Ankle Fracture Rehab ProtocolPhase I – Initial Stability (0 to 6 weeks)

Weight bearing status is dependent on surgeon preferance / fixation strength. Assume  Non-weight-bearing (NWB) in cast or splint.

Ambulatory device training (walker or crutches) and transfers. General lower extremity strengthening – SLR, quad sets, etc.

Phase II – Early Range of Motion/Gait training (6-8 weeks)

Patient is placed in a removable cast boot in orthopedics office (6 weeks). Begin NWB ankle ROM exercises – PF, DF, inversion, and eversion. Gradually increase weight-bearing (PWB) status so patient is full weight

bearing WBAT) by the end of the 8th week. Advance to cane. Advance with aggressive stretching program. Isometric exercises for PF, DF, inversion and eversion. Seated towel toe crunches and push aways (intrinsic foot musculature). Stationary bike for range of motion. Ice for swelling.  Minor swelling usually occurs as patient increases weight-

bearing status. 

Phase IV – Return to Function (After 8 weeks)

Theraband strengthening exercises - DF, PF, inversion, eversion. Advance to home exercise program.

Mini squats, toe raises (bilateral and unilateral) Advance daily stretching Unilateral standing balance (eyes open, eyes closed) Strength program (2-3 sets of 10 repetitions) Total gym squats and toe raises Leg press Hamstring curls Leg extension Endurance Bike Treadmill walking (advance to lateral stepping, backwards walking)

Proprioceptive Exercises – advance per tolerance and patients functional needs

4-way straight leg raises with tubing (a.k.a. "steamboats") Proprioceptive star – toe touch and lunges Rebounder Fitter Seated BAPS board, progress to standing Mobilisations per therapist Modalities PRN – Fluidotherapy, moist heat, ice

Review References

Brotzman, S.B. and Brasel, J. "Foot and Ankle Rehabilitation," Clinical Orthopedic Rehabilitation.  Mosby, 1996. pgs. 258-263.

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Ankle and Foot Fractures

Contents[hide]

1 Definition/Description 2 Clinically Relevant Anatomy 3 Epidemiology /Etiology 4 Characteristics/Clinical Presentation 5 Differential Diagnosis 6 Diagnostic Procedures 7 Examination 8 Medical Management 9 Physical Therapy Management 10 Resources 11 Clinical Bottom Line 12 Recent Related Research (from Pubmed) 13 References

Definition/Description

An ankle fracture is a fracture in a bone that shapes the ankle. This can be the end of the fibula (malleolus lateralis), the end of the tibia (malleolus medialis) or both (bimalleolar fracture). They usually result from an external rotation injury to the

ankle.

Ankle fractures are classified by the AO classification. More information about this classification:

http://www.physio-pedia.com/index.php5?title=AO_classification

Be aware that many people mistake an ankle fracture for an ankle sprain. This injuries are quite different and need an accurate and early diagnosis.

Clinically Relevant Anatomy

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Epidemiology /Etiology

There are different causes for an ankle fracture:- A big force that works into the bone. For example a kick or a smack during sport activities or a car accident.- A little piece of the bone tears off when there is pulled at a ligament. For example when you stumble. - Twisting or rotating your ankle - Rolled your ankle

Characteristics/Clinical Presentation

- Difficulties or even inability to walk or load the ankle. (it is possible to walk with less severe breaks, so never rely on walking as a test of whether a bone has been fractured.- Pain - Swelling, along the length of the leg or more localized- Blisters (over the fracture site).- Bruising (soon after the injury).- Difference in appearance.When an ankle has been broken, there is not only structural damage to the skeletal structure, but also to the ligament tissue (deltoid ligament and the anterior and posterior tibiofibular ligaments) and possibly nervous and musculoskeletal tissue around the ankle complex.. This can result in impaired balance capacity, reduced joint position sense, slowed nerve conduction, velocity, impaired cutaneous sensation and decreased dorsal extension range of motion[1]

Differential Diagnosis

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Diagnostic Procedures

To evaluate the ankle in the acute fase, we use the ‘Ottawa ankle rules’. Ottawa_Ankle_Rules

Examination

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Medical Management

Most patients with a malleolus fracture require 6 weeks of immobilization. Patients with an initially non-displaced fracture or who were treated surgically will generally require 4 weeks of non-weight bearing in a short-leg cast or removable walking boot, followed by 2 weeks in a walking cast or boot. The removable boot will allow for earlier range-of-motion exercises.Surgery is needed for many types of ankle fractures. While not always necessary, surgery for ankle fractures is not uncommon. The need for surgery depends on the appearance of the ankle joint on X-ray and the type of ankle fracture.Adequate reduction with congruency of the joint has been reported as one of the most important indications of a good end result. Inadequate reduction may lead to osteoarthritis.

