Ankle and Foot Fractures: Difference between revisions

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== Differential Diagnosis<br> ==
== Differential Diagnosis<br> ==


*Rheumatoid Arthritis  
*Rheumatoid Arthritis  
*Gout and Pseudogout  
*Gout and Pseudogout  
*Ankle Dislocation  
*Ankle Dislocation  
*[[Ankle Impingement|Ankle Impingement]]<br>
*[[Ankle Impingement|Ankle Impingement]]
*[[Compartment Syndrome of the Foot|Compartment Syndrome of the Foot]]  
*[[Compartment Syndrome of the Foot|Compartment Syndrome of the Foot]]  
*[[Compartment Syndrome of the Foot|Compartment Syndrome of the Foot]]Deep Venous Thrombosis and Thrombophlebitis
*Deep Venous Thrombosis
*[[Peroneal Tendonitis|Peroneal Tendinopathy]]  
*[[Peroneal Tendonitis|Peroneal Tendinopathy]]  
*[[Sinus Tarsi Syndrome|Sinus Tarsi Syndrome]]  
*[[Sinus Tarsi Syndrome|Sinus Tarsi Syndrome]]  
*A[[Ankle Sprain|nkle ligament sprains]].
*[[Ankle Sprain|Ankle ligament sprains]].


The clinical presentation of some subtle fractures of the ankle can be similar to that of ankle sprains. This similarity makes that ankle fracture is often mistaken as ankle sprain. These injuries are quite different and need an accurate and early diagnosis.<ref name="12">Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician. 2002; 66(5):785-94.</ref><br>
The clinical presentation of some subtle fractures of the ankle can be similar to that of ankle sprains. This similarity makes that ankle fracture is often mistaken as ankle sprain. These injuries are quite different and need an accurate and early diagnosis.<ref name="12">Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician. 2002; 66(5):785-94.</ref>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==

Revision as of 23:02, 23 March 2017

Description[edit | edit source]

A fracture is an interruption of the continuity of bone, this page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabiliation of such injuries. Fractures of the ankle joint are common amongst adults. Kannus et al. report an incidence of up to 174 cases per 100 000 persons per year in a Finish population.[1] Fractures of the foot are less common.

Fractures of the ankle[edit | edit source]

ANF1.png

Ankle fractures are most commonly diagnosised through clinical examination and x-ray. Ottawa rules provide clinicians with a tool to decide whether the joint should be imaged or not. Several classifications exist and are used to determine severity of injury and management. Examples are Dannis-Webber that identifies level of injury and Lauge-Hansen and uses mechanism of the injury.

Complications include reduced range of motion at the ankle and foot joint as a result of peri-articular and intra-articular adhesions or disruption of articular surfaces. Disruption to articular surfaces may lead to development of osteoarthritis. 

Fractures without displacement can be treated with a below knee cast that may be applied for 3-6 weeks. If displaced, a surgeon should reduce the fragments to there normal anatomical position of the joint. If this cannot be achieved by manipulation and plaster cast then an individual may have to undergo an open reduction with internal fixation (ORIF) followed by immobilisation in a plaster cast.[2]

Fractures in the foot[edit | edit source]


Clinically Relevant Anatomy[edit | edit source]

Figure 3-Ankle ligaments.PNG

The ankle joint[edit | edit source]

The ankle joint also known as talocrural joint is made up of three bony structures: the distal ends of the tibia (shinbone) and fibula and the talus. The tibia and fibula have specific parts that make up the ankle:

  • Medial malleolus - inside part of the tibia
  • Posterior malleolus - back part of the tibia
  • Lateral malleolus – end of the fibula

The tibia and fibula form the ankle joint with structure and stability provided by connective tissues:

  • Interosseous membrane
  • Anterior, posterior, and transverse tibiofibular ligaments

The collateral ligaments stabilize the joint against abduction and adduction forces. Laterally, the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), and, medially, the broad fan of the deltoid ligament and the plantar calcaneonavicular ligament, whose medial border is blended with the forepart of the deltoid ligament.[3]

Figure 4- Foot bones.PNG

The foot[edit | edit source]

The foot contains 26 bones. The foot is divided into three main parts: hindfoot, midfoot and forefoot.

  • Hindfoot is composed of 2 bones, calcaneus and talus. They form the subtalar joint
  • Midfoot is made up of 5 bones, navicular, cuboid and 3 cuneiforms (medial, intermediate and lateral). The bones are connected to the forefoot and the hindfoot by muscles and the plantar fascia (arch ligament).
  • Forefoot is consists of 19 bones, which are 5 metatarsals, 14 phalanges.

