STRESS
FRACTURES
A Review
M.
fifty
and
and
B. DEVAS
OF THE
of
Fifty
Cases
and
R.
SWEETNAM,
From
the Middlesex
FIBULA
in Athletes
LONDON,
ENGLAND
Hospital
Stress
fractures
of the lower
part of the fibula are common
in athletes.
This paper
reviews
such injuries
and discusses
the natural
history,
signs, symptoms,
radiographic
appearances
treatment.
All were seen in the Athletes’
Clinic
at the Middlesex
Hospital
between
1952
1955, at which
they represented
an approximate
incidence
of 3 per cent of new patients
seen.
An excellent summary
of the literature
was given
by Burrows
(1948),
who
recorded
twenty-four
stress
fractures
of the lowest
third
or middle
third
of the fibula,
and a larger
number
in the uppermost
third.
Since then ten more
have been published,
eight in children,
by Griffiths
has
not
(1952)
been
noted
and
two
by Richmond
and
Shafor
CLIMCAL
Table
The
I gives
circumstances
The
high
were
confirmed
(1955).
incidence
in athletes
before.
details
in
of the present
which
they
MATERIAL
series.
occurred
All the
have
we
been
have
been
be traced.
not
the
during
from
the
Five
same
stress
period,
fractures
but
conditions
of
investigated
running
not
patients
remainder
of
the
whom
could
fibula
in athletes,
sport
(Table
hard
on
and
are
was
factor
state
and
the
II),
surfaces
important
believe,
we
radiologically.
in the thirty-one
follow
up.
The
seen
excluded
series.
The
were
fractures
studied
able
to
it
most
the
in
of
is
training
apparent
that
common
and,
etiology.
HiSTORY
The
ten
patients
days
within
and
groups
The
divided
the
III).
Those
(Table
severe
themselves
of symptoms,
hours.
this
experienced
presented
onset
twenty-four
insidious,
two
usually
the
after
onset
series
was
an
felt
painfully
came
into
aged
I
A marathon
runner
aged thirty-eight
felt a sudden
pain in his leg at the
twenty-second
mile.
He had sustained
a stress fracture
in the mid-shaft
of the
fibula.
The downward
and inward
direction
of the fracture
line is unusual.
FIG.
818
at
thirty-eight
the
end
insidious
no
a
crippled.
this
who
of
onset
particular
or
was
rather
pain
abrupt
mile
in
had
the
series
runner
acute
(Fig.
pain
1).
There
symptoms
became
above
the
common.
the
onset
marathon
a sudden
more
when
a
or
into
the patient
normal
and
man
was
experienced
twenty-second
increasing
after
oldest
he
his
moment
gradually
during
The
category;
abrupt
sharply
suddenly
and behind
the outer
side of the ankle;
no doubt
that at one moment
he was
next
about
occasionally
was
quite
with
which
pain
but
started
apparent
An
was
but
either
activity.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
STRESS
The
tender
pain
spot
was
well
malleolus.
frequently
Walking
upstairs
caused
was
pain
at
OF
of as being
behind
spoken
back
to the
FRACTURES
of the
possible
the
fibula.
with
site
Sometimes
a greater
of the
DETAILS
OF
of
STRESS
or lesser
Football
.
46
2
rackets
FRACTURES
of limp,
OF THE
Male
.
.
Female
.
.
on hard roads
Running
on
FIBULA
46
3
IN
jumping*
rackets
(One
or going
.
.
26
Right
.
.
22
ATHLETES
FOLLOW-UP
16
.
9
.
.
.
.
.
.
2
2
bilateral)
.
Out
of training
This
athlete
30
.
Usual
1
.
was normally
ONSET
OF
.
a middle
12
.
29
sport
2
distance
runner.
III
THIRTY-ONE
.
sport
Unusual
TABLE
Abrupt
AT
on soft ground.
case
In training
OF
running
the
lateral
ATHLETES
Left
THIRTY-ONE
SEEN
hard surfaces
football
Running
but
the
II
IN
FRACTURES
Running
Squash
located
above
Site
TRAINING
STRESS
Playing
patient
Bilateral
AND
wrru
the
noticed
fifty fractures)
TABLE
MODE
degree
1
CONDITIONS
*
and
was
Sex
.
Long
ankle
I
athletes:
sport
Running
Squash
the
fracture.
(Forty-nine
Type
819
FIBULA
a swelling
TABLE
CLINICAL
THE
STRESS
Insidious
FRACTURES
.
.
19
DIAGNOSIS
Stress
history
fractures
and
of
physical
the
signs
fibula
are
be
can
recognised
without
difficulty
if the
characteristic
appreciated.
Clinical
examination
always
shows
an area of tenderness,
usually
just above
malleolus,
and pain is elicited
at this site by pressing
the fibula
towards
the tibia.
the
is present
at
becomes
VOL.
