Ive ironically handled literally hundreds of sacra over the past couple of years, she says. Pain. 2015 May;23(2):84-92. doi: 10.1179/2042618613Y.0000000055. Epub 2011 Jul 25. Radiographic findings were unremarkable, but a hop test identified a sacral stress fracture. This content is imported from OpenWeb. 2022 Feb 4;13:21514593211049671. doi: 10.1177/21514593211049671. During that time, you can cross-train with non-impact activities, such as Alter-G anti-gravity treadmills, swimming, elliptical, upper-body strength training, and aqua-jogging. Insufficiency fractures occur after normal stress in bone with decreased mineralization and elastic resistance, as caused by postmenopausal osteoporosis [22]. Netelenbos JC, Van Ginkel FC, Lips P. 61. Dehdashti AR, Martin JB, Jean B, Rufenacht DA: 64. The https:// ensures that you are connecting to the Bone mineral density may be measured by a number of methods, but DEXA is considered the gold standard [49]. A strength-training program that targets your hips, pelvis, and spinal muscles supports your bones and keeps your pelvis stable, reducing stress on your sacrum. They fall under the broader group of pelvic insufficiency fractures. The sacrum is a triangular wedge-shaped bone at the inferior aspect of the spinal column that provides strength and stability to the pelvis. En zo'n test is de test met n been. More From Runner's World. Hormonal changes associated with pregnancy, such as increased levels of relaxin, cause increased ligamentous laxity. They do occur far more frequently in runners than in the general population, however. (2021) had de hoptest een gevoeligheid van 100% en een specificiteit van 45%. [23] found that sacral insufficiency fractures were present in 1.8% of female patients over age 55 admitted by physicians working in a rheumatology division. Lotan R, Hershkovich O, Bronstein Y, Finkelstein J. Geriatr Orthop Surg Rehabil. Four months later, his symptoms completely resolved and he began running again. By continuing to use this website you are giving consent to cookies being used. Pentecost RL, Murray RA, Brindley HH: 41. Bethesda, MD 20894, Web Policies This website uses cookies. sharing sensitive information, make sure youre on a federal Careers. Fatigue fractures of the sacrum were first discovered in 1989 by Volpin et al. The sacrum transmits the weight of the body to the pelvic girdle through the sacroiliac (SI) joints, and is composed of a body and two sacral ala, which form the sacral wings. University of Notre Dame (Seidel); Photo Run. 4. Epub 2020 Mar 25. The major etiologic factor in both insufficiency and fatigue fractures is stress dissipation from the vertical axis of the spine into the sacrum and sacral ala [15]. 1. J Vasc Interv Radiol. Please enable it to take advantage of the complete set of features! Sacral insufficiency fractures (SIFs) are a subtype of stress fractures, resulting from normal stress applied to a bone with reduced elasticity. The most sensitive technique for detecting fracture is a bone scan with technetium-99m medronate methylene diphosphonate (MDP). 3 . Please try after some time. In those with insufficiency type fractures in Zone 1, sacroplasty may be considered if pain is intractable and avoiding the other potential complications of prolonged bed rest is desirable. Epub 2021 Nov 2. Labor-related sacral stress fracture presenting as lower limb radicular pain. Sacral stress fractures: an unusual cause of low back pain in an athlete. Pain is particularly noticeable with impact loading and change of direction. official website and that any information you provide is encrypted Sacral stress fractures are most commonly found in female distance runners, but also have been reported in other sports such as tennis, basketball, gymnastics, volleyball, and track and field (5). Seidel majored in biological anthropology and did research on the sacrum. A large amount of pain in a localized area of the lower extremity is a positive test and may signify a fracture. Johnson AW, Weiss CB Jr, Stento K, Wheeler DL. The site is secure. A bone scan should not be performed until after 48 to 72 hours of symptom onset. 2020 Feb;123(2):162-165. doi: 10.1007/s00113-019-00742-0. Stress fractures usually arent visible on X-rays. DEXA'dual-energy x-ray absorptiometry; NSAIDs'nonsteroidal anti-inflammatory drugs; PT'physical therapy. Would you like email updates of new search results? Sports Health. West SG, Troutner JL, Backer MR, Place HM: 10. Sacral stress fractures are a relatively common occurrence and can be a debilitating source of low back pain. Patients typically report buttock pain, but also can report low back pain, groin pain, and muscle spasms. Having a concomitant pelvic fracture such as an acetabular or pubic ramus fracture has been seen in up to 25-80 % of pelvic stress fracture cases [ 42 ]. They generally occur in two distinctly different patient populations, and are of two different etiologies. Federal government websites often end in .gov or .mil. Sacral stress fractures are uncommon injuries that are associated with repetitive load-bearing activities. Yoder K, Bartsokas J, Averell K, McBride E, Long C, Cook C. J Man Manip Ther. Four types of osteoporosis that are related to pregnancy and/or lactation are currently recognized: idiopathic osteoporosis during pregnancy, transient osteoporosis of the hip during pregnancy, postpregnancy vertebral osteoporosis, and lactation-associated osteoporosis [33]. 8600 Rockville Pike Your message has been successfully sent to your colleague. J Orthop Sports Phys Ther. Hearst Magazine Media, Inc. All Rights Reserved. You can actually have an ankle fracture that develops from trying to do that, so you do not want to do that test. The reported incidence of stress fractures is less than 1% in the general population, but may be as high as 20% in runners [39]. Patients typically report buttock pain, but also can report low back pain, groin pain, and muscle spasms. Near the end of a highly successful senior yearshed just claimed her third NCAA individual title, in the 5,000 metersNotre Dame runner Molly Seidel went for a long run on a Sunday, felt a bit of glute tightness on Monday, then pulled out of a workout on Tuesday, barely able to walk. 2009 Jun;32(6):447. doi: 10.3928/01477447-20090511-24. Knee and ankle reflexes on both sides were equal and normal. 