Some days, recovery isn't about getting better. It's about getting comfortable enough to get through the day.
FROM THE TRENCHES
Some days, recovery isn't about getting better. It's about getting comfortable enough to get through the day.
FROM THE TRENCHES
When I read some of the comments from my Facebook support groups, they sound very familiar. And they bring back terrible memories of those early nights after my ORIF surgery, twisting and turning in the living room recliner, trying to find a position—any position—that I could tolerate.
One woman said that her pain was manageable during the day, but at night she couldn’t get it to calm down and subsequently couldn’t get any rest. She would move from room to room, trying different things, but nothing she did gave her relief. Her doctor didn’t prescribe pain pills as he didn’t want her to get addicted to them—even though she cried every night trying to get the pain to stop.
Another said that eighteen months on, he was still in constant pain and really struggling. He couldn’t walk far and was still unable to drive.
And the words from one young woman made me cry. She described the tough journey she’d been on and how, at times, it felt overwhelming. She wanted to know if others had been through something similar—especially things that helped them cope or recover and stressed how it would mean a lot for people to reach out.
Unfortunately, pain is part of the ankle break/surgery package for most of us. Doctors can describe it, but the people who have actually lived through an ankle fracture tend to describe it differently: throbbing, burning, relentless, exhausting—and sometimes much worse than they expected.
One piece of advice came up over and over: elevate higher than you think you need to. Several people used the phrase “toes above nose.” Simply putting the foot on a pillow or ottoman often wasn't enough. When swelling increased, so did the pain; getting the ankle truly above heart level could make a noticeable difference.
Ice was another favorite, particularly when a cast or splint made it impossible to ice the ankle itself. A number of people recommended putting an ice pack behind the knee. It wasn't a cure, but for some it helped take the edge off both swelling and pain.
Finally, people found relief in surprisingly small things. Rest. Music. Breathing exercises. Getting comfortable enough to sleep. Finding a position that didn't make the ankle throb. None of those replaces medical pain control when you need it, but when you're getting through recovery hour by hour, anything that turns the volume down a notch counts.
Pain relief looks different for everyone, and finding the right balance often involves combining several approaches. Below, we’ll look at common methods of controlling pain, their benefits, and important cautions to keep in mind.
I can’t promise you a miracle, or even profound relief, but hopefully some of these strategies will help you.
The Many Flavors of Ouch
One reason pain management can be frustrating is that “pain” is not one single thing.
Aching or throbbing pain often accompanies the injury, surgery and swelling.
Sharp pain with movement may occur as injured tissues are stressed, particularly early in recovery.
Burning, shooting, tingling or electrical pain may suggest that nerves are irritated. (Think “ZAP!”)
Pressure or increasing pain inside a cast or splint deserves attention, particularly if it is accompanied by numbness, unusually cold or discolored toes, or swelling that’s getting worse.
Knowing how to describe the pain can help your medical team decide how best to treat it.
Does This Pain Have an Expiration Date?
There isn’t a single timetable for pain after an ankle fracture or surgery. The pain you feel during the first few days is usually very different from what may still be bothering you weeks or months later.
The first few days: This is generally the period of acute pain from the injury or surgery itself. Surgical pain is often worst during the first several days, particularly after a nerve block wears off. Swelling can add considerable pressure and throbbing. This is also when prescription pain medication, scheduled over-the-counter medication, elevation, ice or other measures recommended by your surgical team may be most important.
The first few weeks: The intense surgical pain usually begins to ease, but that doesn’t necessarily mean you are pain-free. Swelling, stiffness, incisions, irritated nerves and healing bones and soft tissues can all hurt. Pain may also increase temporarily as you begin moving the ankle, start physical therapy or put weight on the leg.
