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Meta-Analysis
. 2024 Sep 23;9(9):CD005595.
doi: 10.1002/14651858.CD005595.pub4.

Rehabilitation for ankle fractures in adults

Sharon R Lewis  1   2 , Michael W Pritchard  1 , Roses Parker  3 , Henry KC Searle  4 , Paula R Beckenkamp  5 , David J Keene  6 , Chris Bretherton  1 , Chung-Wei Christine Lin  7
Affiliations
Meta-Analysis

Rehabilitation for ankle fractures in adults

Sharon R Lewis et al. Cochrane Database Syst Rev. .

Abstract

Background: Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.

Objectives: To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.

Search methods: We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.

Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.

Main results: We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise. All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data. Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants) Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence). Removable versus non-removable ankle support (25 studies, 2206 participants) Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence). Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants). Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants) Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.

Authors' conclusions: Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.

Trial registration: ClinicalTrials.gov NCT01127776.

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Conflict of interest statement

Four of the review authors (PB, DK, CB, C‐WL) were involved in included studies. These review authors remained independent of data extraction, risk of bias, and any interpretation of findings for these studies.

SL is the former Deputy Co‐ordinating Editor of the Cochrane Bone, Joint and Muscle Trauma Group; she was not involved in the editorial process for this review, and has declared that she has no conflict of interest.

MP has declared that he has no conflict of interest.

RP has declared that she has no conflict of interest.

HS has declared that he has no conflict of interest.

PB has declared that she has no conflict of interest.

DK has declared that he has no conflict of interest.

CB has declared that he has no conflict of interest.

