This young football player presented with a history of recuring right ankle ‘sprains’ and lateral ankle pain. On examination she was highly reluctant to weightbear. She was found to have localised tenderness over the tip of her lateral malleolus.
An AP x-ray image shows a well corticated ossicle measuring about 7mm lying below the distal fibular physis. This is consistent with an os subfibulare. No further imaging was performed.
This player has been successfully managed with a short period in a walking boot (2 weeks) followed by four weeks of reduced activity). She has since been able to return to normal play. She has been completing proprioceptive exercises and wears an ankle brace for football and other sports.
An os subfibulare is a relatively rare accessory ossicle that lies adjacent to the lateral malleolus. In most cases is represents an unfused ossification centre however in some situations it can represent the legacy of a prior avulsion fracture. Many patients settle well with conservative treatment (as outlined in this case). In some cases there can be ongoing pain and disability. In this situation excision of the ossicle is generally advised. Should this young woman develop further pain the next step would be to arrange an MRI of the painful ankle to confirm that there had been disruption of the synchondrosis (before considering any surgical treatment).
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