From the Guidelines
For a left posterior malleolus fracture at 8 weeks post-injury with minimal symptoms, I recommend continuing with the figure-of-8 ankle brace for an additional 2-4 weeks during activities that cause pain (running and extreme plantar flexion), while gradually increasing activity as tolerated. This approach is based on the principle of using functional support for 4–6 weeks, which is preferred over immobilisation, as shown in a study published in the British Journal of Sports Medicine in 2018 1. The use of an ankle brace has been found to have the greatest effects compared with other types of functional support. Some key points to consider in the treatment plan include:
- Gradually increasing activity as tolerated to promote bone healing and strength
- Beginning a structured physical therapy program focusing on ankle strengthening exercises, proprioception training, and range of motion exercises
- Specific exercises such as ankle circles, alphabet tracing with the foot, calf raises, balance exercises on stable and unstable surfaces, and resistance band exercises in all directions
- Applying ice for 15-20 minutes after activities that cause discomfort to manage any inflammation
- Taking over-the-counter NSAIDs like ibuprofen (400-600mg every 6-8 hours with food) as needed for pain
- Continuing normal walking and low-impact activities as these are not causing symptoms. The patient's current status of being able to walk, jump, and only experiencing pain with running and extreme plantar flexion, without any pain or swelling otherwise, suggests that the fracture has likely developed sufficient healing to support most activities, but complete remodeling may take 3-6 months 1.
From the Research
Treatment Approach
The patient has been walking, jumping, and only experiences pain with running and extreme plantar flexion, with no pain or swelling otherwise, 8 weeks post-fracture. Considering this, the treatment approach can be focused on progressive exercises and manual physical therapy.
- The use of a figure of 8 ankle brace for 2 weeks may have helped in providing support and stability to the ankle.
- According to 2, manual physical therapy and exercise targeted at associated impairments in the lower limb can lead to statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion.
- The patient's current level of activity, including walking and jumping, suggests that they may be ready for more advanced exercises to improve ankle strength and range of motion.
Rehabilitation Considerations
When considering rehabilitation for the patient, the following points should be taken into account:
- Early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation may be beneficial, as suggested by 3.
- However, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential, and the potential increased risk of adverse events should be considered.
- The use of functional bracing after ankle fracture may facilitate early mobilization of the ankle joint during recovery, as mentioned in 4.
- A progressive exercise program should be the focus of treatment after the immobilization period, as stated in 5.
Exercise Recommendations
In terms of exercise recommendations, the patient should aim to perform:
- At least 150-300 minutes per week of moderate-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity, as recommended by 6.
- Muscle-strengthening activities of moderate intensity or higher that involve all major muscle groups for 2 or more days per week, as suggested by 6.
- Exercises that target ankle strength and range of motion, such as ankle dorsiflexion and plantarflexion exercises, should be included in the patient's exercise program.