Physical Therapy
Healing the bone is only part of the story. Then you have to teach the ankle how to be an ankle again.
FROM THE TRENCHES
Physical therapy can make recovery feel like a second job — one where progress is sometimes measured in degrees.
“It was work getting to this bend,” wrote one patient at 10 weeks post-op. “But I took it one day (and degree) at a time.”
That may be one of the best descriptions of ankle PT. The improvements can be almost ridiculously small: a little more bend, a little more strength, a stretch that goes farther than it did last week. One patient described doing her PT exercises at home as well as at therapy and planned to “stretch and stretch and stretch till my foot falls off.” Another found that after TENS, exercises, dexterity work, the bike and stretching, her ankle moved so much better that she could walk normally — at least until she sat down and stiffened up again.
The work can also reveal just how much the injury and weeks of immobilization have taken away. One mother described her daughter's significant muscle weakness and atrophy after the cast came off, along with persistent foot and ankle swelling. Her daughter went to PT twice a week and, three months after the injury, was “making huge strides.” Running was still months away, but her mother had learned to be okay with that.
For some people, PT becomes one of the most important parts of recovery. “Physical therapy helped me so much,” wrote one patient who didn't begin walking slowly until about 2½ months after her injury. Another, who had never been to physical therapy before, went into it not knowing what to expect. With three plates and 12 screws and what she described as “horrible” range of motion, she became such a believer that she planned to continue “until my insurance doesn't cover it/I can no longer afford it.”
And then there are the reminders of what all those exercises, stretches and tiny gains are working toward.
One woman who suffered a trimalleolar fracture was told her ankle would never be the same. In the beginning, she said she felt as though she'd been “hobbled like in the film Misery.”
Months later, she could hop, jump, run up and down stairs, take a two-hour Zumba class and had walked 100 miles for charity. She still had two scars and occasionally some swelling if she overdid it.
“I'll take that,” she wrote. “It does get better. Don't give up.”
NOBODY TOLD ME...
Physical therapy after an ankle fracture can be surprisingly humbling.
You may arrive thinking you’re going to exercise and discover that your assignment is to move your foot a few degrees, shift your weight from one side to the other, or stand on one leg without grabbing the table. Things you did without thinking before your injury can suddenly require concentration, effort and, occasionally, a ridiculous amount of courage.
That doesn’t mean PT isn’t working. It means there is a lot more to walking normally, balancing, and stair climbing than most of us ever appreciated.
Why Physical Therapy Matters
A healed X-ray doesn’t necessarily mean a recovered ankle.
Weeks in a splint, cast or boot can leave the ankle stiff, the calf noticeably smaller and weaker, and the muscles throughout the injured leg deconditioned. (I will never forget the horror I felt when my cast first came off and I saw the chicken leg that my calf had turned into over the course of a couple of weeks.) Balance and proprioception — your body’s ability to sense where the joint is in space — can suffer too. And after weeks of protecting an injured leg, you may have picked up compensations such as limping, shortening your stride or avoiding a normal push-off through the foot.
Physical therapy works on putting those pieces back together.
Depending on your injury and where you are in recovery, that can mean restoring range of motion, rebuilding strength, improving balance, correcting your gait and eventually preparing you for stairs, uneven ground, work, exercise or sports.
Just as important, PT can help restore trust in the ankle.
That part is easy to underestimate. Your surgeon may tell you the fracture is healed and that you can put weight on your leg. Your brain may have other ideas.
See also: Learning to Walk Again for more on the mental and physical transition back to weight bearing.
When Does Physical Therapy Start?
There is no universal starting date.
Your surgeon’s instructions depend on the fracture, the repair, associated ligament or tendon injuries, wound healing, and how stable everything is. Some people begin gentle motion relatively early. Others remain immobilized longer and start formal therapy later.
This is one area where somebody else’s recovery timeline can get you into trouble.
The person in your Facebook group doing ankle circles at two weeks may have a completely different injury from yours. The person walking at four weeks may have been cleared for early weight bearing. Your surgeon’s restrictions outrank somebody else’s impressive recovery post.
