Stress Fractures in Sport: Ankle

Stress fractures of the ankle, relatively rare in the general population, are markedly more common in athletes, especially running and jumping athletes. Athletes who participate in extreme training are at high risk, particularly when compounded with other risk factors such as poor mechanics, footwear, and/or acute changes in regimen. Females, especially elite-level athletes, may be at increased risk to due to the female athlete triad of amenorrhea, inadequate caloric intake, and decreased bone density. Athletes classically present with pain exacerbated by the activity, swelling, and focal tenderness. Diagnosis is often delayed, as initial radiographs are often negative. However, advanced imaging with magnetic resonance imaging (MRI) reveals typical patterns of edema, and, in later stages, fracture lines. Concern for endocrine and/or metabolic abnormalities should prompt further workup, particularly if there is concern for the female athlete triad. Stress fractures at the ankle may be low-risk or high-risk based on their potential for healing. In both scenarios, stress fractures of the fibula, distal tibia, medial malleolus, and talus may be treated initially with rest from activity, and possibly immobilization and/or limited weight-bearing in specific cases. Certain factors may indicate operative management, including lack of response to nonoperative management, progression to sclerosis and/or cystic change at the stress fracture site, or potentially in elite athletes with time-sensitive return-to-play needs and/or high risk of progression. In the future, there may be a role for novel modalities, including teriparatide, extracorporeal shock wave therapy (ESWT), bone stimulators, and orthobiologic agents, but further research is needed.