CT) of the sacrum was performed to demonstrate characteristic irregular sclerosis and confirm the diagnosis (Fig. 2). Spondylolisthesis was excluded; bone structure and density were unremarkable. Clinical suspicion of seronegative arthropathy was low, and the blood testing result for human leukocyte antigen (HLA) B27 was negative. Consults with experienced orthopedic and sports medicine physicians concurred with the radiological diagnosis of stress fracture. A treatment program of non-steroidal anti-inflammatory drug (NSAID) and nonimpact running were prescribed, resulting in successful return to play in 5 wk from the initial consult. Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
297
DISCUSSION The incidence of stress fracture in athletes ranges from 1.4% to 4.4%, with preponderance for female marathon athletes (5,6). In athletes, they are believed to be a result of repeated joint impact and weight overload. Past reports of sacral stress fractures in the literature have focused on athletes involved in long distance running, tennis, gymnastics, basketball, and cycling. Sprinters would appear to be seldom, if ever, subject to this injury, given the relatively short window of joint impact. Nevertheless, our report outlines a sacral stress fracture in the case of a sprint and throw athlete. This may be due to the high intensity of impact during the sprint and throw acceleration phase, as well as rotary force involved upon javelin release. Stress fractures found in young athletes are very different from the more commonly encountered insufficiency fracture, which are seen often in elderly populations. Insufficiency fractures are driven commonly by osteoporotic and fragile bone composition, thus subjecting patients to fracture from minor impacts during commonplace activities. Young athletes, on the other hand, have normal bone architecture and density and must be subjected to greater repetitive loads for the development of a stress fracture (2). Sacral stress fractures should be considered part of a differential diagnosis for athletes presenting with lower back, buttock, or groin pain. Clinical suspicion should be particularly heightened in the case of marathon runners, but as more evidence emerges, these fractures should be considered in other subsets of athletes as well. Our case report describes a sprint and throw athlete with a delay in diagnosis of a sacral stress fracture. Misdiagnosis can be attributed not only to a lack of awareness surrounding the presence of these fractures in sprint and throw athletes (low index of suspicion) but also given the usual need for advanced imaging to make the diagnosis. The use of CT, MRI, or nuclear medicine studies is required usually to identify stress fractures in the sacral region of the spine (2). We hope that this case will heighten the awareness of sacral stress fractures and ensure that proper imaging studies are ordered to guide proper
Figure 2: Axial CT demonstrating irregular scleroses in the sacral alas bilaterally (arrows). These correspond to the low-signal suspected fracture lines seen on MRI and confirm the diagnosis.
and expedient diagnosis. We would advocate MRI as the initial test of choice due to the sensitivity for bone edema and the absence of radiation exposure in this young patient population. Where additional imaging is required to confirm diagnosis, a CT limited to the sacral alas can be performed. Conservative treatment is the most commonly recommended treatment for sacral stress fractures, including nonweight bearing aerobic and anaerobic activity and correction of any strength, flexibility, balance, and symmetry deficits (1). Low-impact conditioning activities such as swimming exercise regimens have a beneficial role in treating sacral stress fractures. Adjuncts to conservative treatment include shortterm NSAID or analgesic administration in an effort to aid in pain management (7). Some authorities advocate using acetaminophen in preference to NSAID, which may delay bone healing (3). Once pain free for 10 consecutive days, patients then are counseled to increase mobility slowly, using their symptoms and pain levels to guide their level of activity (1). Conservative treatment in this manner has been shown to be an effective treatment plan, with the majority of patients returning to their regular level of activity in 4Y6 wk (4). In conclusion, it is shown that sacral stress fractures, although rare, are to be considered in athletes, including sprint and throw athletes, presenting with lower back, buttock, or groin pain not responding to conservative treatment. With increased awareness surrounding adequate diagnostic imaging studies for stress fractures, diagnosis can be expedited, therefore limiting radiation exposure and optimizing recovery for athletic patients. The authors declare no conflicts of interests and do not have any financial disclosures.
References 1. Belkin SC. Stress fractures in athletes. Orthop. Clin. North Am. 1980; 11:735Y42. 2. Juhani AA, Martti KJ, Tuomo V. Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur. Radiol. 2004; 14:500Y5. 3. Longhino V, Bonora C, Sansone V. The management of sacral stress fractures: current concepts. Clin Cases Miner Bone Metab. 2011; 8:19Y23. 4. Major NM, Helms C. Sacral stress fractures in long-distance runners. AJR Am. J. Roentgenol. 2000; 174:727Y9. 5. McFarland EG, Giangarra C. Sacral stress fractures in athletes. Clin. Orthop. 1996; 329:240Y3.
