Physical Therapist's Guide to Ankle Fracture
An ankle fracture occurs when a bone on 1 or both sides of the ankle is partially or completely broken. Most ankle fractures are caused by twisting injuries and falls, or injuries experienced during sports or play. Under the age of 50, most ankle fractures occur in men. Over the age of 50, women experience more ankle fractures. The type of fracture varies from simple to complex, and can involve 1 or all 3 bones that make up the ankle joint. It is important to seek treatment after an ankle injury to determine if you have a fracture. Physical therapy shares an important role in your treatment and recovery from an ankle fracture, for a return to normal activity.
An ankle fracture is a completely or partially broken bone on 1 or both sides of the ankle joint. There are several types of ankle fractures, and 1, 2, or 3 bones may be fractured. The classifications based on the number of bones broken are:
- Lateral malleolus fracture. Only the bone on the outside of the ankle, the fibula, is broken.
- Medial malleolus fracture. Only the bone on the inside of the ankle, the tibia, is broken.
- Bi-malleolar fracture. Two bones are broken, the fibula and the tibia.
- Trimalleolar fracture. Three bones are broken, the fibula, tibia, and the posterior malleolus (the tibia at the back of the foot).
The severity of the fracture is classified as:
- Nondisplaced. The pieces of the fractured bone remain lined up.
- Displaced. The 2 parts of the fractured bone do not line up.
- Comminuted. Splinters or multiple small pieces of bone are found at the fracture site.
- Complex Fracture. The soft tissue surrounding the broken bone is severely damaged.
- Compound Fracture. Fracture fragments can pierce the skin.
When a fracture involves several broken bones or the bones do not remain lined up, the fracture is considered to be unstable and requires immediate treatment. A compound fracture also involves a risk of infection.
People who fracture their ankles may experience:
- Immediate, severe pain after a twisting injury or fall.
- A “pop” or “snap” felt or heard at the time of the injury.
- Swelling in the ankle.
- Tenderness or pain in the ankle area.
- Difficulty bearing weight on the ankle when standing, walking.
- Not being able to bear weight on the ankle at all.
- Pain that increases with activity and improves with rest.
- Inability to put a shoe on due to swelling and pain.
- A bump or deformity that may be seen or felt at the ankle.
If you see your physical therapist after an ankle injury, the physical therapist will ask about your medical history, and how the injury occurred. Your physical therapist will observe your ability to walk and bear weight on the injured side, and gently examine the area to observe any swelling, deformity, and tenderness. Your physical therapist also will examine your foot and lower leg to identify whether other areas may be injured. If a fracture is suspected, your physical therapist will consult with your physician. An x-ray is needed to confirm or rule out an ankle fracture. You may then be referred to an orthopedic physician or emergency room for further treatment.
It is important to have an ankle injury assessed by your physical therapist or medical provider soon after an ankle injury, to distinguish a severe sprain from a broken bone.
If the bone is piercing the skin, immediately go to a hospital emergency room.
If you see your physical therapist after your injury and an ankle fracture is suspected, your physical therapist will:
- Instruct you in acute injury care using the RICE formula: rest, ice, compression, and elevation.
- Immobilize your ankle by wrapping it with an ace wrap, or applying a stirrup brace to limit motion and control swelling.
- Apply ice to reduce pain and swelling.
- Instruct you to keep the involved ankle elevated to control swelling.
- Instruct you to walk without putting weight on the injured ankle, using crutches or a walker.
- Make recommendations for additional care with an orthopedic physician or emergency department.
If you have an ankle fracture, treatment will depend on how many bones are broken, and if it is a simple, complex, or compound fracture. Initial treatment involves the realigning and stabilizing of the bones by your physician, and is performed in the hospital emergency room or, if needed, with surgery.
If surgery is required, the affected ankle will be placed in a cast or fracture boot to stabilize it following surgery. A physical therapist will visit your hospital room once you are medically stable, to help you get up and out of bed. Your physical therapist will help you sit up on the bedside, and then stand up. You will not be allowed to put any weight on the involved ankle for about 6 to 10 weeks. Your physical therapist will teach you how to walk with the use of an assistive device, such as crutches or a walker. You will also learn how to go up and down steps and curbs using your assistive device.
When an x-ray confirms that the fracture has healed, your physician will remove your cast. Your physical therapist will work with you to safely put weight on your ankle, and begin treatment to help you return to your normal activity.
If You Do Not Require Surgery
A physical therapist can help treat a broken ankle after it has been treated by a physician and immobilized. After the bone is healed, a physical therapist can help you gain back your strength, motion, balance, and sport skills.
After your injured leg is placed in a cast or a cast boot, your physical therapist will teach you how to walk without bearing weight on the injured ankle, using crutches or a walker. Your physical therapist will teach you how to get in and out of bed, and your car. Your physical therapist will provide you with the equipment that best suits your needs.
When healing of the fracture is seen on an x-ray, your physician will remove your cast, and you will begin bearing weight on that leg again, and continue your physical therapy treatment.
Physical therapy treatment will include:
- Walking Instruction. Your physical therapist will help you begin to put some of your weight on the injured leg, gradually progressing to full weight as your physician recommends.
