Stress Fractures of the Pelvis and Sacrum

Stress fractures of the pelvis and sacrum are uncommon and are considered to be low-risk sites for fracture progression. They are a rare but treatable cause of groin, hip, low back, and buttock pain but can lead to substantial loss of time from athletic participation. The diagnosis may be difficult to make and, therefore, requires a high index of suspicion due to the broad differential diagnosis. Plain radiographs are the first step in imaging evaluation, but magnetic resonance imaging (MRI) is the modality of choice for definitive diagnosis. These injuries are associated with low body mass index (BMI), vitamin D insufficiency, disordered eating, and malabsorption disorders and often necessitate a laboratory workup to determine underlying risk factors. Appropriate treatment includes rest from the causative activity, nutritional support, and biomechanical optimization. In severe, chronic, or recurrent cases, referral for nutritional counseling, hormonal replacement therapies, and mental health support may be necessary. While treatment will vary by fracture location, most stress fractures will heal with rest and modified activity including protected weight-bearing. Rarely, these sites require more aggressive intervention such as prolonged non-weight-bearing or surgical stabilization.