The Chopart joint is the connection between the hindfoot to the midfoot involving the ‘talonavicular joint’ and the ‘calcaneocuboid joint’; the Lisfranc joint connects the forefoot to the midfoot.

Epidemiology /Etiology[edit | edit source]

Ankle fracture is caused by traumas such as falls, twisting injuries and sports-related injuriesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, and therefore it does not only occur in the older, but also in the young and active population.

There are a number of risk factors associated with an increased risk of sustaining foot and ankle fractures including smoking, diabetes, obesity, previous falls and/or fractures, very high or low levels of physical activity, and low bone mineral density (BMD). For older individuals over an age of 50, additional risk factors include female gender, comorbidities and multiple medications.

The higher level of activity in younger males, particularly in risk taking and sports activities, might explain the high rates of ankle and foot fractures in this age group. Younger female, under the age of 50, less active than males, however they have a higher tendency to fall, later in life which coincides with postmenopausal bone loss, resulting in an increase in fracture risk.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Characteristics/Clinical Presentation[edit | edit source]

  • Difficulties or even inability to walk or load the ankle. (it is possible to walk with less severe breaks, so never rely on walking as a test of whether a bone has been fractured.
  • Pain
  • Swelling
  • Bruising (soon after the injury).
  • Difference in appearance.
  • Observable differences compared to the unaffected side

When an ankle has been broken, there is not only structural damage to the skeletal structure, but also to the ligament tissue (deltoid ligament and the anterior and posterior tibiofibular ligaments) and possibly nervous and musculoskeletal tissue around the ankle complex. This can result in impaired balance capacity, reduced joint position sense, slowed nerve conduction, velocity, impaired cutaneous sensation and decreased dorsal extension range of motionCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Fracture Classifications 
[edit | edit source]

Ankle fractures can be classified according to either the AO/OTA, Danis-Weber or Lauge-Hansen classification system.

The Lauge-Hansen classification is based on a rotational mechanism of injury. There are 4 categories and 13 subgroups of ankle fractures detailed in the table below.

Categories Stage (subgroups)
Supination external rotation (SER) 1. Injury of the anterior inferior tibiofibular ligament
2. Oblique/spiral fracture of the distal fibula
3. Injury of the posterior inferior tibiofibular ligament or avulsion of the posterior malleolus
4. Medial malleolus fracture or injury to the deltoid ligament
Supination adduction (SA) 1. Transverse fracture of the distal fibula
2. Vertical fracture of the medial malleolus
Pronation external rotation (PER) 1. Medial malleolus fracture or injury to the deltoid ligament
2. Injury of the anterior inferior tibiofibular ligament
3. Oblique/spiral fracture of the fibula proximal to the tibial plafond
4. Injury of the posterior inferior tibiofibular ligament or avulsion of the posterior malleolus
Pronation abduction (PA) 1. Medial malleolus fracture or injury to the deltoid ligament
2. Injury of the anterior inferior tibiofibular ligament
3. Transverse or comminuted fracture of the fibula proximal to the tibial plafond

The Danis-Weber classification is based on radiographic criteria. It took into consideration the position of the distal fibular fracture in relation to the syndesmosis of the ankle joint. Three categories were created:

  • Type A fracture: below the level of the tibial plafond (syndesmosis) and may be associated with oblique or vertical medial malleolar fractures 
  • Type B fractures: at the level of the tibial plafond (syndesmosis) and extend proximally in an oblique fashion
  • Type C fractures: proximal to the level of the tibial plafond and often have an associated syndesmotic injury. It can be associated with medial malleolus fractures or injury to the deltoid ligament.[3]Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The AO and Lauge-Hansen classification systems are widely used in the clinical diagnosis of ankle injuries. The AO classification system is simple to understand, and it emphasizes the coordinating role of the fibula and syndesmosis of the ankle joint. The Lauge-Hansen classification system emphasizes the different stages of pathological damage in addition to the fracture pattern, and it insists on the understanding of damage to the ankle ligament system. It can provide an extensive assessment of ankle injuries.

