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Sports Injury Prevention & Rehabilitation

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Medial Malleolus Fracture

Also known as Tibia Fracture, Fractured Tibia, Fractured Medial Malleolus, Broken Tibia, Ankle Fracture)
What is a medial malleolus fracture?
A medial malleolus fracture is a condition characterized by a break in the bony process situated at the inner aspect of the ankle known as the medial malleolus.
The lower leg comprises of two long bones, known as the tibia and the fibula, which are situated beside each other. The tibia bone lies on the inner aspect of the lower leg and forms joints with the femur (at the knee), the fibula (near the knee and at the ankle) and the talus in the ankle. The tibia has a bony process situated at the inner aspect of the ankle known as the medial malleolus.
During certain activities such as landing from a jump, or when rolling an ankle, stress is placed on the tibia and medial malleolus. When this stress is traumatic, and beyond what the bone can withstand, a break in the medial malleolus may occur. This condition is known as a medial malleolus fracture.
Because of the large forces required to break the tibia, a medial malleolus fracture often occurs in combination with other injuries such as a sprained ankle or other fractures of the foot, ankle or lower leg.
Medial malleolus fractures can vary in location, severity and type including avulsion fracture, stress fracture, Potts' fracture, displaced fracture, un-displaced fracture, compound fracture, greenstick, comminuted etc.

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 tennis. 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 doctor is essential to assist with diagnosis of a medial malleolus fracture. An X-ray is usually required to confirm diagnosis and assess the severity. 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

For those medial malleolus fractures that are displaced, treatment typically involves anatomical reduction (i.e. re-alignment of the fracture by careful manipulation under anaesthetic) followed by surgical internal fixation to stabilize the fracture (using plates and screws). This may be followed by the use of a protective boot, brace, plaster cast and/or crutches for a number of weeks.
For those fractures that are not displaced, treatment may involve the use of crutches and/or a protective boot or brace, or, plaster cast immobilization and the use of crutches, followed by the use of a protective boot or brace for a number of weeks. The orthopaedic specialist will advise the patient as to which management is most appropriate based on a number of factors, including the location, severity and type of medial malleolus fracture.
Evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. Once healing is confirmed, rehabilitation can progress as guided by the treating doctor.
One of the most important components of rehabilitation following a medial malleolus fracture is that the patient rests sufficiently from any activity that increases their pain (crutches and / or a protective boot are often required). Activities which place large amounts of stress through the medial malleolus should also be avoided, particularly excessive weight bearing activity such as running, jumping, standing or walking excessively (especially up hills or on uneven surfaces). Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities and weight bearing forces is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating therapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the medial malleolus fracture altogether.
Patients with a fractured medial malleolus should perform pain-free flexibility, strengthening and balance exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as balance, soft tissue flexibility and strength are quickly lost with inactivity. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
In the final stages of rehabilitation for a medial malleolus fracture, a gradual return to activity or sport can occur as guided by the treating therapist provided there is no increase in symptoms.
It may be advised upon returning to some sports, particularly those sports requiring rapid change of direction, such as football and netball, that the ankle is either taped or braced for additional support or protection. The treating therapist can advise if this is recommended.

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 therapist.

Physical therapy for a medial malleolus fracture

Physical therapy 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
  • electrotherapy (e.g. ultrasound)
  • taping or bracing
  • the use of a protective boot or brace
  • the use of crutches
  • exercises to improve strength, flexibility and balance
  • hydrotherapy
  • education
  • activity modification
  • a graduated return to activity plan
  • footwear advice

Other intervention for a medial malleolus fracture
Despite appropriate therapy 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 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.