When to Start Physical Therapy After ORIF of Distal Fibula and Tibia
Physical therapy should begin immediately in the first postoperative week after ORIF of the distal fibula and tibia, starting with isometric exercises, ankle pumps, and toe movements when they provoke no pain. 1
Immediate Postoperative Phase (Week 1-2)
The rehabilitation timeline is goal-based rather than strictly time-based, focusing on functional criteria for progression. 1
Early mobilization interventions include:
- 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
- Gentle ankle pumps and toe movements should be performed when they provoke no pain 1
- Edema control with elevation and compression is recommended 1
- Cryotherapy may be applied in the first postoperative week to reduce pain 2
Critical caveat: If immobilization is used for pain or edema control, it should not exceed 10 days, after which functional treatment must commence 1. Prolonged immobilization beyond this period increases the risk of ankle weakness, stiffness, and residual pain. 3
Weight-Bearing Protocol
Weight-bearing should only be allowed when specific criteria are met:
- Correct gait pattern (with crutches if necessary) 1
- No pain during or after walking 1
- No effusion or swelling 1
- No temperature increase 1
Recent evidence from ankle fracture rehabilitation demonstrates that early weight-bearing (within 3 weeks of surgery) probably leads to better ankle function, though the difference may be small and not always clinically important. 3 Importantly, early weight-bearing does not increase re-operation risk. 3
Full weight-bearing should be achieved by 8 weeks postoperatively with correct gait pattern. 1
Ankle Support Strategy (Weeks 0-6)
A removable ankle support is preferred over rigid immobilization for 4-6 weeks, with ankle braces showing the greatest effects. 1 Following surgery, using a removable ankle support may lead to better ankle function and improved quality of life compared to non-removable supports. 3
Structured Exercise Progression
Weeks 2-4:
- Closed kinetic chain exercises for lower extremity strengthening can be safely performed 1
- Progress from isometric to concentric exercises when the ankle does not react with effusion or increased pain 2
Weeks 4-8:
- Calf strengthening with eccentric exercises, starting with body weight and progressing resistance according to tolerance 1
- Balance and proprioception training to restore neuromuscular control 1
- Low-impact cardiovascular conditioning: swimming, cycling, and elliptical training provide ideal activities without excessive stress 1
Objective Progression Criteria (Not Time-Based)
Advancement must be based on these 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
This goal-based approach ensures patient-tailored rehabilitation rather than rigid time-based protocols. 2
Critical Monitoring Points
Close surveillance is essential to identify: 1
- Signs of infection at surgical sites (increased warmth, erythema, drainage)
- Development of compensatory gait patterns that may lead to secondary injuries
- Proper footwear: patients should use supportive, well-fitted shoes during all weight-bearing activities, with thick protective socks and adequate arch support and cushioning 1
Common Pitfall to Avoid
The most significant pitfall is delaying rehabilitation beyond the first postoperative week. Studies demonstrate that despite physical therapy training, weight-bearing compliance to recommended limits is often poor, and adherence decreases over time. 4 However, this should not discourage early mobilization—rather, it emphasizes the need for immediate engagement with physical therapy to establish proper movement patterns and functional goals from the outset.