Key messages
- Putting weight on a broken ankle within three weeks of surgery could improve recovery. But it might not improve recovery enough to matter.
- Using a removable ankle support (which allows someone to stretch and exercise their injured ankle) during the first six weeks after surgery may improve recovery. But, again, the difference might not be important enough.
- There isn't enough evidence to assess the value of physical therapies in recovering after a broken ankle.
Broken ankles
A broken ankle is one of the most common types of broken bone. Sometimes surgery is needed to help fix the broken bone, and sometimes the ankle just needs support for a few weeks while it heals. It usually takes about six weeks for the bone to heal, but can take much longer for someone to get back to their normal activities. Different approaches can be used during this recovery period to increase ankle movement or muscle strength, or both.
What approaches are used to improve recovery?
- Early weight-bearing or delayed weight-bearing. People may be encouraged to start putting weight on their ankle within three weeks of surgery. Alternatively, they may be asked to completely avoid putting weight on their injured ankle for the first six weeks or so.
- Removable ankle support or non-removable ankle support. A brace, splint, or other removable ankle support may be placed around the ankle – this allows people to regularly remove the support to stretch and move their ankle. Alternatively, a cast could be fitted, so that there is no ankle movement.
- Physical therapies. These include different kinds of ankle exercises, perhaps guided by a physiotherapist (or other physical therapist), and people may need to use specialist equipment.
What did we want to find out?
We wanted to find out if any of these approaches were better than the other to improve:
- ankle function (how well a person can do activities involving the ankle, and issues like ankle pain or swelling);
- quality of life;
- treatment satisfaction (how satisfied someone is with their treatment); and
- pain.
We also wanted to find out if any of these approaches were associated with an increased risk of having extra surgery (at a later date) on the ankle.
What did we do?
We searched for studies that looked at different approaches for improving recovery after an ankle fracture. We compared and summarised the results of studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 53 studies involving 4489 adults with a broken ankle. Most people in the studies had surgery to help fix the bone, and others used only ankle supports (with no surgery) in the first few weeks after injury.
Main results
Early versus delayed weight-bearing. Early weight-bearing after surgery for a broken ankle probably leads to very slightly better ankle function (though the difference might not be big enough to matter). Although it may also lead to a better quality of life, the difference might not be big enough to matter. We could not tell if there were differences between the two approaches for people's treatment satisfaction or pain. There may be little or no difference between approaches in how many people need extra ankle surgery.
Removable ankle support or non-removable ankle support (such as a cast).
- For people who have surgery after their injury, a removable ankle support may lead to better ankle function (though for some people it may not be a big enough difference to be important). Similarly, people are probably more likely to have a better quality of life (though the difference might not always be important). We could not tell if there were differences between types of ankle support in terms of pain. There may be little or no difference between ankle supports in the need for extra ankle surgery.
- For people who didn't need surgery, there may be little or no difference between types of ankle support in ankle function or quality of life. We could not tell if there were differences between ankle supports in terms of pain or the need for ankle surgery at a later date.
No studies in this comparison reported treatment satisfaction.
Physical therapies. Studies examined types of therapy that were all very different from one another (including different exercise programmes or different equipment to exercise the ankle). Studies were often small, and we could not tell if any of the approaches were better than another. These studies did not report how many people needed later surgery.
What are the limitations of the evidence?
We could not always be confident in the evidence because people in the studies always knew which approach was being used for their ankle. Some findings showed that there may have been little or no difference. Some studies were very small, and sometimes the approaches were very different from one another.
How current is this evidence?
The evidence is current to March 2023.
Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.
Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.
To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.
We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.
We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.
We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise.
All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data.
Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants)
Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence).
Removable versus non-removable ankle support (25 studies, 2206 participants)
Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence).
Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants).
Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants)
Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.