Compared to Lauge-Hansen classification, AO classification system is more reliable and reproducible and thus has more value in clinical practice, than the Lauge-Hansen classification system. Despite this, the Lauge-Hansen classification system stands as the basis for understanding the mechanics of ankle fractures.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

AO classification/OTA system classifies all long bone fractures with a systematic approach, based on location, topography, and extent of bony lesion. It is based on radiographic criteria and incorporates the mechanism of injury. The fractures are classified as infrasyndesmotic, transsyndesmotic and suprasyndesmotic with further subcategories based on the presence or absence of medial or posterior malleolar injuries.

The table below compares the Danis-Weber, Lauge-Hansen, and AO/OTA classification systems.

Fibular fracture location

Danis-Weber classification


Lauge-Hansen classification
SAD I, II


AO/OTA classification of tibial malleolar fractures

Infrasyndesmotic Type A SAD I, II 44-A1 (isolated lateral)
44-A2 (lateral and medial)
44-A3 (lateral, medial, and posterior)
Transsyndesmotic Type B SER I, II, III, IV 44-B1 (isolated lateral)
44-B2 (lateral and medial)
44-B3 (lateral, medial, and Volkmann’s fracture)
Suprasyndesmotic Type  C

PER I, II, III, IV

PA I, II, III

44-C1 (simple diaphyseal)
44-C2 (multifragmentary)
44-C3 (proximal

OTA = Orthopaedic Trauma Association; SAD = supination adduction; SER = supination external rotation; PER = pronation external rotation; PA = pronation abduction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Avulsion fractures[edit | edit source]

AFF1.jpg

Differential Diagnosis
[edit | edit source]

The clinical presentation of some subtle fractures of the ankle can be similar to that of ankle sprains. This similarity makes that ankle fracture is often mistaken as ankle sprain. These injuries are quite different and need an accurate and early diagnosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Diagnostic Procedures[edit | edit source]

Ottawa rules[edit | edit source]

Ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following:

  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
  • An inability to bear weight both immediately and in the emergency department for four steps.

Additionally, the Ottawa ankle rules indicate whether a foot X-ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following:

  • Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
  • Bone tenderness at the navicular bone (for foot injuries), OR
  • An inability to bear weight both immediately and in the emergency department for four steps.

Ankle fractures are initially evaluated by physical examination and then by x-ray.[3]

To reduce the use of x-rays, an intrasound device can be used to detect malleolar fractures even though it cannot be relied upon alone due to an 85% sensitivity and 52% sensitivity.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Ultrasound had good sensitivity and specificity for diagnosing fifth metatarsal, lateral and medial malleolus fractures in patients with foot and/or ankle sprains. However, sensitivity and specificity of ultrasound for navicular fractures were low.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Imaging[edit | edit source]

Outcomes Measures[edit | edit source]

  • SF-36 includes 8 categories: Physical functioning, Physical role, Bodily pain, General health, Vitality, Social functioning, Emotional role and Mental health)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Kerr-Atkins score for pain and function after calcaneal fracture leading to a best score of 100points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • EuroQol (EQ-5D) to measure the Quality of life and general health statusCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • American Orthopaedic Foot and Ankle Society score based on 9 items: pain, activity and functional limitations, walking distance, difficulties with different terrains, gait abnormality, sagittal range of motion at the ankle and range of motion at the subtalar joint, stability, and alignmentCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Olerud-Molander Ankle Score (OMAS), is an ordinal rating scale from 0 points (totally impaired function) to 100 points (completely unimpaired function) related to 9 different items given different points: pain, stiffness, swelling, stair climbing, running, jumping, squatting, supports and work/activity level.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • FAOS is also a self-administered patient questionnaire and consists of 42 items divided into five subscales: pain, other symptoms, function in daily living (ADL), function in sport + recreation + foot and ankle-related quality of life.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Global self-rated ankle (GSRF) to evaluate their present ankle functionCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • The American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS) score contains 3 components: pain (40 points), function and alignment on a scale of 0- 100 points, 100 best possible scoreCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Foot Function Index (FFI) consists of 23 questions to measure the impact of foot pathology on function in terms of pain, disability and restriction of activity. The lower the score, the better outcomeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Medical Management
[edit | edit source]

Most patients with a malleolus fracture require 6 weeks of immobilization. Patients with an initially non-displaced fracture or who were treated surgically will generally require 4 weeks of non-weight bearing in a short-leg cast or removable walking boot, followed by 2 weeks in a walking cast or boot. The removable boot will allow for earlier range-of-motion exercises.

Surgery is needed for many types of ankle fractures. While not always necessary, surgery for ankle fractures is not uncommon. The need for surgery depends on the appearance of the ankle joint on X-ray and the type of ankle fracture.

