An ankle fracture is a break to one of the bones around the ankle joint. This happens when force beyond the capacity of the bone is placed on the ankle. They can occur as a result of a nasty ankle sprain or direct blow to the ankle, and can vary in severity—from a minor incomplete fracture to a complex comminuted (fragmented) and open fracture. Ankle fractures result in pain, swelling and limited function around the ankle. The break usually occurs at one of the lower leg bones (tibia and fibula), but can also occur to the talus (bone inside the hinge of the ankle).

What causes ankle fractures?

Ankle fractures commonly occur after a severe ankle sprain such as rolling over the ankle. They can also occur after a fall (down some stairs, for example) or from a direct blow such as a kick or vehicle accident. Typically (though not always), after a fracture, you may find it difficult to walk or put any weight on the area. For more severe fractures, a deformity may be seen in the bones. Those people with poor bone health (low bone density, poor nutrition or hormonal deficiencies) are at greater risk of sustaining a fracture. Importantly, fractures will heal, as long as the bones are realigned and given sufficient healing conditions.

How do I know if I have an ankle fracture?

Ankle fractures are the result of serious incidents or major trauma. They are often very painful, even at rest when you are not on your feet. In some cases, you may not be able to walk or put weight on the foot; however, being able to weight-bear does not guarantee that you haven’t sustained a break. The ankle will swell usually immediately after injury.

Your physiotherapist will be able to assess the injury and, if they are concerned about a break, they will refer you for imaging—usually an X-ray. For more serious injuries, with other associated injuries such as ligament strains, an MRI scan may be ordered.  

How can physiotherapy help with ankle fractures?

After a fracture, the first priority is to allow the bones to heal in good alignment. This may involve being put in a boot or cast; however, more severe cases may require surgery and fixation. Your physiotherapist (in combination with your doctor or specialist, if needed) will decide on how long you will need to offload for. In general, it takes about six weeks for bone healing to occur, but this period may be extended in some cases. You will likely not be allowed to weight-bear through the affected leg for a period, though for minor injuries, walking in an immobilising boot may be sufficient protection for the injury.

After your medical advisers are happy that bone healing has been achieved (sometimes confirmed by a repeat X-ray), you will need to begin rehabilitation and receive treatment to help return to your activity. Because of the time spent not moving your ankle, your joint often becomes stiff, and your muscles become weaker. It is crucial that you regain these deficits. You may also still have some pain around the ankle. Your physiotherapist will prescribe a program of exercises and strengthening. They may also perform some mobilisation or soft tissue work around the ankle to help decrease joint stiffness. Once you are progressing well, it is important to work on higher level function such as running, agility drills and jumping/landing to make sure you get back to the same level and better than before your injury.

How effective is physiotherapy for ankle fractures?

Though rehabilitation after ankle fracture is widely accepted, research evidence regarding its effectiveness is less clear. Recent high-quality systematic reviews (summaries of studies) showed that there was a lack of evidence available to support exercise, mobilisation and other treatments after ankle fracture. A high-quality randomised controlled trial showed that exercise rehabilitation may be more important after severe fractures, or in at-risk groups, such as older women. Early movement of the ankle may provide short-term benefits, as well as using a removable cast (such as a moon boot)—though it should only be used if the patient is adherent and sticks to the restrictions given.

What can I do at home?

It is crucial that you adhere to whatever guidelines your physiotherapist has outlined for you to allow the bone to heal. If wearing an immobilising boot, speak to your physiotherapist about whether they are happy for you to take it off at night or not. While you are offloading your affected leg, you will be able to perform strength exercises for the opposite limb. This can help limit muscle and strength loss, as around 20 per cent of the gains are carried over to the opposite side without even moving it.

Once you are allowed to begin moving and exercise, it will be very important to complete all strengthening outlined by your physiotherapist. In the early stages, it may be beneficial to do some exercises in a pool or water (hydrotherapy), and your physiotherapist will be able to recommend this as needed.

How long until I feel better?

Time frames depend on the severity of the injury. Generally, bone healing takes around 6–8 weeks, followed by a period of rehabilitation. Regaining full strength, motion and confidence without pain may take up to six months. Rehabilitation should aim to get your function back to the same level or better than before your injury.