Pelvic Stress Fracture

Pelvic stress fracture is also called as pubic ramus stress fracture, stress fracture of the pelvis, ischial stress fracture and pubic bone stress fracture.

Pelvis is a ring-like structure of bones that is present at the lower end of the trunk. The pelvic bone is a large bone, which is present in two halves on each side of the body known as the hemipelvises, and together they build up the complete pelvis. The hemipelvis on each side consists of amalgamation of three bones called as the ilium, pubis and ischium. Ilium, pubis, and ischium are three separate bones before puberty which are held together by cartilage. Eventually with growing age, these three bones fuse together into one single bone. Ligaments are strong connective tissues that connect the pelvis to the large triangular bone known as sacrum present at the base of the spine. This forms a bowl-like cavity under the rib cage.

A pelvic stress fracture is a condition characterized by a partial crack in any one of the pelvic bones.

Several muscles of the abdomen, lower back, knee and hip are connected to the pelvis. Blood vessels and large nerves going to the legs pass through this pelvic ring. Contraction of these muscles exerts a pulling force on the bone. Weight bearing activities are often responsible for placing compressive forces on the pelvis through the hip joint.

Excessive and too much repetitive forces which are beyond the tolerance limit of the bone force it to damage gradually, which further results in a bony stress reaction and continued damage gradually progresses to a pelvic stress fracture.

The ischium and pubic ramus are the most frequently affected areas in a pelvic stress fracture. These are known as ischial stress fracture and pubic ramus stress fracture depending on the bone affected. Being the lowest part of the pelvic girdle and the point where the muscles of the hamstring and groin get connected, pubic ramus is the most commonly affected bone. However, the pubic symphysis or the front joint present between the two pelvic bones may also get affected, which results from impact and stress transferred up from the foot and repetitive muscular forces.

Pelvic stress fracture is very common among military recruits and female runners. Women are more prone to pelvic stress fracture because of the decreasing bone density after 30 years of age.

• Pelvic stress fracture is usually caused by performing excessive weight bearing activity such as jumping, dancing, running and sprinting.
• In some cases pelvic stress fracture may also be caused due to repetitive kicking in sports such as soccer and football.
• Pelvic stress fractures may be seen in women following pregnancy, if they perform excessive weight bearing activities without good pelvic and core stability.

• Muscle weakness specifically of the pelvic stabilizers, core stabilizers and gluteals.
• Pelvic instability followed by pregnancy.
• Poor flexibility specifically of the abdominals, adductors, gluteals, hip flexors, quadriceps and hamstrings.
• Stiffness in the joint specifically of the ankle, knee, lumbar spine and hip.
• Poor balance.
• Inappropriate footwear.
• Poor foot posture such as high arches and flat feet.
• Discrepancy in the length of the legs.
• Excessive and inappropriate training on uneven and hard surfaces.
• Improper running technique.
• Age.
• Lack of fitness and conditioning.
• Body weight.
• Bone health.
• Menstrual disturbances in females.
• Inadequate diet.

• Patients suffering with pelvic stress fracture often experience localized pain in the pelvic area.
• Exacerbation of pain while performing high impact activities such as exercises, sprinting, hopping, running and jumping which eases away with rest.
• Severe pain may also restrict the patient to perform regular activities.
• Pain in the hip, buttock, groin, or lower back depending upon the bone affected.
• In more severe cases, symptoms may also aggravate while walking and standing.
• Tenderness over the inferior pubic ramus.
• Decreased movement and strength.
• Pain during rest.
• Night ache.
• Pain is also experienced on firmly touching the affected area of the bone.

The potential causes of stress fracture need to be assessed, which can be either biomechanical factors or factors such as low bone density, and addressed accordingly. Other treatment modalities include:

• Anti-inflammatory medications such as ibuprofen and naproxen may help in reducing inflammation and pain.
• Application of ice and cold therapy to the painful regions helps in easing away inflammation, swelling and pain.
• Rest.
• Avoiding activities that aggravate the symptoms.
• Staying off the feet as much as possible for the first couple of weeks.
• Gradual return to sports activities after a period of four to six weeks when the fracture has completely healed.

Physical Therapy: Physical therapy for pelvic stress fracture is important in speeding up the healing process. Physical therapy also decreases the likelihood of recurrences in the future. Physical therapy may include:

• Joint manipulation.
• Soft tissue massage.
• Joint mobilization.
• Clinical Pilates.
• Dry needling.
• Electrotherapy.
• Using crutches and other walking aids.
• Activity modification advice.
• Biomechanical correction such as orthotics, running technique correction and foot taping.
• Education.
• Footwear advice.
• Progressive exercises for improvement of flexibility, strength, balance, core stability and fitness.
• Appropriate plan for returning to sports and activity program.

With right treatment and regular physical therapy and depending on the severity of the fracture, the time taken to recover from pelvic stress fracture and to be able to return to sporting activities can be anywhere from 4 months to a year or more in some cases.

Exercises may need to be performed during recovery period to regain regular function. Given below are some of the exercises.

This exercise is performed by bringing the knee near the chest as far as possible in order to bend the knee until a mild to moderate pain free stretch is felt. Then return back to the initial position. Perform 10 to 20 times ensuring there is no exacerbation of symptoms. Repeat the same on the other leg.

This exercise is performed by lying down on the back with foot flat and knee bent. Now move the knee sideways as far as possible until a mild to moderate pain free stretch is felt and return back to initial position. Perform 10 to 20 times ensuring there is no exacerbation of symptoms. Repeat the same on the other leg.

This exercise is performed by lying down on the back, bending the legs with knees facing towards the ceiling and feet flat on the floor. Gradually raise the bottom by pushing it with the help of feet in order to bring the hip, shoulder and knee in a straight line by tightening the bottom muscles. Hold the position for about two seconds until a pain free stretch is felt. Repeat the exercise 10 times.

A complete subjective and objective examination is necessary to diagnose the condition of pelvic stress fracture. Typically, the following diagnostic tests may be required for confirming the severity and extent of damage.

• X-rays.
• MRI.
• Bone scan.
• CT scan.