Letter to the Editor
Sacral stress fracture, a case report
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Bone oedema can be seen at the sacroiliac joint with a small fracture on the oblique sacral body (White circle).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Introduction</span><p id="para0001" class="elsevierStylePara elsevierViewall">Stress fractures are a quite frequent condition among elite athletes but more difficult to suspect in amateur athletes. Sacrum and pelvis are infrequent locations for stress fractures and a high suspicion is required to consider them in a patient with gluteal pain.</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Case report</span><p id="para0002" class="elsevierStylePara elsevierViewall">We present a 35-year-old male who consulted for gluteal pain that appeared 3 days prior whilst running a half-marathon. He was an amateur athlete, who used to run 5–6 h per week. He had run several marathons and half marathons in the past.</p><p id="para0003" class="elsevierStylePara elsevierViewall">The gluteal pain started during the last 3 kms of the race, without any falling or limping.</p><p id="para0004" class="elsevierStylePara elsevierViewall">The physical examination showed mild limping, pain while walking, increased pain when palpating the deep gluteal compartment and with hip internal rotation.</p><p id="para0005" class="elsevierStylePara elsevierViewall">Musculoskeletal ultrasound was performed, showing a little amount of liquid around the proximal insertion of pyramidal muscle and cortical irregularity of the sacrum around the pyramidal insertion.</p><p id="para0006" class="elsevierStylePara elsevierViewall">Suspecting a sacral stress fracture, an MRI was conducted, showing a transversal fracture of the sacroiliac joint (<a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>), bone edema and edema in the pyramidal muscle insertion.</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0007" class="elsevierStylePara elsevierViewall">Once diagnosed with a sacral stress fracture the patient was recommended to reduce impact activities for a month and progressively resume non-impact exercise/physical activity for another month.</p><p id="para0008" class="elsevierStylePara elsevierViewall">The patient restarted running without pain and limitation, with the same frequency and intensity, 12 weeks after the injury.</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Discussion</span><p id="para0009" class="elsevierStylePara elsevierViewall">Stress fractures are relatively frequent among runners (between 10 and 15 %.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a>), being the tibia and the metatarsal bone the most frequent locations.</p><p id="para0010" class="elsevierStylePara elsevierViewall">Pelvic stress fractures constitute a 1 % of the total<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> and the diagnosis is difficult to reach because of the limitations in the physical examination related to the affected body area. A high clinical suspicion is required in order to request the optimal diagnostic tests: MRI is the gold standard to diagnose stress fractures.<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0011" class="elsevierStylePara elsevierViewall">There are scarce literature series on pelvic and sacral stress fractures, which limits the necessary evidence when talking about the therapeutical options.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> The latest Literature shows a higher number of these injuries amongst women, related with a decrease of the bone density.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> The presence of previous stress fractures is also a risk factor to have a sacral stress fracture. Vertical overload trough the lumbar lordosis seems to be the biomechanical factors related to these injuries, explaining why there is a greater incidence in impact sports such as long distance running or vertical jump. Also, an anterior pelvic tilt has been related to this vertical overload and stress sacral fracture.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">Pain tends to occur in the sacroiliac joint, triggered by palpation or impact physical activity. Some Patients can also report low back pain.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">Due to the characteristics of sacral stress fractures, the diagnosis can be delayed (an average of 6 weeks, with a maximum of 30 weeks according to a recent systematic review).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> The diagnosis is made by CT scan or MRI and the most frequent location is the iliac wing or the sacral body. Bilateral sacral stress fractures have been described.<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0014" class="elsevierStylePara elsevierViewall">Differential diagnosis must include sacroilitis, vertebral fractures, disc pathology, trochanteric bursitis, spondylolisthesis, facets arthrosis, and lumbar or gluteal muscle injuries.</p><p id="para0015" class="elsevierStylePara elsevierViewall">Regarding the treatment, all studies agree with an initial reduction of impact activities, with a progressive return to activity. In a 100-case series, the median return to activity was 7,4 weeks (5–40,5).<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> In some cases, there was no resolution of the symptoms (persistent gluteal pain on physical activity after 2 years of follow up).<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Pain killers are frequently recommended in these patients and some studies have proposed the use of calcium and vitamin D, with controversial results. Calcium and vitamin D do have an effect in preventing stress fractures in case of deficiency, but do not reduce the progression of the injuries.<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">In conclusion, sacral stress fractures are underdiagnosed, so they must be included in the differential diagnosis of lower back pain, gluteal pain and hip pain in impact sport athletes.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "xpalclavsec1856480" "titulo" => "Keywords" ] 1 => array:2 [ "identificador" => "sec0001" "titulo" => "Introduction" ] 2 => array:2 [ "identificador" => "sec0002" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec0003" "titulo" => "Discussion" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-02-26" "fechaAceptado" => "2024-05-06" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1856480" "palabras" => array:4 [ 0 => "Sports medicine" 1 => "Stress fracture" 2 => "Radiology" 3 => "Traumatology" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2116 "Ancho" => 3167 "Tamanyo" => 338943 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance, coronal view. Bone oedema can be seen at the sacroiliac joint with a small fracture on the oblique sacral body (White circle).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics of stress fractures in young athletes under 20 years" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Ohta-Fukushima" 1 => "Y. Mutoh" 2 => "S. Takasugi" 3 => "H. Iwata" 4 => "S. 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