Lateral ankle sprains are very common in children and adolescent athletes. In some injuries, the ligament can avulse a small fragment from the distal fibula, resulting in an avulsion fracture.
In a recent pediatric case series, these avulsions were present in approximately one-third of lateral ankle injuries and were more frequent in younger children compared to adolescents. [1]
The presence of the fragment can alter initial protection and recovery times, but many small, stable avulsions still follow a conservative course.
Initial Treatment of Small, Stable Avulsions
In most cases, a small, undisplaced avulsion of the lateral malleolus is treated conservatively.
This means that surgery is not necessary, and the goal is to protect the ankle during the painful phase, allow tissue healing, and then progressively regain function, strength, and balance.
Options may include:
- functional bandage;
- Aircast-type brace;
- walker boot;
- splint or cast for younger children, those in significant pain, or those who are less cooperative;
- progressive weight-bearing according to pain and clinical indication.
There is no single solution. A 7-year-old child in severe pain, unable to bear weight, is not the same as an adolescent athlete who is already walking quite well after a few days.
An updated meta-analysis from 2026 on low-risk pediatric ankle injuries and fractures found, compared to casting, fewer unscheduled visits, faster return to normal activities, and better function with removable devices, with no significant differences in complications. [11] The choice of device remains linked to stability, pain, age, and the child's cooperation.
In the clinic, it is common to see two similar X-rays, but two completely different children: one limps significantly, is afraid to bear weight, and has considerable swelling; the other walks almost normally. This is where clinical assessment counts at least as much as the imaging.
First Weeks
For small, stable lateral avulsions of the distal fibula, literature and some pediatric guidelines often describe management with a walker/CAM boot or brief immobilization, with weight-bearing as tolerated, for approximately 3–4 weeks [2,3].
Three or four weeks generally describe the main phase of protection, not an automatic date for healing or return to sport. During this period, a progressive reduction in pain, improvement in walking, and resumption of weight-bearing are expected.
At the same time, keeping an ankle immobilised for too long when functional rehabilitation could begin is not always helpful. Stiffness, loss of strength, and fear of movement can become part of the problem.
For this reason, when pain allows, recovery must gradually transition from "protecting" to "reactivating."
From the Second to the Fourth Week: Walking Well Before Thinking About Sport
Recovery of walking often precedes what is needed for sport.
Between the second and fourth week, in uncomplicated cases, the practical goals are:
- walking without a limp;
- reduction of swelling;
- recovery of ankle mobility;
- progressive discontinuation of the brace, if indicated;
- initiation of simple strengthening and control exercises;
- recovery of single-leg balance.
If the child is still walking poorly, avoiding weight-bearing, or reporting significant lateral pain, it is premature to talk about running, jumping, or playing a game.
This is particularly important because distal fibula avulsions are not always an irrelevant finding. Yamaguchi and colleagues observed that, after an ankle sprain in childhood, the presence of a distal fibula avulsion was associated with a higher risk of recurrent sprains [4].
This does not mean that every child with an avulsion will develop instability. However, it does mean that the functional recovery phase should not be skipped.
Between Fourth and Sixth Week
More generally, pediatric ankle fractures tend to heal in approximately 4–6 weeks, although this data includes injuries of varying locations and severity [5].
For many small, stable avulsions, this is the phase where the child gradually returns to usual daily activities: school, stairs, more confident walking, light activities.
But "daily life" and "sport" are not the same thing.
An ankle might be fine for walking in class, but not yet ready for a soccer game, a basketball practice, a volleyball jump, or an intense dance lesson.
This phase should serve to recover:
- strength of the peroneal muscles;
- complete or near-complete mobility;
- single-leg balance;
- control during weight-bearing;
- confidence in movement;
- ability to run without pain.
This is often the phase that is skipped, because the pain decreases and the child "seems healed." But it is precisely here that an important part of preventing recurrence is built.
Return to Sport
For more significant lateral sprains, some pediatric guidelines indicate that sufficient recovery to return to sport may require 5–10 weeks, even with an adequate rehabilitation program [6].
This is a central point.
It is not correct to say that all children with a small avulsion return to sport after 4 weeks. Some recover quickly, others need more time, especially if they play sports involving jumping, sprinting, changes of direction, rotations, or contact.
Return to sport should not be decided solely based on X-rays or the number of weeks passed. It should primarily be based on function.
Before returning, the following should be present:
- walking without a limp;
- running without pain;
- absence of swelling after activity;
- mobility similar to the healthy side;
- good single-leg balance;
- controlled jumps;
- changes of direction without giving way;
- absence of obvious fear during weight-bearing.
For a child who plays soccer, for example, it's not enough to walk without pain: they must tolerate running, braking, changes of direction, single-leg weight-bearing, and ball contact. For those who play basketball or volleyball, the main problem might be landing after a jump. For dance and gymnastics, control, range of motion, and confidence in the movement come into play.