C‐WL has declared that she has no conflict of interest.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. We did not assess risk of bias in Christie 1990 and Keene 2016 because we did not include outcome data for these studies in the review, and there were no outcomes assessed by personnel in Bretherton 2024; thus, these studies include blank spaces.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 1: Activity limitation (using OMAS; at the end of treatment)
1.2
1.2. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 2: Activity limitation (using OMAS; short‐term follow‐up, ≤ 6 months)
1.3
1.3. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 3: Activity limitation (using different measurement tools; long‐term follow‐up, > 6 months)
1.4
1.4. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 4: HRQoL (using different measurement tools; at end of treatment)
1.5
1.5. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 5: HRQoL (using different measurement tools; short‐term follow‐up, ≤ 6 months)
1.6
1.6. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 6: HRQoL (using different measurement tools; long‐term follow‐up, > 6 months)
1.7
1.7. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 7: Participant satisfaction (VAS, /10; end of treatment, and short‐term follow‐up of ≤ 6 months)
1.8
1.8. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 8: Pain (VAS; end of treatment)
1.9
1.9. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 9: Pain (VAS; short‐term follow‐up, ≤ 6 months)
1.10
1.10. Analysis
Comparison 1: Early versus delayed weight‐bearing, Outcome 10: Adverse events
2.1
2.1. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 1: Activity limitation after surgical fracture management (using different measurement tools; end of treatment)
2.2
2.2. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 2: Activity limitation (using different measurement tools; short‐term follow‐up, ≤ 6months)
2.3
2.3. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 3: Activity limitation (using different measurement tools; long‐term follow‐up, > 6 months)
2.4
2.4. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 4: Activity limitation after non‐surgical fracture management (using OMAS; end of treatment)
2.5
2.5. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 5: HRQoL (using different measurement tools; end of treatment)
2.6
2.6. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 6: HRQoL (using different measurement tools; short‐term follow‐up, ≤ 6 months)
2.7
2.7. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 7: HRQoL (using different measurement tools; long‐term follow‐up, > 6 months)
2.8
2.8. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 8: Pain after surgical fracture management (numbers with pain; all time points)
2.9
2.9. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 9: Pain after non‐surgical fracture management (VAS; end of treatment)
2.10
2.10. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 10: Pain after non‐surgical fracture management (VAS; short‐term and long‐term follow‐up)
2.11
2.11. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 11: Adverse events (after surgical fracture management)
2.12
2.12. Analysis
Comparison 2: Removable ankle support versus non‐removable ankle support (e.g. cast), Outcome 12: Adverse events (after non‐surgical fracture management)
3.1
3.1. Analysis
Comparison 3: Physical therapy, Outcome 1: Activity limitation (using different measurement tools; at end of treatment)
3.2
3.2. Analysis
Comparison 3: Physical therapy, Outcome 2: Activity limitation (using different measurement tools; short‐term follow‐up, ≤ 6 months)
3.3
3.3. Analysis
Comparison 3: Physical therapy, Outcome 3: Activity limitation (using different measurement tools; long‐term follow‐up, > 6 months)
3.4
3.4. Analysis
Comparison 3: Physical therapy, Outcome 4: HRQoL (using different measurement tools; at end of treatment)
3.5
3.5. Analysis
Comparison 3: Physical therapy, Outcome 5: HRQoL (using different measurement tools; short‐term follow‐up, ≤ 6 months)
3.6
3.6. Analysis
Comparison 3: Physical therapy, Outcome 6: HRQoL (using different measurement tools; long‐term follow‐up, > 6 months)
3.7
3.7. Analysis
Comparison 3: Physical therapy, Outcome 7: Participant satisfaction (100‐mm VAS; end of treatment)
3.8
3.8. Analysis
Comparison 3: Physical therapy, Outcome 8: Pain (using different measures; at end of treatment
3.9
3.9. Analysis
Comparison 3: Physical therapy, Outcome 9: Pain (using different measurement tools; short‐term follow‐up, ≤ 6 months)
3.10
3.10. Analysis
Comparison 3: Physical therapy, Outcome 10: Pain (using different measurement tools; long‐term follow‐up, > 6 months)
3.11
3.11. Analysis
Comparison 3: Physical therapy, Outcome 11: Pain (numbers with pain; long‐term/end of follow‐up
3.12
3.12. Analysis
Comparison 3: Physical therapy, Outcome 12: Adverse events (during initial fracture management period after surgical treatment)
3.13
3.13. Analysis
Comparison 3: Physical therapy, Outcome 13: Adverse events (after initial fracture management period after either surgical or non‐surgical treatment)
4.1
4.1. Analysis
Comparison 4: Other rehabilitation interventions: electrotherapy versus control, Outcome 1: Activity limitation (interventions given during initial fracture management period; OMAS; all time points)
