Phase 1: Immobilization/Acute Phase (Typically 0-6 weeks, depending on stability and surgery)

• • Goal: Protect the healing fracture, manage pain and swelling, prevent muscle atrophy in non-immobilized areas.
  • Pain and Swelling Management: RICE (Rest, Ice, Compression, Elevation) protocol is primary. Elevation of the limb above the heart is crucial.
  • Immobilization: Cast, boot, or brace as prescribed by the orthopedic surgeon.
  • Weight-Bearing Restrictions: Strict non-weight bearing (NWB) or partial weight-bearing (PWB) using crutches or a walker. Physiotherapists provide gait training with assistive devices, ensuring safety and adherence to weight-bearing precautions.
• Circulation and Muscle Activation (Non-Immobilized Areas):
  • Toe Wiggles: Gentle toe movements to promote circulation and prevent stiffness.
  • Ankle Pumps: Gentle plantarflexion and dorsiflexion within the cast/boot (if permitted) to aid circulation and reduce swelling.
  • Isometric Exercises (Proximal): Gentle contractions of thigh and hip muscles on the affected side (quad sets, glute sets, hip abduction/adduction) to maintain strength and prevent disuse atrophy.
  • Upper Body Strengthening: To facilitate crutch use.
  • Edema Control: Compression bandages, stockings, and retrograde massage (avoiding direct pressure over the fracture site).
  • Wound Care/Scar Management: If surgery was performed, gentle scar massage begins once the incision is fully healed to prevent adhesions and improve tissue mobility.

Phase 2: Early Mobilization/Restoration of Range of Motion (Typically 4-8 weeks, once cleared by surgeon)

• • Goal: Gradually restore ankle range of motion, initiate gentle strengthening, progress weight-bearing.
  • Interventions
  • Removal of Cast/Transition to Boot/Brace: Gradual transition guided by the surgeon.
  • Graded Weight-Bearing Progression: If cleared, gradually increasing weight on the affected limb. This often starts with partial weight-bearing (e.g., 25%, 50%, 75%) and progresses to full weight-bearing, with close monitoring of pain and swelling.
• Active and Passive Range of Motion (ROM) Exercises:
  • Ankle AROM: Gentle ankle circles, plantarflexion/dorsiflexion, inversion/eversion within pain-free limits.
  • Passive ROM (PROM): Gentle, passive stretches applied by the physiotherapist to restore joint mobility, especially dorsiflexion, which is often limited.
• Joint Mobilizations (Manual Therapy):
  • Distraction: Gentle pulling of the joint surfaces to reduce compression and improve overall mobility.
  • Anterior/Posterior Glides of Talus: To improve dorsiflexion and plantarflexion.
  • Subtalar Joint Mobilizations: To restore inversion/eversion.
  • Midfoot Mobilizations: To improve foot arch flexibility and overall foot mechanics.
• Gentle Strengthening (Isometrics/Open Chain):
  • Resisted Ankle Movements: Using resistance bands for plantarflexion, dorsiflexion, inversion, and eversion, starting with low resistance.
  • Seated Heel Raises/Toe Raises: Initially non-weight bearing or light weight-bearing.
  • Soft Tissue Mobilization: Continued massage for scar tissue and surrounding tight muscles (calf, foot intrinsics).

Phase 3: Strengthening and Balance/Proprioception (Typically 8-12+ weeks, once fracture healing is solid)

• • Goal: Restore full muscle strength and endurance, improve balance and proprioception, normalize gait, and prepare for functional activities.
• Progressive Resistance Training:
  • Standing Calf Raises: Bilateral to single-leg progression.
  • Leg Press, Squats, Lunges: To strengthen the entire lower kinetic chain.
  • Eccentric Strengthening: Emphasizing controlled lengthening of the calf muscles (e.g., slow descent during heel raises) to improve tendon resilience.
  • Balance and Proprioception Training: Crucial for regaining stability and preventing re-injury.
  • Static Balance: Single-leg standing on firm surfaces, progressing to unstable surfaces (foam pad, wobble board, balance disc).
  • Dynamic Balance: Balance walks, tandem walking, reaching tasks while balancing.
  • Agility Drills: Stepping over objects, cone drills (once appropriate).
  • Gait Training: Intensive focus on normalizing walking pattern, weaning off assistive devices, and improving walking efficiency on various surfaces.
  • Plyometrics :For return to sport, low-level jumping and hopping activities are introduced gradually to train the ankle for impact absorption.
  • Cardiovascular Conditioning: Stationary cycling, elliptical, swimming (once wound healed) to improve overall fitness.

Phase 4: Return to Sport/Activity (Typically 4-6+ months, depending on sport/activity demands) .

• • Goal: Gradual and safe return to high-impact activities, sports, or demanding work tasks.
  • Sport-Specific or Work-Specific Drills: Exercises simulating movements required for the desired activity (e.g., cutting, pivoting, jumping, running progressions).
  • Agility and Power Training: Further progression of plyometrics, speed drills, and reactive balance exercises.
  • Continued Strengthening and Conditioning: Maintaining and further building strength, endurance, and flexibility.

Advanced Manual Therapy

• Scar Tissue Mobilization: Once incisions are healed, rigorous manual techniques (deep transverse friction, sustained pressure, IASTM) are used to prevent adhesions, improve tissue elasticity, and reduce pain from surgical scars.
• Soft Tissue Release: Continued work on the calf muscles, peroneals, foot intrinsics, and other surrounding muscles to release tension, improve flexibility, and ensure optimal muscle function.
• Joint Mobilizations: As the fracture site becomes more stable, the physiotherapist will use progressively more aggressive joint mobilization techniques to restore full range of motion in the ankle (talocrural), subtalar, and midfoot joints. This is critical for normal gait and preventing long-term stiffness.
• Neural Mobilization: If nerve irritation or entrapment is suspected (e.g., sural nerve, superficial peroneal nerve near the fracture site), gentle nerve gliding exercises can be performed.