title: A novel approach to treatment for chronic avulsion fracture of the ischial tuberosity in three adolescent athletes: a case series.
abstract: Ischial tuberosity fracture and its associated complications are an under recognized diagnosis in the adolescent athlete. Apophyseal injuries of the pelvis in the skeletally immature athlete can occur in multiple locations but are most common at the ischial tuberosity, affecting males more commonly than females.
  The most common cause of ischial tuberosity avulsion fracture is a quick eccentric load to the proximal hamstrings, occurring with kicking as in soccer, football, or dance. Signs and symptoms are similar to a proximal hamstring injury but avulsion injuries often go undiagnosed, as radiographs are not frequently obtained. In acute cases, rest and relative immobilization are the recommended course of care. In chronic cases, including those with delayed diagnosis, or those that remain symptomatic after initial care due to non-union or associated sciatic nerve adhesions, surgery is often performed in order to restore normal anatomy, alleviate symptoms, and help return the athlete to full activity.
  
  
  OBJECTIVE
  The authors' share a novel treatment approach consisting of ultrasound guided percutaneous needle fenestration for the treatment of three adolescent athletes with symptomatic delayed diagnoses of ischial tuberosity fractures. Needle fenestration was followed by a physical therapy progression which was developed based on tissue healing rates, symptom presentation, and the available literature related to proximal hamstring injuries.
  
  
  RESULTS
  Two athletes reported elimination of pain, full functional recovery and return to sport without limitations as measured by use of the Numeric Pain Rating Scale, the Global Rating of Change Scale, and the Lower Extremity Functional Scale. One athlete reported elimination of pain and full functional recovery and chose to return to a new sport. Symptoms of possible concurrent hamstring syndrome are discussed as well the management of this condition.
  
  
  CONCLUSIONS
  This case series introduced a novel approach for treatment of symptomatic delayed union ischial tuberosity fractures in three adolescents prior to consideration of surgical intervention. Percutanous needle fenestration and the described subsequent rehabilitation provided positive treatment outcomes in the presented cases, including full return to athletic and recreational endeavors.
  
  
  METHODS
  Level 5.
authors.affiliation: St. Luke's Rehabilitation, Boise, ID, USA.
authors.forename: Sydney K
authors.initials: SK
authors.lastname: Schoensee
authors.affiliation: St. Luke's Rehabilitation, Boise, ID, USA.
authors.forename: Kurt J
authors.initials: KJ
authors.lastname: Nilsson
keywords: Adolescent apophyseal injury; ischial tuberosity avulsion; percutaneous fenestration; percutaneous tenotomy