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Plain Radiograph Alignment Features Associated With Medial Malleolar Stress Fractures in Athletes: A Matched

Tomohiro Matsui1,2, Kazuya Sugimoto1,3, Kimio Miura3

  • 1Sports medicine, Orthopaedic Foot & Ankle Center, Takanohara Central Hospital, Nara, Japan.

Foot & Ankle Orthopaedics
|December 1, 2025
PubMed
Summary

Medial malleolar stress fractures (MMSFs) in athletes are hard to detect early on X-rays. A smaller tibial anterior surface (TAS) angle may indicate higher risk, aiding early diagnosis.

Keywords:
athletic injuriesdiagnosismedial malleolar stress fractureradiographic analysistibial anterior surface angle

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Area of Science:

  • Orthopedic imaging
  • Sports medicine
  • Radiographic analysis

Background:

  • Medial malleolar stress fractures (MMSFs) present diagnostic challenges due to subtle radiographic findings.
  • Delayed diagnosis of MMSFs can impede athletes' return to play.
  • Identifying radiographic alignment patterns may improve early clinical suspicion for MMSFs.

Purpose of the Study:

  • To investigate radiographic features of MMSFs in athletes.
  • To compare specific ankle alignment angles on plain radiographs between athletes with and without MMSFs.

Main Methods:

  • Retrospective observational case-control study.
  • Matched 1:1 comparison of athletes with MMSFs and control athletes.
  • Radiographic measurements included tibial anterior surface (TAS), tibial medial malleolus (TMM), tibial bimalleolar (TBM), and tibial lateral surface (TLS) angles.

Main Results:

  • The medial malleolar stress fracture (MMSF) group exhibited a significantly smaller tibial anterior surface (TAS) angle compared to controls (86.3° ± 2.1° vs. 89.3° ± 1.6°, P < .01).
  • Receiver operating characteristic analysis indicated an optimal TAS angle cutoff of 87.8° for MMSFs, with 73.9% sensitivity and 91.7% specificity.
  • No significant differences were found in TMM, TBM, or TLS angles between groups.

Conclusions:

  • A smaller TAS angle is associated with increased susceptibility to MMSFs in athletes.
  • TAS angle measurement on plain radiographs can aid in raising clinical suspicion for MMSFs during early evaluation.
  • These findings may assist in earlier diagnosis, especially when advanced imaging is unavailable.