What is the recommended treatment for a young, active patient with an Anterior Superior Iliac Spine (ASIS) avulsion?

ASIS Avulsion Treatment in Young, Active Patients

For young, active patients with ASIS avulsion fractures displaced >1 cm, surgical fixation is strongly recommended to achieve faster recovery, earlier mobilization, and quicker return to sports, while conservative management with rest and NSAIDs is appropriate for minimally displaced fractures (<1 cm). 1, 2

Treatment Algorithm Based on Displacement

Minimally Displaced Fractures (<1 cm)

• Initial conservative management with rest, NSAIDs as first-line treatment, and ice therapy to reduce acute inflammation 1
• Position the hip in partial flexion (approximately 60°) during the initial rest period to reduce tension on the sartorius and tensor fascia latae 3
• Bed rest duration averages 18-27 days for conservative treatment 2
• Progressive physical therapy with supervised exercises should begin once acute pain subsides 1

Displaced Fractures (>1 cm)

• Surgical fixation is strongly indicated for fragments displaced more than 1 cm, particularly in young athletes with high sports demands 4, 2
• Surgical options include:
  • Hybrid fixation using both cannulated compression lag screw (countersunk to avoid impingement) plus tape bridge construct for reinforcement 5
  • Suture anchor technique when the fragment is too small to accept screw fixation 4
• Surgery enables significantly faster mobilization (average 7.2 days vs 24.1 days for conservative treatment, p=0.02) 2
• Markedly improved range of motion at 6 weeks post-surgery compared to 3 months for conservative treatment (p=0.02) 2

Rehabilitation Protocol

Post-Surgical Rehabilitation

• Early mobilization with partial weight bearing possible within 2-10 days post-operatively 2
• Full range of motion typically achieved by 4 weeks 4
• Return to pre-injury sports activity level by 10-12 weeks 4, 2

Conservative Rehabilitation

• Active supervised exercises are preferred over passive interventions once pain subsides 1
• Progressive resistance training for hip flexors implemented in intermediate phase 1
• Full return to activity typically by 18 weeks 3

Monitoring and Follow-Up

• Clinical assessment of pain levels, strength, range of motion, and functional testing specific to the patient's athletic activities 1
• Radiographic follow-up at 6 weeks, 3 months, and 1 year to confirm union 2
• Referral to sports medicine specialist or orthopedic surgeon if symptoms worsen or fail to improve after 4-6 weeks of appropriate conservative treatment 1

Critical Pitfalls to Avoid

• Do not underestimate displacement on initial radiographs - consider advanced imaging (MRI or ultrasound) if clinical suspicion is high despite negative plain films 6
• Avoid direct corticosteroid injection into the tendon itself, as this increases risk of tendon rupture; injections should only be directed to local sites of inflammation 1
• Do not delay surgical consultation in young athletes with >1 cm displacement who wish to return to competitive sports 2
• Be aware of incomplete fractures that may not be visible on plain radiographs but can be detected on MRI or ultrasound 6

Prevention of Recurrence

• Maintenance strengthening program for hip flexors and core muscles 1
• Proper warm-up protocols before athletic activities, particularly sprinting and explosive movements 1

Complications

• Minor heterotopic ossification may occur in approximately 13% of surgical cases but typically requires no further treatment 2
• Hardware removal may be necessary but carries minimal risk when performed by experienced surgeons 2
• Deep wound infection is rare with proper surgical technique 2