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Ankle Fracture Diagnosis and Rehabilitation

5/25/2018

1 Comment

 
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.
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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. 
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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.
​

​-Dr. Chris Fox, PT, DPT, OCS

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1 Comment
Tex Hooper link
12/8/2021 05:16:14 pm

I like what you said about preparing for neurovascular pain. I need to get a vascular examination of my dad's heart. I'll have to consider seeing the doctor this week.

Reply



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  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test