Before beginning exercises on your own, know what you have actually been cleared to do.
What PT Is Trying to Accomplish
Rehabilitation generally progresses from mobility → strength → balance and control → function.
Those stages overlap, and you won’t necessarily move neatly from one to the next.
Getting the Ankle Moving Again
Early rehabilitation may focus on restoring motion that disappeared during immobilization.
Depending on your surgeon’s restrictions, exercises may include gentle ankle movements, ankle “alphabets,” calf stretches and other range-of-motion work.
The movements can look almost laughably simple.
Then you try them.
A stiff postoperative ankle may barely move at first, and comparing it with the uninjured side can be startling. Improvement is often measured in degrees rather than dramatic breakthroughs.
The goal isn’t to force the ankle into submission. (Yes, yes it is. Says me.) It’s to gradually regain usable motion without asking healing tissues to tolerate more than they are ready for.
Rebuilding Strength
Immobilization takes a toll quickly, particularly on the calf.
As healing progresses, therapy may add resistance bands, heel raises and progressively more demanding strengthening exercises. Work may also extend well beyond the ankle. Your hips, glutes, quads and core all contribute to balance, gait and lower-extremity control.
The Home Exercises Matter
There is an unfortunate truth about physical therapy: your therapist cannot do your recovery for you.
The home exercise program is where repetition happens. That doesn’t mean doing more than you were prescribed or deciding that if 10 repetitions are good, 50 must be better. It means doing the right exercises, with the right technique, at the frequency your therapist recommends.
If you don’t understand an exercise, ask your therapist to demonstrate it again. If you know perfectly well that you will never do six different exercises four times a day, say so. A realistic program you actually follow is more useful than an elaborate one you abandon.
Learning to Balance Again
Balance is one of those abilities you don’t appreciate until it disappears.
Therapy may progress from standing with both feet planted to shifting weight, standing on the injured leg, reaching while balancing, using unstable surfaces or performing increasingly difficult movements.
These exercises aren’t filler. They help retrain proprioception and the rapid muscular responses that help keep an ankle stable when you step on uneven ground or unexpectedly lose your balance.
Fixing the Limp
Being allowed to walk and walking normally are two different milestones.
After weeks of protecting an injured leg, limping can become a habit. The body is remarkably good at compensating. You may take a shorter step, avoid rolling through the foot normally, turn the foot outward or rush to get your weight back onto the good leg.
For me, I tended to walk laterally, shifting from one leg to another instead of bending. I still do it when I get up in the night to go the bathroom.
A physical therapist can identify those compensations and work on restoring a more normal gait.
This matters because repeatedly moving poorly can shift stress elsewhere — into the knee, hip, back or opposite leg.
See Learning to Walk Again for a closer look at the transition from protected weight bearing to independent walking.
How Much Should PT Hurt?
This is one of the most useful conversations you can have with your therapist.
Rehabilitation can be uncomfortable. Stretching a stiff ankle, challenging weak muscles and increasing activity may produce soreness. But “PT is supposed to hurt” is not a useful rule.
Pain is information.
Tell your therapist what you feel, where you feel it, how intense it is and — importantly — what happens afterward. An exercise that feels tolerable in the clinic but leaves your ankle dramatically more painful or swollen for the rest of the day may need to be modified.
The goal is progressive challenge, not punishment.
And if you develop sudden or severe pain, a significant change in swelling, redness or warmth, or another symptom that concerns you, don’t simply assume it is part of rehabilitation.
See Pain Management During Recovery and Pulmonary Embolism and Deep Vein Thrombosis for symptoms that deserve more attention.
Progress Isn’t Always a Straight Line
Ankle recovery has an annoying habit of making you think you’ve conquered something and then reminding you that you haven’t.
You may walk beautifully in the morning and limp after a busy afternoon. You may increase your exercises and see more swelling that evening. You may master one balance exercise and be astonishingly bad at the next one.
Look at the trend rather than a single day.
If your range of motion, strength, balance, endurance and function are gradually improving, an occasional bad day doesn’t erase that progress.
