What is the expected return to play timeline for a patient with a conservatively treated distal fibula fracture (12 weeks post-injury) who is healing well and wants to return to playing hockey?

Return to Play After Distal Fibula Fracture in Hockey Player

A patient with a conservatively treated distal fibula fracture who is healing well at 12 weeks post-injury can safely return to playing hockey when they are pain-free and have regained full function, typically around 12-16 weeks post-injury. 1

Clinical Assessment for Return to Play

• Patients should be clinically followed until they are pain-free before increasing activity in a controlled manner 1
• Return to play should be determined based on:
  • Absence of pain with weight-bearing activities 1
  • Full range of motion compared to the uninjured side 1
  • Restored strength and proprioception 1
  • Ability to perform sport-specific movements without discomfort 1

Imaging Considerations

• No additional imaging is typically required after the initial diagnosis of a stress fracture if the patient is healing well clinically 1
• If there are concerns about healing or persistent symptoms, MRI can provide prognostic information about return to play timeline 1
• MRI grading of fracture severity correlates with return to play timeline - higher grades require longer recovery 1

Return to Play Protocol

• A progressive, step-wise return to play protocol should be implemented:
  • Begin with light aerobic activities (stationary bike, swimming) 1
  • Progress to sport-specific training without contact (skating drills) 1
  • Advance to non-contact team training 1
  • Return to full contact practice 1
  • Return to competitive play 1
• Each step should be completed without pain or swelling before advancing 1

Timeframes for Return to Sport

• For distal fibula fractures treated conservatively with good healing at 12 weeks, return to full competitive hockey is typically possible between 12-16 weeks post-injury 1
• Professional hockey players with various fractures miss an average of 13.8 ± 9.9 games 2
• High-level athletes often return to sport sooner than recreational athletes, with elite athletes returning to at-risk sports at approximately 9-10 weeks for certain fractures 3

Risk Factors for Delayed Return

• Trabecular bone injuries take longer to heal than cortical bone injuries 1
• Decreased bone mineral density extends recovery time 1
• Presence of persistent pain or swelling with activity indicates need for continued protection 1
• Inadequate rehabilitation of strength, balance, and proprioception increases re-injury risk 1

Protective Equipment Considerations

• Use of a protective device or brace during initial return to play may be beneficial 1
• Taping techniques can provide additional support during the transition back to full competition 1

Common Pitfalls to Avoid

• Returning too early increases risk of re-injury or development of chronic instability 1
• Inadequate rehabilitation of proprioception and balance can lead to functional instability even with good fracture healing 1
• Failure to address biomechanical issues that may have contributed to the initial injury 1
• Neglecting to progressively increase training load during return to play 1

Given that the patient is 12 weeks post-injury, healing well, and has been treated conservatively, they are likely at an appropriate timepoint to begin return to hockey, provided they meet the clinical criteria of being pain-free with full function and can complete sport-specific movements without symptoms 1.