Sleeping after an Ankle Fracture
Apparently, breaking your ankle also breaks your sleep.
Nobody warns you that nighttime may become one of the hardest parts of ankle fracture recovery. You finally get through the logistics of the day, prop up your leg, settle into bed—and your ankle starts throbbing. Or itching. Or sending electrical zaps through your foot. Or the boot suddenly feels like a medieval torture device.
Meanwhile, you’re trying to keep the leg elevated, you can’t sleep in your usual position, getting to the bathroom is an expedition, and your brain has chosen 2 a.m. to contemplate everything that has gone wrong with your life. Which may be considerable lately.
Sleep matters during recovery. Your body is doing a tremendous amount of repair work, and adequate sleep supports tissue healing, immune function and physical and emotional recovery. Unfortunately, knowing you need sleep doesn’t necessarily make it happen.
FROM THE TRENCHES
Spend a little time in an ankle fracture support group and one thing becomes obvious: people are exhausted.
For some, sleep comes in fragments:
“Sleep like a newborn. Probably four- to five-hour stretches at most right now. Take naps when you can. Once I could shower regularly and get back in my bed, it got exponentially better.”
Others would be delighted with four hours:
“I’m so tired of not sleeping for more than an hour or two at a time.”
Sometimes the problem is the very thing that’s supposed to protect the ankle. One person slept reasonably well in a splint until she was moved into a boot two weeks after surgery:
“I barely slept last night due to the boot putting pressure on my incision.”
Another became so fed up with her bulky boot that she tried replacing it with an Ace bandage for the night. At 2 a.m., she rolled over and felt as though someone had stabbed her in the ankle. The boot went straight back on—and surprisingly, she slept better.
“Not only does my foot and ankle feel supported, but I wake every morning with my foot in the best position.”
Pillows can require their own trial-and-error period. One person started with an ordinary wedge and hated it, then switched to a contoured memory-foam elevation pillow that kept her leg from rolling off during the night.
The takeaway from all of these experiences isn’t that there’s one correct boot, pillow or sleeping position. It’s that sleep during ankle recovery often requires experimentation. Something that looks perfectly comfortable at 3 p.m. may be unbearable at 3 a.m.
WHY IS SLEEPING SO HARD?
There’s rarely just one culprit. In the early weeks, you may be dealing with several at once:
Pain and throbbing that become more noticeable when you’re lying still
Swelling and pressure inside a cast, splint or boot
Incision tenderness
Itching
Muscle cramps or spasms
Burning, tingling or electrical sensations from irritated or recovering nerves
Having to sleep in an unfamiliar position
Keeping the leg elevated
Worry about accidentally rolling onto or twisting the injured ankle
Medication effects
Reduced daytime activity
Stress, frustration and anxiety
Interrupted sleep for medications or bathroom trips
Before trying to fix your sleep, figure out what is actually waking you up. Is it pain? Pressure from the boot? Swelling? Your sleeping position? Itching? Your brain refusing to shut down?
There may be more than one answer, but identifying the biggest offenders gives you something you can actually work on.
HOW TO SNAG THAT MUCH-NEEDED SHUT-EYE
Get the elevation right
Elevation can reduce swelling and the pressure and throbbing that come with it. But elevation only helps your sleep if you can stay comfortable.
A wedge or contoured leg-elevation pillow may be more stable than stacking several ordinary pillows. If your carefully constructed pillow fortress leaves your hip, knee or back aching—or your leg keeps rolling off it—experiment with the height, firmness and position.
The goal isn’t simply to get your foot high. It’s to find a setup you can actually sleep in.
Keep the covers off a tender ankle
Even the weight of a sheet or blanket can be surprisingly uncomfortable after surgery. A foot tent or blanket lifter keeps bedding suspended above the injured foot while allowing the rest of you to stay covered.
You may also be able to arrange pillows so they support the bedding above your foot without touching it.
Stay ahead of nighttime pain
If you’ve been prescribed pain medication, follow the schedule and instructions given by your medical team rather than waiting until pain becomes severe.
If icing is permitted at your stage of recovery, using cold therapy before bed may help settle swelling and throbbing.
If pain repeatedly wakes you despite following your treatment plan, tell your medical team. You may need a different strategy rather than another night of trying to tough it out.
See the Pain Management During Recovery chapter for much more on medications, icing and other ways to control pain.
Find a sleeping position that works
Back sleeping with the injured leg supported is often the simplest setup, particularly early in recovery.
For dedicated side sleepers, suddenly being told to sleep flat on your back can be miserable. Depending on your injury and your surgeon’s restrictions, you may be able to sleep on your side with pillows supporting and separating your legs so the injured ankle doesn’t twist, drop or bang against the other leg.
Don’t assume you have to spend weeks in a position in which you simply cannot sleep. Ask what positions are safe for you.
