The case

A 16 year old self-proclaimed track star was running the 400 meter sprint when he felt a pop at the bottom of his left buttock. He stopped running. He became mad. His mom became worried. He became your patient.

This has never happened to him before because he states that he always stretches – a lot. On exam he has full range of motion of his back, hips, knees and ankles. There is no neurological deficit and he has normal perfusion of the limb. He ambulates with a slight limp. There is minimal tenderness to palpation in the area of the ischial tuberosity. After a dose of ibuprofen you obtain the following X-Ray.

The patient's X-Ray that you ordered and are now interpreting

The patient’s X-Ray that you ordered and are now interpreting

The Diagnosis

The X-Ray is diagnostic for an ischial apophysis avulsion injury. A what you ask? These types of avulsion injuries are sustained acutely, and this particular one mimics a “pulled” hamstring. They may be related to overuse, and chronic stress. Because the muscles are stronger that the apophyseal anchor in pubertal patients, the bone gives way at the point of hamstring insertion as opposed to the ligament or muscle. Patients often feel a “pop” and the pain is immediate, and exacerbated by movement.

These injuries occur mostly in the pelvis and lower extremities. The history is invariably similar regardless of which apophyseal insertion site is involved – with acute onset of pain and the feeling of a “pop” or “tear.” The following (really helpful) diagram details different muscle insertions and thus can help guide your exam.

Courtesy of

Courtesy of


Treatment is generally conservative with ice, anti-inflammatories and rest prescribed initially. Gradual return to activity is warranted with stretching and strengthening regimens often guided by team trainers, physical therapists or sports medicine physicians for competitive athletes. Surgery is rarely necessary, and orthopedic referral is only indicated for severe displacement or the patient who fails initial conservative management. Recovery can take several weeks, and premature return to sports can risk re-injury. When in doubt, sit ’em out.