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. 2026 Jan 22;18(1):e102100.
doi: 10.7759/cureus.102100. eCollection 2026 Jan.

Incidence of Midfoot Instability Associated With Medial Malleolus Fractures: A Retrospective Cohort Study

Zain Al Abdeen Al Zuabi  1 , Eva R Gil Monzó  2 , Velayudhan B Kiliyanpilakkil  3 , Musammad R Begum  4 , Bianca D Chua  5 , Hesham M Youssef  6 , Wai Wai W Mar  7 , Mohamed H Gad  8 , Natalie B Marzouqa  9 , Chandra S Pasapula  3
Affiliations

Incidence of Midfoot Instability Associated With Medial Malleolus Fractures: A Retrospective Cohort Study

Zain Al Abdeen Al Zuabi et al. Cureus. .

Abstract

Background: The incidence of secondary medial arch instability (talonavicular and first ray instability) associated with medial malleolus fractures has not been totally quantified, and to date, its contribution to poor foot function is unknown.

Methods: Twenty-five patients with various mechanisms of ankle injuries associated with medial malleolus fractures who underwent surgical treatment were assessed for patient demographics, mechanism of injury, type of fracture and quantity of medial malleolus displacement in X-rays prior to surgery, type of fixation, and level of midfoot instability, assessed by determining and quantifying talonavicular laxity and first ray instability.

Results: In rotational ankle fractures with the medial malleolus involved, increased midfoot laxity and first ray instability were present in injured ankles compared to the uninjured (p<0.05). In non-rotational ankle fractures (supination adduction/supination plantar flexion), affected feet also had a mean increase in lateral translation scores and first ray instability scores but without statistical significance (p>0.05). There was no significant difference in the spring ligament thickness between injured and uninjured feet (p>0.05), and the displacement of the medial malleolus was not a predictor for the development of increased talonavicular laxity (p>0.05).

Conclusion: Ankle fractures with medial malleolus fractures have a significantly higher incidence of medial arch instability. Rotational ankle injuries, arising from supination external rotation and pronation injuries, can significantly affect medial arch stability. We advocate that surgical restoration of superficial deltoid-spring/capsular-ligamentous integrity and/or early post-operative orthotics after medial malleolar fractures may protect the first ray destabilization and preserve future foot function.

Keywords: cohort study; first ray instability; medial malleolus; midfoot instability; talonavicular laxity.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. HRA and Health and Care Research Wales (HCRW) issued approval 20/PR/0408. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. (A) Use of the digital Klauemeter to assess the dorsal sagittal first ray instability. (B) A dorsal probe applied to the metatarsal head with one hand fixing the second metatarsal to the base allows application of a dorsal force with the other hand.
Figure 2
Figure 2. Lateral translation (LT) score assessment. (A) Spring ligament (SL) and the first metatarsal axis. (B) Small strain in the SL can be amplified visually into a large shift at the hallux using the talonavicular axis and the first metatarsal to amplify strain in the SL. (C) The ankle, talus and calcaneum are immobilised in a padded clamp. The second metatarsal is then aligned with the tibial crest (resting foot position). (D) A lateral force is applied to the foot metatarsal head until an end point is reached. The position of the hallux pre and post force application is noted and then measured. SL strain is amplified to lateral forefoot translation which acts as an indirect measure of SL/DSL strain
DSL: Deltoid-spring ligament
See this image and copyright information in PMC

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