Fracture of Medial or Latelar Malleolus of the Ankle: Physical Therapy

Last update: April 2023
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What are the different types of ankle fractures?

When we talk about a broken ankle, we are referring to an ankle fracture and not a simple ankle sprain.

There are four main types of ankle fractures, depending on the broken bone(s).

👉 Here are their different names in common and medical language:

• Fracture of the medial malleolus or internal malleolus, or unimalleolar fracture: only one malleolus is broken.
• Bimalleolar fracture: both the medial and lateral malleoli are broken. It is also known as a double ankle fracture.
• Trimalleolar fracture, or triple ankle fracture: this name can be confusing as there are only two malleoli in the ankle. When we talk about a trimalleolar fracture, we are referring to a fracture of both malleoli and the lower part of the tibia that is located at the foot level.
• Complex ankle fracture: both malleoli, the lower end of the tibia, and the fibula (previously called the peroneal bone), which are the two bones of the leg, are broken. (I have also written a more specific article on these tibia and fibula fractures and physical therapy)

Regardless of the type of fracture, an ankle fracture can be with or without bone displacement. A fracture with bone displacement often requires more extensive care, including surgery.

These different ankle fractures can be closed or open.

When an ankle fracture is open, it means that the bone is sticking out of the skin. Open ankle fractures are rarer and usually occur after a very significant trauma (often a motorcycle accident). They require more significant care and monitoring.

Regardless of the type and severity of the fracture, rehabilitation of at least a few sessions is often necessary either in the days following the fracture (less common) or in the weeks following (more frequent).

What are the symptoms of a broken ankle?

An ankle fracture rarely goes unnoticed, even a fracture of only one malleolus.

After a fall or trauma, the broken ankle swells and becomes very painful. This is called functional impotence: it is impossible to put weight on the fractured foot. Even without weight-bearing, the pain is significant.

Other signs may occur but are not systematic:

• The skin changes color, becoming blue or purple.
• The ankle is deformed.

How is the diagnosis of an ankle fracture made?

To diagnose an ankle fracture, the Ottawa ankle rules are commonly used. These rules are a set of clinical criteria used to determine if an ankle X-ray is necessary in cases of ankle injury.

Here are the criteria:

1. Pain in the malleolar zone (the bony protuberances on either side of the ankle)
2. AND :
   • the inability to bear weight immediately after the injury and in the emergency department for four steps, OR
   • bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
   • bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
3. OR pain in the midfoot zone (the area of the foot between the ankle and the toes)
4. AND:
   • the inability to bear weight immediately after the injury and in the emergency department for four steps ,OR
   • bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
   • bone tenderness at the navicular bone (for foot injuries).

If any of these criteria are met, then an X-ray of the ankle is necessary to rule out a fracture. If none of the criteria are met, then an X-ray is usually not needed.

Only an X-ray can confirm the diagnosis and exclude the diagnosis of a simple ankle sprain, which causes the same symptoms (pain, functional impotence, swelling) but to a lesser degree. The X-ray also determines the type of fracture and guides the type of care.

Fractured ankle: what is the treatment?

Here are the answers to the most frequently asked questions about treating a broken ankle.

When does broken ankle needs surgery?

An operation for an ankle fracture is performed under general or epidural anesthesia. Screws and plates are most often used to reattach the fractured bone fragments.

The operation lasts 1 to 2 hours. The patient usually stays in the hospital for at least 1 day, or a few days in the aftermath.

Is surgery always necessary? No. (Cochrane, 2012b) Surgeons determine whether surgery is necessary or not based on several parameters:

• the severity, precise location, and type of fracture;
• the patient’s general health.

When one is not operated on after an ankle fracture, it is called conservative treatment and not surgical.

Ideally, surgery for an ankle fracture is performed on the same day as the fracture. This decreases the risk of complications. (Int Orthop, 2013).

How long should you wear a cast after an ankle fracture?

Wearing a cast is not always necessary after an ankle fracture.