The goals of surgery are always the smooth anatomical reconstruction of the joint surface and the protection of the injured ligamentous structures to enable early postoperative functional therapy of the joint. Adequate reduction with congruency of the joint has been reported as one of the most important indications of a good end result. Inadequate reduction may lead to osteoarthritis.

The timing of definitive surgical treatment depends mainly on the soft-tissue findings, is possible only if the soft tissues are not critically vulnerable (few hours after the trauma). And so the need for surgery depends on the appearance of the ankle joint on X-ray and the type of ankle fracture.

While not always necessary, surgery for ankle fractures can be done with 3 kinds of metal plate and multiple screws: one-third tubular plate; locking compression (LCP) metaphyseal plate for lateral malleolar fracture and Weber B fracture; LCP distal fibula plate Weber A fracture and Weber B fracture.[3][4]

Types of plates- from left to right: conventional one-third tubular plate; a LCP metaphyseal plate; a LCP distal fibula plate

Physical Therapy Management
[edit | edit source]

Conservative treatment is applied for non-displaced fractures and surgical treatment is applied for displaced intra-articular fractures. Factors such as wounds concerns, medical co-morbidities and non-compliance of the patient may affect the decision in favour of conservative treatment. Bandaging and elevation of the foot is part of calcaneal fractures treatment that have been applied for a long time. Elevation, splinting and non-weight bearing for up to 12 weeks are parts of conservative treatment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Fractures that are stable with non-displaced or only slightly displaced fragments can be treated conservatively. The procedure depends mainly on patient compliance. Type A fractures does not need to be immobilized in a cast, but can rather be treated like external ligament ruptures in a stabilizing ankle orthosis for early function with pain-adapted full weight-bearing.
All fractures that are not of type A should be treated in a so-called walker or vacuum shoe.[3]

After 6 weeks of immobilization, the ankle can be fully loaded. There is no standardized rehabilitation program after cast removal. Each program is individually chosen from a standardised set of exercises (Figure 7) to ensure consistency. There program contains exercises of three categories: ankle mobility + strengthening exercise, stepping exercise and weight bearing + balancing exercise. The patients can continue exercising at home and independent from physiotherapists also with the help from patient information leaflet given as support guide.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

(Physiotherapy Following an Ankle Fracture).

Home exercise program

Physiotherapists are often involved in the rehabilitation, which starts quickly (1 week) after the period of immobilization. Most people experience pain, swelling, stiffness, muscle atrophy and decreased muscle torqueCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, impaired ankle mobility, impaired balance capacity and increased ankle circumferenceCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title at the ankle after cast removal. Consequently, patients complain of limitation in activities involving the lower limb, such as stair climbing, walking and reduced participation in work and recreation. It has been found that patients with unimalleolar fractures report less activity limitation than those with bimalleolar or trimalleolar fractures[5]

Passive joint mobilization is commonly used to work on the problems of pain and joint stiffness, in order to allow an earlier return to activities. For this technique, the physiotherapist manually glides the articular surfaces of a joint to produce oscillatory movements. It has been proven that manual therapy, such as joint mobilization, produces analgesic effects. It also increases elasticity of joint structures through interactions at the local, central nervous system and psychological levels (Figure 8) [6]

Passive joint mobilization

Joint mobilizations aim to relieve pain and improve range of motion (ROM) of injured joints which can lead to an increase in functional activities. Using Maitland’s classification, Grade I and Grade II joint mobilizations are performed primarily to decrease joint pain, and Grade III and Grade IV joint mobilizations are used to increase joint ROM.

Prolonged immobilization leads to a decrease in ankle dorsiflexion range of motion. Anterior-to-posterior talocrural joint mobilizations are purported to increase dorsiflexion ROM and decrease joint stiffness after immobilization.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

There is evidence that, after a surgical treatment for an ankle fracture, a training program, started within one week after cast removal and continued for 12 weeks (with 2 appointments per week), shows superior results compared to usual care, regarding patient scored function and muscle strength in the plantar flexors and dorsiflexors of patients under the age of 40. The patients had to do home exercises daily, prescribed by the physiotherapist, appropriate to the functional status at the time. Functional goals are loaded ankle dorsiflexion, plantairflexion, on-leg-stance, rising on toes, rising on heels, normalized walking pattern when walking on even ground, on stairs and at comfortable speed[7]