In some children, residual pain and swelling can last longer, even several months, despite an overall favorable evolution [7]. This should not be alarming, but it helps explain why recovery does not always follow perfectly linear timelines.
Residual Ossicle Near the Malleolus
After a sprain or a small avulsion, a small bone fragment may remain visible over time near the tip of the fibula. In some cases, it is an asymptomatic finding; in others, it can create doubts in subsequent X-rays, especially after new injuries.
Pediatric studies have suggested that some subfibular ossicles may have a post-traumatic origin, meaning they are the result of previous avulsions [8]. More recently, Li and colleagues emphasized how distinguishing an acute avulsion from a subfibular ossicle can be complex and how dynamic ultrasound can help in selected cases [9].
For parents, however, the practical message is simple: if a child has persistent pain, repeated sprains, or a feeling of giving way, it's not enough to say "there's a little bone." It's necessary to understand if that finding is truly irrelevant or if it is part of the clinical problem.
When to Re-evaluate
In most cases, the outcome is favorable. However, it is prudent to re-evaluate if:
- the child is still unable to bear weight after a few days;
- lateral pain remains significant;
- swelling does not improve;
- nocturnal or progressive pain appears;
- limping persists longer than expected;
- the ankle "gives way";
- repeated sprains occur;
- the child is unable to resume running or jumping.
The initial X-ray is important, but it does not always conclude the diagnostic process. Some studies have shown that distal fibula avulsions can be difficult to recognize in the initial stages and that ultrasound or re-evaluation may play a role in doubtful cases or those with an inconsistent course [10].
In most small lateral avulsions, treatment is conservative, and the prognosis is good. Initial protection, progressive recovery of mobility, strength, and balance, and return to sport based on function help reduce recurrences and persistent pain.
References
[1] Jones J, Schultz C, Lampe K, Van Pelt B, Podvin C, Miller S, Chung J, Wyatt C, Johnson B, Ellis H, Wilson P. Pediatric Lateral Ankle Avulsion Fractures: Age-Specific Patterns and Diagnostic Clues. J Pediatr Orthop. 2026;46(1):6-12. doi:10.1097/BPO.0000000000003078. PMID: 40778671.
PubMed: https://pubmed.ncbi.nlm.nih.gov/40778671/
[2] Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot Ankle Clin. 2015;20(4):705-719. doi:10.1016/j.fcl.2015.07.004. PMID: 26589088.
PubMed: https://pubmed.ncbi.nlm.nih.gov/26589088/
[3] Perth Children’s Hospital. Fractures — Ankle. Emergency Department Guideline.
[4] Yamaguchi S, Akagi R, Kimura S, Sadamasu A, Nakagawa R, Sato Y, Kamegaya M, Sasho T, Ohtori S. Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. Knee Surg Sports Traumatol Arthrosc. 2019;27:2774-2780. doi:10.1007/s00167-018-5055-7. PMID: 29992464.
PubMed: https://pubmed.ncbi.nlm.nih.gov/29992464/
[5] American Academy of Orthopaedic Surgeons. Ankle Fractures in Children. OrthoInfo.
Link: https://www.orthoinfo.org/diseases--conditions/ankle-fractures-in-children/
[6] Royal Children’s Hospital Melbourne. Ankle Sprains — Emergency Department Clinical Practice Guideline.
Link: https://www.rch.org.au/clinicalguide/guideline_index/fractures/Ankle_Sprains_-_Emergency_Department/
[7] Cambridge University Hospitals NHS Foundation Trust. Ankle sprains and avulsion fractures in children.
Link: https://www.cuh.nhs.uk/patient-information/ankle-sprains-and-avulsion-fractures-in-children/
[8] Lee DY, et al. Posttraumatic Subfibular Ossicle Formation in Children. J Pediatr Orthop. 2018.
[9] Li X, et al. Lateral Ankle Avulsion Fracture Versus Subfibular Ossicles in Pediatric Lateral Ankle Sprain: A Novel Dynamic Ultrasonographic Technique. J Pediatr Orthop. 2026. doi:10.1097/BPO.0000000000003094.
[10] Takakura Y, Yamaguchi S, Akagi R, Kimura S, Tanaka H, Yasui T. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. BMC Musculoskelet Disord. 2020;21:276. doi:10.1186/s12891-020-03287-1. PMID: 32345266.
PubMed: https://pubmed.ncbi.nlm.nih.gov/32345266/
Disclaimer: Content for general informational purposes only. It does not replace medical evaluation.
[11] Badhe N, Ferdinand K, Chilaka J, Yap RY, Durand C, Marson BA. Outcome of ankle fractures in children: an updated systematic review and meta-analysis. Ann R Coll Surg Engl. 2026. doi:10.1308/rcsann.2025.0124. PMID: 41622914.