For surgically treated ankle fractures, some teams recommend a simple protective brace (such as an Aircast or walking boot) or even no immobilization at all. Early ankle mobilization (without weight-bearing) is then recommended.

Others recommend strict immobilization for at least 6 weeks, by cast.

There is still little comparative data available to know which method works best for the largest number of people. It seems that in the long term, there is no difference: people with casts recover as well as those without.

In the short term, however, it seems that people who are not immobilized compared to those who are immobilized:

• have fewer deep vein thromboses (blood clots);
• have more infections at the operative site;
• have more deteriorated implanted hardware (screws and plates), which requires surgical revision more often. (JOSPT, 2014)

An alternative may be to use a removable brace that allows the ankle to be mobilized, for example under the supervision of physiotherapists. This seems to have little or no long-term effects (Cochrane 2012).

How long does it take to walk after a broken ankle?

Whether or not you have surgery, walking is possible immediately with an ankle fracture. That is, on the same day as the accident or operation.

Your orthopedic surgeon, doctor, or physiotherapist will tell you which type of walk is possible in your case, among the following 3:

• strict non-weight-bearing walk: you use two crutches, a walker, or a walking frame and hop on the healthy leg. You never put your foot on the ground when walking, even with crutches;
• touch weight-bearing walk: you use two crutches but can put the fractured foot on the ground, putting as little weight as possible on it;
• partial weight-bearing walk: you use two crutches, can put the fractured foot on the ground, but put little.

Walking becomes easier as the weeks go by. In general, a check-up X-ray is planned six weeks after the accident to see if the bones have healed. If they have, you can return to normal walking in the following weeks, depending on the level of pain.

To regain normal walking without crutches, as before the ankle fracture, it takes between 2 to 6 months.

See: How to Start Walking After Ankle Fracture?

What kind of walking boot/brace should be worn?

If you are not casted or after cast removal, some people sometimes recommend wearing a walking boot. This is a fairly rigid and enveloping brace that maintains the ankle in a certain position and facilitates walking.

You can certainly do without it. But depending on your situation, it may be practical to wear a walking boot. For example, if you have:

• young children who may bump into your ankle when you walk; a need to quickly resume outdoor travel;
• difficulty putting weight on your foot and walking with just crutches. In this case, a walking boot may be able to help you.

You can buy one at a pharmacy, a medical supply store, or online. Here is what a walking boot looks like on Amazon.

Will broken ankle heal on its own?

Yes, broken ankle can heal on its own with the help of the body’s natural self-healing abilities.

When a bone is broken, the body responds by creating an inflammatory response, which helps to trigger the healing process. This inflammatory response can cause swelling, pain, and stiffness in the affected area, but it also helps to bring nutrients and oxygen to the site of the injury, which is necessary for the healing process.

However, it’s important to note that the severity of the break and the location of the fracture can impact the body’s ability to heal the broken ankle on its own.

In some cases, surgery or other medical interventions may be necessary to ensure proper healing and prevent long-term complications.

Ankle fracture: how does physical therapy work?

In France, after an ankle fracture, physiotherapy sessions are systematically prescribed. These can be started at different times:

• From the first few days after an ankle fracture, whether it is operated on or not, whether it is immobilized or not;
• Six weeks or more after an ankle fracture, once the cast is removed or the operated fracture consolidated.

The objectives of rehabilitation are not the same during these two phases. Physiotherapy sessions are prescribed by a surgeon, an emergency doctor, or more rarely the treating doctor.

Physical therapy for the first 6 weeks

During the first 6 weeks after a fractured ankle, the main objective is for the fractured bones to consolidate. There is no rehabilitation technique that can accelerate this natural process.

The goal of rehabilitation during this phase is to prevent too much loss of the patient’s muscular and functional abilities, especially in older people. For children or athletic adults, supervision by a physiotherapist is often dispensable if the person remains active.