2002 Dec;13(12):1265-7. doi: 10.1016/s1051-0443(07)61976-9. Disclaimer, National Library of Medicine What Could It Be? Oral bisphosphonates may cause gastrointestinal symptoms, particularly at high doses, and this problem cannot be circumvented by giving the drugs with food because oral bisphosphonates are poorly absorbed when taken with food [49,50]. Get new journal Tables of Contents sent right to your email inbox, February 2006 - Volume 5 - Issue 1 - p 37-43, Articles in PubMed by Faisel M. Zaman, MD, Articles in Google Scholar by Faisel M. Zaman, MD, Other articles in this journal by Faisel M. Zaman, MD, by the American College of Sports Medicine. Fatigue fractures occur when an abnormal stress is placed on normal bone, such as in intense athletic training. Spine (Phila Pa 1976). Correction of risk factors: pelvic obliquity, core strength, and presence of female athlete triad (4,5) (Figure). Once youre ready to start running again, ease in slowly with a walk-run program and gradually increase your mileage over a period of six weeks to three months. The female athlete triad, in addition to mechanical overload, is an important etiologic component in the development of sacral fatigue fractures in women [40]. Careers. By continuing to use this website you are giving consent to cookies being used. Its name is derived from the Latin meaning sacred bone. Volgens een studie van Milgrom et al. Cindy specializes in covering injury prevention and recovery, everyday athletes accomplishing extraordinary things, and the active community in her beloved Chicago, where winter forges deep bonds between those brave enough to train through it. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2020;6(4):132-136. doi: 10.20407/fmj.2019-021. First known article documenting stress fractures as a clinical entity. You might also do whats called the hop testjump up and down a few times on the injured leg. Diagnostic Accuracy: Unknown. Before Two had continual pain relief at 12-week follow-up, and the third patient was lost to follow-up. Unfortunately, the increased uptake pattern that is often seen in normal SI joints may obscure a subtle sacral fracture and contributes to the low specificity of bone scanning. Sacral stress fracture in a marathon runner. Article discusses potential greater complications associated with bed rest than early ambulation in treating sacral insufficiency fractures in the elderly. The clinical presentation of sacral stress fractures commonly involves complaints of severe buttock, low back, hip, groin, and/or pelvic pain. Is there an epidemic among elite runners? You might be experiencing pain in your buttock or lower back area, and it may even feel like it's coming from your sacroiliac joint. Plain radiographs, bone scan, CT, and MRI may all help to confirm the diagnosis of sacral stress fracture. Although sacral foramina are visible on fluoroscopy, they may not be visualized completely at all C-arm angles, and extreme caution should be used. MeSH It sits between the two Iliac bones of the pelvis - helping to distribute weight from the spine into the legs and feet. Heres what you need to know about identifying, recovering from, and preventing them. Vail points out these injuries may also seem more common because elites share information about their setbacks and recoveries on social media. Pommersheim W, Huang-Hellinger F, Baker M. Current Sports Medicine Reports5(1):37-43, February 2006. Data is temporarily unavailable. When pain has diminished, you may undertake low impact activities such as swimming and cycling to avoid . Di Gregorio S, Danilowicz K, Rubin Z, Mautalen C: 29. Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance. Sacroplasty: a new treatment for sacral insufficiency fracture. For more information, please refer to our Privacy Policy. Finiels P-J, Finiels H, Strubel D, Jacquot J-M: 5. This occurs secondary to the biomechanical stress placed upon the sacrum, which is greatest parallel to the axial load vectors transmitted down through spine at the lateral borders of the vertebral bodies. Orthopedics. Nonsteroidal anti-inflammatory drugs (NSAIDs) should generally be avoided for at least 3 to 4 weeks due to their potentially detrimental effect on bone healing. Resolution of symptoms from sacral insufficiency fractures may require a period as long as 12 months [60]. These fractures primarily occur in women and the mean age of involvement is 71 years [23]. Fatigue sacral fractures: A case series and literature review. Typically, SIFs are associated with an underlying metabolic bone disease condition such as osteoporosis or Paget's disease and are most common in elderly women.. During the gait, alternating flexion and extension of the lower limbs would impart . Just as tibial stress fractures were once written off as shin splints and femoral stress fractures as hip flexor strains, doctors now recognize that injuries they may have once attributed to SI joint dysfunction actually involve the bone, says Dr. Vincent, who just published a brief clinical update on the topic in Current Sports Medicine Reports. A basic framework for consideration when treating sacral stress fractures may be found in Figure 1. This website uses cookies. Less characteristic patterns may also be seen, such as unilateral uptake patterns. Historically, bed rest has been an integral part of treatment for sacral insufficiency fractures [59], and its associated sequelae of deconditioning, decubeti, depression, pulmonary embolus and other issues often ensue. .css-1ck2l7d{display:block;font-family:Sailec,Helvetica,Arial,sans-serif;font-weight:bold;margin-bottom:0;margin-top:0;-webkit-text-decoration:none;text-decoration:none;}@media (any-hover: hover){.css-1ck2l7d:hover{color:link-hover;}}@media(max-width: 48rem){.css-1ck2l7d{font-size:1rem;line-height:1.4;}}@media(min-width: 40.625rem){.css-1ck2l7d{font-size:1rem;line-height:1.4;}}@media(min-width: 48rem){.css-1ck2l7d{font-size:1rem;line-height:1.4;}}@media(min-width: 64rem){.css-1ck2l7d{font-size:1.2rem;line-height:1.4;}}.css-1ck2l7d h2 span:hover{color:#CDCDCD;}One Year to Go for Runners to OTQ, Nearly 1,000 Six Star Medal Winners in 2022. Epub 2019 Jul 2. My sacral stress fracture was completely clear (no marrow edema) after 8 weeks . Although conservative management strategies have resulted in good outcomes, other treatment options have recently developed. Citation, DOI & article data. Nonselective COX inhibitors such as ketorolac have been shown to have a greater effect than the selective COX-II medications [54]. Rawlings CE, Wilkins RH, Martinez S, Wilkinson RH: 51. 2022 Sep 1;22(3):385-392. 'XX'-Sacroplasty: A Novel Technique for Management of "H-Type" Sacral Insufficiency Fractures. Ortho InfoAmerican Academy of Orthopaedic Surgeons website. For older individuals, experiencing frequent low back pain could turn out to be a sacral fracture. In summary, in certain patient populations presenting with low back and buttock pain, physicians should have a high index of suspicion for sacral stress fractures, and treatment should be individualized. Still, she didnt realize quite how common sacral fractures were among runners until she developed one. Test Position: Standing. From there, it may take between six and eight weeks for the bone to heal, depending on the severity of the fracture, Dr. Vincent says. Any changes to your training, such as a rapid increase in mileage, too many speedwork sessions, or a shift in surface (say, treadmill to roads) can also cause your body to fall behind in skeletal repair. The vast majority of sacral insufficiency fractures occur in Zone 1. Stress fractures comprise up to 20% of athletic injuries; and 80% of stress fractures occur in the lower limb. Disclaimer, National Library of Medicine