apophyses that are more susceptible to failure than the
tendonous insertion. These are usually the result of a
sudden, forceful concentric or eccentric contracture or
rapid, excessive passive lengthening. Common sites
of these avulsions about the pelvis are the insertion of
the sartorius into the anterior-superior iliac spine, the
rectus femoris superior head insertion into the ante-
rior-inferior iliac spine, and the insertion of the ham-
strings into the ischial tuberosity. These injuries are
also seen in the proximal femur with the insertion of
the hip abductors into the greater trochanter and the
insertion of the iliopsoas into the lesser trochanter.TREATMENT
- Nonsurgical management has been the mainstay of
treatment in most series with good to excellent results
reported. In the case of severe displacement of the
avulsed fragment (especially noted in avulsions of the
ischial tuberosity or the greater trochanter) surgical
intervention has been recommended; however, most
authorities do not recommend surgery for these
injuries. Metzmaker and Pappas defined a rehabilita-
tion treatment protocol for these injuries including (a)
rest, using proper positioning to unload the injured
apophysis and ice/analgesics; (b) initiation of gentile
active and passive range-of-motion excercises; (c)
progressive resistance beginning when 75% of motion
is achieved and ending when 50% of strength is
returned; (d) integration of stretching and strengthen-
ing exercises with functional activity; and (e) return to
competitive sport at 8 to 10 weeks (Metzmaker and
Pappas, 1985).
•Skeletally immature patients are also susceptible to
chronic traction injuries at these apophyses and this is
referred to as apophysitis. Apophysitis is treated con-
servatively with rest followed by functional rehabili-
tation of the involved muscle group (Busconi and
McCarthy, 1996).
STRESS FRACTURES
PELVIS
- Pelvic stress fractures should be suspected in athletes
such as long-distance runners and military recruits.
The most common site is the junction between the
ischium and inferior pubic ramus. Tenderness to pal-
pation directly over the fractured bone can be helpful
in locating the lesion. A positive standing sign has
been described in which a patient develops discomfort
in the grain while standing unsupported on the ipsilat-
eral leg. - Plain radiographic signs, such as periosteal reaction or
fracture line, can lag behind the clinical presentation
by as long as 3 weeks. Magnetic resonance imaging
and bone scan can provide an earlier diagnosis.
Tumors should at least be considered in the differen-
tial diagnosis. Treatment consists of rest with empha-
sis on protected weight-bearing, flexibility, and
aerobic nonimpact exercises such as swimming or
cycling. Return to sport can be delayed up to 6
months.FEMORALNECK- While femoral neck stress fractures are not as
common as pelvic stress fractures, if treated incor-
rectly, the results can be disastrous. Similar to pelvic
stress fractures, these present with groin pain and an
antalgic gait. Pain will be worsened by flexion and
internal rotation of the hip. Again, radiographic evi-
dence may lag behind by 3–4 weeks. Magnetic reso-
nance imaging and bone scan may be helpful in earlier
diagnosis. Two types of femoral neck stress fractures
exist. The first type is a compression side femoral
neck stress fracture. These occur in the inferior medial
aspect of the neck and usually respond to restriction to
nonweight-bearing status until radiographic evidence
of healing has occurred. The more worrisome type is
the tension side femoral neck stress fracture. This is a
transverse fracture along the superior margin of the
neck. Internal fixation is recommended for nondis-
placed fractures. Immediate closed or open reduction
and internal fixation is recommended for displaced
fractures. Fracture displacement can lead to avascular
necrosis of the femoral head (Boden and Osbahr,
2000).
OSTEITIS PUBIS- Primary osteitis pubis is caused by repetitive micro-
trauma and is difficult to treat. Most cases of osteitis
pubis are secondary, however. Retained sutures from
hernia or urogynecological repair may cause osteitis
pubis. Traumatic osteitis pubis is a fatigue fracture
involving the bony origin of the gracilis muscle at the
pubic symphysis. When the bony lesion is located at
the lower margin of the symphysis, this may be
referred to as gracilis syndrome. Endometriosis,
pelvic inflammatory disease, and tumor must also be
considered in the differential, often necessitating a
biopsy. - On physical examination, patients will have tender-
ness to palpation directly on the pubis. Although
activity may aggravate the symptoms, patients with
primary osteitis may get some relief. While the diag-
nosis is usually confirmed by magnetic resonance
imaging (MRI) or bone scan, the distinction between
338 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE