When can physical therapy start after an ankle fracture?

Physical Therapy Timing After Ankle Fracture

Physical therapy should begin early following ankle fracture, with functional treatment starting within 48-72 hours after immobilization removal, as this approach provides better outcomes compared to delayed rehabilitation. 1, 2

Initial Management Post-Immobilization

• First 48-72 hours after immobilization removal:

  • Begin with gentle range of motion exercises and early weight-bearing as tolerated 1
  • Apply PRICE protocol (Protection, Rest, Ice, Compression, Elevation) to manage initial pain and swelling 2
  • Avoid complete immobilization as it delays recovery 1

• Support during early rehabilitation:

  • Use functional supports (ankle brace preferred over tape or elastic bandage) for 4-6 weeks 1
  • Semi-rigid ankle support provides better functional outcomes and faster return to activities 2
  • Walker boot or stirrup brace may reduce pain and improve gait symmetry compared to elastic bandages 3

Rehabilitation Protocol

Phase 1 (Weeks 1-2 after immobilization removal)

• Manual joint mobilization to increase ankle dorsiflexion range of motion 1
• Gentle active range of motion exercises 2
• Progressive weight-bearing as tolerated 1
• Pain management with NSAIDs or acetaminophen as needed 2

Phase 2 (Weeks 3-4)

• Progress to proprioceptive and neuromuscular exercises 1, 2
• Increase strengthening exercises for ankle and lower extremity 2
• Continue manual therapy combined with exercise therapy for better outcomes 1

Phase 3 (Weeks 5-6 and beyond)

• Sport-specific or activity-specific exercises 2
• Balance and coordination training to prevent recurrent injuries 1
• Continue supervised exercise therapy for a total of 4-6 weeks post-immobilization 2

Evidence for Early Rehabilitation

Research shows that early rehabilitation after ankle fracture leads to significant improvements:

• Patients receiving impairment-based manual physical therapy after immobilization showed clinically meaningful improvements in function and ankle range of motion at 4 weeks 4
• Early functional rehabilitation reduces the risk of recurrent injuries (RR 0.37; 95% CI 0.18 to 0.74) 1
• Functional treatment allows patients to return to sports 4.6 days earlier and to work 7.1 days earlier than those with prolonged immobilization 2
• Early operative fixation followed by early rehabilitation reduces hospital length of stay (mean 5 days vs. 9.5 days for delayed surgery) 5

Cautions and Considerations

• Ensure fracture stability before initiating weight-bearing activities
• Monitor for signs of complications (increased pain, swelling, or instability)
• If pain persists beyond 6 weeks, consider further evaluation for complications such as osteochondral lesions or impingement syndrome 2
• Criteria for advancing rehabilitation should include pain-free walking, improving range of motion, and restored strength 2

Follow-up Recommendations

• Re-examination 3-5 days after beginning rehabilitation to assess progress and adjust treatment plan 2
• Complete the full 4-6 week rehabilitation program to maximize outcomes and prevent future injuries 1, 2
• Continue proprioceptive exercises beyond the formal rehabilitation period to prevent recurrent injuries 2

Early initiation of physical therapy with a focus on functional treatment rather than immobilization provides the best outcomes for patients recovering from ankle fractures, improving mobility, reducing pain, and facilitating faster return to normal activities.