4.2
4.2. Analysis
Comparison 4: Other rehabilitation interventions: electrotherapy versus control, Outcome 2: Pain (10‐cm VAS; end of treatment)
4.3
4.3. Analysis
Comparison 4: Other rehabilitation interventions: electrotherapy versus control, Outcome 3: Pain (interventions given during the initial fracture management period; VAS; short‐term follow‐up, ≤ 6 months)
4.4
4.4. Analysis
Comparison 4: Other rehabilitation interventions: electrotherapy versus control, Outcome 4: Pain (numbers with pain; long‐term follow‐up, > 6 months)
5.1
5.1. Analysis
Comparison 5: Other rehabilitation interventions, Outcome 1: Pain (using different measurement instruments; at end of treatment)
5.2
5.2. Analysis
Comparison 5: Other rehabilitation interventions, Outcome 2: Adverse events (interventions during initial fracture management with surgical treatment)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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    1. Ahl T, Sjoberg HE, Dalen N. Bone mineral content in the calcaneus after ankle fracture. Acta Orthopaedica Scandinavica 1988;59(2):173-5. - PubMed
    1. Ahl T. Ankle fractures, with special reference to early postoperative weight bearing. Danderyd, Sweden: The Department of Orthopedics, Karolinska Institute, Danderyd Hospital, 1988.
Ahl 1987 {published and unpublished data}
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Ahl 1993 {published and unpublished data}
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Egol 2000 {published and unpublished data}
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Finsen 1989 {published data only}
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Fitzgerald 1994 {published data only}
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Franke 2008 {published data only}
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Ginandes 1999 {published data only}
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Gorodetskyi 2010 {published data only}
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Handolin 2005 {published and unpublished data}
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Hedstrom 1994 {published data only}
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Hernandez 2006 {published and unpublished data}
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Honigmann 2007 {published data only}
    1. Honigmann P, Goldhahn S, Rosenkranz J, Audige L, Geissmann D, Babst R. After treatment of malleolar fractures following ORIF - functional compared to protected functional in a vacuum-stabilized orthesis: a randomized controlled trial. Archives of Orthopaedic and Trauma Surgery 2007;127(3):195-203. - PubMed
Jansen 2018 {published data only}
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Kearney 2021 {published data only}
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    1. ISRCTN17809322. AIR: ankle injury rehabilitation [Ankle injury rehabilitation: is it feasible to conduct a randomised controlled trial to assess the difference between functional bracing versus plaster cast for the treatment of fixed ankle fractures (AIR)]. trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN17809322 (first received 5 November 2015).
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Keene 2016 {published data only}
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Keene 2022 {published data only}
    1. ISRCTN16612336. Ankle fracture treatment: enhancing rehabilitation – the AFTER study [Optimising mobility after ankle fracture in older adults: a multi-centre pilot randomised controlled trial]. trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN16612336 (first received 31 July 2018).
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Kortegangas 2019 {published data only}
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    1. NCT01758835. PRCT-study of different non-operative treatment protocols of ER-stress negative Weber-B unimalleolar ankle fractures [Evaluation of different non-operative treatment protocols of ER-stress negative Weber-B unimalleolar ankle fractures. A prospective randomized multicenter trial]. clinicaltrials.gov/ct2/show/NCT01758835 (first received 1 January 2013).
Lehtonen 2003 {published data only}
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Lin 2008b {published and unpublished data}
    1. ACTRN12605000143628. Clinical trial of joint mobilisation after ankle fracture. www.anzctr.org.au/ACTRN12605000143628.aspx (first received 9 August 2005).
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Losch 2002 {published data only}
    1. Losch A, Meybohm P, Schmalz T, Knopf E, Fuchs M, Dresing K. Prospective randomised study on the cost/benefit analysis of early functional after-treatment in operatively treated ankle joint fractures [Prospektiv randomisierte studie zur kosten-/nutzenanalyse der fruhfunktionellen nachbehandlung bei operativ versorgten sprunggelenkfrakturen]. Hefte zu der Unfallchirurg 2002;284:232-3.
Matthews 2020 {published data only}
    1. ISRCTN11212729. Early motion and directed exercise (EMADE) in ankle fracture fixation [Early motion and directed exercise (EMADE) post ankle fracture fixation: a pragmatic randomised controlled trial]. www.isrctn.com/ISRCTN11212729 (first received 13 March 2017).
