Working Diagnosis:
Transverse nondisplaced stress fracture of the proximal fibular shaft

Treatment:
The patient was placed in a Donjoy hinged lateral J brace for support and stabilization. She was asked to remain non-weight-bearing for 6 weeks. During this time a bone stimulator was also prescribed and was used twice daily for 4 weeks (it took 2 weeks to receive authorization from insurance). She was prescribed Tramadol initially, but did not require this medication after day 5.

Outcome:
The patient was evaluated in the office 6 weeks after the injury. She had self-discontinued use of her crutches a few days prior to the visit and was ambulating pain free. She had not yet begun exercising and was in the 4th week of using her bone stimulator twice daily. Labs and DEXA scan did not reveal any underlying pathology or reason for her stress fracture. On exam she no longer had any tenderness of the proximal fibula. She had no swelling and no tenderness in the lower leg. She was ambulating with a slight gait abnormality due to prolonged use of crutches, but was pain free. Range of motion of the knee and ankle was full and resistance testing did not create any pain. She was referred to physical therapy to restore proper strength and single leg balance. She was advised to follow the instructions of her Physical Therapist and adhere to a gradual return to activity plan. It was recommended that she try low impact activities, such as a bike or elliptical trainer prior to advancing to higher impact activities.

Author's Comments:
Stress fractures are common in endurance athletes. In female athletes, stress fracture should prompt consideration for the female athlete triad. This patient had a normal work-up. In order to prevent re injury, return to running should be progressed slowly, using a graded program or implementing the 10% rule.

Editor's Comments:
This case demonstrates an unusual presentation of a stress fracture. While the location and presentation of this patient's injury are less common, stress injuries are common in endurance athletes. By understanding what are common injuries in runners and then obtaining a thorough patient history, the authors were able to narrow their differential diagnosis and perform and appropriate work-up.

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