Top Contributors - Ewa Jaraczewska and Jess Bell
Introduction[edit | edit source]
Clinically Relevant Anatomy[edit | edit source]
The ankle joint complex can be divided into three parts: the talocrural, talocalcaneonavicular and subtalar parts. The talocrural (TC) joint is formed by three bones and a complex ligamentous apparatus. The tibia, fibula and talus are connected by the collateral ligaments and the syndesmotic ligament complex.
Ankle Joint[edit | edit source]
Bones[edit | edit source]
The ankle is formed by three bones: the talus, tibia and fibula. The anatomical structure of the foot consists of the hindfoot, midfoot and forefoot. Each part of the foot is composed of several bones. The lower leg and foot constitute the ankle. The following bony elements of the ankle joint are part of this structure:
The talocrural joint (TC or sometimes called the tibiotalar joint) is referred to as the ankle joint. The articulating surfaces are the lateral and the medial malleoli, distal end of the tibia and the talus. The primary movements of the TC joint are dorsiflexion and plantarflexion in the sagittal plane.
In the hindfoot, the talus and calcaneus articulate and form the subtalar joint (ST, also known as the talocalcaneal joint). The ST joint has three articulations, and the talus and calcaneus both have three articulating facets. The main motions at this joint are inversion and eversion of the ankle and hindfoot.
The Chopart joint (or MT, midtarsal or transverse tarsal joint, talocalcaneonavicular joint) is the "junction" between the hindfoot and midfoot. This joint includes the talonavicular and calcaneocuboid joints, and allows forefoot rotation. The navicular articulates with all three cuneiform bones distally. In addition to the navicular and cuneiform bones, the cuboid bone has a distal articulation with the base of the fourth and fifth metatarsal bones.
Below is a summary of the ankle articulations:
Ligaments[edit | edit source]
The ligaments of the ankle consist of:
- The medial ligaments (the deltoid ligament)
- The medial collateral ligament (MCL) is divided into two layers: superficial and deep
- The lateral ligaments
- The lateral collateral ligament complex (LCL) is composed of three ligaments: the anterior talofibular, calcaneofibular, and posterior talofibular ligaments
- The tibiofibular syndesmosis - i.e. the ligaments connecting the distal epiphyses of the tibia and fibula
- The tibiofibular syndesmosis articulation includes the anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and the interosseous tibiofibular ligament.
You can read more about ankle ligaments here.
Muscles[edit | edit source]
The lower leg muscles are divided into four compartments: the superficial posterior compartment, the deep posterior compartment, the lateral compartment, and the anterior compartment. The primary plantarflexors of the ankle are located in the posterior compartment. Muscles of the lateral compartment plantarflex the ankle and evert the foot. All the muscles within the anterior compartment perform ankle dorsiflexion.
More information on the muscles and fascia of the ankle can be found here.
Neural and Vascular[edit | edit source]
Neural[edit | edit source]
The tibial nerve and common peroneal nerve (also known as common fibular nerve) originate at L5, S1 and S2. The tibial nerve provides motor fibres to gastrocnemius, soleus, tibialis posterior, flexor digitorum longus, and flexor hallucis longus. Its sensory fibres occasionally supply the area typically innervated by the deep peroneal nerve.
The superficial branch of the common peroneal nerve sends motor fibres to peroneus (fibularis) longus and brevis. The deep branch sends motor fibres to tibialis anterior, extensor digitorum longus, extensor hallucis longus, extensor digitorum brevis (rarely innervated by the tibial nerve). The sensory fibres of the superficial branch supply the anterolateral part of the leg and much of the dorsum of the foot and toes. The deep branch supplies the skin between the first and second toes.
The sural nerve originates from the tibial nerve and cutaneous branches of the common peroneal nerve. It is divided into the sural communication nerve and lateral sural cutaneous nerve. Its sensory fibres innervate the posterior aspect of the distal leg and the lateral aspect of the foot.
Vascular[edit | edit source]
The following arteries supply the distal aspect of the lower leg:
- Popliteal artery: superficial posterior compartment including gastrocnemius, soleus and plantaris muscles.
- Tibial artery
- Anterior tibial artery: proximal tibiofibular joint, knee joint, ankle joint, muscles and skin of the anterior compartment of the leg.
- Posterior tibial artery: soleus, popliteus, flexor hallucis longus, flexor digitorum longus and tibialis posterior.
- Fibular artery: popliteus, soleus, tibialis posterior, and flexor hallucis longus muscles.
- Sural artery: gastrocnemius muscle, soleus muscle and plantaris muscle.
You can read more about the neural and vascular systems of the ankle here.
Classifications of Fractures[edit | edit source]
Clinically relevant classifications for ankle fractures include the following:
- Malleolar (and its subcategories according to the Danis–Weber ABC classification)
- Distal tibia
- Any ankle fracture-dislocation
- Any bimalleolar or tri-malleolar ankle fracture
- Any lateral malleolar fracture with a significant talar shift on any plain radiograph view at any time.
An ankle fracture is considered stable if none of the above criteria are met.
