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? We discuss the typical presentation and treatment options.
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 on 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 bone. Usually, 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. Hoping is usually 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, an MRI will 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 must rest from sports and impact activities. If you give this injury enough rest for the bone to heal, it generally has a good outlook.
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 bone softening (osteoporosis). Your doctor may order tests like a DEXA scan and blood profile.
Acute phase of a fibula stress fracture
We recommend a walking boot until the acute pain settles in the early stages. Regular ice will also 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, avoiding unnecessary walking, even in a boot, would be best.
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. During this phase, you could also start cycling for 20 minutes every third day.
After 6-8 weeks, you can bear weight 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. An anti-gravity machine may sometimes allow you to return to impact activity earlier.
Chronic phase of a fibula stress fracture
In this phase, you are ready to start a progressive walk/run program. 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 x 5, 3rd week: 3 minutes jogging, and 2 minutes walking x 5, etc.).
You should continue with cross-training and rehab.
You can restart formal running once you run pain-free for 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
This treatment is a unique form of ultrasound that has been shown to accelerate bone healing. This ultrasound is different from the regular therapeutic ultrasound used by a physiotherapist. Exogen should be used for 20 minutes daily for 2-4 weeks.
Focused shockwave therapy
Recent evidence suggests that shockwave therapy might enhance bone healing. We generally recommend one focused shockwave session per week for 4-5 weeks.
Alter G
Alter G, or an anti-gravity machine, 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. We usually begin Alter G training after the acute phase of stress fracture healing.
Other frequently asked questions about fibula stress fracture:
Can you walk on a fibula stress fracture?
It depends on how painful the stress fracture is. If you are limping, offloading the fracture using a walking boot is better. Generally, we use a boot for 2-4 weeks until the acute pain settles.
How long does a stress fracture of fibula take to heal?
It depends on the severity of the stress fracture at the time of diagnosis. Generally, we recommend rest from impact activity for 6 weeks with another 6 weeks of graduated 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 who is 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 a walking boot to a shoe
- Vitamin D and athletes
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