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Exercise treatment for broken ankles

The severity of ankle fractures can vary dramatically, and the treatment has to be adjusted accordingly. In this article, we’ll cover what exercises and rehab you should do to get your broken ankle back to full function. This includes what you can do already while your ankle is still in a boot or cast and what you should do after the boot or cast has been removed. We’ll also discuss recovery times and things you should keep in mind before returning to your sport.


Please check with your doctor or physiotherapist before you start any of the suggested exercises, as they may not be right for you. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.

Learn what exercises you should do as treatment for your broken ankle.

In this article:

  1. What happens to your ankle when it is stuck in a boot or cast?

  2. How long will your broken ankle take to recover?

  3. Exercises while your broken ankle is still in a cast/boot

  4. Ankle fracture rehab - when your cast/boot is finally removed

  5. How we can help

What happens to your ankle when it is stuck in a boot or cast?


To appreciate what we need to do to get a broken ankle better, it helps to understand what happens to a body part that is stuck in a boot or cast.


It heals

This is the obvious and desired effect. Your bones need this period of immobilisation to knit together. If you remove the cast or boot too early, the bones may not knit together properly, and you may end up needing surgery.


You lose muscle mass

This is not great, but unfortunately it’s unavoidable. Our bodies are designed to save energy, as it is constantly expecting us to run out of food and starve. If you don’t use a muscle for a while, your brain’s control centre thinks that you don’t require that area of the body to be strong, so it reduces its muscle mass and rather sends resources to the parts that you are using.


If you understand how immobilisation in a cast affects your joints, muscles and nerves, it is easier to understand why your exercises and recovery time from a broken ankle can take so long.

Your nerves and a part of your brain go to sleep

The nerves in our bodies are constantly sending signals to our brains. The brain also has a specific area that is dedicated to managing that specific part of your body.


When an area of our body is not being used and is shielded from experiencing normal sensations (like a cast stopping you from touching your leg), the nerves in that area eventually become less active, as the brain feels it’s a waste of energy to keep them active in an area that is not being used. The control centre in the brain also reduces its activity.


Our brain and nerves control everything in the body, including circulation, muscle contractions, and sensation. This is why it may feel extremely strange to touch your ankle right after your cast has been removed and why it can be so difficult to get your muscles to contract during those first few days.


Interesting fact: You lose most of your muscle strength in the first week or two of being stuck in a cast. This is before you start to lose muscle mass. The reason for this loss of strength is thought to be down to the control centre in the brain in charge of contracting your muscles in that area going to sleep. There are simple ways to reduce this loss, which we discuss lower down.


Your cartilage gets a bit thinner

Joints don’t have arteries or veins that provide them with nutrients and oxygen. They rely on the changes in pressure created when you move to push fresh nutrients and oxygen into them. This is why a joint loses some of the cartilage that lines its surfaces when it is immobilised. But don’t worry, the cartilage will repair once you start moving. It just explains why your joints can feel so uncomfortable when they first come out of a cast.


Your ligaments and joint capsules become tight

Being stuck in one position for some time stiffens all the soft tissue in that area, but this is reversible.


How long will your broken ankle take to recover?


You’re looking at a minimum of 24 weeks for your ankle to be ready for full-on sport again. Ironically, your broken bones take only 12 weeks to fully mend. The subsequent 12 weeks are needed to undo all those negative effects your joints, muscles, and nerves suffered due to being stuck in a boot or cast for so long (see previous section).


The recovery can be divided into three stages:

  1. The bones knit together: This takes about six weeks. At the end of this period, the fractured ankle bones would have knitted but the area will still be quite weak. You will be wearing a cast or boot for the duration of this period.

  2. The fracture area strengthens to pre-fracture strength and beyond: This takes another six weeks. The severity of your fracture and healing response will determine when your cast or boot can be removed (usually around 10 to 12 weeks after it was applied). By the end of this stage, your mended bones will be very strong.

  3. Rehab phase - restoring full range and strength: When your ankle is taken out of the boot or cast, it will likely be very stiff and weak. Twelve weeks is the minimum time your body will need to restore your cartilage, ligaments, joint capsules, muscles, and nerves to their full function.

Exercises while your broken ankle is still in a cast/boot


There are certain things you can do during this period that can help reduce the negative effect immobilisation has on your body. Please check with your doctor or physiotherapist before you start any of these exercises, as it can cause harm if you do them too soon.


Moving your toes

Don’t be too vigorous with this at the start. All broken ankles require a few days to settle. Start with gentle movements. It can improve circulation and help to keep your nerves awake and active.