    1. Matthews P, Scammell B, Ali A, Nightingale J, Coughlin T, Khan T, et al. Early motion and directed exercise (EMADE) versus usual-care, following ankle fracture stabilisation surgery; a pragmatic randomised controlled trial. Physiotherapy 2020;107:e12-3.
    1. Matthews PA, Nightingale J, Coughlin T, Scammell B, Ollivere B. Early motion and directed exercise (EMADE) versus usual care, post ankle fracture fixation: a pragmatic randomized controlled trial. In: Orthopaedic Trauma Association Annual Meeting: Program Committee Highlight Papers, PAPER #67. 2019:128.
    1. Matthews PA, Scammell BE, Ali A, Coughlin T, Nightingale J, Khan T, et al. Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial. Trials 2018;19(1):304. - PMC - PubMed
Molund 2020 {published data only}
    1. Molund M, Hellesnes J, Berdal G, Andreassen BS, Andreassen GS. Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial. Clinical Rehabilitation 2020;34(8):1040-7. - PMC - PubMed
    1. NCT04168307. Physiotherapy versus use of a new ankle trainer device after ankle fracture operation [Conventional physiotherapy versus use of a new ankle trainer device after Weber B ankle fracture operation. a randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT04168307 (first received 19 November 2019).
Moseley 2005 {published and unpublished data}
    1. ACTRN12610000979055. Exercise or advice after ankle fracture [In patients after immobilisation for ankle fracture, is a rehabilitation program consisting of exercises prescribed by physiotherapists more effective than a single session of advice in reducing activity limitation and improving quality-adjusted life years?]. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335930&isReview... (first received 11 November 2010).
    1. Moseley AM, Herbert RD, Nightingale EJ, Taylor DA, Evans TM, Robertson GJ, et al. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2005;86(6):1118-26. - PubMed
    1. Nightingale EJ, Moseley AM, Herbert RD. Passive dorsiflexion flexibility after cast immobilization for ankle fracture. Clinical Orthopaedics and Related Research 2007;456:65-7. - PubMed
Moseley 2015 {published data only}
    1. Beckenkamp PR, Lin CC, Herbert RD, Haas M, Khera K, Moseley AM, Team Exact. EXACT: exercise or advice after ankle fracture. Design of a randomised controlled trial. BMC Musculoskeletal Disorders 2011;12(148):1-7. - PMC - PubMed
    1. Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW, and EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA 2015;314(13):1376-85. [PMID: ] - PubMed
    1. Moseley AM, Beckenkamp PR, Herbert RD, Haas M, Lin CC. EXACT: exercise or advice after ankle fracture - a randomised controlled trial. Physiotherapy 2015;101:e133-4. - PMC - PubMed
Nilsson 2009 {published and unpublished data}
    1. ACTRN12609000327280. Effects of a neuromuscular training program on pain and function after surgically treated ankle fracture. A prospective randomised controlled trial. www.anzctr.org.au/ACTRN12609000327280.aspx (first received 22 May 2009).
    1. Nilsson GM, Jonsson K, Ekdahl CS, Eneroth M. Effects of a training program after surgically treated ankle fracture: a prospective randomised controlled trial. BMC Musculoskeletal Disorders 2009;10:118. - PMC - PubMed
Palke 2022 {published data only}
    1. Henkelmann R, Palke L, Schneider S, Müller D, Karich B, Mende M, et al. Impact of anti-gravity treadmill rehabilitation therapy on the clinical outcomes after fixation of lower limb fractures: a randomized clinical trial. Clinical Rehabilitation 2021;35(3):356-66. - PubMed
    1. 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 Musculoskeletal Disorders 2017;18(1):1-6. - PMC - PubMed
    1. 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 Musculoskeletal Disorders 2017;8(1):1-6. - PMC - PubMed
    1. NCT02790229. Postoperatively treated patients with lower limb fracture with or without an anti-gravity treadmill [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 bicentric prospective randomized trial]. clinicaltrials.gov/ct2/show/NCT02790229 (first received 3 June 2016).
    1. Palke L, Schneider S, Karich B, Mende M, Josten C, Böhme J, et al. Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: a randomised clinical trial. Clinical Rehabilitation 2022;36(1):87-98. - PubMed
Park 2021 {published data only}
    1. Park JY, Kim BS, Kim YM, Cho JH, Choi YR, Kim HN. Early weightbearing versus nonweightbearing after operative treatment of an ankle fracture: a multicenter, noninferiority, randomized controlled trial. American Journal of Sports Medicine 2021;49(10):2689-96. - PubMed
Rasmussen 2006 {published and unpublished data}
    1. Rasmussen S, Sperling KP, Jensen PK. Aircast pneumatic walker reduces pain and enhances rehabilitation after supination-eversion type 4 fractures. In: Østgaard S , editors(s). Abstracts, Danish Orthopaedic Society Meeting. Odense, Denmark, 2000.
    1. Rasmussen S, Sperling KP, Jensen PK. Enhanced rehabilitation and reduced pain with pneumatic walker after internal fixation of malleolar fracture: a randomized study of efficacy in 40 patients (as supplied 13 February 2006). Data on file.
Reed 1998 {published and unpublished data}
    1. Reed M, Wright K, Du Fosse J, Cross A. Ankles can be immobilized in a backslab or wool and crepe post-operatively: a randomized prospective trial. Injury 1998;29(2):152-3.