The AO/OTA system classifies fractures for the entire body. In the ankle, fractures are divided into malleolar, distal tibia, and fibular fractures. This system of classification is most commonly used to classify malleolar fractures, and is based on the severity and complexity of the injury:
- Type A: infrasyndesmotic fibular injury (with three subgroups)
- Type B: transsyndesmotic fibular fracture (with three subgroups)
- Type C: suprasyndesmotic injury (with three subgroups)
A revised version of the AO/OTA classifications separates fractures for epiphyseal, metaphyseal, and diaphyseal fractures. When multiple fractures and fracture systems occurs, several labels can be applied. 
You can learn more about AO/OTA classification here.
Clinical Presentation[edit | edit source]
Patients present to the emergency room with ankle fractures due to falls, inversion injuries, sports-related injuries, or minor trauma due to diabetes, peripheral neuropathy and other medical conditions. The most common symptoms when an ankle fracture is suspected include:
- Swelling of the ankle
- Inability to weight bear
Diagnostic Procedures[edit | edit source]
You can read about ankle investigations and tests here.
Outcome Measures[edit | edit source]
A wide variety of outcome measures are available to use in adults with ankle fractures:
- Olerud Molander Ankle Score (OMAS)- the most frequently collected primary outcome measure
- Measurements of ankle range of motion - the second most frequently collected primary outcome measure
- American Orthopaedic Foot and Ankle Society Ankle Hind-Foot Scale (AOFAS)
- The Lower Extremity Functional Scale (LEFS)
- The 36-item Short-Form Survey (SF-36)
- Visual Analogue Scale for pain (VAS-Pain)
- Manchester Oxford Foot Questionnaire (MOXFQ)
- American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Score (AAOS)
- Ankle Fracture Outcome of Rehabilitation Measure (A-FORM)
- Foot and Ankle Ability Measure (FAAM)
- Adequate Patient Reported Outcome Measures in ankle instability reported by Hansen et alinclude:
- Modification of Functional Ankle Instability (IdFAI)
- Ankle Instability Instrument (AII)
- European Foot and Ankle Society Score (EFAS score)
Management / Interventions[edit | edit source]
General Considerations[edit | edit source]
In order to choose the most appropriate intervention after an ankle fracture, the physiotherapist must consider the following:
- The presence of a “variety” of protocols with a lack of conclusive recommendations
- Two trends in the literature:
- Traditional protocol includes incremental weight bearing after 6 weeks, with full weight bearing at 12 weeks, based on the mechanism of injury, and the involvement of other soft tissues.
- Early mobilisation protocol includes early weight bearing (before 6 weeks), early exercises, general conditioning, orthoses, and manual therapy.
- The OUTCOMES of the traditional protocol include:
- The OUTCOMES of an early mobilisation protocol include:
- No more complications than the traditional protocol
- Earlier return to work than the traditional protocol
- Decreased risk of thromboembolism and osteoporosis
- Decreased risk of Complex Regional Pain Syndrome (CRPS)
- Improved general well-being and social re-interaction of the patient
- Decreased socio-economic costs
Early Mobilisation Protocol[edit | edit source]
Early phase (3 – 6 weeks post-surgery)[edit | edit source]
- Desensitisation of CRPS: brushing, mirror therapy
- General conditioning in non-weight bearing (NWB) and partial weight bearing (PWB): arm ergometer, stationary cycling, Pilates on reformer, circuit training gym
- Prepare for full weight-bearing (FWB) gait at 6 weeks
Full weight bearing: PWB - FWB (4 - 6 weeks post-surgery)[edit | edit source]
- Functional rehabilitation:
- Cardio-vascular fitness (cycling)
- cycling (spinning)
- swimming (no kicks)
- Strengthening exercises with less than 50% of body weight
- Proprioceptive exercises (Balance Error Scoring System(BESS) with crutches)
- Cardio-vascular fitness (cycling)
Full weight bearing (week 6-8 post-surgery)[edit | edit source]
- Gait (cycle to warm up, then walk)
- Decline squats
- Proprioceptive exercises: Tandem standing lunge with twists, perturbation exercises (pull at stable base)
Full weight bearing (week 8-10 post-surgery)[edit | edit source]
- Walk with resistance bands and weights
- Step up and step overs
- 1 leg balance/ aeroplane
- Star Excursion Balance Test (SEBT)
Week 10 to final phase[edit | edit source]
- Walking endurance with load (walking to work and back with a backpack)
- Jumping and landing (indoor climbing wall)
- Total time since accident – 14 weeks: hiking, post-traumatic stress therapy
- Orthoses: hiking boots, inserts, compression sleeve for lower legs
Resources[edit | edit source]
- Henkelmann R, Schneider S, Müller D, Gahr R, Josten C, Böhme J. Outcome of patients after lower limb fracture with partial weight-bearing postoperatively treated with or without anti-gravity treadmill (alter G®) during six weeks of rehabilitation - a protocol of a prospective randomized trial. BMC Musculoskelet Disord. 2017 Mar 14;18(1):104.
- Matthews PA, Scammell BE, Ali A, Coughlin T, Nightingale J, Khan T, Ollivere BJ. Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial. Trials. 2018 May 31;19(1):304.
