Abstract
Stress fractures are a very common overuse injury in the athletic population. Overall, these injuries consist of approximately 15–20 % of all visits to sports medicine clinics. A stress fracture not only leads to discomfort of the affected extremity but also can cause decreased athletic performance, lost training time, and medical expense. Pelvic stress fractures are less common than lower extremity stress fractures and can be divided based on location into: sacral stress fractures, pubic ramus stress fractures, and iliac wing stress fractures as well as apophyseal avulsion fractures. These “low-risk” stress fractures generally present in female long distance runners and military recruits; however, these injuries should be considered in any athlete who experience repetitive loads to the axial skeleton. Diagnosis can be difficult and requires a high-level of suspicion as patients present with vague low back pain (sacral stress fractures) or groin discomfort. Radiographic evaluation can aid in diagnosis and consists of plain radiographs as well as advanced imaging such as magnetic resonance imaging (MRI) and/or bone scintigraphy. Treatment rarely requires operative management and involves cessation of the causative activity for 4–10 weeks with gradual return to physical activity. Additionally, any patient with a suspected pelvic stress fracture should undergo a metabolic evaluation consisting of blood and urine work as well as the intake of calcium and vitamin D. The purpose of this chapter is to evaluate the clinical presentation, evaluation, diagnostic tools, and management of stress fractures of the pelvis in the athletic population.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17(5):309–25. Epub 2007/04/07.
Hosey RG, Fernandez MM, Johnson DL. Evaluation and management of stress fractures of the pelvis and sacrum. Orthopedics. 2008;31(4):383–5. Epub 2008/05/06.
Wentz L, Liu PY, Haymes E, Ilich JZ. Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Mil Med. 2011;176(4):420–30. Epub 2011/05/05.
Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46–58.
Bergman AG, Fredericson M, Ho C, Matheson GO. Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. Am J Roentgenol. 2004;183(3):635–8. Epub 2004/08/31.
Gaeta M, Minutoli F, Vinci S, Salamone I, D’Andrea L, Bitto L, et al. High-resolution CT grading of tibial stress reactions in distance runners. Am J Roentgenol. 2006;187(3):789–93. Epub 2006/08/25.
Nussbaum AR, Treves ST, Micheli L. Bone stress lesions in ballet dancers: scintigraphic assessment. Am J Roentgenol. 1988;150(4):851–5. Epub 1988/04/01.
Groshar D, Lam M, Even-Sapir E, Israel O, Front D. Stress fractures and bone pain: are they closely associated? Injury. 1985;16(8):526–8. Epub 1985/09/01.
Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures. The concept of bone strain. Sports Med. 1987;4(1):65–75. Epub 1987/01/01.
Miller C, Major N, Toth A. Pelvic stress injuries in the athlete: management and prevention. Sports Med. 2003;33(13):1003–12. Epub 2003/11/11.
Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return to play of stress fractures. Clin J Sport Med. 2005;15(6):442–7. Epub 2005/11/10.
Diehl JJ, Best TM, Kaeding CC. Classification and return-to-play considerations for stress fractures. Clin Sports Med. 2006;25(1):17–28, vii. Epub 2005/12/06.
Volpin G, Milgrom C, Goldsher D, Stein H. Stress fractures of the sacrum following strenuous activity. Clin Orthop Relat Res. 1989;243:184–8. Epub 1989/06/01.
Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. 2004;86-A(2):382–96. Epub 2004/02/13.
Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 2001;29(1):100–11. Epub 2001/02/24.
Major NM, Helms CA. Sacral stress fractures in long-distance runners. Am J Roentgenol. 2000;174(3):727–9. Epub 2000/03/04.
McFarland EG, Giangarra C. Sacral stress fractures in athletes. Clin Orthop Relat Res. 1996;329:240–3. Epub 1996/08/01.
Eller DJ, Katz DS, Bergman AG, Fredericson M, Beaulieu CF. Sacral stress fractures in long-distance runners. Clin J Sport Med. 1997;7(3):222–5. Epub 1997/07/01.
Holtzhausen LNT. Stress fracture of the sacrum in two distance runners. Clin J Sport Med. 1992;2:139–42.
Major NM, Helms CA. Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes. Skeletal Radiol. 1997;26(12):711–7. Epub 1998/02/07.
Ahovuo JA, Kiuru MJ, Visuri T. Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol. 2004;14(3):500–5. Epub 2003/10/25.
Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am. 2002;40(2):313–31. Epub 2002/07/18.
Delcamp DD, Klaaren HE, Pompe van Meerdervoort HF. Traumatic avulsion of the ligamentum teres without dislocation of the hip. Two case reports. J Bone Joint Surg Am. 1988;70(6):933–5. Epub 1988/07/01.
Lee JK, Yao L. Stress fractures: MR imaging. Radiology. 1988;169(1):217–20. Epub 1988/10/01.
Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997;16(2):291–306. Epub 1997/04/01.