Physical Therapy Management

After 6 weeks of immobilization, the ankle can be fully loaded. There is no standardized rehabilitation program after cast removal. Each program is individually[1]

Physiotherapists are often involved in the rehabilitation, which starts quickly (1 week) after the period of immobilization. Most people experience pain, swelling, stiffness, muscle atrophy and decreased muscle torque[2], impaired ankle mobility, impaired balance capacity and increased ankle circumference[1] at the ankle after cast removal. Consequently, patients complain of limitation in activities involving the lower limb, such as stair climbing, walking and reduced participation in work and recreation. It has been found that patients with unimalleolar fractures report less activity limitation than those with bimalleolar or trimalleolar fractures[3]

Passive joint mobilization is commonly used to work on the problems of pain and joint stiffness, in order to allow an earlier return to activities. For this technique, the physiotherapist manually glides the articular surfaces of a joint to produce oscillatory movements. It has been proven that manual therapy, such as joint mobilization, produces analgesic effects. It also increases elasticity of joint structures through interactions at the local, central nervous system and psychological levels[4]

There is evidence that, after a surgical treatment for an ankle fracture, a training program, started within one week after cast removal and continued for 12 weeks (with

2 appointments per week), shows superior results compared to usual care, regarding patient scored function and muscle strength in the plantar flexors and dorsiflexors of patients under the age of 40. The patients had to do home exercises daily, prescribed by the physiotherapist, appropriate to the functional status at the time. Functional goals are loaded ankle dorsiflexion, plantairflexion, on-leg-stance, rising on toes, rising on heels, normalized walking pattern when walking on even ground, on stairs and at comfortable speed[5]

 

When the cast is removed, many patients have a plantarflexion contracture (http://www.physio-pedia.com/index.php5?title=Plantarflexion_contracture). This contracture is not caused directly by fracture but develops as an adaptive response to immobilization. The addition of a program of passive stretches has no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization[6]

Ankle Eversion

Ankle eversion is the movement of turning the sole of the foot outwards and is controlled by the peroneal muscles on the outer calf.

Active Ankle Mobility

Active ankle movements such as these are great in the early stages after an ankle injury. They will help to increase ankle movement and also pumping the ankle up and down will help reduce swelling.

Ankle Eversion with Band

Ankle eversion is also sometimes known as supination and is the movement of turning the foot so the sole faces outwards (away from the other foot). A resistance band is very useful for ankle exercises.

Box Jumps

Calf Raise on Step

The calf raise is a widely used exercise to strengthen the calf muscles. There are many variations and resistance machines are also available.

Dorsi flexion with band

Dorsiflexion is the movement of pulling the foot upwards. Using a resistance band to perform this movement will strengthen the shin muscles.

Eccentric Heel Drop

The eccentric heel drop places the emphasis of the movement on the downward phase so that the calf muscles must contract as they lengthen to control dorsiflexion.

Heel Toe Balance

The heel toe balance exercise, sometimes called a tandem stance is designed to start to work on proprioception and balance. This is a good build-up to wobble board work.

Heel Toe Walking

Heel toe walking is a great exercise for the ankle and calf muscles. It will strengthen all muscles of the lower leg, as well as help improve proprioception or balance.

Hopping Exercises

Hopping exercises are important in late stage rehabilitation in lots of sports. They

help to improve balance, proprioception and explosive strength.

Isometric Inversion & Eversion

Isometric inversion and eversion. This exercise is used to begin to strengthen the ankle invertors (tibialis posterior) and evertors (peroneals) in the early stages of treatment.

Medicine Ball Catch

The medicine ball catch exercise is designed to challenge the single leg balance with an unknown. This develops proprioception after lower limb injuries.

Plantar flexion with band

Plantar flexion is the ankle movement of moving the foot down, pointing the toes away from the body. Using a resistance band is an early stage exercise for calf strengthening.

Posterior Tibialis Exercise

The posterior tibialis exercise targets this muscle specifically by combining the two

movements which it performs. This muscle may need strengthening to help reduce overpronation.

