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Stress fractures of the medial malleolus are uncommon and considered high-risk due to potential complications such as progression to complete fracture, delayed union, nonunion, and chronic pain. Identified risk factors include varus alignment of the lower limb, chronic anteromedial impingement, excessive pronation/supination, broad talar neck, and ankle instability. To our knowledge, no reports of recurrence after surgical treatment have been reported. An 18-year-old male professional football player presented with medial right ankle pain. He was diagnosed with a medial malleolar stress fracture and underwent surgical treatment with cannulated screw fixation. After a full recovery, he experienced a recurrence of the fracture after discontinuing the use of custom-made foot insoles. A second surgery using a malleolar plate and bone graft was performed, and the patient resumed his sports career successfully with continued use of the foot soles. Surgical treatment is the best treatment for medial malleolar stress fractures in high-demanding athletes, without any known case of recurrence. Lower limb malalignment, particularly the cavovarus foot, may also play a role in recurrence, as observed in this case. Varus limb malalignment has been associated with this fracture type and could be a contributing factor to recurrence. Recurrent medial malleolar stress fractures are rare, and this case presents a unique scenario of treatment failure due to biomechanical alterations. The surgical treatment yielded successful outcomes when combined with custom-made foot soles for lower limb alignment support. However, further research and reports on recurrence are needed to fully comprehend the risk factors for these challenging fractures in high-demanding athletes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Macedo Campos et al.)