Working Diagnosis:
Completed stress fracture of the left medial malleolus

Treatment:
The patient was successfully treated with operative fixation provided by three percutaneous screws
Case Photo #6 , Case Photo #7 , Case Photo #8 . He tolerated the procedure well and there were no complications.

Outcome:
Four weeks following surgery, the patient was non-weight bearing using a knee scooter, followed by two weeks in a walking boot. Six weeks postoperatively, x-rays demonstrated callus formation, there was no pain on exam and he subsequently began physical therapy. Eight weeks following surgery, he was advanced to full activity and able to participate in the bowl game.

Author's Comments:
Stress fractures are overuse injuries frequently observed in athletics, most commonly affecting the tibia and tarsal bones. However, isolated medial malleolar stress fractures are rare with an incidence ranging from 0.6%-4.0%, consequently, there is no uniform treatment strategy. Conservative measures consist of a non-weight bearing cast for 6-8 weeks, then transitioning into a walking boot if asymptomatic. This strategy runs the risk of non-union further prolonging the recovery. Alternatively, percutaneous fixation can be performed providing a more controlled outcome and shorter recovery time. Therefore, high functioning patients would likely benefit from a more active treatment strategy.

Editor's Comments:
Medial malleolar stress injuries typically occur during running and jumping sports. The repetitive pronation and impingement of the talus on the medial malleolus during ankle dorsiflexion and tibial rotation is the most common cause. Like in this clinical case, x-rays will be negative up to 70% of the time with MRI being the diagnostic test of choice. Return to play with conservative treatment can be up to 12 weeks. While the competitive level of the athlete and necessity for a faster recovery may dictate treatment, screw fixation is typically recommended if there is a visible fracture line seen on plain films or concern for complications, such as non-union.

References:
Orava S, Karpakka J, Taimela S, Hulkko A, Permi J, Kujala, Urho (Hospital Meditori and the Sports Research Unit, University of Turku T. Stress Fracture of the Medial Malleolus. J Bone Jt Surg. 1995;77 (3):362-365.

Menge TJ, Looney CG. Medial Malleolar Stress Fracture in an Adolescent Athlete. J Foot Ankle Surg. 2015;54(2):242-246. doi:10.1053/j.jfas.2014.11.017

Gross CE, Nunley JA. Medial-sided stress fractures: Medial malleolus and navicular stress fractures. Oper Tech Sports Med. 2014;22(4):296-304. doi:10.1053/j.otsm.2014.09.007

Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. 5th ed. Lippincott Williams & Wilkins; 2014.

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