Not every lingering pain means there's a complication. But sometimes there is a reason.
Ankle-fracture recovery comes with a mind-boggling array of aches, swelling, strange sensations and not-so-pretty-looking body parts.
Your toes may turn purple. Your ankle may swell into a shape that resembles a tree trunk. Incisions can look alarming. Numbness, tingling, stiffness and random shooting pains—thank you, nerves—can all make appearances.
Most of these things turn out to be part of recovery.
Some don't.
The difficulty is knowing the difference. Many among us have found ourselves staring at an incision at 10 p.m. wondering whether it’s normal healing or the beginning of a problem.
While this isn't meant to be a catalog of everything that can go wrong after an ankle fracture, here’s your guide to some of the things worth calling your orthopedic team about rather than waiting until your next scheduled appointment.
FROM THE TRENCHES
Eight weeks after surgery, a woman in my fracture support group was dealing with a small scabbed area on her incision that hurt whenever her boot touched it. She could feel it pulling when she was doing her ROM exercises from PT, and that it felt like it might pop open. The sore spot was making her afraid to push her range of motion, even as she felt pressure to be further along and to start walking without her walker.
Another woman recovering from hardware removal noticed something poking out through her incision. She gave it a tug—and kept pulling. Out came what appeared to be a piece of surgical suture. The incision hadn’t looked particularly alarming beforehand.
And in another case, two years after surgery, one person with two plates and 12 screws noticed that her foot had suddenly begun feeling tight and swelling again. She reported that she’d done very well up until the last two weeks, but now she was worried the metal had perhaps shifted. Whether the hardware was actually responsible isn't the point. Something had changed after two years of stability, and she noticed it.
In all these cases, the obvious thing to do is contact the doctor. But sometimes it’s not so obvious.
Eight months after a trimalleolar fracture, four metatarsal fractures and a broken bone in her other foot, one woman was still having significant trouble walking. A CT finally showed bone spurs and an area of nonunion in the tibia.
She said that she was both happy and sad. She felt happy that she was validated and that she wasn’t just a baby or a crazy person. The other side of it? She was sad because she wanted to get on with her life and heal, and the CT scan meant that wasn’t going to happen yet.
The Usual Suspects
Most ankle-fracture recoveries don’t involve serious complications. But when trouble does show up, some problems are more common than others.
Infection
Any operation creates a route through the skin, which means infection is a possibility after ORIF or any later surgery, including hardware removal.
A little redness immediately around an incision isn't necessarily alarming, particularly early on. Neither is some swelling, bruising or tenderness. What matters more is the direction things are going. An incision that had been settling down and then becomes increasingly red, hot, swollen or painful deserves attention. So does pus or cloudy drainage, an incision that begins to open, a bad odor, or fever and chills.
Deep infection involving the hardware or bone is much more serious than a superficial skin infection, which is one reason surgeons want to hear about suspicious wound changes early.
WORTH KNOWING
If you're worried about an incision, take a clear photograph. Besides being useful if your surgeon's office asks you to send one, photos taken a day or two apart can help show whether redness or swelling is spreading.
Wound Problems
An incision doesn't have to be infected to cause trouble. The edges can separate, an area can be slow to close, or the skin can become irritated by sutures, staples, dressings or a boot rubbing against it.
The ankle isn't an especially generous place when it comes to soft tissue. There isn't much padding over some of the bones and hardware, and swelling puts additional tension on healing skin. Significant ankle injuries can also damage the skin and soft tissue before the surgeon ever makes an incision.
Call if an incision is opening rather than closing, drainage persists or increases, the surrounding skin is breaking down, or part of the wound looks markedly different from the rest. If a cast, splint or boot is rubbing directly over an incision, that's worth addressing, too.
When the Cast or Splint Feels Too Tight
Swelling often increases during the first few days after an injury or surgery, which is one reason elevation gets mentioned approximately six thousand times during ankle-fracture recovery.
A cast or splint can feel snug without being dangerous. But rapidly increasing pain or pressure, severe tightness, worsening numbness or tingling, or toes that become unusually pale, blue, cold or difficult to move are different.
One rare but serious reason is compartment syndrome, in which pressure builds within a closed muscle compartment and interferes with circulation and tissue function. The classic warning sign is severe, worsening pain that seems out of proportion to the injury or surgery and isn’t adequately relieved by pain medication. The area may feel unusually tight or firm, and moving or stretching the affected muscles can cause intense pain. Numbness, tingling or weakness may develop as pressure increases. Acute compartment syndrome is an emergency and needs immediate medical attention.
Numbness, Tingling and Nerve Symptoms
Nerves don't particularly enjoy ankle fractures, swelling, surgery or being compressed inside immobilization devices. Temporary numbness, tingling, burning or altered sensation can occur during recovery. Skin around a surgical incision may remain numb for quite a while, and sometimes a patch of altered sensation never completely disappears.
The question again is whether the symptom is expected and stable or new and worsening.