Proprioception Exercises

Proprioception is our sense and awareness of the position of our body parts and is closely linked to balance. Having good proprioception helps to reduce the risk of injury.

Resistance Band Inversion

Inversion (also known as pronation) is the movement of turning the foot so that the sole faces inwards. A resistance band is great for this exercise and other ankle exercises.

Resistance Band Jump

The resistance band jump exercise is a great late stage proprioception test! Hops and jumps can be used in the early stages but using the band adds an extra challenge

Resisted Eccentric Inversion

Resisted eccentric inversion is a great exercise for using after ankle sprains to help reduce the chance of future injuries.

Seated Calf Raise

The seated calf raise exercise is used to strengthen the calf muscles, especially Soleus. It is an early stage exercise which can be progressed to standing once this is pain free.

Step Back

Step back exercises can be used as late stage ankle exercises to increase push-off strength, but will also work the hip and bum muscles.

Stork Balance

The stork balance is a simple single leg balance exercise, although various progressions can be added to make it more difficult. It improves balance and proprioception.

Strengthening Exercises for the Foot

The following guidelines are for information purposes only. We recommend seeking

professional advice before beginning rehabilitation.

Toe Raise

Toe raise or foot raise exercises work the shin muscles at the front of the lower leg. This is an early stage exercise which can be progressed using a resistance band.

Wobble Board Exercises

The main aim of using a balance board is to improve proprioception. This is our sense and awareness of the position of our body parts.

Rehabilitation exercises:

Lower leg & Ankle Knee & thigh Hip & groin Core & Abdominal Back Shoulder Arm & elbow Wrist & hand

Ankle dislocation rehab protocolDistal fibular fracture and deltoid ligament repair

General considerations

Patient will be walking with crutches and touchdown (toe-touch) weight bearing on the surgical leg for 4 - 6 weeks post-op.

Patient will be in a removable boot for 6 weeks or longer, pending x-rays.

Avoid unnecessary walking or standing for the first 2-3 weeks to control swelling and pain.

Ice ankle/foot 3-5 times (15 minutes each time) per day to control swelling and inflammation.

Elevate leg above the heart as much as possible to control swelling and inflammation.

Come out of boot twice daily for 20 minutes each time to allow skin to breathe and to promote skin healing.

Clean skin with wipe while out of boot. Keep cast and liners very clean to avoid infections. Wipe down inside plastic of boot

daily with alcohol and wash the liner every other day. No ankle range of motion exercises for 4 weeks. Ankle isometrics inside the boot

should be done daily. No impact or cutting exercises/activities for 3 months post-op. M.D. follow-up visits at Day 1, Month 1, Month 6 and Year 1 post-op.

Weeks 1 - 4:

M.D. visit at day 1 post-op to change dressing and review home program. Start ankle isometrics inside the boot immediately post-op. Do 5 repetitions of 5

second contractions. Repeat this 5x per day. No ankle range of motion exercises for 4 weeks. Nurse appointment at day 14 for suture removal and check-up. Gait training with crutches to minimize compensations and to enforce touchdown

weightbearing status on the surgical leg.

Exercises:

Toe curls and toe spreads Quad-sets with straight-leg raises Gluteal sets Well-leg biking Upper body training

Weeks 4 - 6:

Follow-up x-ray at week 4 to monitor healing. Pending x-ray findings, may start partial weightbearing still using crutches and

walking boot. Can start using AirCast Stirrup splint for sleeping only instead of the walking boot. Start ankle partial range of motion (ROM) and non-weightbearing to partial

weightbearing ankle isotonic exercises. Soft tissue treatments for swelling, mobility and healing.

Weeks 6 - 8:

Follow-up x-ray at week 6. Pending x-ray findings, may start weightbearing as tolerated and progressive

weaning of assistive devices (single crutch to cane to no device, if necessary). Can wean off boot and use AirCast Stirrup instead. Gait training to normalize movement patterns. Start to seek full ankle range of motion per patient tolerance and without flare-ups. Start weightbearing strength and balance exercises. Begin joint mobilizations to seek full range of motion.

Weeks 8 - 12:

Increase functional weightbearing exercises and activities. Avoid impact and cutting activities until week 12.

Can start to wean off AirCast Stirrup if the patient has enough dynamic control and stability of the ankle.

Aim for ankle range of motion to be full by week 12. Continue with mobilizations.

