Stress fractures of the medial malleolus

Six athletes, all engaged in running activities at the time of injury, presented with tenderness over the medial malleolus and ankle effusion. Three patients had a fracture line which could be seen on radiographs. These patients were treated by open reduction and internal fixation using two 4.0 cancellous screws. The other three patients had normal radiographs but bone scans showed increased uptake over the medial malleolus. These patients were treated with cast and immobilization. We believe that each of these patients suffered a stress fracture of the medial malleolus. We suggest that the possibility of a stress fracture be considered in the differential diagnosis of patients who present with 1) chronic or subacute pain over the medial malleolus and ankle effusion, and 2) a history of running activity at the time of injury or running activities aggravating the pain. Bone scans appear to be more sensitive than radiographs in detecting a stress fracture of the medial malleolus. We propose that athletes with radiographic signs of a medial malleolar fracture who desire early return to full participation should be treated by open reduction and internal fixation. For these patients, early motion can be initiated. Other athletes whose fracture cannot be detected on radiographs but whose malleolus shows increased uptake in the area on bone scans can be treated nonsurgically with immobilization and then progressive increase in activity. All of our patients returned to full activity between 6 and 8 weeks after treatment was initiated.