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    Ankle Fractures

    What is an ankle fracture?

    • Ankle fractures occur when a bone, or bones, that make up the ankle joint are stressed beyond their capability resulting in a fracture.

    How common are ankle fractures?

    • Ankle fractures are rare amongst the general population affecting less than 0.1% of people each year (1,7).
    • The most common causes of ankle fractures are twisting injuries, falls and sports related injuries (9).
    • Ankle injuries and fractures are more common amongst a sporting population (10).

    Should I worry?

    • No.
    • With the right rehabilitation approach ankle fractures normally recover well.
    • Ankle fractures are not linked to other serious pathology.

    Who is most likely to suffer from ankle fractures?

    • There are similar fracture rates overall between women and men.
    • Men have a higher rate as young adults.
    • Women have higher rates in the 50 to 70 year age group (1,2).
    • More common in those who take part in sport (10).

    What are the common symptoms?

    • Impaired walking ability, often (but not always) an inability to weight-bear through the affected foot and ankle.
    • Pain localised to the ankle.
    • Swelling around the ankle and foot.
    • Bruising around the ankle and foot.
    • Deformities of the bones around the ankle.

    What can I do?

    • If you suspect you have fractured your ankle it is recommended that you attend A&E.
    • A period of non-weight-bearing or partial weight-bearing is normally required following an ankle fracture.
    • Whilst your weight-bearing status might limit you, you should still try to stay active within your limitations.
    • A musculoskeletal specialist can provide appropriate advice to help best aid recovery.

    How long will it take to recover?

    • This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
    • Initial recovery is usually within 6 to 12 weeks.
    • Most people fully recover within 12 months (3).
    • Some patients may require prolonged rehabilitation.
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    1. Introduction

    Ankle fractures most commonly occur following some form of trauma and typically present with swelling, bruising and deformities of the bones around the ankle. Inversion (turning ankle inwards) injuries account for 90% of fractures and fractures can occur with simultaneous tears of the ligaments that help support the ankle joint.

    Most cases of ankle fractures will require a cast or boot to allow the bones to heal. In cases where the tibia (the main bone that takes the weight in standing) is broken and the bones are not aligned, surgery may be required. Recovery will require a comprehensive rehabilitation programme. We review research on a regular basis and continually update our website to ensure we are giving the best advice by bringing together current evidence with our clinical expertise.

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    2. Signs & Symptoms

    3. Causes

    Symptoms usually develop after some form of trauma. The elderly and people taking part in sports involving landing, pivoting and uneven ground are more susceptible to sustaining an ankle fracture. In the older population, osteoporosis has not been proven to be a contributing factor, however falls in the older population are a contributing factor so addressing falls risk is important (4).

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    4. Risk Factors

    This is not an exhaustive list. These factors could increase the likelihood of someone sustaining an ankle fracture. It does not mean everyone with these risk factors will develop symptoms.

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    5. Prevalence

    In the general population, ankle fractures affect less than 0.1% of the population yearly (1,7). It is more common in young males (under 50 years of age) (1). More common in people who are heavily involved in sport, particularly sports that require jumping/landing and walking/running on uneven surfaces such as athletics, rugby and football. Most fractures in the elderly are female (over the age of 50).

    6. Assessment & Diagnosis

    Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a working diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis. X-rays are often needed to find out if and where a bone is broken and how much damage there is (2).

    Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.

    7. Self-Management

    As part of your treatment, your musculoskeletal physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your fractured ankle and provide rehabilitation. This will include activity modification strategies as well as other useful treatments aimed at reducing discomfort.

    If you are required to wear a boot or cast, ensure you gently move your toes and bend your knee to ease stiff muscles and maintain healthy blood flow to the affected limb. Regular adherence to a condition-specific rehabilitation programme is important in the management of this condition. It should be noted that rehabilitation exercises are not always a quick fix but if adhered to on a consistent basis (weeks to months), over time they have been shown to yield positive outcomes.

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    8. Rehabilitation

    Rehabilitation after ankle fracture can begin soon after the fracture has been treated using different types of immobilisation which allow early commencement of weight-bearing or exercise (6). Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing ankle fractures. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.

    9. Ankle Fracture Rehabilitation Plans

    Early Plan

    This programme focuses on maintaining the range of movement within the ankle, appropriate loading of the affected joint and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.

    Early Plan - Rating

    Intermediate Plan

    This is the next progression. More focus is given to progressive loading of the ankle and lower limb strengthening. Pain should not exceed 3/10 whilst completing this exercise programme.

    Intermediate Plan - Rating

    Advanced Plan

    This programme is a further progression with challenging, progressive loading of the affected ankle complex. Pain should not exceed 3/10 whilst completing this exercise programme.

    Advanced Plan - Rating
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    10. Return to Sport/Normal Life

    For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

    11. Other Treatment Options

    For more complex fractures, potentially involving multiple bones and soft tissue structures, surgery might be required.

    12. Links for Further Reading

    https://www.nhs.uk/conditions/broken-ankle/

    https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-should-i-care-for-my-plaster-cast/

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    Book an Appointment

    Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

    We have Pure Physiotherapy clinics across the country including Norwich, Ipswich, Manchester, Bolton, Wakefield and Sheffield. Please view our clinics to find the closest physiotherapy clinic for you.

    References

    1. Daly, P.J., Fitzgerald, R.H., Melton, L.J. & Llstrup, D.M. (1987). Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthopaedica Scandinavica, 58(5), 539-544.
    2. Court-Brown, C.M., McBirnie, J. & Wilson, G. (1998). Adult ankle fractures—an increasing problem?. Acta orthopaedica Scandinavica, 69(1), 43-47.
    3. McPhail, S.M., Dunstan, J., Canning, J. and Haines, T.P. (2012). Life impact of ankle fractures: Qualitative analysis of patient and clinician experiences. BMC musculoskeletal disorders, 13(1), 1-13.
    4. Lee, D.O., Kim, J.H., Yoo, B.C. & Yoo, J.H. (2017). Is osteoporosis a risk factor for ankle fracture?: Comparison of bone mineral density between ankle fracture and control groups. Osteoporosis and sarcopenia, 3(4), 192-194.
    5. Lin, C.W.C., Donkers, N.A., Refshauge, K.M., Beckenkamp, P.R., Khera, K. & Moseley, A.M. (2012). Rehabilitation for ankle fractures in adults. Cochrane database of systematic reviews, (11).
    6. Juto, H., Nilsson, H. & Morberg, P. (2018). Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 2009–2013 and classified according to AO/OTA. BMC musculoskeletal disorders, 19(1), 1-9.
    7. NICE. (2016). Fractures (non-complex): assessment and management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text].
    8. Fong, D.T.P., Hong, Y., Chan, L.K., Yung, P.S.H. & Chan, K.M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports medicine, 37(1), 73-94.
    Other Conditions in Ankles, Orthopaedics

    Lateral Ankle Sprain

    Pain and loss of function following an injury to the ligaments on the outside of the ankle.

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    Achilles Tendinopathy

    Pain, swelling and stiffness of the achilles tendon that joins the heel bone to the calf muscles.

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    Benign Joint Hypermobility Syndrome

    Above normal movement or flexibility. A condition that is on a spectrum, meaning you can have mild to extreme levels of hypermobility.

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    Tibialis Posterior Tendinopathy

    A condition involving injury to the tendon found around the bone at the inner side of the ankle leading to pain and weakness.

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