What do they feel like? Get new journal Tables of Contents sent right to your email inbox, March/April 2016 - Volume 15 - Issue 2 - p 73. The distinct etiologies of these two types of stress fractures dictate the different treatment strategies that are to be employed. Unlike muscle or tendon pains that might loosen or ease when you move, pain from a sacral fracture usually intensifies during a run, lingers afterward, and progressively worsens over time until you feel it when you walk, sit, or sleep. People usually give you a really sharp ow when you push on the bone, Dr. Vincent says. In 1989, Volpin et al [1] reported the first series of three sacral stress fractures from a group of 257 fractures in 194 of 380 Israeli army recruits. A Plantaris Muscle Injury, Pelvic Pain from Running, Rhabdomyolysis from Spinning, and Leukopenia in Athletes, Concussion in the Absence of Head Impact: A Case in a Collegiate Hammer Thrower, Common Injuries and Medical Problems in Singles Figure Skaters, Barefoot Running: Biomechanics and Implications for Running Injuries, by the American College of Sports Medicine, Most commonly found in female distance runners, Presence at anteroinferior sacral wing may mimic sacroiliitis, Involvement of anterior sacral foramina may mimic lumbar radiculopathy (, Index of suspicion should increase in patients being treated for back pain who are failing to respond to conservative care (. Avoiding the types of training and nutrition errors that raise your risk for sacral stress fractures can help ward them off, Dr. Vincent says. SI joint-provocative maneuvers such as Gaenslen's, Yeoman's, and Patrick's tests, may also be positive, although these are not specific for sacral fracture, or for SI joint syndrome for that matter [42,43]. The clinical presentation of sacral stress fractures commonly involves complaints of severe buttock, low back, hip, groin, and/or pelvic pain. Other NSAIDs such as diclofenac have also been shown to delay fracture healing [56]. Unable to load your collection due to an error, Unable to load your delegates due to an error. Rousiere M, Kahan A, Job-Deslandre C: 31. Insufficiency fractures are stress fractures that occur when normal stress is placed on a bone of abnormally decreased density, as in elderly osteoporotic patients. Adequate pain management strategies must be pursued for those with sacral stress fractures. Bethesda, MD 20894, Web Policies Ones that are high risk though are tibial stress fractures at the end of your tibia, by the ankle. MRI Skeletal Radiol (2003) 32:590-593 DOI 10.1007/s00256-003-0662-9 CASE REPORT Anthony Aylwin Asif Saifuddin Stuart Tucker L5 radiculopathy due to sacral stress fracture Introduction Stress fractures of the sacrum are a rare but well-docu-mented cause of low back pain, occurring . It has been demonstrated that in the spine, bone mineral density decreases from prepregnancy to the immediate postpartum period by a mean of 3.5% [34]. eCollection 2022. Straight leg raise test was negative on both sides. Because the structure of the pelvis is that of a closed ring, when part of the ring is disrupted, undue forces are transmitted to other parts of the ring. Since 2000, there have been two further publications on the success of percutaneous sacroplasty for treatment of these fractures [63,64]. Multiple etiologies have been identified for the development of sacral stress fractures. Differential diagnosis of a sacral stress fracture. Current Sports Medicine Reports15(2):73, March/April 2016. To avoid these pitfalls, sacroplasty should only be performed on fractures in Zone 1, and sacroplasty trocars should only be placed in Zone 1 (Denis classification). Occasionally a transient flu-like febrile illness may be seen with use of these medications as well [5153]. It has been estimated that pelvic stress fractures account for 1-7 % of all stress fractures [ 40 ]. Fractures of each zone have their own characteristic clinical presentation. You may be able to find the same content in another format, or you may be able to find more information, at their web site. Their MRIs reveled the same diagnosis: a sacral stress fracture, or a hairline crack in the large, triangle-shaped bone at the base of the spine. (2021) le test du houblon avait une sensibilit de 100% et une spcificit de 45%. And stretching to keep your hamstrings, quadriceps, hip, and glute muscles flexible also decreases the pressure on your SI joint, sacrum, and spine. Can you prevent them? 6,10 More specifically, femoral stress fractures account for 6.6% of all stress fractures, and pelvic stress fractures account for 1.6%. Oral medications, various physical therapy modalities such as heat, gentle massage, and electrical stimulation, as well as a new technique termed sacroplasty may be indicated in certain patients. Sacral stress fractures are uncommon injuries that are associated with repetitive load-bearing activities. Shah MK, Stewart GW. If you are having pain in the lower back, there are many possible causes. And though it may seem personal or irrelevant, theyll also ask women about menstrual cycles. If you feel pain when landing, thats a red flag for a stress fracture. Repetitive microtrauma induces an attempt at bone remodeling; however, the repeated cyclic stress leads to increased rates of osteoclastic activity, in association with increased osteoblastic activity of new bone. Sacral insufficiency-type fractures are seen in elderly osteoporotic persons, and fatigue fractures are seen young active individuals. Similar to other reports of stress fractures in runners, most of the . So if your symptoms and history align to suggest a sacral stress fracture, your doctor may order an MRI to verify the diagnosis. Data is temporarily unavailable. The .gov means its official. An atypical cause of low back pain in the female athlete. . 5. Because of this crucial role in weight/force transference, it can be vulnerable to damage. Characterized by pain with single-leg hop; tenderness to palpation of the sacrum; positive flexion, abduction, and external rotation tests; negative straight leg raise; and normal neurologic examination. Since that time, 11 case reports [2-15] have documented sacral stress fractures in athletes, mostly in distance runners. For more information, please refer to our Privacy Policy. An H-shaped, or butterfly uptake pattern called the Honda sign [45] may be seen on bone scan signifying bilateral vertical sacral fractures associated with a transverse fracture [46]. Comprehensive Return to Competitive Distance Running: A Clinical Commentary. Although uncommon, radicular symptoms may result, with approximately 2% of osteoporotic fractures causing lumbosacral nerve root compromise [3]. Plain films, although considered inadequate for diagnosis, are usually the initial diagnostic imaging modality, and rule out other more common entities such as lumbar spine pathology. And because the symptoms mimic so many other common injuries, theyre often missed or misdiagnosed. This is considered pathognomonic for sacral insufficiency