What is it?
Stress fractures are overuse injuries of the bone. Healthy bone responds to repetitive forces by remodeling and becoming stronger. Injury occurs when there is disruption in this remodeling process. Many things can cause improper remodeling and lead to stress fractures (see prevention below).
The fibula is the smaller of the two long bones that make up the lower leg. It is on the outside part of the leg and typically only bears about 15% of the body weight. In contrast to the tibia which is larger and supports 95% of the body’s weight. Fibular stress fractures are considered a “low-risk” stress fracture. It is rare for the fibula to completely crack in a manner we usually picture when thinking of a broken bone. There are no long term consequences from this injury if properly rehabilitated.
Symptoms
Symptoms of fibular stress fracture may include:
• Localized dull pain at/above the outer ankle bone
- Initially pain is only present while exercising
- Pain progresses to occur not only during but also after exercise
- Eventually, pain is constant day and night.
Pain is made worse by walking, running or jumping and better with rest.
• Visible swelling or a bony bump at the site of the pain may be present
• Tender to touch over the bone
Sports Medicine Evaluation and Treatment
Diagnosis of a fibular stress fracture is usually made based on a history of progressive focal bone pain in the setting of a person who has suddenly increased their activity level. The physician will use a physical exam and x-rays to confirm the diagnosis. In some cases advanced imaging such as a bone scan, MRI, or CT scan may be suggested. Advanced imaging is often unnecessary unless it will change treatment recommendations. If the plain x-ray is normal and the diagnosis is in doubt then advanced imaging is indicated (MRI is currently the test of choice).
On exam your physician may:
• Feel over the outer ankle bone for a pain, swelling, and/or dome shaped bump.
• Check your feet, ankles, knees, and hips for alignment
• Tap on the bottom of your heel to see if this causes pain in the lower leg
• Ask you to hop on the affected leg
Treatment of fibular stress fracture usually involves:
GENERAL RULE: If you are experiencing pain you are delaying healing. Pain indicates that micro-trauma is still occurring, which means healing is not occurring. Treatment involves stopping the pain (without medications!).
• Stop the activity which caused the injury
• “Modify” activities of daily living so that you are pain-free
- Common modifications: crutches, walking boot, temporary clerical duties, less time on feet
- Maintain fitness with alternative exercise: pilates, rowing, swimming, biking, yoga, Zumba programs
• Physical therapy to address underlying alignment, strength, or flexibility imbalances if present
• Consider a strength and conditioning coach specific to your sport
- Identify training errors
- Create a sport specific core strength and flexibility plan
Injury Prevention
If you are getting pain over a bone, stop activity and get it checked out. A little extra rest at the right time with a change in your training plan may be the difference between making it to the starting line vs sitting out.
Suggestions to prevent lower extremity stress fractures include:
• Avoid sudden changes in activity. One common mistake is doing “too much, too soon.”
• Get adequate rest. The duration of recommended recovery time will vary based on age, fitness level, and activity.
• Know your limitations. Make modifications when needed to stay within your ability.
- Underlying skeletal build (People with flat feet,” knock knees” or bow-legs are at increased risk)
- Being overweight for your body frame Current unrelated injury (foot, ankle, knee, hip injuries in one leg can cause overuse of the opposite leg)
• Proper bone health begins with a diet rich in Calcium and Vitamin D and based on fresh fruits and vegetables
• Proper fitting equipment, such as tennis shoes, cleats, etc.
• Consider your environment, for example, change routes if you are always running on sloped road surface
Return to Play
1. You may advance activities as pain dictates (stay out of your “pain zone” which includes pain during, after, or the next morning).
2. Decrease forces form above: weight loss if you are above goal body weight
3. Decrease forces from below: strengthening the feet, (+/- shoe wear?)
NOTE: An athlete may be allowed to participate in sport with a fibular stress fracture, but should not be expected to improve and may very well make things worse. This should only be done with close physician oversight.
AMSSM Member Authors
Crystal Hnatko, DO and Courtney Ann Dawley, DO
References
Robertson, GA., Wood AM. Lower limb stress fractures in sport: Optimizing their management and outcome. World J of Orthop 2017 March 18; 8(3): 242255
