Differential Diagnosis of Fibular Pain in a Patient With a History of Breast Cancer

Abstract

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 incom...