Ha, Chris

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.

Background Current literature has shown benefit of radial pressure wave (RPW) and focused shockwave (FSW) for management of proximal hamstring tendinopathy (PHT), although there remains a lack of consensus on treatment parameters and optimal patient positioning. Purpose The purpose of this narrative review and clinical commentary is to report what has been described for patient positioning during treatment of PHT with RPW or FSW and propose an alternative side lying approach. Methods A search was conducted of MEDLINE/PubMed and EMBASE electronic databases for studies published from January 2005 to January 2026. Key search terms included proximal hamstring tendinopathy, shockwave therapy, extracorporeal shockwave treatment, radial pressure wave, hamstring tendinosis, hamstring tendinitis, and hamstring pain. Studies were included if they evaluated RPW or FSW for the treatment of PHT. Results Six manuscripts were identified for inclusion, two randomized controlled trials (RCT), two retrospective reviews, and two case reports; a total of 217 patients (145 female, 72 male) with PHT were treated with RPW and/or FSW. One RCT provided an in-depth description of patient positioning during shockwave treatment with the patient supine, with the hip and knee flexed, compared to other manuscripts detailing clinical focusing techniques only. One case report involving a para swimmer included a figure of treatment with the patient in a prone position. Improvement in patient reported outcomes with RPW and/or FSW was noted, with one RCT showing no differences between physiotherapy compared to RPW and FSW treatment. Conclusion RPW and FSW have some evidence regarding their benefits for treatment of PHT but controlled studies are limited and no consensus on treatment protocols or patient positioning during treatment have been determined. The authors’ preferred approach in treating PHT involves having the patient side lying with the hip and knee flexed to allow patient and clinician comfort while also creating compression of the proximal hamstring about the ischial tuberosity. It remains unclear how variance in patient positioning affects patient-reported outcomes. Future studies using RPW and FSW should include documentation of patient positioning when evaluating RPW and FSW efficacy. Level of Evidence 5

Background: Ultrasound-guided percutaneous fasciotomy and debridement (USPFD) is a minimally invasive treatment for patients with plantar fasciopathy refractory to conservative management. Previous studies have shown clinical improvement with USPFD, but pain relief and patient satisfaction have not been demonstrated beyond 2 years. Methods: This retrospective case series included patients who underwent USPFD at a quaternary academic medical center between April 2013 and January 2018, with refractory plantar fasciopathy and at least 4 years’ follow-up. Patient outcomes were assessed through electronic surveys and telephone interviews. Primary outcome measures included mean changes in visual analog scale pain (VAS-Pain) scores and patient satisfaction via Likert scale. Secondary measures included VAS-Pain with the first 5 steps, VAS-Pain during daily weightbearing, and procedural complications. Results: Seventy unique procedures were identified among 62 patients. Follow-up data were obtained from 51 of 62 patients (82%) who responded to surveys or phone calls. This corresponded to 58 of 70 procedures (83%) at a mean postprocedure follow-up of 6.6 ± 1.4 years. Patients had a mean duration of symptoms of 2.1 ± 3.0 years prior to the procedure. Baseline VAS-Pain was 6.8 ± 2.2 and final follow-up VAS-Pain was 0.7 ± 1.1. At the last follow-up, patient-reported VAS-Pain with first 5 steps was 0.9 ± 1.6 and VAS-Pain with weightbearing through the day was 1.3 ± 1.8. Overall, 91% (53/58) of the procedures were considered successful, where patients responded they were “satisfied” or “very satisfied” and 52 of 58 (90%) procedural responses indicated that based on the outcome, they would recommend the procedure to others. Final follow-up VAS-Pain, VAS-first 5 steps, and VAS-weightbearing, were all improved in the success vs failure groups ( P ≤ .002). No complications were reported. Conclusion: USPFD was associated with high patient satisfaction and durable pain relief for chronic plantar fasciopathy at an average follow-up of 6.6 ± 1.4 years.

Background/Objectives: Although Osgood–Schlatter disease (OSD) is often self-limiting following apophyseal closure, it may cause persistent symptoms into adulthood, affecting physical and functional activities. The purpose of this systematic review is to summarize the current evidence on the efficacy of hyperosmolar dextrose injection for patients with OSD unresponsive to conservative treatment. Methods: Multiple databases were searched for studies investigating the efficacy of hyperosmolar dextrose injection in patients with OSD. Two reviewers independently extracted data and evaluated the risk of bias. Meta-analyses were performed to compare hyperosmolar dextrose injection with placebo injections. Results: Four studies including three randomized controlled trials (RCTs) and one case series involving a total of 166 (162 males and 4 females) patients with 184 knees were included in this review. At three months, there was no significant difference in patient-reported improvement from baseline between hyperosmolar dextrose injection and placebo injections (standardized mean difference [SMD] = 1.92, 95% confidence interval [CI], −0.12 to 3.96; I2 = 96.2%). However, a meta-analysis of two RCTs including athletic pediatric patients found a pooled risk ratio of 2.11 (95% CI: 1.12 to 3.98, I2 = 30.73%) for pain-free return to sports at three months. In addition, at one year, a meta-analysis of two RCTs showed greater patient-reported improvement from baseline with hyperosmolar dextrose injection compared to placebo (SMD = 1.09, 95% CI, 0.62 to 1.56; I2= 0%). Conclusions: Based on the limited number of RCTs, although no improvement in patient-reported outcomes is seen at three months, hyperosmolar dextrose injection may safely facilitate a pain-free return to sports at three months and lead to patient-reported improvement at one year. However, further high-quality RCTs are needed to substantiate these findings.