Intended for healthcare professionals

Clinical Review Lesson of the week

Avulsion fracture of the ischial tuberosity in adolescents—an easily missed diagnosis

BMJ 2004; 329 doi: (Published 08 July 2004) Cite this as: BMJ 2004;329:99
  1. Sam Gidwani (, specialist registrar1,
  2. Jakub Jagiello, senior house officer1,
  3. Martin Bircher, consultant1
  1. 1 Department of Orthopaedics and Trauma, St George's Hospital, London SW17 0QT
  1. Correspondence to: S Gidwani, 122 Durham Road, London SW20 0DG
  • Accepted 11 November 2003


Avulsion fracture of the ischial tuberosity is a rare injury in comparison with mid-substance tears of the hamstrings, and its diagnosis is often missed. Such fracture usually occurs between puberty and late adolescence in those who do a lot of sport—it is in puberty that the secondary ossification centre or apophysis appears and in late adolescence that it fuses. In other words, fracture occurs at a time when the apophysis is the weakest link in the chain of muscle, tendon, and bone. The cause is usually forcible contraction of the hamstrings, as in sports such as sprinting and hurdling.

In adolescent patients with a history of proximal hamstring injury and current ischial tenderness, a radiograph of the pelvis should be performed. This is to exclude the presence of an avulsion fracture, which may be substantially displaced.

A prompt diagnosis of a displaced avulsion fracture of the ischial tuberosity will enable early surgery where appropriate. This in turn will prevent the development of chronic pain on sitting and walking and an inability to return to sporting activities.

Case reports

Case 1

A 14 year old boy was sprinting during a 200 m race when he suddenly developed a severe pain posteriorly in the proximal part of his left thigh. He collapsed to the ground in pain and could not complete the race.

His general practitioner advised him to rest to allow the presumed hamstring injury to settle. Despite prolonged physiotherapy, he still had pain when he jogged. Two years after the injury, he was referred to …

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