Sacral Stress Fracture is an increasingly common injury in female endurance athletes (specifically female marathon runners). What is a sacral stress fracture, what are the risk factors, and what is the treatment and recovery time?
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Let’s break break break, break
a bone it down.
Sacral Stress Fracture Definition and Causes
The sacrum is the triangular bone at the base of the spine beneath the lumbar spine and above the pelvis. The meeting point of the sacrum and the pelvis is known as the Sacroiliac joint, or SI Joint, which is the area that my pain initially presented.
Sacral Stress Fractures are pretty rare, and occur most often in endurance athletes and older women as a result of hormonal changes and osteoporosis. Endurance runners might suffer from this type of stress fracture due to the repetitive stresses and impact, while older women are often dealing with hormonal changes due to menopause and/or osteoporosis, or low bone density. Other diseases or conditions resulting in malabsorption of vitamins and minerals can also be a risk factor, as well as abnormal periods or Amenorrhea (or the absence of periods).
Soooooooo, let’s think about the boxes in that list that I check off:
- Endurance athletes (I run marathons)
- Osteopenia (lower than average bone density) due to
- Malabsorption of vitamins and minerals during formative years (I was diagnosed with Crohn’s Disease at 13, so I didn’t absorb major bone health contributors at the most formative time)
- Medication side effects (I have been on and off of corticosteroids throughout my treatment for Crohn’s Disease
- Abnormal or Absent periods (I have always had an abnormal cycle and sometimes absent periods)
So yeah. I was pretty much doomed.
I do want to note that sacral stress fractures are pretty rare. In fact, most of the doctors that I have spoken to had not even met a patient with one yet! But you know me, I’m alllllll about living beyond expectation, right?
Symptoms and Diagnosis of Sacral Stress Fractures
Looking back at my symptoms, they are very consistent with a sacral stress fracture:
- Pain in hip or pelvis (yup)
- Pain in buttocks or groin (buttocks)
- Increase in pain during exercise (um YES)
- Lower back tenderness (not really, but I did have lower back aches)
- Swelling at lower back (not really, but my MRI did show some swelling)
To diagnose a Sacral Stress Fracture, there are a few evaluative tests that can be done in the office (such as the hop test, one of the go-tos for stress fractures, and which I failed) as well as imagine (X-ray, CT Scan, MRI, Bone Scan). I passed the Xray done on my initial visit, but according to the doctors that I have spoken with, not only do x-rays not always catch stress fractures, sometimes stress fractures do not show up immediately. MRI is generally the test of choice for diagnosis, but it is expensive, so doctors tend to wait before ordering one. My MRI displayed an acute stress fracture (as opposed to a stress reaction) in the left sacral ala, thus why my pain presents on the left side.
Sacral Stress Fracture Treatment
As with any sort of stress fracture, rest and offloading is the main course of treatment. Surgery is not usually an option, as the injury is not a full fracture, so there are no moving parts. But how do you rest you pelvis and spine? Um, you kind of use them for a lot of things!
- Rest is pretty self explanatory: sit (properly) on your well-cushioned biscuit. When sitting or standing, it is important to sit squarely with proper spine curvature and pelvic tilt as much as possible.
- Off loading: well, we do have to move around, generally, so crutches or a cane are generally recommended. Unlike what Alex thought, hopping around is also not really recommended, as that will jar your pelvis and spine and you are trying to keep everyone happy. I am crutching around with my left leg lifted to allow that area of my spine to heal.
- If the stress fracture is very severe, there are bracing options and also bed-rest (HECK no)
Basically, if it hurts, don’t do it. For me, I find the majority of my pain when bending at the waist, being jarred, things like running (and sometimes walking, but not really right now), and certain moves where I am actively positioning myself. For the most part, I’m letting Alex pick things up off the floor, which is why our apartment looks even more of a hot mess right now. None of that “you can tell an injured runner by how clean their house is.” You’ll know I’m healed when I’m actually cleaning again!
There are a few active non-surgical options, including electrical bone stimulation, shock wave therapy (which we actually used to do with the horses), and vertebroplasty (or injecting bone cement into the fracture), but those are very aggressive treatments.
Sacral Stress Fracture Healing Time
Of course, this is completely dependent on the person and the injury, but we are anticipating that I will be on crutches for at least 4 weeks. A second MRI may be necessary to check on healing. But some people may take several months.
Return to Activity after Sacral Stress Fracture
When I am cleared by the doctors to return to activity (and this may happen before I am off of crutches) I will likely be starting with the stationary bike, swimming, and pool running. Because this is also a spinal injury, we do not want to introduce too much activity or twisting of the spine, so swimming will probably come last of those. Also, I was able to ride the upright bike without pain up to the day that I was put on crutches. Spin bike and elliptical will be a bit further off, but will be integral in reintroducing me to weight-bearing exercise, as might a step mill or stairmaster. I will be put on the treadmill or back to running last.
Rehabilitation and physical therapy-wise, I will need help combating the muscular imbalances that are sure to result from what will be nearly 2 months of unbalanced use of the side of my body. That will mean targeted strengthening of pretty much everything from my rib cage down (remember, I can’t really do any core work right now because of my spine) to the arches of my feet (which will certainly lose strength and put me at risk for overuse injury).
Long Term Issues after Sacral Stress Fracture
Honestly, not too much. If I had torn the muscle, we would be at a significant disadvantage because that muscle would have to be rebuilt and then retaught how to act as a muscle. In the case of bone injury, the bone simply needs to heal. Once I am fully healed, this should be a problem, though it does indicate an area of weakness for me in the future. PT and rehab will help me strengthen the area to defend against that.
Stress Fracture Prevention
We already have gone over why this has happened to me, and I think that the fact that I’ve been able to train for all my marathons without stress injuries proves that I am very smart about that aspect of loading my body. The issues come afterwards, as my body works to recover, I have a bit less structure in my weekly workouts, and I run much faster for the majority of my miles.
I think that this last point is a huge contributor to my stress injuries. I ran my most consecutive high mileage weeks ever this summer, but without problem because I was running with trainees and thus running slower, being more gentle with my body. After the marathon… UNLEASH. Not even doing “speedwork,” but if you think about it, compared to this summer, every run was speedwork! So, with regards to continuing running, step one will be to slooooowwww doooowwwwnnn.
Step two will be to see the bone health specialist to discuss my bone density. There are some medications called bisphosphonates that they might put me on. These medications increase bone density in patients with chronic issues. They might be able to help me with the osteopenia (not necessarily take me to “normal” range density but at least to improve things). I already take calcium and vitamin D, so I don’t see much else being able to be helped there. There is also the chance that getting pregnant and my hormones normalizing/self-regulating might promote better bone health.Is a Sacral Stress Fracture the end of your running career? #runchat #running #stressfracture Click To Tweet
I know that this is a lot of information, but I hope it was useful! Let me know if you have any questions!
What is the most obscure injury that you’ve ever had?