Medial malleolar stress fractures are relatively rare injuries, accounting for only 0.6% to 4.1% of all lower extremity stress fractures.

They occur in athletes who engage in repetitive jumping and running, such as basketball players and track and feel athletes.

Athletes often present with nonspecific pain and normal radiographs.

Surgical intervention ensures a quicker rate of healing and lower nonunion risk

X-rays: The majority of medial malleolar stress fractures are vertically oriented, and the fracture line typically extends proximally from the junction of the tibial plafond and medial malleolus. However, many athletes present with normal radiographs and nonspecific ankle pain. Clinicians should include this fracture in their differential diagnosis of ankle pain in the jumping athlete and consider advanced imaging.

Magnetic resonance imaging (MRI): MRI can assist in detecting bone edema and stress reaction, which may occur before a stress fracture (Figure 23-1). Medial malleolar stress reactions present
with symptoms similar to those of stress fractures, but lack an obvious fracture line on computed tomography (CT). By detecting such stress reactions early, steps may be taken to prevent the stress reaction from progressing into a full-blown stress fracture. Obtained preoperatively, MRIs can also assist in detecting osteochondral defects. MRI has the additional advantage of avoiding radiation exposure.

CT: CT scans are critical to the understanding of fracture geometry and should be obtained preoperatively on all patients. Most often, the fracture line is vertical, originating anteriorly and inferiorly at the junction of the medial malleolus and tibial plafond with an intact posterior cortex (Figure 23-2). In addition to these stress fractures, CT scans can help identify tibial and talar osteophytes.

Malleolar stress fractures can be treated either conservatively with immobilization and reduction in weight-bearing activities or with surgery. However, conservative treatment has been associated with prolonged healing rates and tendency toward nonunion. With conservative treatment, fracture union and return to full activity can take as long as 6 to 8 months.

With operative treatment, return to play can be expected as early as 3 months following surgery. Given the upper limit of how long nonoperative treatment can take, surgery is the preferred method of treatment for these fractures.

Historically, the reported operative treatment of medial malleolar stress fractures had been the use of two partially threaded cancellous screws placed obliquely to the fracture similar to a standard transverse medial malleolus fracture. Biomechanical studies then showed the superiority of perpendicular screw placement across fracture lines compared to oblique placement with regard to maximizing fracture compression.