Romero Zepeda 2008 {published data only}
    1. Romero Zepeda EE, Cadenas Tovar M, Vargas Espinosa JM, Huape Arreola MS, Garcia Tizoc SO. Comparison between Robert Jones dressing and "U" splint in ankle fractures [Estudio comparativo de la utilidad del vendaje tipo Robert Jones y la ferula en U en las fracturas de tobillo]. Acta Ortopedica Mexicana 2008;22(1):40-4. - PubMed
Schubert 2020 {published data only}
    1. Schubert J, Lambers KT, Kimber C, Denk K, Cho M, Doornberg JN, et al. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot and Ankle International 2020;41(6):658-65. - PubMed
Seiger 2009 {published data only}
    1. Seiger C. Effect of pulsed shortwave diathermy and joint mobilization on range of motion, pain, and edema of surgically repaired hypomobile ankles. ProQuest Dissertations & Theses (PQDT), 2009.
Siddique 2005 {published data only}
    1. Siddique A, Prasad CV, O'Connor D. Early active mobilization versus cast immobilization in operatively treated ankle fractures: a prospective analysis of early functional recovery. European Journal of Trauma 2005;31(4):398-400.
Smeeing 2020 {published data only}
    1. Briet JP, Houwert RM, Smeeing DP, Pawiroredjo JS, Kelder JC, Lansink KW, et al. Weight bearing or non-weight bearing after surgically fixed ankle fractures, the WOW! Study: study protocol for a randomized controlled trial. Trials 2015;1:1-8. - PMC - PubMed
    1. NTR3727. The WOW! Study. Weight-bearing or non-weight bearing. trialsearch.who.int/Trial2.aspx?TrialID=NTR3727 (first received 28 November 2012).
    1. Smeeing DP, Houwert RM, Briet JP, Groenwold RH, Lansink KW, Leenen LP, et al. Weight bearing or non-weight bearing after surgical treatment of ankle fractures: the WOW! Study. A multicenter randomized controlled trial. In: OTA Annual Meeting. 2017:135. - PMC - PubMed
    1. Smeeing DP, Houwert RM, Briet JP, Groenwold RH, Lansink KW, Leenen LP, et al. Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial. European Journal of Trauma and Emergency Surgery 2020;46(1):121-30. - PMC - PubMed
Sondenaa 1986 {published and unpublished data}
    1. Sondenaa K, Alho A, Hoigaard U, Smith D. The effect of immobilization in a plaster cast on ankle fractures after stable osteosynthesis. A randomized trial. Acta Orthopaedica Scandinavica 1982;53:710.
    1. Sondenaa K, Hoigaard U, Smith D, Alho A. Immobilization of operated ankle fractures. Acta Orthopaedica Scandinavica 1986;57(1):59-61. - PubMed
Stockle 2000 {published data only}
    1. Stockle U, Konig B, Tempka A, Sudkamp NP. Cast immobilization versus vacuum stabilizing system. Early functional results after osteosynthesis of ankle joint fractures [Gipsruhigstellung versus vakuumstutzsystem. Fruhfunktionelle ergebnisse nach osteosynthese von sprunggelenksfrakturen]. Unfallchirurg 2000;103(3):215-9. - PubMed
Stuart 1989 {published data only}
    1. Stuart P, Brumby C, Smith S. Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures. Injury 1989;20(6):323-6. - PubMed
Tropp 1995 {published and unpublished data}
    1. Tropp H, Norlin R. Ankle performance after ankle fracture: a randomized study of early mobilization. Foot and Ankle International 1995;16(2):79-83. - PubMed
Van den Berg 2018 {published data only}
    1. Lewis SR. Information request for Cochrane Review [personal communication]. Email to: J Hoogendoorn 10 October 2022.
    1. Van den Berg C, Haak T, Weil NL, Hoogendoorn JM. Functional bracing treatment for stable type B ankle fractures. Body Cast 2020;35(1):7-12. - PubMed
    1. Van den Berg C, Haak T, Weil NL, Hoogendoorn JM. Functional bracing treatment for stable type B ankle fractures. Injury 2018;1(49):1607-11. - PubMed
Van Laarhoven 1996 {published and unpublished data}
    1. Van Laarhoven CJ, Meeuwis JD, Van der Werken C. Postoperative treatment of internally fixed ankle fractures: a prospective randomised study. Journal of Bone and Joint Surgery - British Volume 1996;78(3):395-9. - PubMed
Venesmaa 2004 {published data only}
    1. Venesmaa P, Arokoski J, Airaksinen O, Eskelinen J, Suomalainen O, Kroger H. Comparing postoperative immobilisation of ankle fractures with aircast or standard cast: a randomised prospective study [abstract]. Journal of Bone and Joint Surgery - British Volume 2004;86(Suppl 3):255-6.
Vioreanu 2007 {published data only}
    1. Vioreanu M, Dudeney S, Hurson B, Kelly E, O'Rourke K, Quinlan W. Early mobilization in a removable cast compared with immobilization in a cast after operative treatment of ankle fractures: a prospective randomized study. Foot & Ankle International 2007;28(1):13-9. - PubMed
    1. Vioreanu M, O'Briain D, Dudeney S, Hurson B, O'Rourke K, Kelly E, et al. Early exercising in removable cast compared with immobilisation in cast after operative treatment of ankle fractures. A prospective randomised study. Journal of Bone and Joint Surgery - British Volume 2005;88(Suppl II):280.
Wetzler 1991 {published and unpublished data}
    1. Wetzler M, Whitelaw G, Lee P. The post-operative management of ankle fractures with pneumatic braces versus short leg cast. Orthopaedic Transactions 1991;15:719.
Wilson 1991 {published and unpublished data}
    1. Wilson FM. Manual therapy versus traditional exercises in mobilisation of the ankle post-ankle fracture: a pilot study. New Zealand Journal of Physiotherapy 1991;19(3):11-6.

