Stress Fracture, Right Ankle, Sequela (ICD Code: M84.371S)

Name of the Condition

• Stress Fracture, Right Ankle, Sequela
• Technical terms: Sequela of stress fracture

Summary

A stress fracture in the right ankle refers to tiny cracks in the ankle bones resulting from repetitive force or overuse. "Sequela" indicates that there are residual effects or complications from a previous stress fracture that has not fully healed.

Causes

• Repetitive stress or overuse on the ankle joint
• Sudden increase in physical activity
• Poor training practices or improper sports techniques
• Bone insufficiency due to conditions such as osteoporosis

Risk Factors

• High-impact sports like running or basketball
• Sudden increase in activity intensity or duration
• Female gender (especially post-menopausal women)
• Pre-existing bone conditions like osteoporosis

Symptoms

• Persistent pain in the right ankle during activity
• Swelling and tenderness to touch
• Pain that diminishes with rest but returns when activity resumes

Diagnosis

• Physical examination and assessment of pain history
• Imaging tests such as X-rays, MRI, or bone scans to confirm stress fracture

Treatment Options

• Rest and activity modification to allow healing
• Use of protective footwear or braces
• Physical therapy to strengthen ankle and improve flexibility
• Surgery, in rare cases, to repair severe fractures

Prognosis and Follow-Up

• Most stress fractures heal well with proper rest and treatment
• Regular follow-up appointments to monitor healing progress
• Gradual return to physical activity as guided by a healthcare provider

Complications

• Chronic pain or persistent disability
• Risk of developing arthritis in the affected joint
• Possible repeat fractures if proper healing is not achieved

Lifestyle & Prevention

• Gradual increase in activity levels, allowing the body to adjust
• Proper footwear that supports and cushions the feet
• Adequate nutrition including calcium and vitamin D for bone health
• Strengthening exercises for joints and surrounding muscles

When to Seek Professional Help

• Persistent or severe pain in the right ankle despite rest
• Noticeable swelling, bruising, or inability to bear weight on the leg
• Any signs of infection such as redness, heat, or increasing pain

Additional Resources

• American Orthopaedic Foot & Ankle Society: aofas.org
• National Osteoporosis Foundation: nof.org

Tips for Medical Coders

• Ensure the distinction between 'initial encounter', 'subsequent encounter', and 'sequela' when coding the condition
• Double-check for laterality; the condition specifies the right ankle
• Sequela coding should reflect the condition's residual effects, not the acute injury itself