Weight-Bearing Recommendations for Ankle Sprains and Fractures
Ankle Sprains: Early Weight-Bearing with Functional Support
For ankle sprains, immediate functional treatment with early weight-bearing as tolerated is the treatment of choice, combined with a lace-up or semi-rigid ankle brace for 4-6 weeks. 1, 2
Initial Management Protocol
Apply the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) with cold application for 20-30 minutes, but do not rely on RICE alone as definitive treatment—it lacks evidence for effectiveness as a standalone intervention. 2
Begin weight-bearing as tolerated immediately after injury, avoiding only activities that cause pain. 1, 2
Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks—this is superior to immobilization and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner). 1, 2
Critical Timing for Rehabilitation
Start supervised exercise therapy within 48-72 hours after injury, focusing on range of motion, proprioception, strength, coordination, and functional exercises—this has Level 1 evidence for effectiveness. 1, 2
Avoid immobilization beyond what is needed for initial pain control (typically 3-5 days maximum), as prolonged immobilization delays recovery without improving outcomes. 1, 2
Return to Activity Timeline
Mild sprains (distortion): Return to mostly sitting work at 2 weeks, with full return to work and sports at 3-4 weeks depending on task requirements. 1
Moderate to severe sprains (partial/total ligament rupture): Return to sedentary work at 3-4 weeks, with full return to work and sports at 6-8 weeks depending on physiotherapy results. 1
Ankle Fractures: Immediate Weight-Bearing After Stable Fixation
For operatively treated ankle fractures with stable fixation, immediate protected weight-bearing as tolerated in a walking boot from postoperative day 1 is superior to non-weight-bearing with cast immobilization. 3
Evidence-Based Protocol
Allow immediate weight-bearing as tolerated in a walking boot starting postoperative day 1 after stable internal fixation—this approach demonstrated superior functional outcomes (OMAS 43 vs 35 at 6 weeks, p=0.005) compared to 6 weeks of non-weight-bearing. 3
Early weight-bearing (starting at 2 weeks postoperatively) is non-inferior to 6 weeks of non-weight-bearing in terms of ankle function at 12 months, with faster return to preinjury activities (9.1 vs 11.0 weeks, p<0.001). 4
Patients with early weight-bearing protocols achieve full weight-bearing at 7.7 weeks versus 13.5 weeks with traditional non-weight-bearing (p=0.01), without increased complication rates. 5, 6
Functional Outcomes and Cost-Effectiveness
At 6 weeks postoperatively, early weight-bearing patients demonstrate significantly better ankle range of motion (41 vs 29 degrees, p<0.0001), higher Olerud/Molander scores (45 vs 32, p=0.0007), and improved SF-36 physical and mental component scores. 6
Immediate weight-bearing is cost-effective, with expected cost savings of €798 and a quality-adjusted life-year gain of 0.04 compared to non-weight-bearing protocols. 3
Early weight-bearing results in earlier return to work (p=0.028) and sports (p=0.005) without increasing wound complications, infections, or fixation failures. 6, 7
Surgical Considerations
This protocol applies to all standard types of unstable ankle fractures (Weber B/C, Lauge-Hansen supination external rotation stage 2-4) after stable internal fixation using standard techniques. 4, 7, 3
The surgeon must confirm stable fixation intraoperatively before implementing immediate weight-bearing protocols. 5
No cases of nonunion, fixation failure, or loss of reduction were observed with early weight-bearing protocols in multiple randomized controlled trials. 4, 6
Return to Activity Timeline for Fractures
Post-surgical with immediate weight-bearing: Resume sedentary work when weight-bearing is tolerated (typically 2-3 weeks), return to physically demanding jobs and sports at 12-16 weeks. 1
Traditional non-weight-bearing protocol (if used): Non-weight-bearing with crutches for 2 weeks, weight-bearing as tolerated at 3-6 weeks, cast replaced by brace after 6 weeks, return to physically demanding work at 12-16 weeks. 1
Common Pitfalls to Avoid
Do not immobilize ankle sprains beyond 3-5 days—prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits. 1, 2
Do not delay weight-bearing after stable fracture fixation—traditional 6-week non-weight-bearing protocols are outdated and result in worse functional outcomes, longer recovery times, and higher costs. 3
Do not use elastic bandages or tape alone—lace-up or semi-rigid braces are significantly more effective for functional support. 2
Avoid heat application for acute injuries—only cold therapy is recommended in the acute phase. 2