Recurring Sacral Stress Fractures in the Male Distance Runner

Abstract

Reccurring Sacral Stress Fractures in the Male Distance Runner Waugh TJ, Stoller GL, Brooks EK, Dailey SW: Miami University Oxford, Ohio Background: A twenty year old male collegiate distance runner (170 cm and 62 kg) complained of low back pain in March 2015. The patient reported right sided low back tightness that felt like a bad spasm traveling from the lower back down into the lower leg. History of this runner revealed a non-displaced stress fracture in the left sacral ala with a stress reaction on the right sacral ala in November 2013. In April 2014, the distance runner possessed yet another sacral stress fracture. In March 2015, an assessment was made that the patient presented an acute case of piriformis syndrome due to lack of athletic participation. As two weeks went by with no positive results through rehabilitation, worsening pain, and given the pre-existing conditions of the patient, the Team Physician ordered an MRI. Differential Diagnosis: It is possible that the runner could have had an acute disc herniation, muscle strain, degenerative disc disease, or spondylolisthesis. A vertebral compression fracture, sacroiliac joint dysfunction, lumbar facet arthropathy, and sciatica are all differential diagnoses that the clinicians in this case needed to be aware of. It is also important to assess the possibilities of a lumbosacral strain and a sacroiliac joint sprain. Treatment: The MRI report revealed a high grade stress reaction in the right sacral ala. A non-displaced stress fracture in the right superior portion of the left sacral ala was also discovered. The patient was told to rest without any exercise for four to six weeks. After the stress fracture was resolved, the athlete has been encouraged not to participate in any repeated load-bearing types of activities until the source of the problem has been identified. Uniqueness: There is an uncommon nature of sacral stress fractures in males. It is important to realize that individuals who are constantly participating in repeating load-bearing activities are more prone to sacral stress fractures. Sacral stress fractures normally present themselves in women who have the female athlete triad. Research has shown that the influence of energy balance and hormonal fluctuations are significant factors associated with injuries in amenorrheic female athletes. The testosterone levels in young men normally lead to healthy and strong bones. This case report is a prime example that has the potential to teach clinicians all over to always look at the big picture and keep in mind all of the possible differential diagnoses. Conclusions: Physician's have hypothesized that the calcium level in this patient is too high which is causing parathyroid levels to decrease, resulting in low bone density. Since calcium and the parathyroid hormone have an inverse relationship, moderation between the two is essential. However, if one is too high, the other is too low decreasing bone density. Another hypothesis is that low testosterone levels in the patient are causing low bone density. This rare case is far from over as there is numerous investigative work to still be done. Clinical Application: Correctly diagnosing a sacral stress fracture is very difficult due to the wide range of differential diagnoses that its symptoms can present. Clinicians should never rule out the possibility of a sacral stress fracture when clients present low back pain, diffuse buttocks pain, and a history of repetitive loading actively. Although the clinicians in this case did not originally think this injury was another sacral stress fracture, they never ruled out the possibility due to the patient's described pain and pre-existing conditions. The clinicians in this report considered all possible diagnoses before making an assessment. Further research still needs to be performed in order to provide the most effective treatment and outcomes for future patients. Word Count: 597