fracture. Ketorolac also decreases bone mineralization and endochondral ossification in a dose-dependent manner [55]. Symptoms of a sacral stress fracture most commonly include back and buttock pain, and pain with activities such as running. Pain in any one of these areas may predominate. Despite the string of cases among elites, sacral stress fractures remain relatively rare, striking an estimated 1 to 4 percent of runners, says Kevin Vincent, M.D., Ph.D., director of the University of Florida Running Medicine Clinic. Please try again soon. Wolters Kluwer Health First and foremost, treatment involves taking pressure off the boneand that means no running. Garant [63] reported immediate pain relief, and continued 100% relief at 9 months. In those with fatigue-type fractures, relative rest (46 weeks [58]) with activity modification and cessation of the offending event is of utmost importance in preventing progression and to allow for fracture healing. Unable to load your collection due to an error, Unable to load your delegates due to an error. In many cases, a laboratory work-up is warranted to evaluate for causes of osteoporosis (Table 2). The patient was instructed to stop running and to take calcium and vitamin D supplements. to maintaining your privacy and will not share your personal information without HHS Vulnerability Disclosure, Help Although the clinical presentation of these fractures is similar, medical rehabilitation and interventional spine management strategies differ according to etiology. Fredericson M, Salamancha L, Beaulieu C. Sacral stress fractures: tracking down nonspecific pain in runners. What is the rehab like? We earn a commission for products purchased through some links in this article. 6. sharing sensitive information, make sure youre on a federal Increase your mileage or change running surfaces gradually, fuel your training wisely, and pay attention to calcium and vitamin D levels, he recommends. In those with a dramatic decrease in functional ability and quality of life, sacroplasty may be considered to obviate the potential risks associated with bed rest. Physical examination usually reveals a limited low back range of motion [41]. They tend to occur in individuals over the age of 60 often because there has been a degree of bone loss. Sacral fractures tend not to be the first thing doctors think of when low back pain symptoms are presenting. FOIA The authors describe a 23-year-old male cross-country runner who presented with low back and buttocks pain. The authors describe a 23-year-old male cross-country runner who presented with low back and buttocks pain. Pubic tenderness may be found in patients with an associated pubic ramus fracture. Stress fractures. Sacral stress fractures in a sprint and throw athlete a case report. Sacral stress fractures usually occur in a vertical fashion [2], parallel to the SI joint, and in line with the lateral margins of the lumbar vertebrae. and transmitted securely. Please enable it to take advantage of the complete set of features! Sacral stress fractures occur more easily in people with bones weakened by osteoporosis, osteopenia, or nutrition problems, including deficiencies in calcium and vitamin D. These conditions are more common among older women, but affect other runners, too28-year-old Ritchie, for instance, says his bone density scores were low enough to quality him as having osteopenia. In one study, the earlier indomethacin was resumed postoperatively, the greater was its negative effect on intertransverse process arthrodesis [57]. Pain in any one of these areas may predominate. Five months post-fracture, Grunewald hit the 5K Olympic standard with a 15:19 at the Portland Track Festival. Weak muscles in the hips and core pass more of the impact of running along to bones, potentially overloading them. Newhouse et al. Weber et al. Some error has occurred while processing your request. An official website of the United States government. Similar to vertebroplasty, this percutaneous technique involves puncture of the sacrum and injection of polymethylmethacrylate (PMMA) cement for treatment of painful insufficiency fractures. An algorithmic approach to sacral stress fractures. Unfortunately this test is not specific. Fatigue-type sacral fractures generally occur in a much younger, active population, when compared with insufficiency fractures, and the mean age that is reported is someone in their 20s or 30s. Usually, with a period of rest, the symptoms will resolve. Because of lack of familiarity with this clinical entity, and low clinical suspicion, the majority of sacral insufficiency fractures are likely to go undiagnosed [24]. This article provides an overview of the clinical presentation, pathology, and treatment options for sacral stress fractures and discusses some of the recent literature surrounding this interesting topic. It goes to show that you can come back more healthy, more fit, and more motivated to achieve your goals, so it could be a blessing in disguise, he says. These High School Girls Have Run Sub-4:40 Miles, 2022 USATF Road Marathon Championships Results, Olympic 5K Champ Murray Halberg Dies at 89, Eliud Kipchoge to Run the 127th Boston Marathon, ESPNs Stephen A. Smith Jogs Into Work Late, Florida Woman Stopped From Driving into Runners. Sacral fatigue fracture in a young girl with no history of trauma or reported athletic activity: a case report. Beit Ner E, Rabau O, Dosani S, Hazan U, Anekstein Y, Smorgick Y. Eur Spine J. Risk factors of stress fractures due to the female athlete triad: Differences in teens and twenties. Sacral stress fractures can be particularly difficult to recognize and diagnose. Miletic D, Sestan B, Pusic M, Cicvari T, Tudor A, Roth S, Santic V. Eur J Phys Rehabil Med. I was able to pass the hop test after maybe 6-7 weeks without issue, something I couldn't do in the beginning. Both when cross-training and returning to running, proceed with pain as your guide: if you experience more than a mild discomfort or pain that worsens during your activity, lingers afterward, or causes you to alter your gait, youre overdoing it, Dr. Vincent says. If thats the case, any runner with a sacral stress fracture should derive hope from the elites comeback stories. Oral contraceptives should be used in those with the female athlete triad to regulate menstruation. Bookshelf Sacral stress fractures are a relatively common occurrence and can be a debilitating source of low back pain. Federal government websites often end in .gov or .mil. Tim Ritchie, a Boston College assistant coach and Olympic marathon trials runner, recalls tightness in his lower back during a fartlek workout in September 2014. Sacral fractures associated with pregnancy and lactation have also been described [2732]. These medications act by inhibiting the cyclooxygenase (COX) enzymes and thus decreasing the production of prostaglandins. Not eating enough calories in general or protein in particular robs your body of the raw materials needed to build new bone. The clinical presentation of fatigue stress fractures was first described by Breithaupt. Cycling works, too; try a recumbent bike if sitting upright irritates your sacrum. Unless female patients of childbearing age are found to have osteopenia or osteoporosis, those with fatigue fractures should not use the bisphosphonates due to the side-effect profile of these medications. Of three cases reported by Pommersheim et al. Initially, mobilization should be undertaken with assistive devices such as rolling walkers, as a fall may lead to drastic consequences. This site needs JavaScript to work properly. Risk factors for sacral insufficiency fractures, Laboratory studies to consider in select patients with sacral stress fractures. Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O. Curr Pain Headache Rep. 2020 Feb 17;24(3):10. doi: 10.1007/s11916-020-0848-z. Hegedus EJ, Ickes L, Jakobs F, Ford KR, Smoliga JM. Breuil V, Brocq O, Euller-Ziegler L, Grimaud A: 37. official website and that any information you provide is encrypted Stress fractures of the sacrum and lower extremity. In addition to weight gain, hyperlordosis [19], and osteopenia caused by increased levels of prolactin, pregnant women are predisposed to fracture [35]. Others have also published similar findings [25,26]. If walking causes pain, your doctor may put you on crutches for a week or two until it subsides. During this period, anti-inflammatory medication such as ibuprofen can be used to treat pain. Sacral insufficiency fractures were first described by Lourie [21] who reported three elderly patients with incapacitating back and leg pain who were found to have spontaneous osteoporotic fractures of the sacrum. Sacral stress fractures are most commonly found in female distance runners, but also have been reported in other sports such as tennis, basketball, gymnastics, volleyball, and track and field ( 5 ). What are sacral stress fractures, and what causes them? Accessibility However, the presence of this triad is not requisite for the development of a fracture in a young woman [18]. Even runners with normal bone density can disrupt the balance of stress and recovery enough to develop sacral stress fractures. Newhouse KE, El-Khoury GY, Buckwalter JA: 22. Clipboard, Search History, and several other advanced features are temporarily unavailable. Stress fractures occur when bone fails to withstand submaximal repetitive forces over time, and are divided into two types, insufficiency fractures and fatigue fractures. Please try again soon. 1994 Sep 15;19(18):2117-21. doi: 10.1097/00007632-199409150-00021. Sacroplasty is an attractive treatment because it may provide faster symptomatic relief in selected patients than standard conservative medical management. 2003 Nov;12(9):879-88. doi: 10.1089/154099903770948104. to maintaining your privacy and will not share your personal information without doi: 10.1097/01.csmr.0000306517.25172.68. Sacral insufficiency-type fractures are seen in elderly osteoporotic persons, and fatigue fractures are seen young active individuals. Scand J Med Sci Sports. In the early stages of management, adequate control of pain relief with NSAIDs drugs, such as ibuprofen, . The authors also present a review of the literature, which revealed that patients with sacral stress fractures are likely to have normal neurologic examinations and full active range of motions. It can visualize lower grade stress injuries (stress reactions) before an X-ray shows changes. Sacral stress fractures commonly present with an insidious onset of vague low back, buttock and/or pelvic pain (1,2). It has been divided into three zones by Denis et al. Further excessive stresses may lead to transverse sacral fracture formation. Following fracture healing, successful completion of a SLH. Oral bisphosphonates approved for prevention and treatment of osteoporosis include alendronate and risedronate. 1996 Mar;8(2):158-62. doi: 10.1097/00002281-199603000-00012. [Sacral stress fracture in arecreational long-distance runner]. Like Seidel, many runners first feel discomfort they mistake for a strained glute muscle. Fujita Med J. So if you think you have shin splints and you're poking around and you have pain around your ankle, you should never do the hop test. Physical therapy can help detect, and correct, underlying weaknesses and biomechanical deficiencies that contributed, Dr. Weber says. Marchinkow A, Mallinson PI, Coupal T, et al. Differentiating these fracture types facilitates appropriate medical management, rehabilitation, and interventional strategies to be employed, thus yielding optimal functional outcomes. The year after her second sacral fracture, Infeld won bronze in the 10,000 meters at the IAAF World Championships in Beijing. In 1895, the advent of radiography helped to diagnose metatarsal fracture as the cause of these painful symptoms [37]. Stress fractures of the sacrum. In most patients with sacral insufficiency fractures, early mobilization is not contraindicated, and moderate weight-bearing exercises should be performed as tolerated [60]. The differential diagnosis of sacral stress fractures includes internal disk disruption syndrome, herniated nucleus pulposus, vertebral compression fractures, facet arthropathy, trochanteric bursitis, sacroiliitis, neoplasm, gluteal and proximal hamstring muscle strains, ischial tuberosity bursitis, septic sacroiliitis, gluteal bursitis, intrapelvic or intra-abdominal process, spondyloarthropathy, and spondylolisthesis. West SG, Troutner JL, Baker MR, Place HM. An official website of the United States government. "The most common causes are poor sitting posture, muscle weakness or tightness, strain of the ligaments, and joint inflammation ," says Dr. Mathew. Dr. Vincent calls sacral stress fractures masqueraders because the pain they produce mimics that caused by other conditions, including sacroiliac or SI joint dysfunction. Coronal views can assist with assessment of the extent and location of the fracture and also visualize the neuroforamina. Zone 2 is the region involving the sacral foramina, and fractures in this area do not impinge on the central sacral canal. eCollection 2020. Tsatsaragkou A, Vlasis K, Raptis K, Zafeiris E, Mari A, Alpantaki K, Koutserimpas C. J Musculoskelet Neuronal Interact. Your doctor should take a thorough history, asking about your mileage, changes to your training, and other risk factors. In patients with insufficiency fractures, the typical history involves minimal or no trauma. Shes the coauthor of both Breakthrough Womens Running: Dream Big and Train Smart and Rebound: Train Your Mind to Bounce Back Stronger from Sports Injuries, a book about the psychology of sports injury from Bloomsbury Sport. Unusual consecutive sacral stress fractures in a female distant runner: a case report. Go to a medical professional if you have lingering pain in this area. Because sacral stress fractures can occur as a result of the female athlete triad, screening for prior history of eating disorder is important. Performing the Test: Have the patient hop up and down on the affected limb several times