Working Diagnosis:
Bilateral iliac bone stress fractures

Treatment:
Activity modification including the use of a wheelchair for several weeks secondary to significant pain with slow progression to crutches then to ambulating without assistance. Patient used anti inflammatory medications as needed for pain.

Outcome:
Prolonged rehabilitation course due to persistent pain which gradually decreased to allow return to normal daily activities.

Author's Comments:
Pelvic stress fractures are overall very uncommon, comprising 1-2% of all stress fractures (1.) Pelvic stress fractures have been described at the pubic rami and sacrum (2,3). There have also been two case reports detailing unilateral stress fractures of the iliac bone (4,5). Literature searches have yielded no reports of bilateral iliac bone stress fractures.

This patient's case illustrates a complex mix of risk factors which do not completely explain her injury. Risk factors include: female gender, history of pregnancy and breastfeeding, suboptimal training, and possible history of prior injury. She did not, however, demonstrate low vitamin D or C, low bone mineral density, or disordered eating. Her gait, subtle predisposing anatomic variations, and type of footwear could not be factored into her risk factors. The complexity of her case certainly reinforces recommendations for preventative measures in a variety of runners.

Editor's Comments:
Stress fractures are commonly encountered problem in sports medicine. They account for a significant percentage of overuse injuries and up to 15% of injuries in runners. The majority of stress fractures occur in the lower extremity with stress fractures of the tibia, metatarsals, and fibula being the most commonly reported in the literature. Only 1% to 7% of reported stress fractures affect the pelvis or the sacrum. Track and field athletes incur pelvic bone stress injuries at a significantly higher rate (4%. Female military recruits have the highest reported incidence at 22% of all stress fractures.

References:
1. Lapp JM. Pelvic Stress fracture: Assessment and risk factors. J. Manipulative Physiol Ther 2000 Jan 23 (1):52-5

2. Hill PF, Chatterfi S, Chambers D, Keeling JD. Stress fracture of the pubic ramus in female recruits. J Bone Surg Br. 1996 May; 78(3) 383-6.

3. Volpin G, Milgrom C, Goldsher D. Stein H. Stress fractures of the sacrum following strenuous activity. Clin Orthop Relat Res. 1989 Jun; (243):184-8

4. Touhy J, Nattiv A. Iliac stress fracture in a male collegiate track athlete. Curr Sports Med Rep. 2008 Sep-Oct; 7(5):252-4

5. Atlihan, D., D.C Quick, and C.A. Guanche. Stress fracture of the iliac bone in a young femal runner. Orthopedics. 26:729-730, 2003.

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