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226 - Sacral stress fracture in a triathlete treated with extracorporeal shockwave therapy and PRP: a case report

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

KL

Kathleen LeFiles, BS

Medical Student
University of Arizona College of Medicine-Phoenix
Phoenix, Arizona, United States

Co-Author(s)

CD

Callie Davies, MD

Sports Medicine Physician
The Mayo Clinic
Phoenix, Arizona, United States
JP

Julie Pohlad, PT, D.P.T., C.H.T., SCS

Physical Therapist
The Mayo Clinic
Tempe, Arizona, United States

Corresponding Author(s)

Chris Ha, DO

Physical Medicine and Rehabilitation Physician
The Mayo Clinic
Scottsdale, Arizona, United States

Case Diagnosis: A 48-year-old male triathlete presented with 2 months of dull, pinpoint pain in the left gluteal region. There was no history of trauma. He had recently increased his training regimen for a competition. He noted concomitant weight loss prior to symptom onset. Exam revealed tenderness to palpation of the left posterior gluteal region. Hip provocative maneuvers were negative. Radiographs of the left hip and pelvis showed no fractures. Subsequent MRI confirmed a fracture in the left S1 sacral ala. A DEXA scan T-score was normal.

Case Description: Treatment included training cessation, offloading with crutches, physical therapy, extracorporeal shockwave therapy, and nutritional optimization. His pain improved and he gradually returned to training. Five months later, however, he developed recurrent left gluteal pain. A repeat MRI showed a persistent sacral ala fracture. The patient underwent repeat shockwave therapy, followed by platelet-rich plasma (PRP) injection in the left SI joint and sacral body 2 hours later. At 6-week follow-up, he noted significant pain improvement and was gradually returning to sport activities.

Discussions: Sacral stress fractures are an uncommon cause of low back and gluteal pain in high-impact or endurance athletes, with MRI as the diagnostic gold standard. While most athletes can expect full recovery with conservative treatment, prolonged recovery and risk of re-injury remains, particularly for athletes with high training demands. For this reason, there has been interest in exploring regenerative medicine treatments to accelerate healing or allow for earlier return to sport.

Conclusions: Combination therapy with platelet-rich plasma (PRP) and extracorporeal shockwave may benefit refractory sacral stress fracture pain. This is the first case report exploring this treatment paradigm for sacral stress fractures. Further investigation into the efficacy and durability of the combined use of PRP and shockwave in such cases is warranted.