Weeks 12 and beyond:

Start sport-specific training. Increase the intensity of strength, balance, coordination and functional training for

gradual return to activities and sports. Return to specific sports is determined by the physical therapist through functional

testing specific to the targeted sport.

The ankle is where the talus bone of the foot and the tibia (shin bone) and fibula of the leg connect and move. Trauma here can cause a break in any or all of these bones and significant pain usually results immediately after the injury. If you suspect you have a broken bone in your ankle, your first step should be to seek medical attention immediately. Failure to do so may result in significant loss of function.

Ankle fractures almost always occur during a traumatic event to the body. Automobile accidents, falls, and sports injuries can all lead to ankle fractures. Common signs of an ankle fracture include pain, swelling, bruising, and an inability to bear weight on the broken ankle.

What to Expect After an Ankle Fracture

While at the hospital following an ankle fracture, your doctor will attempt to reduce the fracture. This procedure helps to align the broken bones and allow for normal healing to take place. If the break is severe, a surgical procedure may be performed called an open reduction internal fixation (ORIF). During this procedure, your surgeon will align the broken bones and then hold the bones in place with metal rods

and screws.

After your ankle fracture is reduced, your ankle will most likely be casted. This immobilizes the ankle and allows the bones to heal properly. Many times after an ankle fracture, you will require some sort of assistive device to walk. You may also be under specific weight bearing restrictions. Be sure to ask your doctor how much weight you are allowed to put on your ankle as it heals.

Physical Therapy After an Ankle Fracture

Once your fracture is reduced and immobilized, you may be referred to physical therapy to learn how to use your assistive device like crutches, a cane, or a walker. Your physical therapist should also be able to help you understand your weight bearing restrictions. Gentle exercise for the muscles of the knee and hip may be performed to ensure that the muscle groups that help you walk do not get too weak while the fracture heals. If you are in a cast or a brace, most likely you will not be performing exercises for your ankle.

After your fractured ankle has healed, your doctor will remove the cast and allow you to bear more weight on your ankle. You still may be using an assistive device like a quad cane or crutches to walk.

At this point, your physical therapist can fully evaluate your ankle to help provide the proper treatment. Components of the ankle evaluation may include:

Gait Range of motion Strength Swelling Pain Scar assessment (if you had an ORIF surgery)

After a thorough evaluation, your physical therapist can begin providing treatment. He or she may use therapeutic modalities like heat, ice, or electrical stimulation to help treat swelling or pain around your ankle.

Exercise should be a main component of your ankle rehabilitation following a fracture. Exercises to improve ankle range of motion and strength are paramount. Exercises for the hips and knees may be used as well. Most likely you will be required to perform a home exercise program. Be sure to follow your physical therapist's directions closely and ask questions if you have any.

Wolff's law states that bone grows and remodels in response to the stress that is placed upon it. Your physical therapist can help prescribe exercises that apply the right stress in the correct direction to ensure that maximal bone healing occurs and

that your fractured ankle will function properly.

Gait training will also be important following an ankle fracture. Your physical therapist can help you progress from using an assistive device to walking independently.

If you have had surgery to reduce your ankle fracture, there may be scar tissue around the incision. Your physical therapist can perform scar tissue massage and mobilization to help improve mobility of the scar. He or she can also teach you how to perform scar massage techniques on your own.

An ankle fracture can lead to significant loss of function and limit your ability to walk, run or participate fully in work and recreational activities. Physical therapy after an ankle fracture can help you improve mobility and help you safely return to normal activity and function.

Ankle Fracture Exercises

1. Live Well Library 2. Adult Health Advisor 3. Ankle Fracture Exercises

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As soon as it doesn’t hurt too much to put pressure on the ball of your foot, start stretching your ankle using the towel stretch. When this stretch is easy, try the other exercises.

Towel stretch: Sit on a hard surface with your injured leg stretched out in front of you. Loop a towel around your toes and the ball of your foot and pull the towel toward your body keeping your leg straight. Hold this position for 15 to 30 seconds and then relax. Repeat 3 times.

Standing calf stretch: Stand facing a wall with your hands on the wall at about eye level. Keep your injured leg back with your heel on the floor. Keep the other leg forward with the knee bent. Turn your back foot slightly inward (as if you were pigeon-toed). Slowly lean into the wall until you feel a stretch in the back of your calf. Hold the stretch for 15 to 30 seconds. Return to the starting position. Repeat 3 times. Do this exercise several times each day.

