16 year old soccer player. Presents to your sports clinic the day after his injury MOI: Went to kick with left foot, planted with right, and felt a pop in his right hip. He was unable to continue due to pain, and was helped off the pitch, able to weight bear but pain with walking.
Differentials? (See below for list)
Examination: Well, healthy appearing. Able to straight leg raise with lower limb in neutral extended knee and lower limb in External rotation and abduction versus resistance. Hip ROM normal and non painful with impingement tests. Nontender ASIS, AIIS. Tender over right iliac crest He points to his right side lateral to his ASIS as the source of his pain. Xray: Figure 1 – AP Pelvis – Rissers lines evident bilaterally Figure 2 – Left iliac crest – Close up of AP Pelvis Figure 3 – Close up of right Iliac crest on AP Pelvis
Discussion: The anterior 1-2/3’s of the iliac crest apophysis acts as the origin for the internal oblique muscles and to some extent the transverse abdominus. These muscles are important for trunk rotation and stability through running and kicking movements. It also acts as the insertion point for the external oblique. Inferior to the crest there are gluteus medius and tensor fascia lata origins peripherally and deep the iliacus. Iliac crest apophysitis secondary to chronic oblique traction can occur in running sports: cross country running, soccer, lacrosse etc. This is typically associated with a gradual onset. This case demonstrates an acute avulsion of the iliac crest in an upward fashion likely resulting more from the abdominal muscles. As opposed to cases where the iliac crest is tractioned inferiorly and laterally as may occur from over traction from gluteus medius or tensor fascia lata (See figure 4). Differential for iliac crest pain would include – hip pointer (bone contusion), iliac crest apophysitis, iliac crest avulsion fracture, ASIS avulsion fracture, oblique strain, iliacus strain, TFL strain, glut strain.
Figure 4 – Iliac crest Muscle Attachment Anatomy
Diagnosis: Right iliac crest apophyseal avulsion fracture
Management: Crutches, weight bearing as tolerated for first 7- 10 days. Maintain hip strength and ROM. Progression of core strengthening after 14 days. Progression to jogging weeks 3-6 as tolerated and eventually sprinting as tolerated by week 6-8 as tolerated. 6-8 weeks to return to soccer There is no current role for surgical management for this condition.
Dr. Neil Dilworth (June 3, 2018-06-13)
Coulier, B., (2015). Acute Avulsion of the Iliac Crest Apophysis in an Adolescent Indoor Soccer. Journal of the Belgian Society of Radiology . 99 ( 2 ) , pp . 20–24 . DOI: http://doi.org/10.5334/jbr-btr.876
Kjellin I, Stadnick ME, Awh MH. Orthopaedic magnetic resonance imaging challenge: apophyseal avulsions at the pelvis. Sports Health. 2010 May;2(3):247-51.