The next several months: Pain often becomes less constant and more connected to activity. You may feel reasonably good in the morning and hurt after walking, exercising or being on your feet all day. Swelling and aching at the end of the day can persist long after the fracture itself has healed. Muscles, tendons and joints that have been immobilized also have to adjust to working normally again. Frequently, after sleeping or sitting for a long time, your first steps will be painful and stiff. (This last one is me.)
A year and beyond: Some people are essentially pain-free. Others continue to have intermittent discomfort for a year—or years. Persistent pain can come from many sources, including stiffness, nerve irritation, tendon problems, scar tissue, arthritis or irritation from surgical hardware. Occasionally, pain becomes chronic and requires further evaluation or treatment.
Recovery is rarely a straight line. Having a painful day after several good ones doesn’t necessarily mean something has gone wrong. But pain that is severe, worsening rather than gradually improving, suddenly different, or accompanied by new swelling, redness, warmth, fever, numbness or other concerning symptoms deserves a call to your medical team.
The important question changes as recovery goes on. Early on, it may be “How do I get through this pain?” Months later, it may be “Why does this still hurt?”
Nerve Blocks for Surgical Pain
Nerve blocks are often used as part of anesthesia for ankle surgery and can provide powerful pain relief during the hours when postoperative pain may be at its worst. A regional nerve block involves injecting local anesthetic near the nerves that carry pain signals from the leg or ankle, temporarily making the area numb and sometimes difficult or impossible to move. For my ORIF surgery, along with other anesthesia, I had an ultrasound-guided popliteal sciatic nerve block that kept my leg numb for about 18 hours, getting me through some of the most painful hours after surgery.
Blocks eventually wear off, sometimes rather abruptly, so it’s important to know the postoperative pain-medication plan and when to begin it rather than waiting until the block is completely gone and the pain has caught up with you.
Acetaminophen (Tylenol)
Acetaminophen is one of the most commonly used over-the-counter pain relievers. It reduces pain and fever but doesn’t reduce inflammation.
Widely available and generally well tolerated, it’s often useful for mild to moderate pain, and may be used as part of a pain-control plan designed to reduce the need for opioids.
Too much acetaminophen can cause serious liver damage, so check the labels carefully. Some prescription pain medications and cold remedies also contain acetaminophen, making it easy to accidentally take more than intended.
Ibuprofen and Other NSAIDs
Nonsteroidal anti-inflammatory drugs, or NSAIDs, reduce pain and inflammation, including swelling, making them useful for many types of musculoskeletal pain. Examples include ibuprofen (Advil, Motrin) and naproxen (Aleve).
They can be effective for joint and muscle soreness and may reduce the amount of opioid medication needed after some surgeries.
The downsides? NSAIDs can irritate the stomach and increase the risk of ulcers and bleeding; affect the kidneys and raise blood pressure; and aren't appropriate for everyone, particularly people with certain kidney, heart, stomach or bleeding problems.
There's another concern when you're recovering from a fracture: inflammation is an essential part of the early bone-healing process. Because NSAIDs suppress inflammation, researchers have questioned whether they can delay healing or increase the risk of nonunion, when a broken bone fails to heal.
The evidence is mixed. Some studies have found an increased risk of nonunion, particularly with prolonged NSAID use, while others have found little or no effect. Short-term use appears to carry less risk.[i] In fact, orthopedic trauma guidelines conditionally recommend NSAIDs after fractures because their pain-relieving benefits generally outweigh the relatively small potential risk to bone healing.
Still, the drug, dose, duration of use and your individual circumstances matter. Ask your orthopedic surgeon whether NSAIDs are appropriate during your particular stage of fracture healing.
MY TAKE ON IT
I veered away from taking NSAIDs because I was afraid they would slow my healing. But I was also afraid of taking acetaminophen as my blood work showed elevated liver enzymes after only a few weeks. And the opioids and muscle relaxants were serious drugs I wanted to avoid because of how sleepy, foggy and constipated they made me.
But I needed something to help with the pain, as my surgeon (who may have been a little fed up with me) pointed out.
