Objective: To emphasize continued reassessment, appropriate imaging referral, and staged conservative management when high-volume runners have persistent or worsening medial ankle and distal tibial pain.
Clinical Features: A 23-year-old male collegiate student and ultramarathon runner with a 2-year history of intermittent bilateral medial ankle pain sought care for worsening focal right distal tibial and ankle pain. Initial radiographs were unremarkable. Because symptoms progressed despite early conservative management and running tolerance declined substantially, magnetic resonance imaging was obtained.
Intervention and Outcome: Magnetic resonance imaging revealed a distal tibial stress fracture with surrounding periostitis and bone marrow edema, as well as concurrent posterior tibial tenosynovitis. Management included cessation of running, temporary walking-boot use, protected weight bearing, orthopedic co-management, patient education, progressive ankle and lower-extremity rehabilitation, and a self-directed graded return-to-running program. The patient later reported completing a 50-kilometer race without recurrent symptoms and stated that follow-up MRI findings were unremarkable.
Conclusion: Bone stress injury should be considered in high-volume endurance athletes with worsening focal tibial pain, reduced running tolerance, or symptoms that do not follow the expected course of tendinopathy. Normal radiographs do not exclude early tibial bone stress injury. Reassessment, timely advanced imaging, interdisciplinary co-management, and staged rehabilitation are important for reducing risk of progression and supporting safe return to running.
Author Keywords: Ultramaraton Running, Posterior Tibial Tendon, Tibial Stress Fracture, Bone Stress Injury, Conservative Care, Chiropractic
Author Affiliations: TC, RV, AK, JS: Palmer College of Chiropractic; BB: Feilding Palmer Hospital
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