New loss of sensation, increasing weakness, an inability to move the toes normally, or numbness accompanied by a very tight cast or splint should be reported promptly. Burning, electric-shock sensations or extreme sensitivity that persists or becomes worse should also be discussed with your doctor.
When the Bone Isn't Healing as Expected
Bone healing takes time, and surgeons generally look for progressive healing over a series of visits.
Sometimes, however, healing takes considerably longer than expected. Delayed union means the fracture is healing more slowly than anticipated. Nonunion means the bone has failed to unite. These aren't diagnoses you can make at home based on how the ankle feels; they are determined through your symptoms, examination and imaging.
Persistent pain at the fracture site can be one reason a surgeon takes another look, particularly if pain isn't following the expected trajectory or begins increasing after a period of improvement. Continued tenderness, difficulty progressing with weightbearing, or concerning findings on follow-up X-rays may lead to additional imaging or changes in treatment.
Hardware Problems
Hardware can sometimes become prominent or irritating, particularly around an ankle where there isn't much tissue between metal and skin. Tendons can also become irritated by nearby hardware.
Feeling the outline of a plate or screw doesn't by itself mean anything is wrong. Plenty of people can feel their hardware. Persistent focal pain directly over it, increasing tenderness, a sensation of something catching or snapping, skin irritation over prominent hardware, or new symptoms after the ankle had been doing well are reasons to bring it up with your surgeon.
Hardware removal is sometimes an option after the fracture has healed, but troublesome hardware isn't automatically the explanation for every lingering pain. The original injury can leave cartilage, tendon, ligament, nerve and other soft-tissue problems behind as well.
For much more on this, check out the chapter on Hardware Removal After Ankle Surgery.
Complex Regional Pain Syndrome
Complex regional pain syndrome, usually shortened to CRPS, is uncommon, but worth knowing about.
This chronic pain condition can develop after an injury or surgery. The pain is typically greater or more persistent than would be expected from the original injury and may be accompanied by extreme sensitivity to touch, burning pain, swelling, changes in skin temperature or color, sweating changes, stiffness or changes in hair and nail growth.
Some of those symptoms overlap with things that can happen during ordinary ankle-fracture recovery, which is one reason CRPS shouldn't be self-diagnosed from a checklist. But pain and sensitivity that seem distinctly out of proportion, particularly when accompanied by other unusual changes in the foot or ankle, deserve medical evaluation. Earlier recognition and treatment can matter.
A Sudden Setback
Recovery isn't a straight line. A bad day after physical therapy, a long day on your feet or a little too much enthusiasm when you're first allowed to walk doesn't necessarily mean you've damaged anything.
A significant new event is different. A fall, a hard twist, accidentally putting full weight on an ankle that isn't cleared for it, or hearing or feeling a pop followed by new pain or swelling is worth reporting. Depending on what happened and where you are in healing, your surgeon may simply reassure you—or may want another X-ray.
The same applies to a substantial unexplained change. If yesterday's manageable pain has suddenly become today's severe pain and there isn't an obvious reason for it, contact your doctor.
And Then There's the Blood Clot
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are potentially life-threatening complications that deserve more than a few paragraphs. See the DVT and Pulmonary Embolism chapter for the full discussion.
For the abbreviated version: new or unexplained calf swelling, warmth, redness or pain—particularly when one leg is noticeably different from the other—warrants medical attention. Sudden shortness of breath, chest pain, coughing up blood, fainting or other symptoms suggesting a pulmonary embolism require emergency evaluation.
When Should You Call?
A useful rule is to pay attention to change. Pain that is suddenly much worse, swelling that is dramatically different, an incision that had been improving and now looks worse, sensation or movement that has changed, or a recovery that seems to have taken a significant turn in the wrong direction deserves attention.
Some situations shouldn't wait for a routine callback: symptoms suggesting a pulmonary embolism, loss of circulation to the foot, rapidly worsening severe pain with a tight swollen limb, or other severe or rapidly developing symptoms need urgent or emergency evaluation.
For everything else, a meaningful change is worth passing along to your orthopedic team rather than saving it for the next scheduled appointment.
NOBODY TOLD ME
One of the stranger parts of ankle-fracture recovery is how quickly your definition of "normal" changes. Before the injury, a purple foot, numb skin and an ankle twice its usual size would have sent you straight to a doctor. A few weeks into recovery, you may find yourself looking at the same foot and thinking, Eh, it's looked worse.
That growing familiarity is useful. You learn what your particular ankle does after you've been upright too long, after physical therapy or at the end of the day. But it also makes new or distinctly worsening symptoms more obvious.
You know what your recovering ankle normally looks and feels like better than anyone else does. When it suddenly stops behaving like your normal recovering ankle, that's information you should share with your doctor.
MY TAKE ON IT
My husband tends to be casual when recovering from anything medical, and as a result, he avoids a lot of stress. I swing the other way, and have spent considerable time chewing on whether or not my smorgasbord of symptoms is normal. I could probably stand to borrow a little of his nonchalance. But when something genuinely changes, I'd still rather make the call.