Sacral Stress Fracture

What is a sacral stress fracture?

  • Are you a runner or an active person who has pain in the buttock or low back area?

  • Maybe you’ve been told that you’ve got a problem with your sacroiliac joint, but it just isn’t getting better with physiotherapy or osteopathy?

  • Perhaps you notice the pain every time your run, or when you’re putting your foot down when walking?

You may have a sacral stress fracture.

Sacral stress fractures can be difficult to spot, if they’re not thought of. In my experience, they are often confused with sacroiliac joint pain, or pain being referred from the lumbar spine.

Most of the patients I meet who have a sacral stress fracture, are fit and active runners. If you’ve noticed a pain that’s building up in your buttock when you run, you might be harbouring a stress fracture.

What causes sacral stress fractures?

Behind every stress fracture are a number of contributing factors. If you’re a runner or a triathlete, and you’ve upped your mileage too quickly, or not been able to do strength work in the gym, you can generate a bone stress injury.

Equally, if you’ve not been getting enough calories on board, not getting enough sleep, or are combining an arduous training schedule with hectic job and a young family, you can end up in trouble.

So why does the sacrum get unlucky in particular? Many of my patients who have a sacral stress fracture will have some subtle stiffness in their hip on the affected side. The hip stiffness is often caused by FAI, and the slightly abnormal biomechanics may be why excessive loading of the sacrum occurs.

The most commonly affected area of the sacrum is the ‘ala’ bone – hence the term sacral ala stress fracture.

How might I know I have a sacral stress fracture?

1. Pain.

Stress fractures can be a bit sneaky and the pain might move around and come and go.

You might be experiencing pain in your buttock or lower back area, and it may even feel like it’s coming from your sacroiliac joint.

Sometimes it can be bad at night time, and other times, you might just be ‘aware’ of a sensation there.

You might find that you’re ok when you start a run or your workout, only to find that begins to crescendo, or stops you from running altogether. Sometimes it might only give you pain after you’ve exercised.

If it gets really bad, you may notice it every time you put your foot to the ground, or it might even make you limp.

2. Physical examination.

In my view, one of the simplest tests you can do, is the single leg hop test.

Got no pain when you hop on your good leg side, but can feel the essence of your pain reproduced on your bad side? That’s a stress fracture until proven otherwise.

‘Gaenslen’s’ test is a physical examination test your physio or osteo might perform to see if they can reproduce your pain.  This test stressed your sacroiliac joint. If it brings on pain, it can’t distinguish between an inflammed sacroiliac joint and stress fracture, but if it’s negative, it’s less likely that you have a sacral problem.

3. Clues in your medical history.

If you’ve had a previous history of stress fractures, a big change in your training regime, or you’ve not been fuelling correctly, you’re at risk of a stress fracture.

Statistically, women are more prone to stress fractures than men, but I meet many men who’ve landed up with a sacral stress fracture.

If you’ve been told that you have low or reduced bone mineral density (e.g. osteopenia or osteoporosis), or if your menstrual cycle has become disrupted, you’re at risk of a stress fracture.

I have found the service offered by Dr Cath Spencer-Smith to be outstanding. I had a troublesome sacral injury that had been bothering me for months. Cath successfully made a diagnosis, organised for MRI scans and set out a treatment plan in 3 days, and I am now well down the road to recovery.  As a keen amateur triathlete, the service provided here, is as close to a dedicated professional medical support team as I will ever get. It is so reassuring to know that this kind of focused and no-nonsense treatment is available to us ordinary folk.

How is a sacral stress fracture diagnosed?

An MRI scan is the very best way to prove or disprove that you have a sacral stress fracture. An MRI can also rule out other conditions that may mimic a stress fracture, or may be contributing to the mechanics that generated the stress fracture.

You can’t diagnose or rule out a stress fracture with an X-ray or an ultrasound scan.

In years gone by, we used a nuclear bone scan to look for hot spots which might locate a stress fracture, but they involve radiation exposure and are unnecessary now that we have MRI scanning.

What is the treatment for a sacral stress fracture?

If you suspect that you might a have a stress fracture, please don’t ignore it – get help and get a proper diagnosis. You need that MRI scan.

Once a sacral stress fracture has been diagnosed, as well as temporarily quitting your running, you might need to go onto crutches for a while, until your pain settles.

Most stress fractures need a good amount of healing time – there’s a lot of ‘bony negative equity’ to be repaid with rest.  How long is long enough?  Think six weeks minimum before you might be OK to return to training, and sometimes it may need to be longer, e.g. 3 months.

Sacral stress fractures can take a little longer than other types of stress fracture to heal, so you need to be patient.

Once you’re comfortable, you may be given the green light to do some cycling or swimming, to help maintain your fitness while you continue to heal.

You’re going to need to do some physio or osteo to target any deficiencies that you might have which contributed to the fracture. For example, if you’re not great at stabilising around the pelvis when running, you’ll need to get that optimised before you return to impact work.

I honestly can not commend Dr. Spencer-Smith enough. I was having a hard time with the NHS after an accident left me with a rare and controversial type of hip fracture, and decided rather nervously to invest privately (I don’t have insurance).

It was the best decision I could have made.

For the first time, I felt I was with a doctor who actually understood the fracture (this woman more than knows her stuff!), who took the time to explain things thoroughly to me, who took my future health seriously, and who gave me a good treatment plan to follow. Whereas I had different advice with the NHS (and yet all would tell me ‘you’ll be fine, but not like you were’), she was the first to be firm but positive – I’d have to take my healing more seriously, but I could get back to normal.

Dr Spencer-Smith is also one of the warmest, kindest and down-to-earth doctors I’ve come across, and I’ve lived in over six countries. I’d recommend her to anyone, she has re-affirmed my faith in the medical profession.

Do we need to any other tests?

Sometimes we might choose to repeat the MRI scan if your stress fracture is taking it’s time to mend, but nearly everyone gets there in the end (and I’ve never needed to send anyone for surgery for this problem).

I believe that all patients who’ve had a stress fracture should have some blood tests to look for any underlying medical conditions (and to check vitamin D levels etc).

It’s also important to have a DEXA scan test, which looks at your bone mineral density status.

Taking a good look at your diet (have you been under-calorie-ing?) is important, as many runners and endurance athletes can fall prey of REDS (relative energy deficiency syndrome).

And lastly, correcting training errors, looking at your foot wear, and reflecting on your sleep patterns will help you to get to a robust place.