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Sacral Stress Fractures: They See You, But Are You Seeing Them?

Harris, Charles E. III BS; Vincent, Heather K. PhD, FACSM; Vincent, Kevin R. MD, PhD, FACSM

Current Sports Medicine Reports: March/April 2016 - Volume 15 - Issue 2 - p 73
doi: 10.1249/JSR.0000000000000245
Clinical Pearls

1Rosalind Franklin University of Medicine and Science, Chicago, IL; and 2University of Florida, Gainesville, FL

Address for correspondence: Kevin R. Vincent, MD, PhD, FACSM, University of Florida, 3450 Hull Road, Gainesville, FL 32608; E-mail:

Sacral stress fractures can be particularly difficult to recognize and diagnose. Although uncommon, sacral stress fractures should be suspected in athletes, particularly female runners presenting with low back or buttock pain (2–4,6). Sacral stress fractures are most commonly found in female distance runners, but also have been reported in other sports such as tennis, basketball, gymnastics, volleyball, and track and field (5). Patients typically report buttock pain, but also can report low back pain, groin pain, and muscle spasms. Pain is particularly noticeable with impact loading and change of direction.

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Differential Diagnosis

Sacroiliitis, spondylolysis (pars defect), piriformis pain, sacroiliac joint dysfunction, back strain, radiculopathy, scoliosis, juvenile disc disorder, Scheuermann’s kyphosis (1,4).

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Physical Examination

Characterized by pain with single-leg hop; tenderness to palpation of the sacrum; positive flexion, abduction, and external rotation tests; negative straight leg raise; and normal neurologic examination.

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Diagnostic Tests

X-rays commonly negative, typically visualized with MRI and CT scan.

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Weight bearing as tolerated until able to ambulate without pain (10 to 14 d). Nonimpact cross-training for 6 to 8 wk, then resumption of running or impact activity. Correction of risk factors: pelvic obliquity, core strength, and presence of female athlete triad (4,5) (Figure).

Figure. Axia

Figure. Axia

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  • Most commonly found in female distance runners
  • Pain in sacral area with single-leg hop
  • Point tenderness on sacrum
  • Presence at anteroinferior sacral wing may mimic sacroiliitis
  • Involvement of anterior sacral foramina may mimic lumbar radiculopathy (2)
  • Index of suspicion should increase in patients being treated for back pain who are failing to respond to conservative care (2,4,5)
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1. Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Prim. Care. 2005; 32: 201–29.
2. Fredericson M, Salamancha L, Beaulieu C. Sacral stress fractures: tracking down nonspecific pain in runners. Phys. Sportsmed. 2003; 31: 31–42.
3. Johnson AW, Weiss CB Jr, Stento K, Wheeler DL. Stress fractures of the sacrum. An atypical cause of low back pain in the female athlete. Am. J. Sports Med. 2001; 29: 498–508.
4. Knobloch K, Schreibmueller L, Jagodzinski M. Rapid rehabilitation programme following sacral stress fracture in a long-distance running female athlete. Arch. Orthop. Trauma Surg. 2007; 127: 809–13.
5. Marchinkow A, Mallinson PI, Coupal T, et al. Sacral stress fractures in a sprint and throw athlete — a case report. Curr. Sports Med. Rep. 2014; 5: 297–8.
6. Shah MK, Stewart GW. Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine. 2002; 27: 104–8.
Copyright © 2016 by the American College of Sports Medicine.