Figure 1: Axial fat sat T2W image demonstrating bone edema within the sacral alas (arrows). The sclerotic fracture line is identifiable as a central, low-signal, irregular zone within the edema (arrow head).
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Volume 13 & Number 5 & September/October 2014
6. Rodrigues LM, Ueno FH, Filho ES, et al. Sacral stress fracture in arunner: a case report. Clinics (Sao Paulo). 2009; 64:1127Y9. 7. Shah MK, Stewart GW. Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine (Phila Pa 1976). 2002; 27:104Y8.
Athletic Sacral Stress Fracture
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Sacral Stress Fractures in a Sprint and Throw Athlete V a Case Report Adam Marchinkow; Paul Ian Mallinson, MBChB; Tyler Coupal, BMSc; Donald Robertson Lloyd-Smith, MD; Peter Loren Munk, MD; and Hugue A. Ouellette, MD Introduction Sacral stress fractures in athletes are rare clinical diagnoses that are found most commonly in female long distance or marathon runners (5,6). Previous literature also has described these fractures in athletes involved in repetitive high-impact sports such as tennis, basketball, gymnastics, volleyball, and military training (5Y7). To the authors’ knowledge, however, sacral stress fractures have yet to be determined in the sprinting and throwing athlete. Given the scarce literature describing sacral stress fractures, the primary objective of this report was to outline their clinical and radiological characteristics to aid diagnosis. The secondary objective was to provide continued awareness surrounding the incidence of sacral stress fractures in high-performance athletes. Case Report A 20-year-old male varsity sprint and throw (javelin) athlete presented with a 2-year history of worsening lower lumbar back pain. The patient has no significant medical history, particularly no previous back trauma or sportsrelated injuries. His training regimen consisted of two practices a day, Monday through Saturday. These workouts consisted of a 45-min warm-up, 2 h of track workouts, and 1 h of weight training and core strengthening. At the start of fall training, the patient was asymptomatic and underwent a preseason physical examination and was cleared medically. This included functional movement screening, a series of seven movements, which generates a score based on how fluid and symmetrical the body movements are. The patient scored 19/21 with no apparent asymmetry and therefore was deemed not to be at excessive risk of injury. Four weeks into the season, the patient began to experience frequent lumbar muscular spasm with constant mild pain. The athletic physical therapy team assessed him, and he was diagnosed initially with paraspinal muscular tension and strain. Regular massage treatments immediately following training provided short-term pain relief Address for correspondence: Paul Ian Mallinson, MBChB, University of British Columbia/Vancouver General Hospital, Vancouver, British Columbia, Canada; E-mail: [email protected]. 1537-890X/1305/297Y298 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
throughout his first track season, but a sustained response was not accomplished. The lumbar back pain progressed, and halfway through his second season, he reported significant increase in sharp back pain following exercise activity and dull ache at rest. The athletic physical therapy team continued to perform massage, ultrasound, and transcutaneous electrical nerve stimulation (TENS) therapy; however this now provided no pain relief. The pain had progressed to the point where lumbar rotation and extension now were restricted significantly. In particular, exercises involving axial loading and back extension were most painful. Repeat assessment revealed the patient to be in perfect health, with the exception of the lumbar back pain. This pain and the tenderness were limited to the paraspinal muscles and lower back. There were no radiating pain, leg numbness, tingling, weakness, bladder/bowel control issues, or loss of muscular strength globally. He had negative slump and straight leg raise tests but tender paralumbar musculature. The active range of external rotation, flexion, and extension of the hips was decreased bilaterally, although no neurovascular compromise was found. There was no clear diagnosis for his progressively debilitating back pain. As a result of the increased back pain, the athlete required significant decreases in workout intensity, which provided mild relief of his lumbar symptoms. The patient’s family physician ordered anteroposterior (AP) and lateral radiographs of the lumbar spine, which were normal and did not yield a diagnostic result. Upon consultation with a medical specialist, a lumbosacral magnetic resonance imaging (MRI) was ordered for further investigation. MRI of the L1 to S5 region showed abnormalities in the partially imaged superior aspect of both sacral alas, which was suggestive of bilateral superior sacral stress fractures (Fig. 1). A subsequent focused dual-energy computed tomography (CT) of the sacrum was performed to demonstrate characteristic irregular sclerosis and confirm the diagnosis (Fig. 2). Spondylolisthesis was excluded; bone structure and density were unremarkable. Clinical suspicion of seronegative arthropathy was low, and the blood testing result for human leukocyte antigen (HLA) B27 was negative. Consults with experienced orthopedic and sports medicine physicians concurred with the radiological diagnosis of stress fracture. A treatment program of non-steroidal anti-inflammatory drug (NSAID) and nonimpact running were prescribed, resulting in successful return to play in 5 wk from the initial consult. Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
