Ankle Fractures
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.
Frequently Asked Questions
- Ankle fractures occur when a bone, or bones, that make up the ankle joint are stressed beyond their capability resulting in a fracture.
- 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).
- No.
- With the right rehabilitation approach ankle fractures normally recover well.
- Ankle fractures are not linked to other serious pathology.
- 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).
- 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.
- 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.
- 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.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain – the pain may be moderate to severe and not always localised at the fracture site. You may also experience pain throughout the foot or even in your knee. Dependent upon the fracture type, you might find the pain is too severe to allow walking without support.
- Swelling – caused by excess fluid due to the fracture and soft tissue damage.
- Bruising – which may spread down to the toes or upwards into the leg.
- If a bone is sticking out, your ankle is facing an odd angle and/or your toes look white or feel numb, you should seek help immediately.
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).
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.
- Under 25 years of age – people are generally more active so there is a higher risk.
- Gender – younger men and older women are more prone.
- Being overweight – increased load on the joints as well as known systemic effects.
- Poor lower limb strength – muscles not able to control inversion (turning in)/eversion (turning outwards) of the foot.
- Training involving excessive landing/jumping/running on uneven surfaces – increased risk of turning the ankle inwards/outwards.
- Poor balance (proprioception) – this reduces the reaction time of the muscles which control inversion/eversion.
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.
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 Fractures
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
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.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
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.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging, progressive loading of the affected ankle complex. Pain should not exceed 4/10 whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
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
References
- 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.
- Court-Brown, C.M., McBirnie, J. & Wilson, G. (1998). Adult ankle fractures—an increasing problem?. Acta orthopaedica Scandinavica, 69(1), 43-47.
- 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.
- 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.
- 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).
- 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.
- NICE. (2016). Fractures (non-complex): assessment and management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text].
- 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
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.
Lateral Ankle Sprain
Pain and loss of function following an injury to the ligaments on the outside of the ankle.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Achilles Tendinopathy
Pain, swelling and stiffness of the achilles tendon that joins the heel bone to the calf muscles.