On the other hand, if you repeatedly lose ground, pain is increasing rather than decreasing, swelling is becoming more pronounced, or you simply aren’t progressing, bring it up. Your therapist and surgeon may need to reassess what is limiting you.
Returning to Sports and Higher-Level Activity
For an athlete, “I can walk” is nowhere near the finish line.
Running, jumping, cutting, riding, hiking and other sports can require considerably more strength, balance, endurance and control than ordinary daily activities. Rehabilitation may eventually include single-leg strengthening, hopping, plyometrics, agility drills and movements specific to your sport.
This is where a therapist with experience treating athletes — and preferably some understanding of your particular sport — can be especially valuable.
Tell your therapist what you actually want to get back to. “Normal activity” is a very different goal from returning to jumping horses, running a 10K or playing competitive tennis. (Ask me how I know this.)
The final stage of rehabilitation should prepare you for your life, not merely get you discharged from PT.
WORTH KNOWING: Aquatic Therapy
Water can provide a useful bridge between limited mobility and full land-based exercise.
Buoyancy reduces the amount of body weight the injured leg must support, while water resistance allows muscles to work through movement. Depending on the stage of recovery, aquatic therapy may be used for walking, range-of-motion exercises, strengthening and balance work.
It can be particularly appealing when full-weight-bearing exercise on land is still difficult or painful.
There is one important catch after surgery: you generally need to wait until the incision is completely healed and your surgeon has cleared you to get into a pool. An open or incompletely healed surgical wound and pool water are not a good combination.
Not every PT facility offers aquatic therapy, but if land-based rehabilitation is particularly difficult, it may be worth asking whether it is appropriate for you.
If You Don’t Click with Your Physical Therapist
You’re going to spend a fair amount of time with this person, and the relationship matters.
A good therapist should be able to explain what you’re working on and why, adjust exercises when something isn’t working, listen when you report pain or other problems, and understand the activities you hope to return to.
That doesn’t mean your PT should let you avoid everything difficult. Quite the opposite. A good therapist knows when to push you — and when pushing harder is not the answer.
If you consistently feel unheard, your goals are being dismissed or you don’t understand the plan, ask questions. If the relationship still isn’t working, it is reasonable to consider another therapist.
MY TAKE ON IT
Years ago, I had surgery for a badly dislocated shoulder, a result of a hang-gliding accident. My doctor’s words were that “it looked like shrapnel had gone off in there.” I had to keep the arm immobile for six weeks, and by the time I was allowed to move it again, well… I couldn’t.
I very much wanted to return to hang-gliding, but landing a glider successfully requires being able to lift both of your arms well above your head. My first physical therapist shook his head when I told him that’s what I wanted to be able to do. “You might need to find a new sport,” he said.
Instead, I found a new physical therapist.
This one—Chris, who will always hold a beloved place in my heart—asked me to explain exactly what motion I’d need to be able to do, and to demonstrate it with my good arm. He told me that it wasn’t going to be easy, and I’d have to fight, but he’d get me there. And he did.
While I didn’t want someone to blow smoke up my rear and tell me that I could do things that were impossible, I did want someone positive who could support me to the best of his ability.
ASK YOUR SURGEON
Before or during physical therapy, useful questions include:
When am I cleared to begin PT?
Are there any movements or exercises I should avoid?
Are there restrictions because of a tendon, ligament or other injury in addition to the fracture?
When can strengthening and balance work begin?
What symptoms should make me stop therapy and contact you?
Are there specific milestones you want me to reach before returning to work, driving, exercise or sports?
Mindful Moves
Physical therapy is where recovery starts becoming active.
For weeks, much of your job may have been to protect the ankle and let your body heal. PT changes the assignment. Now you begin asking the ankle to move, bear weight, become stronger, balance and eventually do the things you took for granted before you were injured.
Some of the victories will seem absurdly small: a little more dorsiflexion. Your first decent heel raise. Ten seconds standing on one leg. Walking across a room without thinking about every step.
They count.
Bone healing may get you out of the cast.
Rehabilitation helps give you your life back.