- Gait Training. Your physical therapist will offer specific instruction and exercises to restore a normal walking pattern. The focus will be on how your foot and ankle move, and the timing of your steps. You may practice on a treadmill at low speed, on level ground, and on steps.
- Reducing Swelling. Swelling is common after an ankle fracture. Treatment may include gentle massage, the use of a compression wrap, ice, or heat, and elevating the affected ankle when at rest.
- Exercise. Your physical therapist will design an exercise plan to begin when the cast is removed to help you strengthen and regain motion in your injured ankle. It is important to regain the ability to bend your ankle to restore your full walking ability.
- Restoring Ankle Mobility. Your physical therapist may use manual (hands-on) therapy to gently move your foot and ankle joints and surrounding tissues to reduce stiffness, and increase the ankle's bending range of motion.
- Return to Work/Play Activity. As you regain strength and flexibility, your physical therapist will provide activity training specific to your job, leisure activity, or sport.
Return to full participation in sports and work activities generally occurs 12 to 16 weeks after an ankle fracture.
Note: Physical therapy treatment is different for each person and depends on your type of injury, how you are healing, and whether you had surgery, as well as your age and physical health.
Not all ankle fractures can be prevented. However, some precautions may be taken.
To reduce your risk of ankle injury:
- Wear appropriate protective gear when participating in sports.
- Train to reach your top strength and fitness levels.
- Wear proper shoes, and replace athletic shoes regularly.
To reduce your fall risk:
- Remove obstacles and clutter from hallways and rooms in your home.
- Work and play in well-lighted areas.
- Use night lights in the home.
- Install grab bars to tub/shower areas.
- Add railings to both sides of stairways.
- Maintain strength and fitness throughout your life.
James is a 17-year-old high-school student and a star soccer player for his school. While at soccer practice last week, James twisted his right ankle and fell. He felt sudden and severe pain at the outside of his ankle. When his teammates helped him up, he realized that he couldn't put weight on his right foot to walk. The team's physical therapist was at practice that day, and immediately examined James’ ankle. The right ankle and foot were swelling, and the area on the outside of the ankle was extremely tender to touch.
The physical therapist suspected a severe ankle sprain and possible fracture. He applied ice to the ankle and asked James to keep his leg elevated. He consulted with the team physician; they decided James needed to go to the local hospital's emergency room. James' ankle was placed in a splint, and he was transported to the hospital.
X-rays confirmed a mildly displaced fracture of the lateral malleolus. James had surgery within 24 hours of his injury to fixate the fracture and line up the bones. James' lower leg was placed in a cast. Before leaving the hospital, a physical therapist showed him how to move in and out of bed, and how to use crutches to avoid putting weight on his right leg. She also taught him how to go up and down steps and navigate curbs with his crutches.
After 6 weeks, James' physician confirmed that his fracture had healed enough to allow his cast to be removed. James was given a walking boot, and referred to outpatient physical therapy.
James' outpatient physical therapist taught him how to put some weight on his right ankle, while still using his crutches to walk. He also taught him range-of-motion exercises to improve his ability to bend his ankle. He used gentle hands-on therapy to move James' ankle and foot; to reduce swelling, and improve flexibility and range of motion. They reviewed how to control swelling with the use of ice, compression with an elastic ankle wrap, and elevation to be applied periodically throughout the day.
After 8 weeks, James was allowed to put his full weight on his right foot, and transition out of the walking boot to a regular walking shoe. He worked with his physical therapist to restore his normal walking pattern. His exercises were progressed to include resistance using an elastic band, and stretching exercises to further improve his flexibility and mobility.
Ten weeks after his injury, James was able to work on exercises to improve his balance and coordination. He also was able to build up his strengthening exercises.
After 12 weeks, James began a walk/jog program, and hopping and agility exercises. James’ range of motion was near normal and his pain was gone. James continued to work daily with the home-exercise program designed by his physical therapist, to achieve his goal of returning to the soccer field.
After 16 weeks of hard work, James was ready to train for a new soccer season with his team, fully confident and ready to play!
All physical therapists are prepared through education and experience to treat ankle fractures. However, you may want to consider:
- A physical therapist who is experienced in treating sports injuries, or orthopedic conditions. Some physical therapists have a practice with a focus on sports medicine and orthopedics.
- A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedics and sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have fractured an ankle.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of ankle fracture. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014; 111(21):377–388. Free Article.
Centers for Disease Control and Prevention. Falls among older adults: an overview. Updated December 30, 2014. Accessed February 4, 2015.
Mill JM, Svoboda SJ, Gerber JP. Diagnosis of an isolated posterior malleolar fracture in a young female military cadet: a resident case report. Int J Sports Phys Ther. 2012:7(2):167–172. Free Article. American Academy of Orthopedic Surgeons’ website. Fractures. Updated October 2012. Accessed February 15, 2015.
American Academy of Orthopedic Surgeons’ website. Fractures. Updated October 2012. Accessed February 4, 2015
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Mary Kay Zane, PT, OCS. Reviewed by the MoveForwardPT.com editorial board.
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