Stress Fractures of the Medial Malleolus

Medial malleolar stress fractures account for only 10% of all stress fractures of the foot and ankle, but they can cause significant disability and loss of participation time, particularly in high-level athletes. They are most common in patients between the ages of 20 and 40 years and occur almost exclusively in athletes involved in sports that involve running and jumping. Medial malleolar stress fractures are considered at high risk for progression to complete fracture, delayed union, or nonunion and often are treated as acute fractures. An aggressive nonoperative protocol of nonweight-bearing cast immobilization (usually for 6 weeks) may be successful if the stress fracture is diagnosed soon after symptoms appear, but time to complete healing and safe return to activity may be as long as 6 to 8 months, an unacceptable solution for most elite athletes. Open reduction and internal fixation with 2 or 3 fully threaded cortical screws generally allow faster healing and return to activity when compared with nonoperative treatment.