References to studies excluded from this review

ACTRN12610000557033 {published data only}
    1. ACTRN12610000557033. Early mobilisation post ankle fracture fixation. www.anzctr.org.au/ACTRN12610000557033.aspx (date registered 09 July 2010).
ACTRN12611001096943 {unpublished data only}
    1. ACTRN12611001096943. A prospective randomised study comparing functional outcomes in patients weightbearing at two weeks versus six weeks following surgical fixation of ankle fracture. anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611001096943 (first received 7 October 2011).
ACTRN12613000631707 {unpublished data only}
    1. ACTRN12613000631707. Comparison of protected early postoperative range of motion exercises versus cast immobilization in ankle fractures requiring surgery. [Protected early motion versus cast immobilization in postoperative Weber A,B,C ankle fractures. A prospective randomized control study to assess time to return to work.]. anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12613000631707 (first received 4 June 2013).
Albin 2019 {published data only}
    1. 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. Journal of Orthopaedic and Sports Physical Therapy 2019;49(5):310-9. [PMID: ] - PubMed
Büker 2019 {published data only}
    1. Büker N, Şavkın R, Ök N. Comparison of supervised exercise and home exercise after ankle fracture. Journal of Foot and Ankle Surgery 2019;58(5):822-7. [PMID: ] - PubMed
DRKS00021487 {published data only}
    1. DRKS00021487. Outcome Iwalk 2.0 orthosis compared to using Unetrarm crutches on patients with (partial) relief after foot or ankle surgery. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 28 July 2020).
Gan 2014 {published data only}
    1. Gan TY, Kuah DE, Graham KS, Markson G. Low-intensity pulsed ultrasound in lower limb bone stress injuries: a randomized controlled trial. Clinical Journal of Sport Medicine 2014;24(6):457-60. [PMID: ] - PubMed
Güngör 2022 {published data only}
    1. Güngör HR, Büker N, Şavkın R, Ök N. Early unprotected weight bearing and pre-scheduled supervised rehabilitation program after surgical treatment of ankle fractures. Archives of Bone and Joint Journal 2022;10(2):183-9. [PMID: ] - PMC - PubMed
N0055190984 {published data only}
    1. N0055190984. Post operative management of ankle fractures treated with ORIF, 6 weeks in cast vs no cast and active early physiotherapy. portal.nihr.ac.uk/Profiles/NRR.aspx?Publication_ID=N0055190984 (accessed 11 March 2008).
NCT01127776 {published data only}
    1. NCT01127776. Bi-trimalleolar fracture and APOS System Treatment APOS-IL 001. clinicaltrials.gov/show/NCT01127776 (first posted 21 May 2010).

