title: DISTAL FIBULAR STRESS FRACTURE IN A FEMALE RECREATIONAL RUNNER: A CASE REPORT WITH MUSCULOSKELETAL ULTRASOUND IMAGING FINDINGS.
abstract: OBJECTIVE
  This case report describes a physical therapist's use of diagnostic ultrasound imaging in the decision making process used to refer a patient to a physician for a suspected fibular stress fracture. The purpose of this case report is to 1) describe the history, subjective examination, and objective examination findings of a fibular stress fracture, 2) describe the ultrasound findings associated with a fibular stress fracture, and 3) describe the decision making process of a physical therapist in the decision to refer the patient to a medical physician for further work-up.
  
  
  METHODS
  A 52-year-old female recreational runner with a recent increase in running intensity self-referred to a physical therapist with a 19-day history of lateral lower leg pain. Examination revealed relatively normal ankle range of motion, mild weakness of ankle invertors and evertors, no increase in pain with resisted muscle tests of the ankle, and tenderness to palpation over the fibularis brevis muscle and distal fibula. Diagnostic ultrasound examination of the fibularis muscles revealed cortical irregularity of the distal third of the fibula in the location of tenderness.
  
  
  RESULTS
  The physical therapist used the abnormal ultrasound findings, running history, symptoms, and physical examination for differential diagnosis, and decided to refer the patient to a physician for further examination. Radiographs revealed a fibular stress fracture. Follow-up ultrasound imaging demonstrated a mixed hypoechoic-hyperechoic appearance of the fibular cortex typical of healing fracture and the presence of bony callus.
  
  
  CONCLUSIONS
  Diagnostic ultrasound imaging is increasingly being used by physical therapists to guide rehabilitation. Ultrasound imaging of musculotendinous structures may display adjacent bone. Physical therapists should be knowledgeable of normal and abnormal bony ultrasound imaging findings. Abnormal ultrasound findings may be one sign indicating the need to refer a patient for consultation by a physician.
authors.affiliation: University of the Sciences, Samson College of Health Sciences, Department of Physical Therapy, Philadelphia, Pennsylvania, USA.
authors.forename: Lisa T
authors.initials: LT
authors.lastname: Hoglund
authors.affiliation: University of Delaware, Department of Physical Therapy, Newark, Delaware, USA.
authors.forename: Karin Grävare
authors.initials: KG
authors.lastname: Silbernagel
authors.affiliation: Rothman Institute, Foot and Ankle Service, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Taweel
keywords: Differential diagnosis; musculoskeletal ultrasound; running; stress fracture