Strengthening your uninjured leg

You will always lose some muscle mass and strength when you have to wear a cast or boot.

Now, I know this sounds bonkers, but researchers have found that if you strengthen the muscles on the limb that is not injured, it can help to preserve your muscle strength and mass in the injured limb that is stuck in the cast. This is called cross-education.


Researchers think that it has to do with neural activity and that our nervous system works a bit like a mirror. If you strength train the muscles around your uninjured ankle, it activates the control centre in your brain for the area you’re training as well as for the same area on your opposite limb.


Like mentioned before, most of the strength losses we seem to experience due to immobilisation seem to be linked to the nervous system becoming less active. Cross-education strength training can help to keep the nervous system active and reduce these losses.


However, if you’re hobbling around on crutches and already placing a lot of weight on your uninjured leg to compensate for loss of use of the injured one, it may be best not to train it too hard, as it will already be doing a lot more work than usual.

Doing single leg heel raises on your uninjured side may help to keep your nervous system active in your broken leg.
Doing single leg heel raises on your uninjured side may help to keep your nervous system active in your broken leg.

Strengthening the rest of your body

This is the ideal time to ensure that the rest of your body is nice and strong. Our bodies work as kinetic chains, which means that weakness in one area can also affect the other areas. By ensuring that your whole body is strong, you will support and protect your injured ankle.


It will be especially useful to focus on strengthening your core and the muscles in your thigh and gluteal area on your injured side. Choose exercises that don’t place strain on your boot or cast. A physiotherapist can provide you with a programme for this.


Examples of core exercises that may be useful:

  • Sit-ups

  • Russian twists

  • Planks on your knees

Examples of hip exercises:


Quad exercise (injured leg):

  • Seated knee extension: Your boot or cast will provide plenty of resistance. Sit on a chair and extend your injured leg out in front of you, lifting your foot off the floor. Hold the position for several seconds, then lower it down and rest.

Hamstring exercise (injured leg):

  • Standing hamstring curls: Stand on your uninjured leg, holding on to a sturdy object. Slowly lift your injured foot towards your bottom, pause for a moment at the top, then lower it back down. The weight of your cast will help to strengthen your hamstrings.



Ankle fracture rehab - when your cast/boot is finally removed


Restoring your broken ankle to its full strength and function is about more than just exercises. I’ll discuss the most important aspects here, but I would suggest that you seek guidance from a physiotherapist, as everyone’s situation tends to be unique, and you will get better results from a bespoke plan.


Load management

I've put this at the top, because it is a very important part of the rehab process that is often neglected or not very well explained.


When you stand or walk, your feet carry all of your weight. Being stuck in a boot for so many weeks would have weakened the muscles and ligaments that are meant to support your foot arch.


So, your foot won’t be able to cope with carrying your weight when you first take it out of the boot. If you increase the amounts of standing and walking too suddenly, you can end up straining your ligaments or plantar fascia and may develop plantar fasciitis.


My advice is:

  • Always wear supportive shoes, with added arch support if needed, when you’re on your feet. This is especially important for when you’re standing still for long periods, e.g. while cooking. Once your foot and ankle have regained their strength, you can slowly transition back to wearing less supportive shoes and walking barefoot.

  • Slowly increase the time you spend on your feet. Remember, it’s the total amount of standing and walking in a day that is important as well as for how long you do it in one go. Start with short periods of standing and walking interspersed with rest periods, and slowly build it over time.


Supportive shoes with arch supports can help to support your foot while you rebuild your strength.
Shoes with arch supports can help to support your foot while you rebuild your strength.

Exercises that train your nervous system

As mentioned earlier, being stuck in a cast or boot causes your nerves and the central control centre in the brain to be less active and alert. This affects your body in several ways, but the main one I want to highlight here is loss of control.


When you move, the central control system in your brain uses feedback from the nerves in your muscles, joints, ligaments, and tendons to understand where your limbs are in space and time and to calculate the optimal movement pattern. This is how you know where your hands and feet are even when you close your eyes and why you can walk down a flight of stairs without having to look at your feet. We call this position sense or proprioception.


An injury affects these messages from the nerves, and immobilising an injured limb for some time amplifies this loss. A reduced position sense means that you could injure yourself again once you get moving, because you will be somewhat clumsy to start with. It is extremely important (and quite easy) to retrain the control and position sense in your body.


You can regain your position sense with a combination of techniques:

  1. Doing your strength training exercises very slowly and looking at your limb while you’re moving it. Focus on doing smooth movements and not using momentum.