References to studies awaiting assessment

ISRCTN15497399 {published data only}
    1. ISRCTN15497399. Does early mobilisation after ankle fracture surgery enhance recovery? [Does early mobilisation after ankle fracture surgery enhance recovery? A pragmatic multi-centre randomised controlled trial with qualitative component and health economic analysis comparing the use of plaster versus Aircast® boot]. www.isrctn.com/ISRCTN15497399 (first received 8 January 2015).
Khojaly 2021 {published data only}
    1. ISRCTN76410775. Do we have to keep patients in a cast and prevent them from weight bearing after surgical repair of ankle fractures? [Is post-operative non-weight-bearing necessary? A pragmatic randomised multicentre trial of operatively treated ankle fracture (DoWeCAST?)]. www.isrctn.com/ISRCTN76410775 (first received 20 May 2019).
    1. Khojaly R, MacNiocaill R, Shahab M, Nagle M, Taylor C, Rowan FE. Is postoperative non-weight-bearing necessary? INWN study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture. Trials 2021;22(1):369. - PMC - PubMed
NCT02609347 {published data only}
    1. NCT02609347. Manual therapy after ankle/hindfoot fractures [Immediate effects of manual therapy for patients after ankle/hindfoot fractures]. clinicaltrials.gov/ct2/show/record/NCT02609347 (first received 20 November 2015).
NCT02779244 {unpublished data only}
    1. NCT02779244. Early weight bearing for unstable ankle fractures undergoing operative stabilization [Early weight bearing for unstable ankle fractures undergoing operative stabilization: is it safe and does it improve outcomes?]. clinicaltrials.gov/ct2/show/NCT02779244 (first received 20 May 2016).
NCT02923479 {published data only}
    1. NCT02923479. Robot-assisted rehabilitation of ankle fractures: efficacy and comparison with traditional methods [Robot-assisted ankle rehabilitation using the high-performance robotic device IIT-ARBOT: a pilot randomised controlled study]. clinicaltrials.gov/ct2/show/NCT02923479 (first received 4 October 2016).
NCT04235907 {published data only}
    1. NCT04235907. Telerehabilitation following ankle fractures [Telerehabilitation following ankle fractures: a pilot study]. clinicaltrials.gov/ct2/show/record/NCT04235907 (first posted 22 January 2020).
Shin 2000 {published data only}
    1. Shin KS, Kim JS, Lee DW, Kim JS. Effect of early active and weight bearing in rigid fixation of ankle fracture. Journal of the Korean Society of Fractures 2000;13(2):361-7.

