Stress fractures of the ankle

Malleolar stress fractures are rare and often misdiagnosed. Delay in diagnosis leads to prolonged pain, significant disability, and loss of time in sport. Clinicians should have a high suspicion for stress fractures about the ankle in active young individuals who participate in high-impact endurance and jumping activities. Patients typically present with insidious atraumatic ankle pain with point tenderness over the medial or lateral malleolus. Plain radiographs are rarely positive, and MRI is often needed to confirm the diagnosis of a stress fracture about the ankle. Lateral malleolar stress fractures are more common than medial and will often heal with rest and activity modification. A period of immobilization is sometimes required and care should be taken to ensure that any ankle malalignment is treated. Medial malleolar stress fractures are at high risk for progression to fracture completion and nonunion. These fractures also respond to similar conservative treatment; however, operative intervention is warranted in select cases.