An interscholastic female distance runner suffered an avulsion fracture of the iliac crest during a cross-country race. Conservative treatment of 5 weeks of non-weight-bearing followed by graduated strength-and-flexibility activities allowed for a full recovery, with no limitations. This case demonstrates that health care professionals should recognize that distance running can cause avulsion fractures.
A 17-year-old female interscholastic runner (160 cm, 51 kg) was running a 5-km cross-country race. While leading and approaching the final 200 m of the race, she initiated her sprint to the finish and felt a “pull” in her hip roughly 100 m later. After winning the race, she went to her coach and the attending athletic trainer and complained of intense pain (an 8 on a 1-to-10 scale) in her right hip and abdomen. On physical examination, the athlete had general tenderness over the right, lower abdomen and the iliac crest. The athletic trainer suspected a soft tissue injury and gave the athlete an ice pack and instructed her to “ice daily, rest for a few days, and see a physician if it gets worse.”
Three days later, the athlete presented to her primary care physician with increased pain and inflammation in the right hip. During the physical examination, the athlete was alert and in no acute distress, had normal vital signs, and reported no issues with gastrointestinal or genitourinary functioning. The athlete was sensitive to palpation of the affected area, but a tuning-fork test for diagnosing a fracture yielded no pain. The examining physician instructed the athlete to continue with ice treatments for pain and inflammation and to start cross-training with a cycle ergometer and elliptical machine, as long as she was free of pain. She was in compliance with the physician-recommended management strategy for the next week, but pain returned and worsened as the week progressed, and she returned for a second consultation.
On the second visit, radiography was ordered and revealed an avulsion fracture of the right iliac crest, with a 2-cm separation (Figure 1). The athlete was placed on non-weight-bearing activities for 5 weeks and fitted with crutches. Follow-up radiography 3 weeks later revealed partial bone healing (Figure 1). Five weeks after the injury, the athlete was cleared to start a progressive walking-to-jogging regimen that included alternating 3-minute intervals of each for a total time of 30 minutes, daily, for 3 weeks. She proceeded to return gradually to activities over the next 12 weeks, following a regimented, sequential program of strength-and-flexibility activities, primarily with resistance bands, until full-speed running was allowed.
Initial radiograph (left) revealing an avulsion fracture of the right, iliac crest (arrow), and a follow-up radiograph (right), 3 weeks later, indicating partial healing of the bone fragment to the iliac crest (arrow).
The athlete went on to recover fully, with no limitations, and successfully competed in the interscholastic spring track season. She earned a scholarship to run collegiately, and ran the ensuing fall season, with no recurring injuries.
Avulsion fractures of the iliac crest are rare.1–3 Pelvic avulsion fractures typically occur in teenagers, with an average age of 14.4 years,1 because the pelvic apophyses are not completely ossified.4,5 The incidence rate, by sex, is 13:1, male:female,4 and the mechanism causing the injury generally is “a rapid, longitudinal force applied through the apophyseal plates.”6 These movements, when performed forcefully, especially eccentrically, can place a high load on the abdominal musculature, and if the tensile force exceeds the capacity of the iliac crest's apophysis, an avulsion fracture occurs.4,6 As a point of comparison, the classic “hip pointer” in American football involves a tackle whereby an opponent strikes the abdominal oblique muscle, causing a violent tensile strain to the osseous insertion on the iliac crest. In the current case, our athlete, when accelerating at the end of her race, appears to have created a listing action of the pelvis to replicate, if not exceed, the tensile forces observed in tackle football.
The prevalence of apophyseal avulsion injuries has increased over the past few decades, and this increase is purported to be from more youth being involved in sports.7 The typical case involves a male teenager, often a soccer or tennis player.7 Interestingly, our patient was a female teenager, and the fact that the injury occurred during distance running makes this case unique. In reviewing 203 cases where athletes suffered a pelvic avulsion fracture, only three involved the iliac crest, and they were in tennis, gymnastics, and soccer.2 A later case was reported in wrestling,6 and since then other cases have been reported in sprinters and gymnasts.5,7,8
Generally, avulsion fractures of the pelvis are caused by explosive activities, often with twisting motions of the trunk, which is why such a prevalence exists in soccer, tennis, and gymnastics. Running, specifically sprinting, has been reported as a cause of pelvic avulsion fractures involving the iliac crest, often from track sprinting events or similar activities.8
The only other case of a pelvic avulsion fracture in a distance runner we could find in the published literature involved a collegiate male harrier, who suffered an avulsion fracture of the anterior superior iliac spine, and not the iliac crest, during an interval workout.9 The researchers reported that the runner was rounding a tree and “felt a snap in his left hip and subsequently fell to the ground.” The description indicates that the injury was immediate, violent, and disabling. He was treated conservatively and allowed to begin aquatic activities and cycle ergometry within a week after the injury because he was “a persistent, somewhat typical distance runner. . .[and] had a desire to maintain his current fitness level.” His recovery was rapid, being pain free in 14 days, and he started jogging “3 to 4 miles” (approximately 5 to 6.5 km) daily thereafter. He competed in an 8-km cross-country race just 19 days after his injury, finishing within 4 seconds of his personal record. The authors noted radiography showed his growth plate had yet to close fully and that the continuing bone formation may have been a contributing factor in his recovery.
