Working Diagnosis:
Right sacral ala stress fracture secondary to leg length inequality and vitamin D deficiency

Treatment:
Sacral Stress Fracture
The General principles of treatment of stress fractures apply to sacral stress fractures and treatment plans should be tailored to the athlete for optimum recovery.
Initial treatment is rest and avoidance of painful activity. The patient may need to be non-weight bearing for a few days to weeks until there is no pain with ambulation. Activity Modification should be aimed to decrease impact loading of affected bone.
Cross training and physical therapy, which include core and hip strengthening, can be initiated after 1-2 weeks with no symptoms.
If pain free with above activity patient can initiate graduated running and cross country regimen
Total rehabilitation time is 4 to 8 weeks
2. Leg Length Discrepancy
Treat with shoe orthotic insert or heal lift therapy
3. Vitamin D Deficiency
Ergocalciferol(Vitamin D) 50000 units PO once weekly for 8 weeks, then 1000 units PO daily

Outcome:
Our patient was put on rest for 2 weeks and started with cross training and PT when patient was pain free. 1 month follow up from initial diagnosis returned to clinic with no pain with activities of daily living or treatment program. Patient completed physical therapy and had full recovery and return to full activity and cross country running within 10 weeks of onset of injury.

Author's Comments:
Sacral stress fracture is an uncommon injury only accounting for 4% of all stress fractures in runners.
Studies have shown that leg length inequality and a sudden increase in mileage or intensity of a running regimen are risk factors for all stress fractures including the sacrum.
Sacral stress fractures typically occurs on the ipsilateral side of the long leg, also the osteopathic dysfunctions found on this patient are typical compensations for leg length inequalities.
Other considerations would be if a patient had the female athletic triad or advanced in age a DEXA scan would be warranted.

References:
Diehl JJ, Best TM, Kaeding CC. Classification and return to play considerations for stress fractures. Clin Sports Med. 2006; 25(1):17-28.
Knutson, G, et al. Anatomic and Functional Leg-length Inequality: A Review and Recommendation for clinical decision making. Chiropractic and Osteopathy, 2005.
Miller C, Major N, Toth A. Pelvic stress injuries in the athlete. Management and prevention. Sports Med. 2003; 33(13):1003-1012
Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006; 25(1): 29-36.
Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young recruits. Am J Sports Med. 2006; 34(1):108-114.

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