Standing soleus stretch: Stand facing a wall with your hands on the wall at about chest height. Keep your injured leg back with your heel on the floor. Keep the other leg forward with the knee bent. Turn your back foot slightly inward (as if you were pigeon-toed). Bend your back knee slightly and gently lean into the wall until you feel a stretch in the lower calf of your injured leg. Hold the stretch for 15 to 30 seconds. Return to the starting position. Repeat 3 times.

Ankle range of motion: Sit or lie down with your legs straight and your knees pointing toward the ceiling. Point your toes on your injured side toward your nose, then away from your body. Point your toes in toward your other foot and then out away from your other foot. Finally, move the top of your foot in circles. Move only your foot and ankle. Don't move your leg. Repeat 10 times in each direction. Push hard in all directions.

Resisted ankle dorsiflexion: Tie a knot in one end of the elastic tubing and shut the knot in a door. Tie a loop in the other end of the tubing and put the foot on your injured side through the loop so that the tubing goes around the top of the foot. Sit facing the door with your injured leg straight out in front of you. Move away from the door until there is tension in the tubing. Keeping your leg straight, pull the top of your foot toward your body, stretching the tubing. Slowly return to the starting position. Do 2 sets of 15.

Resisted ankle plantar flexion: Sit with your injured leg stretched out in front of

you. Loop the tubing around the ball of your foot. Hold the ends of the tubing with both hands. Gently press the ball of your foot down and point your toes, stretching the tubing. Return to the starting position. Do 2 sets of 15.

Resisted ankle inversion: Sit with your legs stretched out in front of you. Cross the ankle of your uninjured leg over your other ankle. Wrap elastic tubing around the ball of the foot of your injured leg and then loop it around your other foot so that the tubing is anchored there at one end. Hold the other end of the tubing in your hand. Turn the foot of your injured leg inward and upward. This will stretch the tubing. Return to the starting position. Do 2 sets of 15.

Resisted ankle eversion: Sit with both legs stretched out in front of you, with your feet about a shoulder's width apart. Tie a loop in one end of elastic tubing. Put the foot of your injured leg through the loop so that the tubing goes around the arch of that foot and wraps around the outside of the other foot. Hold onto the other end of the tubing with your hand to provide tension. Turn the foot of your injured leg up and out. Make sure you keep your other foot still so that it will allow the tubing to stretch as you move the foot of your injured leg. Return to the starting position. Do 2 sets of 15.

You may do the following exercises when you can stand on your injured ankle without pain.

Heel raise: Stand behind a chair or counter with both feet flat on the floor. Using the chair or counter as a support, rise up onto your toes and hold for 5 seconds. Then slowly lower yourself down without holding onto the support. (It's OK to keep holding onto the support if you need to.) When this exercise becomes less painful, try doing this exercise while you are standing on the injured leg only. Repeat 15 times. Do 2 sets of 15. Rest 30 seconds between sets.

Step-up: Stand with the foot of your injured leg on a support 3 to 5 inches (8 to 13 centimeters) high --like a small step or block of wood. Keep your other foot flat on the floor. Shift your weight onto the injured leg on the support. Straighten your injured leg as the other leg comes off the floor. Return to the starting position by bending your injured leg and slowly lowering your uninjured leg back to the floor. Do 2 sets of 15.

Balance and reach exercises: Stand next to a chair with your injured leg farther from the chair. The chair will provide support if you need it. Stand on the foot of your injured leg and bend your knee slightly. Try to raise the arch of this foot while keeping your big toe on the floor. Keep your foot in this position.

With the hand that is farther away from the chair, reach forward in front of you by bending at the waist. Avoid bending your knee any more as you do this. Repeat this 15 times. To make the exercise more challenging, reach farther in front of you. Do 2 sets of 15.

While keeping your arch raised, reach the hand that is farther away from the chair across your body toward the chair. The farther you reach, the more challenging the exercise. Do 2 sets of 15.

If you have access to a wobble board, do the following exercises:

Wobble board exercises

Stand on a wobble board with your feet shoulder-width apart.

Rock the board forwards and backwards 30 times, then side to side 30 times. Hold on to a chair if you need support.

Rotate the wobble board around so that the edge of the board is in contact with the floor at all times. Do this 30 times in a clockwise and then a counterclockwise direction.

Balance on the wobble board for as long as you can without letting the edges touch the floor. Try to do this for 2 minutes without touching the floor.