297
DISCUSSION The incidence of stress fracture in athletes ranges from 1.4% to 4.4%, with preponderance for female marathon athletes (5,6). In athletes, they are believed to be a result of repeated joint impact and weight overload. Past reports of sacral stress fractures in the literature have focused on athletes involved in long distance running, tennis, gymnastics, basketball, and cycling. Sprinters would appear to be seldom, if ever, subject to this injury, given the relatively short window of joint impact. Nevertheless, our report outlines a sacral stress fracture in the case of a sprint and throw athlete. This may be due to the high intensity of impact during the sprint and throw acceleration phase, as well as rotary force involved upon javelin release. Stress fractures found in young athletes are very different from the more commonly encountered insufficiency fracture, which are seen often in elderly populations. Insufficiency fractures are driven commonly by osteoporotic and fragile bone composition, thus subjecting patients to fracture from minor impacts during commonplace activities. Young athletes, on the other hand, have normal bone architecture and density and must be subjected to greater repetitive loads for the development of a stress fracture (2). Sacral stress fractures should be considered part of a differential diagnosis for athletes presenting with lower back, buttock, or groin pain. Clinical suspicion should be particularly heightened in the case of marathon runners, but as more evidence emerges, these fractures should be considered in other subsets of athletes as well. Our case report describes a sprint and throw athlete with a delay in diagnosis of a sacral stress fracture. Misdiagnosis can be attributed not only to a lack of awareness surrounding the presence of these fractures in sprint and throw athletes (low index of suspicion) but also given the usual need for advanced imaging to make the diagnosis. The use of CT, MRI, or nuclear medicine studies is required usually to identify stress fractures in the sacral region of the spine (2). We hope that this case will heighten the awareness of sacral stress fractures and ensure that proper imaging studies are ordered to guide proper
Figure 2: Axial CT demonstrating irregular scleroses in the sacral alas bilaterally (arrows). These correspond to the low-signal suspected fracture lines seen on MRI and confirm the diagnosis.
and expedient diagnosis. We would advocate MRI as the initial test of choice due to the sensitivity for bone edema and the absence of radiation exposure in this young patient population. Where additional imaging is required to confirm diagnosis, a CT limited to the sacral alas can be performed. Conservative treatment is the most commonly recommended treatment for sacral stress fractures, including nonweight bearing aerobic and anaerobic activity and correction of any strength, flexibility, balance, and symmetry deficits (1). Low-impact conditioning activities such as swimming exercise regimens have a beneficial role in treating sacral stress fractures. Adjuncts to conservative treatment include shortterm NSAID or analgesic administration in an effort to aid in pain management (7). Some authorities advocate using acetaminophen in preference to NSAID, which may delay bone healing (3). Once pain free for 10 consecutive days, patients then are counseled to increase mobility slowly, using their symptoms and pain levels to guide their level of activity (1). Conservative treatment in this manner has been shown to be an effective treatment plan, with the majority of patients returning to their regular level of activity in 4Y6 wk (4). In conclusion, it is shown that sacral stress fractures, although rare, are to be considered in athletes, including sprint and throw athletes, presenting with lower back, buttock, or groin pain not responding to conservative treatment. With increased awareness surrounding adequate diagnostic imaging studies for stress fractures, diagnosis can be expedited, therefore limiting radiation exposure and optimizing recovery for athletic patients. The authors declare no conflicts of interests and do not have any financial disclosures.
References 1. Belkin SC. Stress fractures in athletes. Orthop. Clin. North Am. 1980; 11:735Y42. 2. Juhani AA, Martti KJ, Tuomo V. Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur. Radiol. 2004; 14:500Y5. 3. Longhino V, Bonora C, Sansone V. The management of sacral stress fractures: current concepts. Clin Cases Miner Bone Metab. 2011; 8:19Y23. 4. Major NM, Helms C. Sacral stress fractures in long-distance runners. AJR Am. J. Roentgenol. 2000; 174:727Y9. 5. McFarland EG, Giangarra C. Sacral stress fractures in athletes. Clin. Orthop. 1996; 329:240Y3.
Figure 1: Axial fat sat T2W image demonstrating bone edema within the sacral alas (arrows). The sclerotic fracture line is identifiable as a central, low-signal, irregular zone within the edema (arrow head).
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Volume 13 & Number 5 & September/October 2014
6. Rodrigues LM, Ueno FH, Filho ES, et al. Sacral stress fracture in arunner: a case report. Clinics (Sao Paulo). 2009; 64:1127Y9. 7. Shah MK, Stewart GW. Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine (Phila Pa 1976). 2002; 27:104Y8.
Athletic Sacral Stress Fracture
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
