Name of the Condition

• Common Name: Stress Fracture
• Medical Term: Stress fracture of the right ankle

Summary

A stress fracture in the right ankle is a small crack or severe bruising within a bone. It's commonly caused by repetitive stress or overuse, often affecting athletes and individuals with high physical activity levels.

Causes

• Repetitive force or overuse, often from high-impact activities like running or jumping
• Sudden increase in physical activity intensity or volume
• Poor technique or improper training methods

Risk Factors

• Engaging in high-impact sports such as track and field, basketball, or gymnastics
• Having a bone condition such as osteoporosis
• Poor physical condition, inadequate nutrition, or unsupportive footwear

Symptoms

• Localized pain that develops gradually and worsens with weight-bearing activities
• Swelling, tenderness, or bruising around the affected area
• Pain that diminishes with rest

Diagnosis

• Physical examination by a healthcare professional
• Imaging tests such as X-rays, MRI, or bone scans to identify fractures not visible on standard X-rays

Treatment Options

• Rest and avoidance of activities that exacerbate the injury
• Use of protective footwear or braces to stabilize the ankle
• Physical therapy to strengthen surrounding muscles and improve flexibility
• Gradual return to activity while monitoring symptoms

Prognosis and Follow-Up

• The prognosis is generally good with proper treatment and rest, typically healing within 6-8 weeks.
• Regular follow-up appointments are vital to monitor healing progress and prevent recurrence.

Complications

• If untreated, a stress fracture can lead to a complete fracture.
• Possible chronic instability in the ankle joint, causing long-term issues

Lifestyle & Prevention

• Incorporate cross-training to diversify physical activities and reduce repetitive stress
• Ensure proper footwear with adequate support
• Gradually increase exercise intensity and duration
• Maintain a balanced diet rich in calcium and vitamin D to support bone health

When to Seek Professional Help

• Persistent or severe pain lasting more than a few days, especially if coupled with swelling or difficulty bearing weight
• Sudden increases in pain or changes in the injury site

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• National Osteoporosis Foundation
• Local physical therapy and sports medicine clinics

Tips for Medical Coders

• Ensure the use of the correct laterality code (right ankle) to avoid common errors.
• Confirm that the encounter is coded as an initial encounter, indicated by the "A" at the end of the code.