38 B,
at
this
bony
NO.
level
hard
4.
after
NOVEMBER
in
severe
a time.
1956
and
in
The
appearance
late
cases,
and,
although
of the
swelling
soft
is shown
and
tender
in Figures
lateral
Swelling
first,
it
2 and
3.
M. B. DEVAS
820
AND
R. SWEETNAM
1’
FIG.
Figure
lateral
2-Only
malleolus
by comparing
be seen with
both
ease.
2
ankles
with the legs internally
rotated
Figure
3-The
radiographs
show the
after the onset of symptoms.
FIG.
3
can the swelling
above the right
stress fracture
clearly
five weeks
FIG.
4
In a radiograph
taken
two weeks after the onset of symptoms
a slight
periosteal
reaction
could be seen when the film was held to a naked bulb.
At four weeks (above)
the typical appearances
of a stress fracture
are seen.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
STRESS
The radiographic
is seen ten days
changes
of stress fractures
after the onset of symptoms,
weeks (Fig. 7) the periosteal
Nine
VOL.
38 B,
NO.
4,
weeks
NOVEMBER
FRACTURES
OF
THE
of the fibula frequently
appear
late.
In Figure
5 no abnormality
and in Figure
6 at four weeks the changes
are slight.
At six
new bone and the fracture
are seen more clearly.
FIG.
8
after this stress fracture
occurred
visible and callus is consolidating
1956
821
FIBULA
the fracture
about it.
line
is clearly
M. B. DEVAS
822
9
could
FIG.
Figure
9-This
fracture
AND
R. SWEETNAM
FIG.
be seen
buttressing
clearly
two weeks after the onset.
can still be seen at the fracture
site.
10
Figure
10-Three
years
later
9,
More than one
appears
normal
FIG.
11
projection
may be required
but an oblique
view (Fig.
to show a stress fracture.
12) shows a small mass
diagnosis.
Here
of new
THE
FIG.
12
the antero-posterior
view (Fig. 11)
bone which confirmed
the clinical
JOURNAL
OF
BONE
AND
JOINT
SURGERY
STRESS
The
two
the
fibulae
It
ankles
is
they
be seen
compared
be
realise
seen
seen
may
postero-lateral
not
to
be
clearly
that
easily
OF
when
THE
the
823
FIBULA
legs
are
rotated
a little
that
for
four
six
weeks
only
just
visible
aspect
of
unless
the
the
4).
the
onset
some
just
two
above
is inspected
changes
(Fig.
after
after
fibula
film
radiological
weeks
against
late,
and
5 to 7 show
of symptoms.
weeks
the
are
Figures
is a
inferior
hazy
In
most
patch
of
tibio-fibular
a naked
bulb,
of
the
has
ankle
(Fig.
In
and
a
fracture
few
C
the
the
patients
there
show
stages
line
38 B,
that
because
fibula
is,
visible
of
necessity,
and
the
line
be
first
on
thin
the
callus
radiographs
14
radiographs
seen
the
bone
This
Later,
may
typical
in which
patients
new
in routine
“over-exposed.”
fracture
the
do not
when
running
the
callus
through
the
8).
may
early
of
it is clearly
occasionally
views
VOL.
part
consolidated,
cortex
the
this
so
example
joint.
13
FIG.
centred
(Fig. 13) may show the fracture
when normal
(Fig. 14). Here both are reproduced
in relative
sizes.
carefully
often
an
FIG.
A macrograph
inwards
in profile.
cannot
were
will
most
seen
important
appearance
change
are
are
FRACTURES
NO.
a
a
or
fracture
were
traces
fracture
‘
4, NOVEMBER
callus
1956
was
clearly
it many
visible
not
macrograph”
a little
line
of
in
visible
seen
from
the
later
(Figs.
9 and
over
the
antero-posterior
carefully
not
years
centred
on
ordinary
onset,
projections
tender
non-magnified
or
10).
a few
Oblique
(Figs.
area
films
days
later,
and
lateral
11 and
will
often
(Figs.
12).
In
reveal
the
13 and
14).
824
M.
B. DEVAS
THE
Stress
fractures
of the
fibula
AND
LEVEL
have
R.
SWEETNAM
OF FRACTURE
been
classified
according
to the
level,
but
in this
series
it was impossible
to distinguish
between
fractures
of the lowest
third
and middle
third
from
the history
of the mechanism
of injury,
and apart from the actual
site of the lesion the symptoms
and
signs
were
identical.
could
be identified
the bone (Fig.
15).