She told me to take ibuprofen and that being able to sleep was much more important than the small risk of it slowing my healing.
Opioid Medications
Opioids such as oxycodone and hydrocodone may be prescribed for severe pain after surgery or a major fracture.
They can provide effective relief from intense acute pain and may make the first few days after surgery considerably more manageable, helping patients to sleep and move when severe pain would otherwise prevent it.
Negatives include that they can cause nausea, constipation, dizziness, drowsiness and slowed breathing. They can also impair balance — an especially important consideration when you're already negotiating life on one good leg.
Combining opioids with other sedating medications, including some muscle relaxants, can increase the risk of dangerous sedation and slowed breathing.
Dependence and addiction are possible, particularly with prolonged use.
Gabapentin
Gabapentin is a prescription medication that affects nerve signaling and is sometimes used when pain has a nerve-related quality.
It may be worth asking about if you have burning pain, shooting or electrical sensations, pins and needles, severe sensitivity to touch, or nerve pain that’s keeping you awake.
Gabapentin can cause dizziness, sleepiness and coordination problems, which matters when you're already at increased risk of falling. It should be used only under medical supervision.
Muscle Relaxants
Muscle spasms or guarding can occasionally contribute to pain during recovery, and a doctor may prescribe a muscle relaxant.
These medications can cause significant drowsiness and dizziness and aren't appropriate for every patient. They should be taken only as directed.
Ice Therapy
Cold therapy can reduce swelling and temporarily numb painful tissues.
Protect your skin by wrapping the ice pack rather than applying ice directly.
Short sessions—commonly about 15 to 20 minutes—are generally preferable to prolonged icing.
Follow any specific instructions given by your surgical team.
What if you're in a cast or splint?
You may not be able to get ice anywhere near the ankle. An ice pack placed behind the knee is commonly suggested by orthopedic practices and is something many ankle patients find helpful.
Don't put ice inside a cast or allow the cast or dressing to become wet.
Elevation: Higher Than You Think
Putting your foot on a footstool isn't really elevation.
To reduce swelling effectively, the ankle generally needs to be above the level of your heart. That's where the memorable recovery-group advice comes from:
“Toes above nose.”
Pillows or a foam elevation wedge can help maintain the position without requiring constant effort.
Swelling creates pressure, and pressure hurts. For many people, proper elevation is one of the simplest and most effective ways to make an angry ankle settle down.
Heat Therapy
Heat has a place in recovery, but usually not during the early swollen stage after surgery.
Later in recovery, your doctor or physical therapist may recommend heat to loosen stiff tissues or sore muscles, sometimes before exercises or physical therapy.
Avoid applying heat to a fresh surgical site, over an open incision, to areas with significantly reduced sensation and when substantial swelling or inflammation is still present. Reduced sensation around an injured or surgical ankle can make it surprisingly easy to burn yourself.
TENS
A TENS unit—transcutaneous electrical nerve stimulation—sends a mild electrical current through pads placed on the skin. Some people find that it temporarily reduces pain; others notice little difference.
It can be a useful drug-free option to discuss with your doctor or physical therapist, particularly if pain is lingering beyond the immediate postoperative period.
Don't place electrodes over an incision, broken or infected skin, or areas with little or no sensation. People who are pregnant or who have certain implanted electrical devices or other medical conditions should ask their healthcare provider before using one.
Pain-Relief Patches and Creams
Topical products such as lidocaine, menthol, capsaicin and topical NSAIDs are available for certain kinds of localized pain.
Don’t apply topical pain products directly over a surgical incision or damaged skin. Once the incision is completely healed, ask your surgeon or physical therapist whether a topical product might be useful for persistent localized discomfort.
Listen to Your Body — But Don't Be Afraid of Every Ache
Pain provides information.
Sometimes it's simply your recovering ankle telling you, That's enough for today.
If an activity makes the ankle gradually more sore or swollen, backing off, elevating it and trying less next time may be all that's required.