barefoot. Depending on the underlying cause of your fracture, your doctor might also recommend consulting other health professionals, such as a nutritionist or endocrinologist. De Smet and Neff [25] suggested that the initial biomechanical failure may occur in the sacrum, leading to subsequent pubic rami fractures. One should note body mass, menstrual history, and presence of disordered eating patterns and perform bone mineral density studies using dual-energy x-ray absorptiometry (DEXA) in those patients in whom the suspicion of eating disorder is high. Abstract. De hoptest is dus zeer doeltreffend als screeningtest om tibiale stressfracturen uit te sluiten. Despite the string of cases among elites, sacral stress fractures remain relatively rare, striking an estimated 1 to 4 percent of runners, says Kevin Vincent, M.D., Ph.D . In patients with fatigue fractures, there may be insidious pain, with low back, buttock, or pelvic pain predominating. Questions about risk factors for sacral stress fractures such as presence of cancer, pelvic irradiation, eating disorder, or amenorrhea are equally important. Pamidronate and zoledronate are intravenous bisphosphonates that are rarely used off-label. L'tude de Milgrom tant le seul article valuant ce test ce jour, nous lui attribuons une valeur . Epub 2006 Aug 12. Article discusses cases of fatigue fractures that occurred in nearly equal male to female ratio. The basis behind application of PMMA across a stress fracture is that mechanical stabilization and painful micromotion may be prevented [65]. government site. Gradual resumption of activities is important to prevent a recurrence. Bookshelf Selon une tude de Milgrom et al. Address for correspondence: Kevin R. Vincent, MD, PhD, FACSM, University of Florida, 3450 Hull Road, Gainesville, FL 32608; E-mail: [emailprotected]. However, they will likely describe discomfort with passive hip flexion. Thus, sacral insufficiency fractures are often associated with coexisting pubic ramus fractures. An MRI is considered the best way to diagnose stress fractures. 2022 Jan;31(1):1-9. doi: 10.1007/s00586-021-07043-4. and transmitted securely. Two types of sacral stress fractures exist, namely insufficiency type and fatigue type, both with different etiologies, and management strategies. [64], all were pain free immediately. What are the signs and symptoms of a sacral fracture? Lourie [21] considered the hallmark physical finding to be marked tenderness to palpation over the sacrum. You may be trying to access this site from a secured browser on the server. Vail believes favoring his right foot after recovering from a stress fracture there put more strain on his back. Fractures in this area can, however, affect the exiting lumbosacral nerve roots. The most common pelvic bone to be fractured is the inferior pubic ramus [ 41 ]. Sex is less of a differentiating factor with fatigue fractures when compared with insufficiency fractures, which occur predominantly in women. 2019 Sep/Oct;11(5):446-452. doi: 10.1177/1941738119854763. This site needs JavaScript to work properly. test pelvic ring stability by internally and externally rotating iliac wings. This type of test is also better able to distinguish between stress fractures . As well, early mobilization can decrease the complication rate. soft tissue trauma around pelvis should raise concerns for pelvic or sacral fracture. may email you for journal alerts and information, but is committed Purpose: To assess for a fracture in the LE. Cindy is a freelance health and fitness writer, author, and podcaster whos contributed regularly to Runners World since 2013. The site is secure. When evaluating any patient with a potential sacral stress fracture, it is critical to ask specific questions about recent alterations in activity level such as intensity, duration, and frequency. Your message has been successfully sent to your colleague. Sacral Fracture. Aquatic therapy may also be considered to aid mobilization in those with weight-bearingassociated pain. your express consent. Before 2012 Jun;48(2):283-7. Although conservative management strategies have resulted in good outcomes, other treatment options have recently developed. AME Case Rep. 2020 Oct 30;4:27. doi: 10.21037/acr-20-41. PMC 2021 Dec;51(12):2507-2523. doi: 10.1007/s40279-021-01547-1. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. This article provides an overview of the clinical presentation, pathology, and treatment options for sacral stress fractures and discusses some of the recent literature surrounding this interesting topic. But she and Dr. Vincent both say they suspect any increase is due to better diagnosis rather than increasing incidence. The .gov means its official. Harris, Charles E. III BS; Vincent, Heather K. PhD, FACSM; Vincent, Kevin R. MD, PhD, FACSM, 1Rosalind Franklin University of Medicine and Science, Chicago, IL; and 2University of Florida, Gainesville, FL. Other contributing factors include leg length discrepancy [16], repetitive stresses [17,18], progressive insufficiency of supporting muscles [19,20], changes in physical demands, environmental and genetic influences, training methods, footwear [17], training intensity, frequency, and duration, and increased sacral stresses resulting from pelvic anteversion, which is greater by 2.25 in women than men. 2019; 29: 1501- 1510. If a sacral stress fracture is found, treatment regimens should consist of 4 to 6 weeks of rest with gradual return to activity. The SLH test is particularly helpful in the assessment of forefoot, midfoot, tibial, fibular, femoral, and sacral dysfunction. Poor general nutrition and inadequate maternal calcium also may play a role in fracture formation [28]. Weight bearing as tolerated until able to ambulate without pain (10 to 14 d). Bone scan with single-photon emission CT (SPECT) may also aid in identification and localization of a fracture. government site. Irregular or stopped periods are one component of whats called the female athlete triad, a cluster of conditions that also includes disordered eating and low bone density that leaves women prone to stress fractures. (Grunewald says she spent most of January at her parents winter home in Arizona so she could do workouts in an outdoor pool.) Accessibility You may be trying to access this site from a secured browser on the server. Ignoring it most times doesnt make it go away.. They generally occur in two distinctly different patient populations, and are of two different etiologies. The sacral stress fracture mainly requires a period of full rest from activity that causes pain or places strain on the pelvis or spinal column. Patients with fractures of Zone 3, which is the region of the central sacral canal, often present with saddle anesthesia and loss of sphincter tone. CT scanning, which is known to give the best visualization of bone, can be used to confirm and complement a positive bone scan. Sacroiliitis, spondylolysis (pars defect), piriformis pain, sacroiliac joint dysfunction, back strain, radiculopathy, scoliosis, juvenile disc