The fracture of the sacrum requires rehabilitation that goes beyond simple muscle reconditioning. The resumption of weight-bearing, the restoration of sacroiliac mobility, and the reactivation of the pelvic floor condition the functional return. Here, we detail the areas of focus that recent literature and clinical practice highlight as paramount.
Pelvic floor and sacral fracture: the deficit that classical rehabilitation ignores
A fracture of the sacrum systematically alters the function of the pelvic floor. The sacral roots S2 to S4 innervate the anal sphincter and the urethral sphincter muscles. A fracture line, even if stable, can generate local neuromotor shock, resulting in subtle incontinence, dyspareunia, or loss of perineal proprioception.
We recommend integrating a perineal assessment as soon as the consolidation phase begins. The work is not limited to Kegel exercises: it includes perineal contractions synchronized with expiration, pre-effort locking, and biofeedback via a probe if the patient tolerates the sitting position. This aspect is absent from almost all published online rehabilitation protocols for post-fracture of the pelvis.
Programming exercises after a sacral fracture without assessing the pelvic floor is akin to restoring the framework while neglecting the foundations. The overall functional recovery of the pelvis depends on it.
Progressive sacroiliac mobilization: sequencing of exercises
The fracture of the sacrum rigidifies the sacroiliac joint due to antalgic reflex. The piriformis, gluteus maximus, and hamstring muscles contract to immobilize the area. Resuming mobility without adhering to a precise sequence exposes patients to chronic pelvic girdle pain.
Early post-consolidation phase
The patient works in a supine position with knees bent. Anterior-posterior pelvic tilts (anterior/posterior) constitute the first exercise. The amplitude remains below the pain threshold, with a hold of three to five seconds at the end of the movement.
Pelvic rotations in supine are introduced after the tilts, never before. The patient lets the knees drop to one side and then the other, feet together, controlling the descent. This movement engages sacroiliac mobility in rotation without axial constraint.
Intermediate phase
The quadruped position allows for a controlled increase in load on the sacrum. Two exercises dominate this phase:
- The cat-cow (rhythmic spinal flexion/extension) mobilizes the lumbosacral junction and restores sacroiliac sliding in nutation/counter-nutation.
- The bird-dog (simultaneous extension of the opposite arm and leg) recruits the crossed chains and imposes a locking of the pelvis that enhances motor control.
- The low forward lunge, with the back knee on the ground, stretches the psoas and decompresses the anterior aspect of the sacrum. Prolonged static hold, without bouncing.
We observe that patients who skip the supine phase to go directly to quadruped frequently develop high lumbar compensations.
Sacroiliac belt: real utility in active rehabilitation
The use of a sacroiliac belt during exercises divides practitioners. Its role is to mechanically compress the sacroiliac interlines to reduce painful micro-movement. In the early phase, the belt facilitates the recruitment of deep stabilizers by decreasing the nociceptive signal.
Prolonged use poses a different problem: the patient becomes dependent on external feedback and delays the reflex activation of the transverse and multifidus. We prescribe it during the first four to six weeks of active rehabilitation, then gradually remove it, starting with exercises in supine before eliminating it during load-bearing activities.
Fatigue fracture of the sacrum in runners: resuming sports
The fatigue fracture of the sacrum increasingly affects runners and trail runners, with diagnoses confirmed by MRI. This type of fracture differs from a traumatic fracture by its mechanism (repetitive overload) and the profile of the patient (often young, active, without osteoporosis).
Resuming running after a fatigue fracture of the sacrum often requires a much longer timeframe than patients anticipate. Walking is generally allowed fairly early, but returning to running requires complete consolidation and reconditioning of the pelvis.
The resumption protocol follows a strict logic:
- Strengthening the trunk and hip stabilizers in unloaded conditions (side planks, unilateral glute bridges) for several weeks.
- Progressive reintroduction of brisk walking, then jogging on flat terrain, monitoring for any sacral pain during palpation or single-leg weight-bearing.
- Transition to continuous running only after complete resolution of pain on impact and normalization of dynamic single-leg support.
- Return to trail running (elevation, unstable terrain) as a last resort, as downhill running imposes significant shear forces on the sacrum.
Postponing running in favor of swimming or cycling during the consolidation phase protects the fracture site while maintaining aerobic capacity. The temptation to return too early is the primary factor for recurrence in this patient profile.
Progression criteria and warning signals in sacral rehabilitation
Each transition from one phase to the next is based on clinical criteria, not on a fixed timeline. The absence of pain on direct palpation of the sacrum, the ability to hold a single-leg stance for thirty seconds without trunk compensation, and the recovery of symmetrical pelvic tilting are the three markers we use.
Signals that necessitate a regression: pain radiating into the buttock or perineum during a weight-bearing exercise, a sensation of pelvic instability during walking, or the reappearance of perineal discomfort. Any radiating neurological pain warrants medical evaluation before proceeding.
Rehabilitation after a sacral fracture does not have a standard duration. Bone consolidation, neuromuscular recovery of the pelvic floor, and sports reconditioning follow distinct timelines. Ignoring them sets the stage for chronic pelvic girdle pain that complicates every daily action.