Causes of a medial malleolus fracture
A medial malleolus fracture often occurs in association with a rolled ankle particularly with significant weight bearing forces. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the front or inner aspect of the lower leg or ankle. Medial malleolus fractures occasionally occur in running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball. A stress fracture of the medial malleolus may occur as a result of overuse often associated with a recent increase or high volume of running.
Signs and symptoms of a medial malleolus fracture
Patients with a medial malleolus fracture typically experience a sudden onset of sharp, intense inner ankle or lower leg pain at the time of injury. This often causes the patient to limp so as to protect the medial malleolus. In severe cases, particularly involving a displaced fracture of the medial malleolus, weight bearing may be impossible. Pain is usually felt on the front or inner aspect of the ankle or lower leg and can occasionally settle quickly with rest leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning. Occasionally patients may experience symptoms in the Achilles or calf region.
Patients with a medial malleolus fracture may also experience swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase during certain movements of the foot or ankle or when standing or walking (particularly up hills or on uneven surfaces) or when attempting to stand or walk. In severe medial malleolus fractures (with bony displacement), an obvious deformity may be noticeable. Occasionally patients may also experience pins and needles or numbness in the lower leg, foot or ankle.
Diagnosis of a medial malleolus fracture
A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a medial malleolus fracture. An X-ray is usually required to confirm diagnosis and assess the severity of the fracture. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.
Treatment for a medial malleolus fracture
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Prognosis of a medial malleolus fracture
Patients with a medial malleolus fracture usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in a number of weeks to many months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. In patients with only very minor fractures that are un-displaced (such as an avulsion fracture of the medial malleolus) return to sport can sometimes occur in as little as 6 – 8 weeks as guided by the treating physiotherapist.
Physiotherapy for a medial malleolus fracture
Physiotherapy treatment is vital in all patients with a medial malleolus fracture to hasten healing and ensure an optimal outcome. Treatment may comprise:
soft tissue massage
joint mobilization
dry needling
ice or heat treatment
ankle taping
the use of a protective boot or ankle brace
the use of crutches
the use of heel wedges
exercises to improve strength, flexibility and balance
hydrotherapy
electrotherapy (e.g. ultrasound)
education
activity modification advice
dietary advice to aid fracture healing
a graduated return to activity plan
footwear advice
Other intervention for a medial malleolus fracture
Despite appropriate physiotherapy management, some patients with a medial malleolus fracture do not improve adequately and may require other intervention. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization, pharmaceutical intervention, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the fractured medial malleolus. Occasionally, patients with fractures that are initially managed without surgical intervention may require surgery to stabilize the fracture and a bone graft to aid fracture healing.
Exercises for a medial malleolus fracture
The following exercises are commonly prescribed to patients with a medial malleolus fracture following confirmation that the fracture has healed or that pain free mobiliza