Fredericson M, Salamancha L, Beaulieu C. Sacral stress fractures: tracking down nonspecific pain in distance runners. Phys Sportsmed. 2003;31(2):31–42. Epub 2003/02/01.
Meurman KO. Stress fracture of the pubic arch in military recruits. Br J Radiol. 1980;53(630):521–4. Epub 1980/06/01.
Pavlov H, Nelson TL, Warren RF, Torg JS, Burstein AH. Stress fractures of the pubic ramus. A report of twelve cases. J Bone Joint Surg Am. 1982;64(7):1020–5. Epub 1982/09/01.
Kim SM, Park CH, Gartland JJ. Stress fracture of the pubic ramus in a swimmer. Clin Nucl Med. 1987;12(2):118–9. Epub 1987/02/01.
Thorne DA, Datz FL. Pelvic stress fracture in female runners. Clin Nucl Med. 1986;11(12):828–9. Epub 1986/12/01.
Noakes TD, Smith JA, Lindenberg G, Wills CE. Pelvic stress fractures in long distance runners. Am J Sports Med. 1985;13(2):120–3. Epub 1985/03/01.
Hill PF, Chatterji S, Chambers D, Keeling JD. Stress fracture of the pubic ramus in female recruits. J Bone Joint Surg Br. 1996;78(3):383–6. Epub 1996/05/01.
Slemenda CW, Reister TK, Hui SL, Miller JZ, Christian JC, Johnston Jr CC. Influences on skeletal mineralization in children and adolescents: evidence for varying effects of sexual maturation and physical activity. J Pediatr. 1994;125(2):201–7. Epub 1994/08/01.
Latshaw RF, Kantner TR, Kalenak A, Baum S, Corcoran Jr JJ. A pelvic stress fracture in a female jogger. A case report. Am J Sports Med. 1981;9(1):54–6. Epub 1981/01/01.
O’Brien T, Wilcox N, Kersch T. Refractory pelvic stress fracture in a female long-distance runner. Am J Orthop (Belle Mead NJ). 1995;24(9):710–3. Epub 1995/09/01.
Wilcox Jr JR, Moniot AL, Green JP. Bone scanning in the evaluation of exercise-related stress injuries. Radiology. 1977;123(3):699–703. Epub 1977/06/01.
Touhy J, Nattiv A. Iliac stress fracture in a male collegiate track athlete. Curr Sports Med Rep. 2008;7(5):252–4. Epub 2008/09/06.
Hebert KJ, Laor T, Divine JG, Emery KH, Wall EJ. MRI appearance of chronic stress injury of the iliac crest apophysis in adolescent athletes. Am J Roentgenol. 2008;190(6):1487–91. Epub 2008/05/22.
Fernbach SK, Wilkinson RH. Avulsion injuries of the pelvis and proximal femur. Am J Roentgenol. 1981;137(3):581–4. Epub 1981/09/01.
Salter RBHW. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1962;13(5):349–58.
Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal Radiol. 2001;30(3):127–31. Epub 2001/05/19.
Pisacano RM, Miller TT. Comparing sonography with MR imaging of apophyseal injuries of the pelvis in four boys. Am J Roentgenol. 2003;181(1):223–30. Epub 2003/06/24.
Verma RB, Sherman O. Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment. Am J Orthop (Belle Mead NJ). 2001;30(11):798–806. Epub 2002/01/05.
Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med. 1985;13(5):349–58. Epub 1985/09/01.
Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521–33. Epub 2001/07/31.
Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008;23(5):741–9. Epub 2008/04/25.
Nieves JW, Melsop K, Curtis M, Kelsey JL, Bachrach LK, Greendale G, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM & R. 2010;2(8):740–50; quiz 94. Epub 2010/08/17.
Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. PM & R. 2010;2(10):945–9. Epub 2010/10/26.
Ruohola JP, Laaksi I, Ylikomi T, Haataja R, Mattila VM, Sahi T, et al. Association between serum 25(OH)D concentrations and bone stress fractures in Finnish young men. J Bone Miner Res. 2006;21(9):1483–8. Epub 2006/08/31.
McCabe MP, Smyth MP, Richardson DR. Current concept review: vitamin D and stress fractures. Foot Ankle Int. 2012;33(6):526–33. Epub 2012/06/28.
Sonneville KR, Gordon CM, Kocher MS, Pierce LM, Ramappa A, Field AE. Vitamin D, calcium, and dairy intakes and stress fractures among female adolescents. Arch Pediatr Adolesc Med. 2012;166(7):595–600. Epub 2012/03/07.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Lynch, T.S., Patel, R.M., Amin, N.H., Parker, R.D. (2015). Stress Fractures of the Pelvis. In: Miller, T., Kaeding, C. (eds) Stress Fractures in Athletes. Springer, Cham. https://doi.org/10.1007/978-3-319-09238-6_7
Download citation
DOI: https://doi.org/10.1007/978-3-319-09238-6_7
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-09237-9
Online ISBN: 978-3-319-09238-6
eBook Packages: MedicineMedicine (R0)