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MARCH 2009
DOI: 10.2519/jospt.2009.0403
A 46-year-old avid female runner was referred to physical therapy for left ankle pain following an inversion injury sustained 1 month earlier while running. The patient had a history of breast cancer, but her health screening was otherwise unremarkable. The patient presented with a normal ankle examination, except for localized tenderness to palpation proximal to the distal tip of the left fibula. The physical therapist was concerned about the possibility of a fibular fracture and ordered ankle radiographs, which were read as normal by the radiologist. The physical therapist, however, observed a slight cortical irregularity of the distal fibula on the anterior-posterior radiograph that corresponded with the site of palpation tenderness, and consequently ordered a bone scan to differentiate active versus old pathology. The bone scan revealed an area of increased metabolic activity at the site of the cortical irregularity, so the physical therapist ordered magnetic resonance imaging, which revealed an incomplete nondisplaced distal fibular stress fracture. Subsequently, the patient was referred to orthopedics for fracture management. The patient's history of a primary cancer required advanced imaging to assist in ruling out metastatic disease; symptomatic management of a suspected stress fracture without advanced imaging may be appropriate in a patient without a history of primary cancer.
J Orthop Sports Phys Ther 2009;39(3):230. doi:10.2519/jospt.2009.0403
KEY WORDS: ankle, distal fibular stress fracture, magnetic resonance imaging, radiographs
A 46-year-old avid female runner with a history of breast cancer was referred to physical therapy for left ankle pain. Through differential diagnosis assisted by various types of imaging, the physical therapist was able to diagnose a distal fibular stress fracture.
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