It is necessary to ensure that the ankle does not become stiff if there is no cast. To achieve this, here are some exercises to be done daily (video to come). These exercises should not be painful, either during or after the exercise. At most, a slight unpleasant sensation may be felt during the exercise. It should disappear as soon as the exercise is stopped.

The second goal of rehabilitation during the first 6 weeks is to relieve painful symptoms and the edema potentially associated with the fracture by giving various advice.

Physical therapy after 6 weeks

The second phase of rehabilitation begins 6 weeks after an ankle fracture. Or more precisely, once the consolidation is acquired or in good acquisition. This can be objectively assessed after an X-ray check-up performed about 6 weeks after the diagnosis of the ankle fracture, whether it was operated on or not.

The main objective of this phase is to regain perfectly functional and painless use of the operated lower limb. First, for walking and other activities that put weight on the lower limb (prolonged standing, transfers), then for sports activities.

Rehabilitation generally begins with a progressive reintroduction of the lower limb that has been without support for several weeks. This can be done visually or with the help of a balance. The main indicator is the patient’s pain. The weight tolerated on the ankle should be gradually increased, over days or weeks.

Walking is done first with 2 crutches in 3 steps, then alternately, then with a single crutch, before complete withdrawal. Walking without crutches is possible at best 2 months after an ankle fracture, and most often 3 to 4 months after.

Are there specific rehabilitation techniques to use that work better than others? No. For example, people who have their ankle passively and manually mobilized do not recover better or faster than people who simply do exercises or supervised walking. The same goes for stretching: it is not essential and does not provide any real improvement. The same goes for the use of electrotherapy, ultrasound therapy, or shock waves. (Cochrane 2012)

What matters is that the person gradually puts weight on their lower limb and moves their ankle again, without increasing pain. It doesn’t matter what situations (active, passive, supervised, autonomous) are

Before and after pictures

After the ankle has been immobilized for a long period of time, it can become very stiff. This can be inconvenient, especially for resuming walking and sports. Here is the evolution of ankle dorsiflexion gain in a patient who had a fairly significant ankle joint fracture:

Regaining mobility in the ankle can take much less time (some people have no stiffness at all) or much longer. This depends on many parameters that may not be predictable.

FAQ

Ankle fracture: what is the recovery / healing time ⏱️?

To answer this question, we need to first agree on what we mean by “healing time for an ankle fracture.” Are we talking about bone consolidation, recovering 100% of pre-injury abilities, returning to work, sports, or simply walking?

Here is a summary of these different factors. The timeframes are estimates and can vary depending on various parameters, particularly:

• Pain in the first few days and weeks following an ankle fracture
• Degree of ankle dorsiflexion mobility (the more limited it is, the longer the recovery can be)

	Usual timeline
Bone healing	6-8 weeks
Swelling disappearance	Several months
Resuming walking with crutches without weight bearing or with partial weight bearing	Immediately
Resuming walking with full weight bearing	6 weeks
Return to work	2-4 months
Return to sport	2-6months
Full functional and muscular recovery	6 months – 2 years

On the other hand, the severity of the fracture and the type of treatment are not significant factors affecting the speed of recovery. Here are some more specific data from studies conducted on several hundred people who underwent surgery or not for an ankle fracture (Beckenkamp et al., 2014):

• Recovery is faster during the first three months following the fracture when people gradually regain the use of their lower limbs.
• Six months after the fracture, people estimate they have recovered an average of 80% of their pre-injury abilities.
• Two years after the fracture, this figure increases to 86.6%, but not to 100%. This means that some people who have had an ankle fracture do not fully recover two years after the fracture. The improvement is therefore mainly noticeable in the first six months following the fracture.

The older the person is (over 65), the less well they recover.

However, on average, people who have had an ankle fracture do not have more pain in the years following the fracture than those who have had few fractures. On the other hand, they have more pain in the first four months (Ribeiro et al., 2018).

Is ankle pain normal after a broken ankle?

Whether you have had surgery or a cast for an ankle fracture or not, it is usual to experience pain, even when taking painkillers. These pains are significant in the first few days following the fracture but rapidly decrease in intensity, from the first week.