With respect to the current case, the runner developed an avulsion fracture of her iliac crest from distance running. The added force applied to the iliac crest from the increased effort to improve her speed during the final 200 m of a 5-km race was forceful enough to cause the fracture. This is consistent with other injuries involving running in the literature, but normally with sprinters rather than distance runners.8 Recently, a case involving an Italian 15-year-old female “high level gymnast” was reported where an avulsion fracture of the iliac crest occurred when the gymnast “attempt[ed] to sprint while running at a constant pace.”10 This is the precise mechanism that caused the avulsion fracture in the current case, albeit in a distance runner instead of a gymnast, indicating that health care professionals should be aware of this possibility.
Implications for Clinical Practice
As evidenced in the current case, avulsion fractures can occur through distance running. Health care professionals should consider avulsion fractures in the differential diagnosis when assessing distance runners with persistent hip pain, altered gait, or point tenderness. Conservative treatment generally works well and should involve rest and non-weight-bearing activities until the athlete is pain free (usually 2 to 6 weeks). Graduated strength-and-flexibility activities, often incorporating resistance bands, as tolerated, and cross-training, where appropriate, should be initiated until a gradual return to full-speed running and competition can occur (normally 4 to 8 weeks).11 Conservative treatment is effective with fragments displaced fewer than 3 cm, but open reduction and internal fixation may be required for larger displacements.6,10 With open reduction and internal fixation, the recovery generally involves 6 weeks of non-weight-bearing followed by “active range of motion and supervised strengthening,” as tolerated, for 4 months, with a release to full activities by 6 months.11
Although uncommon, pelvic avulsion fractures do occur, often involving physical activity where forceful, rapid, eccentric contractions of the abdominal musculature occur. We present a case where a female adolescent distance runner developed an iliac crest avulsion fracture from distance running. Conservative treatment typically results in a satisfactory outcome without subsequent limitations.
- Schuett DJ, Bomar JD, Pennock AT. Pelvic apophyseal avulsion fractures: a retrospective review of 228 cases. J Pediatr Orthop. 2015;35(6):617–623. doi:10.1097/BPO.0000000000000328 [CrossRef]
- Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal Radiol. 2001;30(3):127–131. doi:10.1007/s002560000319 [CrossRef]
- Duverney JG. Duverney's fracture. 1751. Clin Orthop Relat Res. 1996;329:4–5. doi:10.1097/00003086-199608000-00002 [CrossRef]
- Pointinger H, Munk P, Poeschl GP. Avulsion fracture of the anterior superior iliac spine following apophysitis. Br J Sports Med. 2003;37(4):361–362. doi:10.1136/bjsm.37.4.361 [CrossRef]
- Albtoush OM, Bani-Issa J, Zitzelsberger T, Springer F. Avulsion injuries of the pelvis and hip. RoFo Fortschr Geb Rontgenstr Nuklearmed. 2020;192(5):431–440. doi:10.1055/a-1082-1598 [CrossRef]
- Steerman JG, Reeder MT, Udermann BE, Pettitt RW, Murray SR. Avulsion fracture of the iliac crest apophysis in a collegiate wrestler. Clin J Sport Med. 2008;18(1):102–103. doi:10.1097/JSM.0b013e31815ad14f [CrossRef]
- Coulier B. Acute avulsion of the iliac crest apophysis in an adolescent indoor soccer. J Belg Soc Radiol. 2015;99(2):20–24. doi:10.5334/jbrbtr.876 [CrossRef]
- Casabianca L, Rousseau R, Loriaut P, et al. Iliac crest avulsion fracture in a young sprinter. Case Rep Orthop. 2015;2015:302503. doi:10.1155/2015/302503 [CrossRef]
- Draper DO, Dustman AJ. Avulsion fracture of the anterior superior iliac spine in a collegiate distance runner. Arch Phys Med Rehabil. 1992;73(9):881–882.
- Losco M, Ceglia MJ, Lazzarini F, De Biase P, Buzzi R. A rare case of avulsion fracture of the iliac crest apophysis in a young female athlete. Trauma Case Rep. 2019;24:100257. doi:10.1016/j.tcr.2019.100257 [CrossRef]
- Schoensee SK, Nilsson KJ. A novel approach to treatment for chronic avulsion fracture of the ischial tuberosity in three adolescent athletes: a case series. Int J Sports Phys Ther. 2014;9(7):974–990.