2.Lars Adin, Pitea Hospital, Department of Radiology, Pitea, Sweden.
3Karin Larsen, The Swedish school of Sport and health sciences, Dean’s office, Stockholm, Sweden
Materials and methods: Five patients previously diagnosed with lower back pain, groin pain, pelvic or back thigh pain underwent a Physical Examination (PE) by a physiotherapist to identify the pathogenesis of the pain. The PE led to the preliminary diagnosis of SRBI in the TI, which was confirmed by an MRI. The patients were treated with rest and Personally Guided Rehabilitation (PGR).
Results : All cases had a positive eccentric hip extension test and pain provocation on palpation on the TI. MRI found different levels of stress reactions/fractures in the enthesis of the TI. After rest and rehabilitation, all subjects returned to their previous level of physical activity.
Conclusion: PE appeared to identify adolescent athlete patients with SRBI in the TI requiring an MRI. The correct diagnosis led to a quick return to the previous level of physical activity.
Clinical relevance: An early and correct diagnosis thru a thorough PE can lead to complete healing and a return to sports.
Keywords: Tuber ischiadicum, stress reaction, stress fracture, Physical Examination
Purpose: To describe five cases of SRBI in the TI, the PE of the condition, MRI, treatment and outcome.
After anamnesis was taken, a PE was performed with an eccentric test of the insertion of the hamstrings muscles with hip flexion > 100 degrees, slightly flexed knee, and pain provocation when palpating the TI insertion of the hamstring muscles. The eccentric test was scored as positive if pain in TI was recognized as a symptom by the patient. The palpation test was also considered positive if the patient recognized the pain in TI as a symptom.
An MRI was performed on 1.5 Tesla Philips Achiva system using sequences for both good anatomical resolution and sequences with high sensitivity for water in order to depict oedema and bleeding in bone marrow and surrounding soft tissue. A radiologist with extensive experience of MRI read the examinations.
Case IV b: The same patient as above, a 15-year-old icehockey player in an elite junior team with practice on and off the ice returned 9months later in December, the same year with similar problems but this time in his left leg. He had a PE and a third MRI examination, the first time for the second trauma. The MRI showed that the first oedema in the right TI had healed completely but a new stress reaction (large oedema) in the TI of the left side was found. The treatment consisted of two-week rest followed by a 6-weekPGR, and a stepwise return to normal physical activity
The PGR was used during different time spans (9 - 20 weeks). They were all followed up with the same PE as in the first examination to ensure that their progress was as expected (i.e. reduced pain). After PGR, all athletes were fully recovered with negative tests in the physical examination and with a return to the same physical activity level as before the injury [Table 1].
There is an opinion that during adolescence, the skeleton is more vulnerable than the tendons and muscles [7, 8]. Frequency and/or excessive load to the growing skeleton can result in an SRBI and pain as symptoms [5]. Stress reactions or stress fractures in the enthesis in the pelvic girdle skeleton can therefore indicate the site of the pelvic pain [5, 7, 8, 9, 10]. This stress reaction or stress fracture has a better tendency to heal if recognized early [7].
Askling showed the complexity of hamstring injuries in adult subjects and the importance of making the right diagnosis for treatment and prognosis of healing time [4]. Adolescent athletes have a more vulnerable skeleton than adults, which can result in stress reactions/stress fractures instead of tendon injuries [5]. In our five cases, the diagnoses were a mistake, when the subjects previously sought care. They were diagnosed with hamstring injury, lower back pain or SI joint pain. Conservative treatment such as manual therapy to the SI joint or the lower back, eccentric training or stretching, had no effect. Two physical tests resulted in a clinical diagnosis, and together with an anamnesis of sudden pain during physical activity or delayed pain after physical activity, an MRI examination confirmed the clinical diagnosis of SRBI in the TI enthesis of the pelvic girdle. In the literatures, there are discussions about SRBI on the TI enthesis, but to our knowledge, no suggestion is given to how to perform a PE in these cases. This study shows that it can be possible to diagnose the stress reaction or stress fracture in the enthesis with a PE. Ultrasound scanning can also be a tool for early diagnosis in this condition [1, 8].
Conclusions: There is a possibility to clinically diagnose patients with SRBI and distinguish between injuries in the lower back, SI joint, muscle tendons or muscle bellies in the back of the thigh and SRBI in the enthesis of the TI, before an MRI has verified the diagnosis. However, it needs to confirm the results of the PE and to exclude the possibility that the MRI findings are due to normal growth, by also performing an MRI on controls.
Recommendations: This is a small-size case study and we therefore recommend larger-size studies with a focus on physical examination. There is also a possibility of supplementing the physical examination by an ultrasound scan to strengthen the early diagnosis and therefore start early treatment followed by PGR to recovery.
Case |
Case I |
Case II |
Case III |
Case IVa |
Case IVb |
Gender/Age |
Male/17 |
Male/14 |
Male/13 |
Male/15 |
Male/15 |
Main Sport |
Football |
Ice hockey |
Track and field |
Ice hockey |
Ice hockey |
Injury activity |
Playing football |
Explosive running |
Explosive running |
Ice hockey |
Ice hockey |
Symptom |
Pain back of thigh |
Pain back of thigh |
Pain back of thigh |
Pelvic pain, |
Groin pain, |
Previous PE |
|
|
Back pain, |
|
Groin injury |
Initial PE a, b |
a+b |
a+b |
a+b |
a+b |
a+b |
MRI affected side |
Stress reaction (oedema) in the skeleton in tuber ischiadicum and in surrounding soft tissues |
Avulsion fracture on tuber ischiadicum 15 mm diastasis |
Stress reaction oedema in the skeleton on tuber ischiadicum, and discrete reaction in the surrounding soft tissues |
Stress reaction (great oedema)in the skeleton in tuber ischiadicum and discrete reaction in the surrounding soft tissues |
Stress reaction (great oedema) in the skeleton in tuber ischiadicum. |
MRI contralateral side |
No reaction |
No reaction |
No reaction |
No reaction |
No reaction. |
Rest time |
6 days |
3 days |
5 weeks |
3 weeks |
2 weeks |
Rehabilitation |
Controlled rehabilitation 20 weeks. Stepwise return to normal physical activity |
Controlled rehabilitation 11 weeks Stepwise return to normal physical activity |
Controlled rehabilitation 4 weeks. Stepwise return to normal physical activity |
Controlled rehabilitation 9 weeks. Stepwise return to normal physical activity |
Controlled rehabilitation 7 weeks. Stepwise return to normal physical activity |
Final PE a, b |
a+b negative |
a+b negative |
a+b negative |
a+b negative |
a+b negative |
Outcome |
Back to normal sport activity |
Back to normal sport activity |
Back to normal sport activity |
Back to normal sport activity |
Back to normal sport activity |
a. Eccentric test hamstrings with hip flexion> 100 and slightly flexed knee – eccentric test with positive pain provocation recognized as a symptom bypatient
b. Pain provocation when palpating tuber ischiadicum insertion. Hamstring muscles recognized as a symptom by patient
c. In the second MRI of the TI we could see that the first injury was completely healed
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