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Ankle Fracture in Sports Medicine Treatment & Management

  • Author: John D Kelly, IV, MD; Chief Editor: Sherwin SW Ho, MD  more...
Updated: Oct 21, 2015

Acute Phase

Rehabilitation Program

Physical Therapy

As always, acute management of ankle fractures involves analgesics for pain, immobilization, and patient comfort. Use either a well-padded posterior splint or a stirrup splint to keep the patient from bearing weight on the ankle until definitive treatment is instituted in 3-4 days.

Small avulsion Danis-Weber type A fractures without medial-sided injury can be symptomatically treated with a walking cast or stirrup brace and ambulation as tolerated. The patient should apply ice to the injured area over a compressive dressing for 20 minutes every 2-3 hours for the first 24 hours and every 4-6 hours thereafter until casting. Keeping the limb elevated above the level of the heart also significantly reduces swelling.

Medical Issues/Complications

Isolated lateral malleolus fractures are the most common fracture involving the ankle. Most inversion injuries result in an isolated sprain of the anterior talofibular ligament. However, a small avulsion fracture can occasionally be seen near the distal portion of the lateral malleolus. Barely visible osseous chip fractures do not alter the routine active management of grade 1 and 2 ankle sprains.

  • Most primary care physicians can treat isolated nondisplaced Danis-Weber type A fractures. [13]
  • More experienced providers can treat stable, nondisplaced fractures of the malleoli with posterior malleolus involvement of less than 25% of the articular surface.
  • Bimalleolar or trimalleolar injuries are always unstable and are treated with open reduction and internal fixation. All displaced medial malleolar fractures are openly reduced and fixed to restore normal ankle congruency and deltoid integrity.


Referral to an orthopedist is advisable for all displaced ankle fractures, because minor changes involving the joint mortise can cause chronic pain and early osteoarthritis. Patients with possible unstable injury (Danis-Weber classification types B or C) or those with bimalleolar fractures should be referred to an orthopedist. In the presence of medial malleolar tenderness and more than 5 mm of medial clear space on the mortise view, make a presumptive diagnosis of deltoid ligament rupture if a displaced fibular fracture is present. Treat these injuries as a bimalleolar fracture, and refer patients with this injury for treatment by an orthopedist.

Referral is also indicated for all trimalleolar fractures, which involve fracture to both the medial and lateral malleoli, along with a fracture to the posterior lip of the tibial plafond. This fracture is usually secondary to an avulsion of the posterior tibiofibular ligament at its insertion site. Fractures that show no radiographic evidence of healing after 8 weeks are best evaluated for adjunctive measures.


Recovery Phase

Rehabilitation Program

Physical Therapy

After the acute phase, cast immobilization can be accomplished with either a short leg walking cast or walking cast fracture boot in a reliable patient with a stable ankle fracture.

Medical Issues/Complications

The ankle should be put in a cast in a neutral position to avoid shortening of the Achilles tendon. Generally, 4-6 weeks of immobilization is required for healing. Cast boots are generally preferred after swelling dissipates so that intermittent motion can commence. If the fracture site is not tender, gradual ankle rehabilitation can begin because clinical healing is present. If no evidence of fracture healing is present, an additional 2-4 weeks of immobilization may be required.


If no evidence of fracture healing is present by 8 weeks, referral to an orthopedist is mandatory.


Maintenance Phase

Rehabilitation Program

Physical Therapy

After completing the immobilization period, the patient should begin ankle rehabilitation. Range of motion and strength returns quickly in young patients, and referral to a physical therapist may not be necessary. Patients motivated to complete rehabilitation at home can perform calf stretching and strengthening exercises, along with range-of-motion activities. Instruct patients to pay particular attention to the attainment of dorsiflexion. Older patients with premorbid conditions often require formal physical therapy to successfully regain strength and range of motion in the ankle.

Contributor Information and Disclosures

John D Kelly, IV, MD Associate Professor, Department of Orthopedic Surgery, University of Pennsylvania, Attending Surgeon Pennsylvania Hospital, Veterans Adminsitration Hospital

John D Kelly, IV, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Pennsylvania Orthopaedic Society, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.


Phillip M Steele, MD Consulting Staff, Primary Care Sports Medicine, Gem City Bone and Joint; Team Physician, University of Wyoming

Phillip M Steele, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Association

Disclosure: Nothing to disclose.

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Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection.
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