Make the boot work for you—or find out whether you need it
A boot can provide reassuring support at night. It can also press against an incision, trap heat and make finding a comfortable position difficult.
Whether you can remove yours for sleep depends on your injury, surgery and stage of recovery. Don’t ditch it because it’s annoying without asking.
If you do need to sleep in it, experiment with the support underneath your leg and check whether pressure is coming from the boot itself or from the way your leg is positioned.
Deal with the itch—safely
Itching under a cast, splint or boot can become maddening, particularly at night.
Don’t stick objects inside a cast to scratch, and don’t put creams, powders or liquids inside it unless your medical team specifically tells you to.
If itching is severe or persistent, or comes with burning, increasing pain, drainage, odor or skin problems, contact your medical team.
Give your brain a fighting chance
Recovery can turn your normal routine upside down. Spending much of the day indoors and inactive can blur the distinction between day and night.
When you’re able, getting daylight during the day, maintaining fairly regular waking and sleeping times, limiting late-day caffeine and creating a predictable bedtime routine can help reinforce your normal sleep-wake cycle.
Try to limit phone, tablet and computer use before bed; both the light from screens and stimulating content can make it harder for your brain to wind down for sleep.
Other wind-down strategies may help, too. Try quiet music, an audiobook or podcast, a short meditation, slow breathing or gentle stretching or chair yoga that doesn’t involve the injured ankle. They’re especially useful because you can do them lying there with your ankle elevated and your eyes closed. The goal isn’t to force yourself to sleep; it’s to give your body and brain something calmer to do while they get there.
Make nighttime boring—in a good way
Before bed, put everything you’re likely to need within reach: water, medications you’re scheduled to take, your phone, glasses and whatever mobility device you need to get safely out of bed.
Clear the route to the bathroom and consider a night-light. If getting to the bathroom is particularly difficult, ask whether a bedside commode makes sense temporarily.
The goal is simple: no 3 a.m. obstacle courses on crutches.
Use naps strategically
If you slept for two hours last night, there’s no prize for forcing yourself to stay awake all day.
Early in recovery, fragmented sleep is common, and naps can help you get needed rest. But if long or late naps seem to be making nighttime sleep even harder, experiment with shorter or earlier ones.
MY TAKE ON IT
For me, a large part of why I couldn’t sleep was the pain—which was largely solved when, at my two-week post-op after my ORIF surgery, I told my surgeon that I often spent nights in the recliner in the living room. Umm, crying. I was crying when I told her.
Although every word was true, I felt like I was being dramatic. I was pretty sure that my surgeon thought I was a psycho. (And it is a bit of a chain reaction: you’re in pain; therefore you can’t sleep, therefore you’re exhausted and you’re probably drugged, too. What I’m saying is that I wasn’t at my most emotionally stable. Yes, I was a psycho.)
Nevertheless, she ended up putting me in a CAM boot, aka a moon boot or Air Cast, instead of the plaster cast she’d originally had me slated to wear for the next four weeks—which is what I’d been wearing for the first two miserable weeks.
My foot and ankle would swell inside the plaster cast, resulting in pressure and pain. I could loosen the CAM boot and relieve both. That was huge.
I also learned that while the opioids did little but constipate me, ibuprofen and Tylenol helped. I’d take a muscle relaxant if I was twisting in bed for more than half an hour, too. Time and healing helped, as well—not that it’s much comfort in the moment.
The moral isn’t that you should try popping muscle relaxants, but that you shouldn’t accept terrible sleep as something you simply have to endure.
Some disruption may be unavoidable, especially during the first weeks, but there are usually variables you can work with: swelling, pain control, elevation, pillow placement, blanket pressure, sleeping position, the boot and your nighttime routine.
Change one thing and see whether it helps. Then change another.
And if pain or another physical symptom is repeatedly preventing you from sleeping, tell your medical team. “I can’t sleep because my ankle hurts all night” is useful information, not just complaining and being a whiner.
WORTH KNOWING
Not every nighttime symptom should be written off as part of recovery.
New or rapidly increasing pain, severe swelling, a cast or splint that suddenly feels excessively tight, new numbness or inability to move the toes, concerning changes in toe color or temperature, fever, drainage or worsening incision problems warrant a call to your medical team.
Persistent inability to sleep also deserves attention. If pain is repeatedly waking you despite following your treatment plan, tell your surgeon. Poorly controlled nighttime pain may mean the plan needs adjusting rather than that you simply need to tough it out.
ASK YOUR SURGEON
Do I need to wear my boot or brace while sleeping?
How long should I continue elevating my ankle at night?
Can I sleep on my side, and are there positions I should avoid?
What should I do if pain consistently wakes me before my next scheduled medication?
Are icing or heat appropriate before bed at this stage of recovery?
Which nighttime symptoms should prompt me to call you?