But recovery also involves gradually asking tissues to do more. Once your doctor or physical therapist has cleared you to progress, some discomfort with rehabilitation doesn't necessarily mean you're damaging the ankle.
The useful question isn't always “Does this hurt?”
It may be “Is this the kind of pain I should expect at this stage, and does it settle afterward?”
Keep a Pain Journal
If your pain is persistent or difficult to explain, jot down:
Where it hurts
What the pain feels like—aching, burning, stabbing, throbbing or tingling
How severe it is
What you were doing when it started
What makes it better or worse
What medication you took and whether it helped
Whether swelling accompanies it
Whether the pattern is changing
You don't need a novel. A few notes on your phone can reveal patterns that are difficult to remember accurately at an appointment.
Advocate for Yourself
If you’re in significant pain despite following the treatment plan, tell your healthcare team. Be specific. Explain what it feels like, when it occurs, whether it wakes you at night, whether it is getting worse and what you can no longer do because of it.
And if significant unexplained pain continues without an adequate explanation or plan, seeking another orthopedic opinion is reasonable.
MY TAKE ON IT
After my initial ORIF surgery for a bimalleolar fracture and ruptured peroneal tendon, I had a lot of pain—and a lot of side effects from the medication. I had terrible nausea and got incredibly constipated from the Oxy, but I was desperate enough to take it for the first couple of weeks.
My leg would swell within my cast, making it impossible to sleep. At my two-week post-op, I complained, and my surgeon subsequently let me go into a CAM boot (moonboot), even though I was non-weightbearing. She initially wanted me to stay in a cast for another four weeks. I could loosen the CAM boot and relieve some of the pressure, which helped relieve my pain. That meant I could actually sleep a little. It ended up being a big thing for me.
As for medications, the muscle relaxant helped me more than the opioids. Not that it left me exactly clear-headed either. But life generally became more tolerable and I got through the worst of it.
Almost a year after my surgery, although much better, I still had significant pain and severely limited dorsiflexion. The front of my foot felt locked and painful, too. I went back to my surgeon for X-rays of my ankle, to see if the front of it had bone chips that could be removed. It didn’t, but to my surprise, my surgeon suggested taking out the outer plate on my ankle. She explained that she had to use such a big plate as my break was so low, but said that it could possibly be interfering with the tendon.
As a result, I had hardware removal surgery. It turned out the hardware wasn’t interfering with the tendon, but there was severe scar tissue that was immobilizing the peroneal tendon. My surgeon removed the scar tissue, and my ankle now has more range of motion and less pain.
The bottom line is that I made my complaints heard—twice—and twice my doctor attempted to resolve some of my pain.
When to Contact Your Doctor
Call your surgeon or medical team if pain is suddenly much worse, steadily worsening rather than improving, or not controlled by the treatment plan they gave you.
Also contact them promptly about symptoms such as:
Increasing numbness or loss of sensation
New weakness or inability to move your toes
A cast or splint that suddenly feels painfully tight
Toes that become unusually pale, blue or cold
Increasing redness, warmth or drainage around an incision
Fever along with worsening surgical-site symptoms
New or rapidly increasing swelling
Severe burning or electrical pain that isn't settling
New calf pain or significant calf swelling warrants prompt medical attention
Chest pain, sudden shortness of breath, coughing up blood or other symptoms suggesting a pulmonary embolism require emergency medical attention.
WORTH KNOWING
Good postoperative pain control should make the pain manageable enough for you to rest, sleep, move safely and participate in your recovery.
[i] Murphy PB, et al. “Efficacy and Safety of Non-steroidal Anti-inflammatory Drugs (NSAIDs) for the Treatment of Acute Pain After Orthopedic Trauma: A Practice Management Guideline.” Trauma Surgery & Acute Care Open. 2023;8:e001056. doi:10.1136/tsaco-2022-001056.