References[edit | edit source]
- Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Reviews. 2021 Aug 10;6(8):692-703.
- Brockett CL, Chapman GJ. Biomechanics of the ankle. Orthopaedics and trauma. 2016 Jun 1;30(3):232-8.
- Ficke J, Byerly DW. Anatomy, Bony Pelvis and Lower Limb, Foot. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546698/
- Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69.
- Milner CE, Soames RW. Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle Int. 1998 Nov;19(11):757-60.
- Szaro P, Ghali Gataa K, Polaczek M. et al. The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging. Sci Rep 2020;10: 20801.
- Yammine K, Jalloul M, Assi C.Distal tibiofibular syndesmosis: A meta-analysis of cadaveric studies. Morphologie, 2021.
- Yamashita M, Mezaki T, Yamamoto T. "All tibial foot" with sensory crossover innervation between the tibial and deep peroneal nerves. J Neurol Neurosurg Psychiatry. 1998 Nov;65(5):798-9.
- Grujičić R. Common fibular (peroneal) nerve [Internet]. KenHub. 2021 [cited 24 July 2022]. Available from: https://www.kenhub.com/en/library/anatomy/common-fibular-nerve
- Olczak J, Emilson F, Razavian A, Antonsson T, Andreas Stark A, Gordon M. Ankle fracture classification using deep learning: automating detailed AO Foundation/Orthopedic Trauma Association (AO/OTA) 2018 malleolar fracture identification reaches a high degree of correct classification. Acta Orthopaedica, 2021; 92(1): 102-108,
- Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007 May;21(5):307-15.
- Fonseca LLD, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. Reproducibility of the Lauge-Hansen, Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 2017 Dec 6;53(1):101-106
- Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma. 2020 May-Jun;11(3):375-379.
- Feger J. AO/OTA classification of malleolar fractures. Reference article. Available from https://radiopaedia.org/articles/aoota-classification-of-malleolar-fractures [last access 29.06.2022]
- Seewoonarain S, Prempeh M, Shakokani M, Magan A. Ankle fractures. Journal of Arthritis. 2016:1-4.
- McKeown R, Rabiu AR, Ellard DR, Kearney RS. Primary outcome measures used in interventional trials for ankle fractures: a systematic review. BMC Musculoskelet Disord 2019; 20 (388).
- Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Archives of orthopaedic and traumatic surgery. 1984 Sep;103(3):190-4.
- Hansen CF, Obionu KC, Comins JD, Krogsgaard MR. Patient reported outcome measures for ankle instability. An analysis of 17 existing questionnaires. Foot Ankle Surg. 2022 Apr;28(3):288-293
- Dawson J, Boller I, Doll H, Lavis G, Sharp R, Cooke P, Jenkinson C. The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery. The Foot. 2011 Jun 1;21(2):92-102.
- Nguyen MQ, Dalen I, Iversen MM, Harboe K, Paulsen A. Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties. Qual Life Res. 2022 Jun 18.
- Hansen CF, Obionu KC, Comins JD, Krogsgaard MR. Patient reported outcome measures for ankle instability. An analysis of 17 existing questionnaires. Foot Ankle Surg. 2022 Apr;28(3):288-293.
- Simpson H. Ankle Fractures Course. Physiopedia. 2022
- Lin CWC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD005595.
- Pfeifer CG, Grechenig S, Frankewycz B, Ernstberger A, Nerlich M, Krutsch W. Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures. Injury. 2015 Oct;46 Suppl 4:S51-7.
- Swart E, Bezhani H, Greisberg J, Vosseller JT. How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members. Injury. 2015;46(6):1127-30
- Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014 May 23;111(21):377-88.
- Albin SR, Koppenhaver SL, Marcus R, Dibble L, Cornwall M, Fritz JM. Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2019 May;49(5):310-319
- Nilsson G, Nyberg P, Ekdahl C, Eneroth M. Performance after surgical treatment of patients with ankle fractures--14-month follow-up. Physiother Res Int. 2003;8(2):69-82.
- Suciu O, Onofrei RR, Totorean AD, Suciu SC, Amaricai EC. Gait analysis and functional outcomes after twelve-week rehabilitation in patients with surgically treated ankle fractures. Gait Posture. 2016 Sep;49:184-189.
- Beckenkamp PR, Lin CW, Engelen L, Moseley AM. Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study. J Orthop Sports Phys Ther. 2016 Apr;46(4):235-42
- Ng R, Broughton N, Williams C. Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems. J Foot Ankle Surg. 2018 Jan-Feb;57(1):149-154.
- Jansen H, Jordan M, Frey S, Hölscher-Doht S, Meffert R, Heintel T. Active controlled motion in early rehabilitation improves outcome after ankle fractures: a randomized controlled trial. Clin Rehabil. 2018 Mar;32(3):312-318.
- Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial. J Orthop Trauma. 2016 Jul;30(7):345-52
- Smeeing DP, Houwert RM, Briet JP, Kelder JC, Segers MJ, Verleisdonk EJ, Leenen LP, Hietbrink F. Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies. PLoS One. 2015 Feb 19;10(2):e0118320.