Stress fractures of fibula are common in runners and can present with pain and swelling just above the ankle. How can you tell you have a fibula stress fracture, and what do you do about it?
Where is the fibula?
The fibula is the smaller of the two bones that make up the lower leg. This bone is located on the outside of the leg, while the larger tibia is on the inside. Generally, the fibula takes only 15% of the total load through the leg compared to 85% through the larger tibia.
Fibula stress fracture symptoms
Stress fractures occur when too much load is placed through the bone. These excessive forces produce fatigue and swelling of bone, leading to small cracks called stress fractures.
Generally, fibula stress fractures present as focal pain in the area of fatigue. Usually, the pain is made worse by walking or running and improved with rest. In the beginning, pain only occurs after activity. However, as the stress fracture worsens, pain occurs during and after exercise. In later stages, you can feel pain all the time, including at night.
How do we diagnose a fibula stress fracture?
In general, we diagnose a stress fracture of the fibula based on the history of increasing pain with activity. Sometimes, there is visible swelling on the outside of the lower leg or ankle. Usually, hopping is uncomfortable, and touching the fibula at the site of bone stress is painful.
Fibula stress fracture radiology
We usually get imaging to confirm a diagnosis if we suspect a fibular stress fracture. An X-ray shows a thickening of the outer part of the bone called the periosteum. In advanced cases, a fracture line is present. However, 50% of patients will show a normal X-ray. Ultrasound or MRI is more sensitive to detecting changes in periosteal thickening, bone swelling, and fracture. In addition, MRI will also rule out other causes of ankle or lower leg pain. Overall, MRI is the investigation of choice if we think you have a fibular stress fracture.
Fibula stress fracture treatment
If you have a stress fracture in your fibula, you will need to rest from sports and impact activity. Generally, this injury has a good outlook if you give it enough rest for the bone to heal.
Overall, your doctor should treat your injury and determine why it developed. For example, you might have training errors, biomechanical issues, or problems with your bone health. Sometimes, a stress fracture is accompanied by low Vitamin D or softening of bones (also called osteoporosis).
Acute phase of a fibula stress fracture
We recommend a walking boot until the acute pain settles in the early stages. Also, regular ice will help resolve the swelling and encourage healing. However, we suggest you avoid anti-inflammatory tablets such as ibuprofen, as recent evidence suggests that these tablets slow down bone healing.
Cross-training during this acute phase, such as swimming and lifting weights, can keep you fit. Also, it would be best to avoid unnecessary walking, even in a boot.
Subacute phase of a fibula stress fracture
After 4-6 weeks, you should be ready to wean out of your boot. Generally, we recommend spending 25% of your time out of the boot for the first week, followed by 50% for the second week. Transitioning from a walking boot to a shoe can take up to 4 weeks. You could also start cycling 20 minutes every 3rd day during this phase.
After 6-8 weeks, you can weight bear without the boot as tolerated. Other exercises include rowing and elliptical cross-training. At this stage, you should also work with a physiotherapist to improve your balance, calf strength, and ankle mobility.
Chronic phase of a fibula stress fracture
You are ready to start a progressive walk/run program in this phase. We suggest starting with daily walks of 20 minutes or three sessions per week. After one week, you should perform a minute of jogging for every 4 minutes of walking (so a total of 5 minutes of jogging every 20 minutes). Then you should continue to add 1 minute of jogging every week (2nd week: 2 minutes jogging, 3 minutes walking x5, 3rd week: 3 minutes jogging, and 2 minutes walking x 5, etc.).
You should continue with cross-training and rehab.
You can restart fitness training once you can run 20 minutes 3 times a week.
If you develop pain or discomfort during recovery, you should stop your activity and rest. Once the pain settles, you can resume rehab at one level below.
Other treatments
Exogen or low-pulsed ultrasound
This treatment is a unique form of ultrasound that has been shown to accelerate bone healing. This ultrasound is different from regular therapeutic ultrasound used by a physiotherapist. Exogen should be used for 20 minutes daily for 2-4 weeks.
Focussed shockwave therapy
Recent evidence suggests that shockwave therapy might play a role in enhancing bone healing. Generally, we recommend one focused shockwave session per week for 4-5 weeks.
Alter G
Alter G is a treadmill that allows you to run at a fraction of your body weight. Therefore, you can often start running much earlier than regular running.
Final word from Sportdoctorlondon about fibula stress fracture
Fibula stress fractures should be considered in any runner who develops pain above the ankle. You should see a doctor experienced in diagnosing and managing runners with ankle pain. An early diagnosis means that recovery and return to running are generally quicker.
Related conditions:
- Calcaneal stress fracture
- Navicular stress fracture
- Hip stress fracture
- Causes of second toe pain
- Transitioning from walking boot to shoe
- Vitamin D and athlete
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