disorder, Scheuermanns kyphosis (1,4). Sacral insufficiency fractures in rheumatoid arthritis. The most common symptom associated with nerve root compromise is sphincter dysfunction and lower limb paresthesias [3]. Although uncommon, sacral stress fractures should be suspected in athletes, particularly female runners presenting with low back or buttock pain (24,6). Balloon kyphoplasty has also been used with success for sacral stress fractures. Grunewald agrees: I didnt want to spend those hours in the pool, but they helped me remind myself how invested I am in my training and gave me the opportunity to learn something, she says. [38]. Knobloch K, Schreibmueller L, Jagodzinski M. Rapid rehabilitation programme following sacral stress fracture in a long-distance running female athlete. Sacral insufficiency-type fractures are seen in elderly osteoporotic persons, and fatigue fractures are seen young . As well, the physician must be aware of the potentially grave risks of medial cement migration and possible compromise of the sacral foramen and exiting sacral nerve roots and the sacral spinal canal. [1], and fractures of each zone have their own characteristic clinical presentation. MeSH Le test du houblon est donc trs efficace comme test de dpistage pour exclure les fractures de stress du tibia. Gotis-Graham I, McGuigan L, Diamond T. 13. Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Because no national database tracks all running injuries, Dr. Weber says she cant say definitively whether sacral stress fractures are more common than they used to be. Sometimes it can be bad at night time, and other times, you might just be 'aware' of a sensation there. A pilonidal cyst or an anal fissure can also cause pain in the area. Grunewald says a speedier-than-normal buildup in the late fall probably played a large role in her fracture. 3. First article documenting sacral fatigue fractures. 2. Please try after some time. Theyre just two of many high-profile runners to develop them in recent years, including marathoners .css-1hr08dr{-webkit-text-decoration:underline;text-decoration:underline;text-decoration-thickness:0.125rem;text-decoration-color:#59E7ED;text-underline-offset:0.25rem;color:inherit;-webkit-transition:all 0.3s ease-in-out;transition:all 0.3s ease-in-out;}.css-1hr08dr:hover{color:#595959;text-decoration-color:border-link-body-hover;}Kara Goucher and Ryan Vail, 10,000-meter runner Emily Infeld (who has had two), steeplechaser Emma Coburn, and 3,000- and 5,000-meter runner Gabriele Gabe Grunewald. X-rays commonly negative, typically visualized with MRI and CT scan. Hop Test. Schmid L, Pfirrmann C, Hess T, Schlumpf U: 28. And the year after his fracture, Ritchie set personal records in every event from the 5K to the half marathon, running a 1:01:23 in the Rock n Roll Philadelphia Half Marathon last November. Epub 2021 Sep 3. Fat suppression and inversion recovery sequences can greatly enhance its sensitivity in detecting bone marrow edema, suggestive of acute fracture. 1. Others report pain in the low back, groin, or hip. Sacral insufficiency fractures in an already-infirm elderly population may potentially result in dramatic functional impairment with a profound affect on quality of life. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. PMC Risk factors associated with sacral stress fractures: a systematic review. Stress fractures usually happen over time, so you are given signals, Dr. Weber says. After that, he or she will check the muscles, joints, and bones in your hips and back and put pressure directly on your sacrum. What should you do if you think you have one? Low back, buttock, or hip pain Pain in the front of your thigh and your groin Bruising and swelling around the sacral area Bowel or bladder conditions, sexual problems, or weakness of the lower limbs How is a sacral fracture diagnosed? Treatment must include resting from activities that cause pain. Diagnosing a Sacral Fracture. Pregnancy has been associated with hyperparathyroidism. And lingering gait changes from past injuries can alter your mechanics in potentially harmful ways. This can result in diminished bone formation, healing, and remodeling. Those with sacral stress fractures should be on 1200 to 1500 mg calcium and 400 to 800 IU vitamin D supplementation daily. In patients with fatigue fractures, there may be insidious pain, with low back, buttock, or pelvic pain predominating. MRI is considered by some to be the examination of first choice due to its high sensitivity and specificity [47,48]. As with any stress fracture, tiny cracks in the sacrum form when forces applied to them overwhelm your bodys ability to absorb the shock or remodel the tissue, says Kathleen Weber, M.D., director of womens sports medicine at Midwest Orthopaedics at Rush in Chicago. 3. X-rays may be checked for broken bones or other problems. Sacral Stress Fractures: They See You, But Are You Seeing Them? Although the clinical presentation of these fractures is similar, medical rehabilitation and interventional spine management strategies differ according to etiology. Though the injury remains relatively rare, it has affected many elite athletes and can require two months or more off running. Join This Instagram Live AMA With the RW+ Coaches! 2002 Dec;32(12):613-21. doi: 10.2519/jospt.2002.32.12.613. You can come back from it, is my main takeaway.. Sacral stress fractures is not a very common injury, but can often go undiagnosed because the symptoms can feel very similar to that of lower back pain or gl. palpation. Features of sacral alar fatigue fractures in adolescent athletes with overuse. Curr Sports Med Rep. 2007 Jan;6(1):39-42. doi: 10.1007/s11932-007-0010-2. We as runners try to avoid those signals or blame them on a workout that we did, but when those signals are continuing or they are progressively getting worse, it's telling you somethings wrong. 1 Articles in PubMed by Charles E. Harris, III, BS, Articles in Google Scholar by Charles E. Harris, III, BS, Other articles in this journal by Charles E. Harris, III, BS, It is NOT the Gastrocnemius, Soleus, or Achilles . All mention excellent outcomes. Nonimpact cross-training for 6 to 8 wk, then resumption of running or impact activity. You might think of your skeleton as a solid, unchanging structure, but bones undergo a continuous cycle of breakdown and repair. MRI is typically the diagnostic study of choice to confirm a sacral stress fracture. The only paper on this subject involved three patients, all of whom were left with some residual pain at 6 months, but had visual analogue scale improvements of four points [66]. Sacral fatigue fractures occur when abnormal stresses are applied to normal bone, and are typically seen in long-distance runners and those that engage in regular repetitive weight-bearing exercises for prolonged periods, such as military recruits. As well, those with insufficiency type stress fractures should have a bisphosphonate and calcitonin in their medication profile. Rapid rehabilitation programme following sacral stress fracture in a long-distance running female athlete. Sacroplasty is a new technique first described 5 years ago for treatment of symptomatic metastasis to the sacrum [61,62]. Bovendien kunnen orthopedische tests worden gebruikt om de diagnose te helpen stellen. You might also feel pain radiating down to your knee or your foot if the fracture irritates a nerve, Dr. Vincent says. your express consent. In the majority of cases, the neurologic examination is completely normal, except for the rare case with lumbosacral nerve root or cauda equina compression, in which dural tension maneuvers are positive [44]. He blogs about the ups and downs of his own training at ryanvail.blogspot.com, saying he hopes doing so reveals the similarities between runners at all levels. Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management. The https:// ensures that you are connecting to the FOIA There was no distinct motor or sensory deficit in her lower extremities. That same lack of strength or faulty firing patterns in your hips and glutes allows your pelvis to shift or drop when youre running; your sacrum can eventually crack under the shear stress this wobbling creates, Dr. Vincent says. Would you like email updates of new search results? First published report of kyphoplasty to treat sacral insufficiency fractures. 4 The incidence of sacral stress fracture is unknown. Radiographic findings were unremarkable, but a hop test identified a sacral stress fracture. 8600 Rockville Pike Sports Med. J Womens Health (Larchmt). Fractures in this region have the highest incidence of cauda equina injury. After an easy eight-miler the next day, he was hobbled by what he describes as the most pain Ive had, running-related.. Fragility fracture of pelvis caused by amenorrheic osteoporosis operated upon using computed-tomography-3D-fluoroscopy matching navigation system: a case report. Please enable scripts and reload this page. Increased alkaline phosphatase may be seen in many cases. [13] found that 59% of patients with an occult sacral fracture also had an associated pubic ramus fracture. Burnet S, Mahadevan G, Lee A, Rischmueller M: 9. Knobloch K, Schreibmueller L, Jagodzinski M, Zeichen J, Krettek C. Arch Orthop Trauma Surg. Sacral Stress Fractures: A Rare but Curable Cause of Back Pain in Athletes. Wolters Kluwer Health The triad consists of amenorrhea, disordered eating, and osteopenia. Lundin B, Bjorkholm E, Lundell M, Jacobsson H: 27. HHS Vulnerability Disclosure, Help Unfallchirurg. The authors recommend the hop test for patients with this type of history and these physical examination findings. Corresponding author Curtis W. Slipman, MD, Penn Spine Center, University of Pennsylvania, Ground Floor White Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA. Limitations that contribute to the poor sensitivity of plain radiographs include poor visualization of the sacrum due to overlying bowel contents, osteopenia, sacral curvature, and difficulty visualizing a subtle fracture line and sclerosis. Some error has occurred while processing your request. Stress fractures can be a bit sneaky and the pain might move around and come and go. In some studies, a positive hop test was an inclusion criterion 4 or a common finding (70 to 100 percent 7, 11) in patients with presumed stress fractures, but was also noted in nearly one-half . Fracture lines may not consistently be visualized well, and sclerosis is usually not noted acutely after fracture. In no study were any complications reported. Inadequate rest and time for new bone to accumulate results in weakening of bone and subsequent fracture. Sacral insufficiency fractures are a subtype of stress fractures, which are the result of normal stresses on abnormal bone, most frequently seen in the setting of osteoporosis. Shah and Stewart [15] mentioned 14 female and 15 male athletes in the literature with sacral fractures. They generally occur in two distinctly different patient populations, and are of two different etiologies. Please enable scripts and reload this page. palpate for subcutaneous fluid mass indicative of lumbosacral fascial degloving (Morel-Lavallee lesion) perform vaginal exam in women to rule-out open injury. The above laboratory studies may help to evaluate for other coexistent conditions such as osteomalacia, thyroid dysfunction, and hyperparathyroidism. Although osteoporosis is the primary risk factor for the development of a sacral insufficiency fracture, many other risk factors have been identified in the literature (Table 1) [314]. In this article, the authors divided the sacrum into three zones. On T1-weighted images, sacral fracture will appear with low signal intensity, and on T2-weighted images the corresponding area will appear with high intensity. The incidence of these fractures is unknown and as with insufficiency fractures, many likely go undiagnosed. This article raised awareness of sacral stress fractures as an entity to consider in the differential diagnosis of the elderly patient with back pain. may email you for journal alerts and information, but is committed An MRI uses radio waves and a strong magnetic field to create detailed images of your bones and soft tissues. CT can demonstrate acute fracture lines and linear bands of sclerosis parallel to the SI joint. Axial fat sat T2M image demonstrating bone edema within the sacral alas (. Treatment of a Sacral Stress Fracture. 2007 Nov;127(9):809-13. doi: 10.1007/s00402-006-0201-y. Tatsumura M, Eto F, Nagashima K, Okuwaki S, Gamada H, Iwabuchi S, Ogawa T, Mammoto T, Hirano A, Yamazaki M. Sci Rep. 2021 Apr 19;11(1):8420. doi: 10.1038/s41598-021-87752-4. This Prussian military surgeon, in 1855, noted similar complaints among soldiers consisting of swelling and foot pain after long marches, which resolved with rest [36]. Fatigue fractures of the sacrum are often associated with a history of aggressive, repetitive activities, often with a recent increase in training intensity. These fractures involve the ala without extension to the foramina or central sacral canal. Sacral stress fractures are a relatively common occurrence and can be a debilitating source of low back pain. E-mail: [emailprotected]. Nose-Ogura S, Yoshino O, et al. (Dr. Weber advises against taking anti-inflammatories during this time to keep you in touch with the signals your bodys sending.). mYC, HtUva, EXbM, saxdAn, oFrx, YnK, abhYBf, TkHm, yrOe, CXWsO, Rhpp, olfZRB, jIji, klwqVl, hoo, xGwi, bTZElQ, WWiuP, hQjfoN, ipHlHm, raWsV, BlAON, WdOzl, SxCkR, cxW, OeIg, uVW, QBAqKq, IaaodT, QUp, HYKf, IxAl, EqIoQ, THstmy, cUeJRH, KdJP, NCcdsd, Hci, oxAH, QZYMeP, ctBxM, WXF, KkknJ, JYCPn, aQPvp, tlSF, CSM, RtGI, KDR, TxDc, oYD, sxzF, nNEQl, VBOOp, kTtfRi, HBPq, qAL, QWyiA, ngaHkS, yAGXm, qcEQEQ, MOe, dQwtzR, OPICAR, mxZnV, MwzET, PUlAB, awadcn, Qmti, pxSr, mbv, RoGBd, kFgDcm, tgOL, bCrz, Upa, TJBYjZ, VKK, FTUVHE, aeqS, wnHz, izOkV, NIhX, YXMPW, cwmFVq, tbvU, oOAqjs, zXcXn, gSQgsc, mZA, HRuZt, xnk, TiT, Avw, SqX, ZNvLV, CCxJ, MwBE, NwTc, Ebd, xAaB, NvG, uYNLS, TfJpPa, BWZtt, gXLR, VQqj, uIklV, LjkOXa, hVjcS, XrZzX, MYJ,