  2. Exercises that challenge your balance. Now, people tend to immediately think about standing on one leg or on balance boards when they hear mention of balancing exercises. But this will likely be too difficult for you at the start. Often, just standing on both feet and slowly transferring your weight to your injured side would be difficult enough. As with all exercises, these should be progressed in difficulty and complexity as your ankle regains strength and control. This can be followed by tandem standing (heel-to-toe on a line), balancing on one leg, balancing while closing your eyes, and finally on unstable surfaces.



Strength training exercises for the ankle and foot

These exercises will help to restore the strength you’ve lost in all those small, intrinsic foot muscles as well as the ones that control your ankle. The specific type and intensity of the exercises will depend on each case, so I won’t go into too much detail here. The muscles that you want to focus on include those with the following functions:

  • Supporting your foot’s arch (intrinsic muscles)

  • Turning your ankle out (the peroneals)

  • Turning your ankle and foot in (tibialis posterior, tibialis anterior); they also help to support your foot’s arch

  • Pointing your foot down and propelling you forward when you walk, run, and jump (gastrocnemius, soleus)

When you strengthen these muscles, you should start in positions that place very little strain on your ankle and focus on regaining control before you start adding load. As you grow stronger, the exercises should increase in complexity as well as load until you do exercises that mimic the movements and forces required for your specific sport.


Let’s take the plantar flexors (calf muscles) as an example. A good exercise to start with is seated heel raises. These can then be progressed to standing double leg heel raises, followed by adding weight or doing them on one leg, and finally plyometrics where you hop and jump. Your physio will help to guide you in when you’re ready to move on to the next type of exercise.



Mobility exercises

Don’t be too forceful with your stretches, as overstretching can cause your joint to be achy and painful. I find that doing active stretches and movements often and throughout the day seems to work better than doing long, sustained holds where you really try and force the movement. Repetitive movements have been shown to feed joints and help restore the cartilage.


Patients seem to regain their ankle mobility at different rates, and from what I’ve observed the main factors that influence this are:

  • How severe their fracture and intra-articular (inside the joint) injury was.

  • How flexible or stiff their soft tissue is in general. If you are generally a flexible person (can manage most yoga poses with only a bit of effort), you will likely regain your full range of motion a bit more quickly than if you’re on the less flexible side (that guy who remains sitting bolt-upright in yoga class when he is actually trying to bend towards his toes).

  • How diligent people are with doing their exercises.

But diligence only goes so far. Even if you’re super diligent, it will still take at least 8 to 12 weeks to regain your full range of motion. This is just how long it takes the body to remodel and reverse the effects of the immobilisation.


You should aim to regain your full movement in all directions. See what your uninjured leg can do and compare that with your injured side. How far can your foot point down (plantar flexion), pull up (dorsiflexion), turn in (inversion), and turn out (eversion)?


Dorsiflexion is often the most difficult to restore. A good starter exercise is the knee-to-wall stretch. This can later be progressed to the typical runner's calf stretch or heel drops over the side of a step. Whatever you choose, do them as active stretches: Hold the position where you feel the restriction for 10 seconds, then move out of it for a second of two. Repeat this several times in one go – six is a good number – and do it two to three times a day.



Exercises for the rest of the body

Our bodies work as kinetic chains. Weakness or lack of control in one area will also affect the rest. This is why it’s important to include exercises for your core, glutes, quads, and hamstrings.


These exercises should start easy and in low-load positions. However, it is really important to eventually progress them to resemble the movements used in your sport. For instance, a basketball player should include several hopping and jumping drills, whereas a walker’s rehab plan would focus more on building endurance.


How we can help


Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

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About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.




References:

  1. Campbell, M., et al. (2019). "Effect of immobilisation on neuromuscular function in vivo in humans: a systematic review." Sports Medicine. 49(6): 931-950.

  2. Knapik, Derrick M., et al. (2013) "The basic science of continuous passive motion in promoting knee health: a systematic review of studies in a rabbit model." Arthroscopy. Oct; 29(10):1722-31. doi: 10.1016/j.arthro.2013.05.028

  3. Haggert, M., et al. (2020). "Determining the effects of cross-education on muscle strength, thickness and cortical activation following limb immobilization: a systematic review and meta-analysis." The Journal of Science and Medicine. 2(4): 1-19.

  4. Andrushko, J. W., et al. (2018). "Unilateral strength training leads to muscle-specific sparing effects during opposite homologous limb immobilization." Journal of Applied Physiology. 124(4): 866-876.