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Abstract & Commentary
Synopsis: Sacral stress fractures should be considered as a possible cause of low back pain in female athletes, especially in the face of menstrual and dietary irregularities.
Source: Johnson AW, et al. Am J Sports Med. 2001;29(4):498-508.
Low back pain is a common complaint among many athletes. The pain may emanate from the low back or may be referred from another site. The purpose of this study is to report on several patients with an uncommon site for a stress fracture. This article presents 5 Division 1 NCAA athletes and 3 other athletes age 19-45 years old with prolonged low back pain. All athletes complained of vague low back pain that failed to respond to routine NSAID agents. Plain radiographs, CT, MRI, bone scans, and bone density studies were ordered on most patients. Menstrual history and diet history were evaluated.
All patients were premenopausal and all bone density studies were above the fracture level. The average time until the athletes returned to their preinjury activity level was 8 months. The most likely identifiable risk factors were an increase in the activity level, inadequate caloric intake, and abnormal menstrual histories.
COMMENT BY JAMES R. SLAUTERBECK, MD
Both low back pain and stress fractures are common in athletes. In athletes with persistent low back pain failing routine nonoperative management, most physicians would consider looking for stress fractures in the pars intrarticulartis but might not consider the sacrum as a potential site. I wonder how many runners, on whom I have ordered a CT scan to rule out a spondylolysis, completed a full dietary and menstrual history, lab, and radiographic work-up only to result in the grab-bag diagnosis of mechanical low back pain, were sent back to running with a sacral stress fracture?
Low back pain can be either musculoskeletal or non-musculoskeletal, ie, discogenic vs. gynecological. Stress fractures can be 1 of 2 types—insufficiency or fatigue. Fatigue stress fractures occur in normal bone and insufficiency fractures occur in osteopenic bone. Therefore, in the work-up for low back pain in running female athletes, one must obtain a good running, menstrual, and dietary history to determine the type of stress fracture.
Aggressive management of these athletes with fatigue stress fractures by obtaining proper history, performing a thorough exam, using consultation with a gynecologist, and aggressively treating the athlete with appropriate rest will return an athlete to full activity. If insufficiency fractures are present, one should consider aggressive medical management for the osteopenia by a qualified physician added to the above. I recommend an early bone scan or MRI in athletes after routine screening radiographs are negative followed by a CT for localization and definition of the fracture. Additionally, bone density studies are important to determine if insufficiency or fatigue stress fractures are present to help guide treatment. The long-term effects of amenorrhea, diet disorders, and osteopenia can lead to devastating osteoporosis later in life. Nutritional and psychological assessment and treatment can be life altering or saving in some cases. Isolated treatment of only the stress fracture in these elite athletes will be fraught with frustration between the coach, athletes, and physician.
Runner’s chronic complaints often can lull the physician into a state of complacency, which can prolong successful treatment of overuse syndromes. Runners’ sacral stress fractures are now on my radar screen for low back pain in athletes.