When should physical therapy start after Open Reduction Internal Fixation (ORIF) ankle surgery?

When to Start Physical Therapy After ORIF Ankle

Physical therapy should begin immediately after ORIF ankle surgery, with early weight-bearing and range of motion exercises initiated within the first 2 weeks postoperatively to optimize functional outcomes and prevent complications.

Immediate Postoperative Period (0-2 Weeks)

Early mobilization is superior to prolonged immobilization. The evidence strongly supports beginning rehabilitation immediately rather than waiting:

• Isometric quadriceps exercises and straight leg raises can be safely prescribed during the first 2 postoperative weeks, improving range of motion without compromising stability 1
• If immobilization is used for pain or edema control, it should not exceed 10 days, after which functional treatment must commence 2
• Prolonged immobilization (4+ weeks) results in significantly worse outcomes compared to functional support and exercise strategies 2

Weight-Bearing Protocol (Weeks 1-6)

Immediate protected weight-bearing in a walking boot from postoperative day 1 is the evidence-based standard:

• Early weight-bearing (within 3 weeks of surgery) leads to better ankle function with mean improvement of 3.56 points on functional scales 3
• Immediate weight-bearing demonstrates superior functional outcomes, greater cost savings, earlier return to work, and similar complication rates compared to 6 weeks of non-weight-bearing 4
• Weight-bearing should only be allowed if there is correct gait pattern (with crutches if necessary), no pain, no effusion, and no temperature increase 1
• Early weight-bearing at 2 weeks postoperatively can be safely considered when stable fixation has been obtained 5

Ankle Support and Mobilization (Weeks 0-6)

Use a removable ankle support (walking boot) rather than a rigid cast:

• Removable ankle support leads to better ankle function (mean difference 6.39 points) and improved quality of life compared to non-removable casts 3
• Functional support for 4-6 weeks is preferred over immobilization, with ankle braces showing the greatest effects 2
• The removable support allows for early range of motion exercises while protecting the surgical site 3

Range of Motion Exercises

Critical timing consideration for ROM exercises:

• Early ankle motion before wound healing (typically <2 weeks) may lead to increased wound complications (pooled odds ratio 3.11,95% CI 1.64-5.90) without improvement in long-term results 5
• After wound healing is confirmed (typically 2 weeks), range of motion exercises should be initiated immediately 5
• Manual joint mobilization combined with exercise therapy provides better outcomes than exercise alone 2

Structured Physical Therapy Program

Begin formal physical therapy within the first 2 weeks with progression based on objective criteria:

Weeks 0-2:

• Isometric exercises when they provoke no pain 1
• Gentle ankle pumps and toe movements
• Edema control with elevation and compression

Weeks 2-4:

• Closed kinetic chain exercises for lower extremity strengthening can be safely performed 1
• Progressive weight-bearing as tolerated with proper gait mechanics
• Begin gentle ROM exercises after wound healing confirmed 5

Weeks 4-8:

• Full weight-bearing should be achieved by 8 weeks postoperatively with correct gait pattern 1
• Calf strengthening with eccentric exercises, starting with body weight 1
• Balance and proprioception training to restore neuromuscular control 1
• Swimming, cycling, and elliptical training are ideal activities providing cardiovascular conditioning without excessive stress 1

Months 3-6:

• Return to running and high-impact sports should not occur before 3-6 months postoperatively 1
• Progression requires complete resolution of pain, restoration of normal gait mechanics, achievement of adequate strength, and successful completion of sport-specific functional testing 1

Progression Criteria (Not Time-Based)

Advancement must be based on objective criteria rather than arbitrary timeframes 1:

• Absence of pain with activities of daily living
• No increase in swelling or warmth after activity
• Ability to perform single-leg stance without compensation
• Normal gait pattern without antalgic components 1

Critical Monitoring Points

Close surveillance is essential to identify:

• Signs of infection at surgical sites: increased warmth, erythema, drainage 1
• Development of compensatory gait patterns that may lead to secondary injuries 1
• Ankle stiffness (reported by 72% of patients at 1 year) 6

Common Pitfalls to Avoid

Do not delay weight-bearing unnecessarily. The outdated practice of 6 weeks non-weight-bearing leads to worse functional outcomes, higher costs, and delayed return to work without reducing complication rates 4.

Do not start aggressive ROM exercises before wound healing. This increases wound complications threefold without improving long-term outcomes 5.

Do not rely solely on time-based protocols. Only 52% of patients return to prefracture activity levels by 1 year, with functional dorsiflexion deficits persisting 6. Progression should be criterion-based, focusing on objective functional measures.