 When the cast is removed, many patients have a plantarflexion contracture that is loss of dorsiflexion, increased stiffness. This contracture is not caused directly by fracture but develops as an adaptive response to immobilization. The addition of a program of passive stretches has no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization[8]

Strength-training may be beneficial after fracture and should be considered as an important rehabilitation option by physical therapy. Because strength loss is one of the most common complications by a foot or ankle fracture.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

After surgery, patients follow rehabilitation program. Young and mobile patients with good ankle mobility and without any ligamentous injury receive instruction in additional weight-bearing or a “walking school” program. Most patients need early postoperative functional treatment with physiotherapeutic guidance to improve joint function and proprioception and to reduce swelling (lymph drainage). Patients who have fractures combined with ligamentous injuries are particularly in need of proprioceptive physiotherapy to protect them from the risk of chronic ankle instability. Normally, a walker is not given postoperatively, so that active and passive ankle motion is possible at all times. While the patient is still in the hospital, as soon as the state of the wound permits weight-bearing, partial weight-bearing up to 10–20 kg is initiated. After six weeks of partial weight-bearing, a follow-up x-ray, and removal of positioning screws (if indicated), weight-bearing is then increased to 10 kg per week. Full weight-bearing and full participation in work and recreational sports are possible 12–16 weeks after the injury, or sooner in high-performance athletes.[3]

Key Research[edit | edit source]

  • Fractures of the Ankle Joint: Investigation and Treatment Options.[3]
  • Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.[9]

Resources
[edit | edit source]

Clinical Bottom Line[edit | edit source]

The evaluation of ankle injuries is a common challenge for family physicians. Diagnosis is made by using knowledge of the anatomy and function of the ankle joint to aid in taking an adequate history and performing an appropriate physical examination. The patient should be questioned about the mechanism of injury, previous injury, disability, treatment and pain. The ankle should be evaluated for ecchymosis, swelling, areas of tenderness and laxity. These measures help to determine what, if any, additional diagnostic procedures may be needed. Most ankle sprains are lateral, affecting the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Other injuries include medial ankle sprains affecting the deltoid ligament, trauma to the Achilles and peroneal tendons, tarsal tunnel syndrome, fractures, syndesmotic sprains, synovial impingement and chronic instability. Criteria for radiographic evaluation include inability to bear weight initially or when examined, and tenderness over the medial or lateral malleolus. Accurate diagnosis is critical for appropriate treatment and minimizing functional disability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Suspected injury is based on the details from the medical history, general physical examination and orthopaedic physical examination. It is important to establish the relationship between the start of painful symptoms and physical activity, generally performed repetitively, abrupt changes in the amount of training and the presence of risk factors.

Initially, pain emerges at the end of the exercises and intensifies over some weeks; it may occur during the entire activity, and be constant during walking. Pain worsens and transforms training into suffering. Training becomes increasingly painful and difficult to continue. Even after some days of rest, returning to activities too early leads to recurrence of the pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Recent Related Research (from Pubmed)
[edit | edit source]

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References [edit | edit source]

  1. Kannus P, Palvanen M, Niemi S, Parkkari J, Jrvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: finnish statistics during 1970–2000 and projections for the future. Bone. 2002;31(3):430-433.
  2. Tidy N, Porter S. Tidy's physiotherapy. 13th ed. Edinburgh: Elsevier; 2013.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Goost H et al. Fractures of the Ankle Joint: Investigation and Treatment Options. Dtsch Arztebl Int. 2014; 111(21): 377–388.fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075279/ (
  4. Huang Z et al. Comparison of three plate system for lateral malleolar fixation. BMC Musculoskelet Disord. 2014; 15: 360. (2B).fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223732/
  5. Lin CC, Moseley AM, Herbert RD, Refshauge KM. Pain and dorsiflexion range of motion predict short-and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study. Australian Journal of Physiotherapy 2009, 55;31-37
  6. Lin C CH, Moseley AM, Refshauge KM, Haas M, Herbert RD. Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial. BMC Musculoskeletal Disorders 2006;7:46
  7. Nilsson G, Jonsson K, Ekdahl CH, Eneroth M. Effects of a training program after surgically treated ankle fracture : a prospective randomised controlled trial. BMC Musculoskeletal Disorders 2009;10:118
  8. Moseley AM, Herbert RD, Nightingale EJ, Taylor DA, Evans TM, Robertson GJ, Gupta SK, Penn J. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture : a randomized controlled trial. Arch Phys Med Rehabil 2005;86 :1118-26
  9. Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003; 236:417