Analysis
accurately
of
shows
forty
an
radiographs
No
are
stress
region
have
with
this
that
the
from
seen
are
gave
fractures
centimetres
fracture
but
one
indication
that
onset
from
oblique
above
line,
an
19 to
this
badly
22).
the
this
instance
coordinated
exertion.
untoward
or violent
of the
fracture
lowest
third
in this
series
muscle
violence
None
radiographs
of
a careful
Between
these
the obliquity
whatever
the
ran
upwards,
of
contraction
abrupt.
The
than academic,
varied.
inwards
at the
With
and
one
patient
showed
and
with
not
stress
had preceded
difference
between
for the latter
may
not.
and
common
only
there
in this
one
muscular
contraction
of the athletes
muscular
extremes,
but
history
damage,
whereas
stress fractures
are
low fractures
tended
to be transverse
malleolus,
level,
from
study;
In
muscular
the lateral
absence
of periosteal
reaction
not always
complete
and did
The obliquity
is well illustrated
is included
fractures
had been insidious
or
muscle
violence
is more
considerable
tissue
in this series
that
(Figs.
from
sudden
repetitive
with
16 to 18.
level
in the
athletes.
of the fibula
patients
excluded
in Figures
whether
the
and fractures
with
noticed
third
Several
were
from
and
any
fractures
be associated
It was
uppermost
shown
occurred
symptoms,
stress
the
been
condition
injury
in the
in the literature.
long-continued
fractures
his
fracture
recorded
many
of fracture
the
preponderance
15
in forty
FIG.
Level
in which
overwhelming
the
site,
exception
forwards.
higher
about
The
six
(Fig.
1)
frequent
on the inner
side of the fibula
suggests
that the fracture
was
not involve
the medial
cortex
(Figs.
8, 11 and 12, and 21 to 24).
in the patient
with bilateral
stress fractures
(Figs.
23 and 24)
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
STRESS
FRACTURES
OF
THE
FIBULA
825
FI(;.
17
With
no other
injury
than making
an awkward
but
violent
kick at football
the player
felt a severe
pain
in his calf.
The
initial
radiographs
showed
no
abnormality
(Fig.
16) but at two and four
weeks
the callus
and
fracture
line can be seen
(Figs.
17
and 18). This is not a stress
fracture
but a fracture
from
muscle
violence.
and soft-tissue
damage
may
he considerable.
FIG.
VOL.
38 B,
NO.
4,
NOVEMBER
1956
18
826
M.
B. DEVAS
AND
R.
SWEETNAM
FIG.
19
FIG.
20
Figure
19-At
one week a fracture
line is seen running
upwards
and inwards.
Figure 20 shows the appearance
at three weeks:
both cortices
have been involved.
This was among
the lowest
of the fractures,
being 35
centimetres
from the tip of the malleolus.
FIG.
A high, long, oblique
(Fig. 21) and at twelve
21
FIG.
22
stress fracture
running
upwards
and medially
is shown
at four weeks
weeks (Fig. 22). There is nothing
to suggest
that the medial
cortex
of
the fibula has been involved.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
STRESS
which
the
occurred
painful
within
ankle
a week
strapped,
FRACTURES
of
only
each
OF
other.
to sustain
He
827
THE
FIBULA
had
attempted
a similar
injury
on
to
the
continue
opposite
running
with
site.
MECHANISM
We
have
commonly
shown
from
(Table
running
II)
on
that
hard
stress
fractures
surfaces.
On
TABLE
SEASONAL
INCIDENCE
OF
of
hard
the
fibula
ground
FRACTURES
IN
FIFTY
to
is better
winter
months
When
stress
VOL.
38 B,
protect
.
.
.
.
4
October
.
.
.
5
May
.
.
.
.
4
November
.
.
.
4
June
.
.
.
.
3
December
.
.
.
6
July
.
.
.
.
1
January
.
.
.
5
August
.
.
.
2
February
.
.
.
9
September
.
.
.
1
March.
.
.
6
himself
(Table
one ankle
fractures.
NO.
from
4,
over
IV)
when
the
the
road
1956
“on
or
grass
his
.
jar
of
foot.
35
each
footfall,
This
may
running
whereas
explain
as a form
FIG.
23
became
painful
an athlete
tried to
The upward
and medial
direction
and medial cortices,
NOVEMBER
most
land
Winter
April
distributed
occur
to
ATHLETES
15
weight
athletes
tends
IV
STRESS
Summer
toes”
in
a runner
“
the
on
high
of training
a soft
seasonal
is most
track
incidence
the
in the
common.
FIG.
24
run it off” with a result that both fibulae had
of the fracture
line, which involves
both lateral
is shown well.
