Ankle Fracture Rehab Protocol

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The goal of this protocol is to provide a clinical guideline for the non-surgical and post-surgical course of physical therapy for a patient who has suffered an ankle fracture.  This is not intended to substitute clinical decision making regarding the patient’s proper progression based on evaluation findings, individual progress, and if/when post-operative complications arise.  If a clinician requires assistance in the progression of a post-surgical patient the surgeon should be consulted. The rehabilitation approach will be individualized depending on the patient’s prior level of function and goals. 

GENERAL GUIDELINES:

• There are different types of ankle fractures, so we recommend you defer to your surgeon and physical therapist for specific progressions to maximize your recovery of your ankle fracture. 
• Healing of bone typically takes approximately 6-8 weeks, but individuals can heal at different rates, you will typically be non-weight bearing or partial weight bearing for 6-8 weeks.  Sometimes lower extremity bones may take 8-10 weeks to heal.
• Following your weight bearing guidelines is crucial to allow for healing of the bone and surrounding tissue.
• Your occupation will dictate your return to work, but if you sit at a desk you should be able to return once you are able to discontinue strong pain medication that may impair your cognition
• Driving can occur within a couple weeks if the left ankle is injured, but if your right ankle is injured then your surgeon will have to determine that you are ready to bear weight through the ankle in order to drive, you should also cease all medication that can affect your timing and decision making judgment while driving.
• Mild swelling and a feeling of tightness may remain for months due to gravity keeping fluid in your foot and ankle while you are up and walking, and this is a normal expectation.

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING (ADLs)

• Full rehabilitation and return to sports can take 6 or more months depending on your activities
• You will have to wear a boot and use crutches or a scooter for approximately 6 weeks when bearing weight
• You will follow a linear rehabilitation program going from non-weight bearing to partial weight bearing to full weight bearing and you will have to walk before you run before you sprint, cut, and jump
• Low impact cardiovascular training such as a bike followed by an elliptical will be beneficial but follow your surgeon and physical therapist’s guidelines
• Strength training in a seated or lying down position will be allowed once your physical therapist and surgeon deem it to be safe to maintain muscular strength and endurance

Rehabilitation Progression

PHASE I: Week 0 – 3:

Goals:

• Protect fracture healing
• Decrease edema and swelling
• Begin light ankle ROM exercises in non weight bearing position
• Maintain environment for healing and prevent deep vein thrombosis (DVT)

Precautions:

• Maintain ankle ROM to prevent DVT
• Avoid getting incisions wet if still open

Weight Bearing Status:

• Usually non-weight bearing with a boot or splint on the ankle and using crutches or a scooter

Exercises:

• Ankle pumps
• Toe squeezes
• Gluteal strengthening
• Light exercise:  seated or lying down

Functional Performance Testing:

• WB: Half-kneeling inline balance test (if applicable)
• NWB: Ankle AROM within 5% of contralateral side

PHASE II: Week 4-6:

Criteria to advance to Phase II:

• Good healing environment
• Decreased swelling
• Performing daily activities safely

Goals:

• Increase ankle ROM
• Increase leg and core strength depending on goals

Weight Bearing Status:

• Transitioning from non-weight bearing to partial weight bearing and preparing for full weight bearing

Exercises:

• Aquatic treadmill if allowed by surgeon and PT based on incision healing
• Ankle AROM in all directions
• More aggressive hip, core, etc. exercise in seated or lying down position
• Light open kinetic chain strengthening exercises (using bands) for ankle
• Gentle low impact cardiovascular exercises (bike)

Functional Performance Testing:

• Normalized (or modified)  LE movement patterns: squat, lunge, dead lift
• Single Limb Balance – 20 sec
• Single Limb heel raise within 10% of contralateral

Phase III:  Week 7 to 12:

Criteria to advance to Phase III:

• Increased ankle ROM actively and passively
• Ready for full weight bearing
• Decreased swelling

Goals:

• Full ankle ROM within individual limits
• Progress to standing exercise for balance, proprioception, and ankle strengthening
• Normal walking pattern
• Progress out of walking boot per surgeon and PT’s decision

Exercises:

• Single leg balance exercises
• Weight bearing lower extremity exercises with low impact (squats, step ups, etc.)
• Focus on strength of the lower extremity and demonstrate equal bilateral strength
• Low impact cardiovascular exercises (bike, elliptical, etc.)

Functional Performance Testing:

• Single Limb heel raise within 5% contralateral
• Normalized LE movement patterns without modification

Phase IV:  3 to 6 Months:

Criteria for advancement to Phase IV:

• Walk normally
• 5/5 ankle strength on the affected side
• Good balance with single leg activities
• Full ankle ROM without discomfort

Goals:

• Begin light jogging and other plyometric exercises per surgeon and PT
• Perform equal heel raises on each leg
• Good running mechanics

Exercises:

• Light plyometric exercises
• Walk-run program
• Light sport-specific training
• More aggressive single leg exercises

Functional Performance Testing:

• Hayden plyometrics (athletic population)
• Fast walking/jogging (general population)
• Single limb heel raise within 5% of contalateral 

Phase V:  Begins at post-operative 6 to 7 Months:

Criteria for advancement to Phase V:

• Tolerating light jogging and running progression without discomfort

Goals:

• Return to previous activity level (running, jumping, cutting, etc.) without pain
• Equal functional testing (balance, hop, strength) on each leg
• Discharge from PT with an exercise program

Exercises:

• Advanced therapeutic exercise
• Plyometric and explosive movement progressions
• Return to sport-specific training

Functional Performance Testing:

• Patient dependent based on goals

Bracing:

• An ankle brace may be prescribed based on surgeon and PT’s decision making