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Ankle fractures: What can help get you back on your feet again?

Created: ; Last Update: March 14, 2013.

photo of woman doing physiotherapy
Using a removable brace or splint and starting gentle exercises or physiotherapy within days of ankle fracture surgery could have short-term benefits. Early movement can also cause problems with wound healing, though.

When people twist their ankle it can become swollen and painful, but the ankle is usually only sprained. This means that muscles and soft tissue around the ankle joint are damaged. You can read more about ankle sprains in our fact sheet. Sometimes, however, the ankle joint is fractured (broken). This is a more serious injury that also affects bones in your shin and/or calf.

Joints are connections between two bones. Ankle joints enable us to move our feet up and down. The ankle joint is made up of three bones:

  • the shinbone (tibia) – the main bone between the knee and ankle,
  • the calf bone (fibula) – a second, smaller bone on the outer side of the leg, and
  • the ankle bone (talus) – a bone in the foot, under the ankle joint.

In a healthy joint, the ends of the bones are covered with a layer of cartilage. This thin, hard layer acts as a shock absorber and protects the bone. The movement of the joint is supported by tendons and ligaments. Tendons connect muscles to bones. Ligaments connect bones to bones and help stabilize joints.

You can find more on this topic in our feature.

If the ankle joint is fractured, the ligaments are often torn too, and cartilage may also be damaged. The foot becomes swollen, is painful and can no longer hold any weight. It takes several days or weeks for the swelling to go down completely. It can take months for the ankle joint to fully recover from the fracture.

Treatments to help the ankle recover

Ankle fractures do not usually need surgery. Whether or not surgery is done depends on many different factors, including how bad the fracture is, where the bones are fractured, and whether the bone fragments are in the right place. Screws or plates could be used to hold the fractured bone together so that it can grow together again. After surgery the ankle will be immobilized (kept still) with a brace, splint or plaster cast. Some braces and splints are removable, making it possible to already start doing gentle exercises during the immobilization phase.

Even if surgery is not needed, the foot is still immobilized at first. Immobilization aims to protect the foot so that the healing process is not disturbed. Braces, splints or casts are generally used for around six weeks. After a while exercises can be done to gradually put more strain on the joint and strengthen it. However, the point at which people are advised to start doing gentle exercises or physiotherapy depends on things like how bad the injury is: some already start a few days after the injury or surgery, and others only start when the brace or cast comes off.

If the healing process is disturbed too early and the fracture does not heal properly, further treatment may be needed. But on the other hand, if a person does not move their foot for a long time, their ankle joint could become less mobile. What is more, immobilizing a leg for a long time increases the risk of thrombosis (a blood clot in the veins). You can read more about that in our information “Can medication prevent thrombosis in immobilized legs?”

Research on how effective rehabilitation interventions are

Researchers from the Cochrane Collaboration – an international network of researchers – wanted to find out which forms of rehabilitation best help ankles recover from a fracture. The main questions were: When should you start moving and putting strain on the ankle again? What are the best ways to do this? And could treatments such as electrotherapy or hypnosis help?

The researchers looked for randomized controlled trials to find out which interventions could help to regain ankle mobility faster, and how they compare with other treatments. The Cochrane researchers included a total of 38 trials in their analysis, involving almost 1,900 people. The participants were male and female adults of all age groups. The individual trials looked at the advantages and disadvantages of:

  • Interventions done during the immobilization phase: When analyzing the trials, the researchers looked separately at data from people who had ankle surgery and those who did not have ankle surgery before the foot was immobilized. The interventions that were studied included different types of splints as well as hypnotherapy.
  • Interventions done after the immobilization phase: These trials looked at interventions such as physiotherapy, stretching or electrotherapy. They were only started once the splint, bandage or cast had been removed. Some of the people in these trials had had surgery, others had not.

Interventions during immobilization

Conservative treatment

Three trials looked into the question of which interventions help best if surgery is not performed (conservative treatment). The pros and cons of wearing two different kinds of splints were compared in two of the trials. The third compared hypnotherapy with physiotherapy (as the standard therapy). The results did not show any clear differences between these interventions.

After surgery

30 trials examined interventions after surgery, such as wearing a bandage or splint, in some cases also combined with either exercises or electrotherapy. It is not possible to determine the advantages and disadvantages of all of the interventions because the trials compared very different therapies and many of the trials were very small.

Ten of these trials checked how effective exercises at an early stage were. The results suggested that the ankle generally becomes more mobile somewhat earlier in people who wear a removable brace or splint after surgery and start doing exercises sooner. In the trials, these participants were also able to get back to everyday activities sooner than participants who wore non-removable splints and started the exercises later. Both groups of participants were similarly active and mobile by the end of the trials, though.

But moving the foot soon after surgery also meant that people were more likely to have minor problems, usually with wound healing. About 24 out of 100 people who already started doing gentle exercises a few days after surgery reported some kind of problem, compared with 10 out of 100 people who started moving the joint later on. This means that about 14 out of 100 participants had problems because they moved their foot earlier. However, serious adverse effects like re-fracturing the ankle were rare in all the groups.

Interventions done after immobilization

Five trials looked at whether individually tailored physiotherapy, stretching, electrotherapy or exercises have an advantage over conventional physiotherapy. None of these therapies were more effective than conventional physiotherapy in making the joint more mobile. These trials included both people who had had surgery as well as those who had not.

Published by the Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

Next planned update: February 2016. You can find out more about how our health information is updated in our text "Informed Health Online: How our information is produced."

References

  • IQWiG health information is based on research in the international literature. We identify the most scientifically reliable knowledge currently available, particularly what are known as “systematic reviews.” These summarize and analyze the results of scientific research on the benefits and harms of treatments and other health care interventions. This helps medical professionals and people who are affected by the medical condition to weigh up the pros and cons. You can read more about systematic reviews and why these can provide the most trustworthy evidence about the state of knowledge in our information “Evidence-based medicine.” We also have our health information reviewed to ensure medical and scientific accuracy.
  • Lin C-W C, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Sys Rev 2012; (11): CD005595. [Summary] [PubMed: 23152232]
© IQWiG (Institute for Quality and Efficiency in Health Care)
Bookshelf ID: NBK131767
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