References to ongoing studies

ChiCTR2100045058 {unpublished data only}
    1. ChiCTR2100045058. The role of rehabilitation therapy in functional recovery after ankle surgery: a prospective randomized controlled study [The role of telerehabilitation therapy in functional recovery after ankle fracture surgery: a prospective randomized controlled study]. www.chictr.org.cn/showproj.aspx?proj=121157 (first received 4 April 2021).
DRKS00024489 {unpublished data only}
    1. DRKS00024489. Standard postoperative care vs. multimodal teletherapy (CASPAR) for rehabilitation following surgical treated ankle fractures. drks.de/search/en/trial/DRKS00024489 (first recieved 2 October 2021).
DRKS00024506 {unpublished data only}
    1. DRKS00024506. Effect of a modern biodynamic feedback system on the postoperative aftercare following surgical treated ankle fractures. drks.de/search/en/trial/DRKS00024506 (first recieved 15 February 2021).
Guo 2022 {published data only}
    1. Guo S, Zhao G, Chen X, Xue Y, OuYang X, Liu JY et al. Effect of transcutaneous electrical acupoint stimulation on bone metabolism in patients with immobilisation after foot and ankle fracture surgery: a randomised controlled trial study protocol. BMJ Open 2022;12:e056691. [DOI: 10.1136/ bmjopen-2021-056691] - PMC - PubMed
IRCT20201124049484N1 {unpublished data only}
    1. IRCT20201124049484N1. The effects of early weight-bearing and mobilization on the outcomes of patients with unstable ankle fractures after internal fixation surgery. irct.behdasht.gov.ir/trial/52563 (first received 6 January 2021).
ISRCTN11830323 {unpublished data only}
    1. ISRCTN11830323. AFTER – Ankle fracture treatment: enhancing rehabilitation trial. www.isrctn.com/ISRCTN11830323 (first received 6 January 2022).
JPRN‐UMIN000039630 {published data only}
    1. JPRN-UMIN000039630. Effect of neuromuscular electrical stimulation on individual quadriceps muscle atrophy in patients with non-weight bearing: a randomized control study. trialsearch.who.int/Trial2.aspx?TrialID=JPRN-UMIN000039630 (first received 1 January 2020).
JPRN‐UMIN000047296 {published data only}
    1. JPRN-UMIN000047296. Effects of ankle joint exercises with visual and auditory feedback on pain, motor function, and quality of life in patients with ankle or foot fractures. center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052476 (first received 27 March 2022).
NCT03970603 {unpublished data only}
    1. NCT03970603. Syndesmosis ankle study [Weight-bearing timing and outcomes after surgical suture button repair of the distal tibiofibular syndesmosis]. clinicaltrials.gov/ct2/show/NCT03970603 (first received 31 May 2019).
NCT04028414 {published data only}
    1. NCT04028414. Effects of early weight bearing on rehabilitation outcomes in patients with traumatic ankle and tibial plateau fractures. clinicaltrials.gov/ct2/show/NCT04028414 (first received 22 July 2019).
NCT04429217 {unpublished data only}
    1. NCT04429217. A study to compare two different managements after ankle surgery: immediate and delayed weight-bearing [Immediate vs delayed weight-bearing after surgical treatment of malleolar fractures: a randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT04429217 (first received 12 June 2020).
NCT04872296 {unpublished data only}
    1. NCT04872296. Weight bearing for fibular fractures [Early weight bearing for isolated fibular fractures: a prospective randomized study]. clinicaltrials.gov/ct2/show/NCT04872296 (first received 4 May 2021).
NCT05280639 {unpublished data only}
    1. NCT05280639. Simplified post op rehabilitation for ankle and pilon fractures [Ankle and pilon fracture post operative rehabilitation: a randomized control trial exploring a simplified wooden block protocol]. clinicaltrials.gov/ct2/show/NCT05280639 (first received 15 March 2022).
NCT05587842 {unpublished data only}
    1. NCT05587842. Early vs delayed weightbearing after surgical fixation of unstable ankle fractures with syndesmosis disruption [Early weightbearing vs delayed weightbearing after surgical fixation of unstable ankle fractures with syndesmosis disruption: a randomized controlled trial]. clinicaltrials.gov/show/NCT05587842 (first received 20 October 2022).
NTR4469 {unpublished data only}
    1. NTR4469. The treatment of stable ankle fractures: brace versus cast immobilization. trialsearch.who.int/Trial2.aspx?TrialID=NTR4469 (first received 14 March 2014).
NTR7143 {unpublished data only}
    1. NTR7143. Prospective randomized controlled trial: early weight bearing after conservative treatment of Weber B ankle fractures. trialsearch.who.int/Trial2.aspx?TrialID=NTR7143 (first received 9 April 2018).
Stinner 2022 {unpublished data only}
    1. Stinner DJ, Rivera JC, Smith CS, Weiss DB, Hymes RA, Matuszewski PE, et al. Early advanced weight-bearing after periarticular fractures: a randomized trial comparing antigravity treadmill therapy versus standard of care. Journal of Orthopaedic Trauma 2022;1(36):S8-13. - PubMed
TCTR20220221004 {unpublished data only}
    1. TCTR20220221004. Early weight bearing after ankle fracture fixation rapid returns of driving: a randomized controlled trial. www.thaiclinicaltrials.org/show/TCTR20220221004 (first received 21 February 2022).

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