828
M.
lt
could
long
toe
the
fracture.
of the
be
flexors
To
legs
a strong
that
the
transmits,
discover
of healthy
by
strong
recurrent
their
the
effect
first
thrust
holding
DEVAS
through
subjects,
downward
prevented
B.
and
of this
the
foot
ball
of
Comparison
of
approximates
the
shadows
(Fig.
the
the
the
26).
in the
radiographs
fibula
corresponding
alteration
to
the
exactly,
It is suggested
that
shows
tibia.
the
in
altered
the
foot.
the
fibula,
the
plantar
stress
that
radiographs
secondly
while
the
radiographs
thrust.
The
of normal
radiographs
and
produces
were
they
of
of
powerful
these
the
are
of the
the
tibia
and
were
leg
taken
exerting
and
foot
was
there
legs were taken with
were superimposed
fibula.
contraction
films
toes
near
of
extra
Movement
positions
position
fibula,
the point
of greatest
stress
being
most frequent
site for a stress
fracture.
the
25).
25
leg lengths,
downward
on the
running
on
and
(Fig.
that
When
fibula,
pull
relative
contraction
the
resting,
frame
FIG.
any
rhythmical
muscle
the
in a wooden
SWEETNAM
from
By means of a wooden
frame adjustable
for different
the calf muscles
first at rest and then exerting
a strong
to show
R.
origin
with
through
them
AND
of
the
superimposed
shaft
of the
flexor
fibula
the
tibial
is clearly
is a “to-and-fro”
inferior
muscles
with
seen
movement
tibio-fibular
joint,
and
of
this
is
TREATMENT
Without
athlete
suitable
Immediate
off”
treatment,
who tries
treatment
results
rest
pain
and
disability
usually
continue
for
three
to
six
months
and
the
to continue
training
without
a period
of rest will lose a whole
season.
With
we have found
six weeks to be the average
time away from athletic
activities.
from
in continued
sport
is essential;
pain,
longer
the
incapacity
all too
and
common
marked
THE
advice
of the
radiographic
JOURNAL
OF
trainer
to “run
changes.
BONE
AND
JOINT
SURGERY
it
STRESS
Adhesive
elastic
heads
to
below
there
is no
reason
tinued
until
there
being
the
previously
fibula
towards
tender
the
Provided
on
there
roads
is
methods
less satisfactory.
continuation
and
that
intensity
of
lactic
of
no
on
pain
then
a soft
is allowed;
regimen
on
six
return
pressure
of
weeks
is the strapping
surface
is con-
firm
compression
about
from
discarded
resumed.
of
symptoms,
activity
is
two
or three
weeks
until
the
training
programme,
but running
treatment
Both
sport,
of
symptoms
indication
This
or
829
FIBULA
the metatarsal
tenderness
area,
THE
forbidden.
is
Other
the
work.
any
gradually
increased
during
athlete
is back to his normal
on
walking
off
Only
training
from
normal
tibia-usually
of symptoms.
gentle
OF
is applied
and
is no longer
the
and
knee
for
over
the onset
strapping
the
FRACTURES
prolonged
thick
pain
it
measure
have
below-knee
in supportive
the
been
disability.
rubber-soled
but
There
running
but
although
it
has
not
recommended
been
tried
found
walking
plasters
and the
strapping,
aggravated
may
shoes
be
is some
reduce
a useful
as
the
prophya form
of
treatment.
FIG.
26
Superimposed
radiographs
of a normal
leg taken in the manner
shown
in Figure
25. The tibia and lateral
malleolus
fit exactly,
but there is
an obvious
double
shadow
of the shaft
of the fibula.
A powerful
contraction
of the flexor muscles
of the calf has approximated
the fibula
to the tibia.
FIG.
26
SUMMARY
I.
2.
An account
is given of fifty
The
characteristic
symptoms,
details
3.
of treatment
The
and
mechanism
experimental
stress
fractures
signs
and
of the fibula
radiological
which
occurred
in athletes.
appearances
are described,
with
prognosis.
of the
injury
has
been
suggested
on
clinical
grounds
and
supported
by
methods.
We would
like to express
encouragement
Mr M. Turney
photographs.
our gratitude
to Mr Philip
Wiles
and
Mr P. H. Newman
in both the clinical
investigations
and the preparation
and other
members
of the Photographic
Department
of this report.
We
of the Middlesex
for their
advice
and
also wish to thank
Hospital
for the
REFERENCES
H. J. (1948):
A. L. (1952):
D. A., and
BURROWS,
GRIFFITHS,
RICHMOND,
Journal,
VOL.
Fatigue
Fractures
of the Fibula.
Journal
of Bone and Joint Surgery,
30-B, 266.
Stress Fractures
of the Fibula in Childhood.
Archives
of Diseases
of Childhood,
27,552.
SHAFOR,
J. (1955):
A Case of Bilateral
Fatigue
Fractures
of the Fibula.
British
Medical
i, 264.
38 B,
NO.
4,
NOVEMBER
1956