Sequential Extracorporeal Shockwave Therapy and Platelet-Rich Plasma for Treatment of Sacral Stress Fracture in a Triathlete

Sacral stress fractures are rare in athletes, present as nonspecific gluteal and/or back pain, and are often missed on radiographs. Standard treatment includes activity modification, physical therapy, and pain medications. However, prolonged recovery and recurrence remain concerns in athletes. There is evidence for the use of extracorporeal shockwave therapy (ESWT) in the treatment of stress fractures, and platelet-rich plasma (PRP) has also shown promise in accelerating bony healing. This case report describes a 48-year-old male triathlete with a recurrent sacral stress fracture unresponsive to conservative management. Following MRI diagnosis, he underwent sequential ESWT and PRP injection, resulting in successful return to competitive training levels at 8-weeks post-treatment. Although an MRI at 3-months post-treatment showed persistent bony edema, his PROMIS-Pain Interference (PI) and Global Pain Scale (GPS) scores improved from 54 to 40 and 62/100 to 4/100, respectively. There is currently no published literature on the sequential use of ESWT and PRP for the treatment of sacral stress fractures. To our knowledge, this is the first documented case of this novel treatment, suggesting a potential role for combination therapy in such injuries. Further research is warranted to validate the efficacy and long-term outcomes of this emerging therapeutic approach in athletic populations.