The peak of pain is at its maximum on average 8 hours after the operation in operated individuals. It is not related to the severity of the fracture. That is, if you have severe pain, it does not mean that you have a severe fracture that should worry you (Hun Won et al., 2019).

Pain can persist for several weeks even at rest, without bearing weight on the leg. This is not worrying, especially if it does not prevent sleeping or carrying out daily activities.

Pain can increase again 6-8 weeks after the ankle fracture when you start putting weight on the leg and walking more. They are still often present 4 months after the ankle fracture but should be mild and subside, for example, at night.

Two years after an ankle fracture, most people have no more pain, even without medication (Ribeiro et al., 2018).

Should I be concerned about a swollen ankle after a broken ankle?

It is usually the opposite that should worry you! The ankle swells systematically after an ankle fracture, and even after an ankle sprain, which is less severe. This is a normal reaction of the body.

This swelling (or edema) lasts for at least several weeks and often several months. It is common for swelling to persist for several years after an ankle fracture, which often causes concern and consultation among patients. However, this is not worrying in itself.

If the edema is not associated with significant pain or discomfort in carrying out certain activities, there is nothing special to do.

The swelling that persists for several months after an ankle fracture can be particularly problematic when it comes to footwear.

Wearing compression stockings or socks can help reduce the swelling, as can avoiding prolonged periods of standing and elevating the swollen leg and foot. See on Amazon

Some physical therapists may recommend the use of compression boots for pressotherapy. However, studies on the effectiveness of this technique are of very low quality. The desired effect is to reduce ankle edema and pain. These effects are likely to occur within minutes after each session, but there is little chance they will persist over time. Therefore, it is a transient improvement in edema, which has no effect on medium- or long-term recovery. (Winge et al. 2017)

What are the possible complications after a bimalleolar fracture?

It should be kept in mind that most people who undergo surgery for an ankle fracture do not experience any complications, either in the days following the operation or several weeks, months, or years later.

A risk factor for complications is not having surgery on the same day as the ankle fracture. However, even in this case, complications are more the exception than the rule. (Int Orthop 2013)

The main complications are:

• infection at the surgical site. In one study, for example, this infection occurred in 0% of patients who underwent surgery on the same day as a unimalleolar fracture, and in 11% of patients who underwent surgery in the days following the fracture;
• non-solidity of the surgical fixation. In this case, a new operation may be necessary.

It is important to remain positive and keep in mind that many people who have had an ankle fracture do not have any lasting effects 6 months or several years after the fracture.

Most of the time, people can return to work and sports activities.

Sometimes, however, people who have or have not undergone ankle surgery may experience:

• chronic pain, which can be relieved by limiting strenuous activities involving the ankle or taking painkillers;
• a loss of ankle mobility, which has little impact on daily life;
• early onset of ankle arthritis.

How do I know if my ankle fracture was not properly treated?

This is a delicate question. It is possible to experience residual pain, swelling, difficulty with certain sports, or even walking several months after an ankle fracture.

It’s difficult to determine if your ankle would have recovered better if treated differently.

What matters is finding solutions to minimize the discomfort in your ankle. To do this, consult with your doctor or physiotherapist. It may be possible to adjust your lifestyle, take pain medication, gradually resume sports activities, or even consult a surgeon.

What are the specificities of ankle fractures in children?

The treatment of ankle fractures in children differs little from that of adults.

Children with relatively simple ankle fractures likely recover better with a non-removable walking brace or, possibly, a removable brace, rather than a rigid cast (Cochrane 2016).

Generally, children do not need rehabilitation. They quickly and spontaneously resume their daily activities once the immobilization or weight-bearing restriction period is over.

They may have a temporary limp for a few weeks, but it disappears over time, at most a few months.

Children with more severe ankle fractures usually require surgery and immobilization with a cast. Physiotherapy sessions are also necessary in the aftermath if the child spontaneously resumes their usual activities without pain.