Ankle Fracture Diagnosis and Rehabilitation

An injury that is often seen in both athletic and sedentary populations is an ankle fracture. These injuries, which are more common in the winter months, are often associated with a  traumatic mechanism of injury (like stepping off a curb wrong or blunt trauma). However, sometimes repetitive microtrauma can lead to stress fractures. This is often associated with overtraining, such as increasing running distances or plyometric training too quickly. Even with these well-recognized sources of injury, we often have difficulty identifying which specific individuals have suffered a fracture vs. a sprain or bone contusion. While x-rays and bone scans are the gold standard for diagnosing fractures, they don't help physical therapists in the direct access arena. Fortunately, we can use the Ottawa Foot and Ankle Rules to help identify patients who likely require imaging for further diagnostic assessment.

Rehabilitation

After the diagnosis of an ankle fracture has been made, the region is typically immobilized with limited weight-bearing. The severity and location of the fracture contributes to the decision on what level of immobilization is required: open reduction internal fixation, CAM boot, aircast, etc... This timeframe for immobilization typically occurs for 4-8 weeks (factors like osteoporosis and peripheral vascular disease may impact the timeframe). Once radiographic evidence of sufficient healing occurs, the patient often begins skilled physical therapy.

Initially, the primary focus will be on reducing swelling and improving joint mobility. This is often done with ROM and stretching exercises, joint mobilization, soft tissue treatment, and modalities. Open-kinetic chain strengthening exercises are typically started once the patient's fear of movement and activity tolerance improved. During this initial acute phase, gait training may be necessary to train the client on how to use crutches, how to maintain appropriate weight-bearing status, etc. As the patient gains mobility and weight-bearing is progressed (based on bone healing), weight-bearing exercises will be progressed. The patient may initially need to perform AAROM exercises in closed-kinetic chain in order to address any apprehension and improve load tolerance, while restoring mobility. Full ankle motion is not required nor expected before weight-bearing is initiated. Once the patient presents with sufficient tolerance, closed-kinetic chain load is progressed further with shuttle squats and calf raises, to full body versions as well. Exercise progression becomes more typical at this point as various methods of loading (lunges, squats, step-ups/downs, etc.). What likely needs to be addressed is stability training in some form to improve reaction and balance when stability is challenged. This can include standing on unstable surfaces, incorporating mental and upper extremity tasks, agility/plyometric training, etc. 

This progression has no set time table. We have to respect the severity of the fracture, co-morbidities, prior level of function, planned activities to return to and more. Always consider the physician and/or surgeon's prescribed progression, but move your patient through the various phases based on how that specific individual is doing. A patient with a fibular fracture that also suffered a common peroneal nerve injury will likely not progress as quickly as the same fracture without neurovascular insult. There is no set timeframe for recovery from injury, so prepare to be flexible. You may need to incorporate other treatment methods to help move your patient through each step (spinal manipulation, nerve mobilization, therapeutic neuroscience education, among others). Regardless of the contributing factors, the therapists' objective is to guide the patient back to their prior level of function safely.
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​-Dr. Chris Fox, PT, DPT, OCS

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