Description of patient:
A 24-years-old professional athlete.

History and previous treatment:
Left ankle trauma in hyperplantar flexion one months before the patient was seen at our patient clinic. An MRI was made which did not show pathology. In retrospect there is an area of slight signal (bone marrow edema) on the medial malleolus (see arrow Picture 2).

Current complaints:
A new trauma in hyperplantar flexion occurred. There is pain and some swelling over the medial malleolus.

Physical examination:
Pain on palpation over medial malleolus. Some swelling. Patient cannot weight bear due to the pain.

Additional investigation (CT/MRI):

Picture 1 & 2: MRI ankle: fracture medial malleolus(red encircled).

Picture 3 & 4: Axial ankle MRI (left) and CT (right) fracture through existing stress fracture and posterior medial malleolus. Red circle in the CT we can see the area of bone absorption which is the pre-existing stress zone. Also anterior "spur" formation which is the result of "repair" of the stress zone. The arrows identifies the fresh fracture line.

Treatment:
The patient underwent ORIF.

Picture 5: Medial approach of the left ankle (A). Inside the black circle, image of the stress fracture in anterior medial malleolus (B). Stress fracture in the anterior medial malleolus (encircled in B) which corresponds to the black circles in the CT (C and D) in which C is 2 slices proximal to D.

Picture 6: At 10 weeks follow-up the CT scan shows anterior bridging (images from distal (left) to proximal (right)). Thus full weightbearing is allowed.