Ankle fractures are among the most common injuries treated by orthopaedic surgeons. Various postoperative rehabilitation strategies have been promoted, but the ability to improve patient-reported functional outcome has not been clearly demonstrated. Mechanism of injury, medical comorbidities, fracture characteristics, dislocation, and method of treatment (operative or nonoperative) and the quality of the fracture reduction have been shown to be causative factors for poor outcomes in some studies, yet discounted in others.[1–3] The role of clinic-based, supervised physical therapy after these injuries is not fully understood. Physical therapy is a common clinical tool used in many areas of orthopaedics to guide return of best possible extremity function and performance. It has been proven, in some studies, to be effective at improving early mobilization and range of motion in patients undergoing joint replacement surgery for hip and knee arthritis.[4,5]
Recent studies, however, are suggesting a more limited role for physical therapy in joint replacement and anterior cruciate ligament surgeries.[4–9] Patients with fractures present a more challenging problem for surgeons and physical therapists because, by its nature, trauma is an unplanned event. Therefore, preoperative physical therapy is unavailable and postoperative physical therapy can be limited by access and cost issues.[10,11] There are theoretical advantages of physical therapist supervised rehabilitation after ankle fracture and fracture-dislocation surgery. Rehabilitation supervised by a physical therapist can be tailored to a patient's specific injury and physical limitations similar to how a personal trainer can individualize exercise in a noninjured person.[12,13] There is accountabilty and coaching for patients as they rehabilitate. The disadvantage of physical therapy is its cost and its inconvenience for patients. Mosely et al conducted a pragmatic randomized trial exploring the outcomes of isolated ankle fractures treated at 7 Australian hospitals. Patients were randomized to a supervised exercise program with advice for self-management or to advice for self-management alone. Less than 50% of the fractures were surgically treated. They found no additional benefits from the supervised exercise program and concluded that the routine use of a supervised exercise program after removal of immobilization for patients with isolated/uncomplicated ankle fractures is unwarranted. Other studies have demonstratd that orthopaedic patients who are provided structured self-directed home-based rehabilitation can achieve similar outcomes to those who receive traditional clinic based rehabiliation services.[15–22] Studies evaluating home exercise programs for elective orthopaedic reconstruction surgery for joint replacement and ACL reconstruction have reported equivalent outcomes compared to clinic-based PT.[23–25]
No other data exists to guide clinical decision making regarding the neccesity of formal physical therapy following the treatment of severe ankle fractures or fracture dislocations. Physical therapy is widely prescribed postoperatively for patients who have been surgically treated for severe ankle fractures. The purpose of this study is to evaluate the effectiveness and outcomes associated with clinic-based, supervised physical therapy (Formal-PT) compared to surgeon-directed rehabilitation (Home-PT) related to postoperative patient-reported functional scores at 6 months.
Our primary hypothesis is that functional outcomes will be similar in both groups at 6-month follow-up. Secondarily, we hypothesize that patients in the Formal-PT and Home-PT groups will have similar rates of complications at 6-month follow-up, including delayed union, joint space incongruity, malunion, and hardware failure. Finally, patients in the Formal-PT cohort will incur a greater cost for their rehabilitation than the Home-PT cohort.
2.1 Patient identification and enrollment
This prospective observational study was carried out with the approval of our Institutional Review Board beginning in 2013. Between August 2012 and September 2013, 80 patients treated by 1 of 10 orthopaedic surgeons (N = 4 orthopaedic trauma, N = 6 foot and ankle) were prospectively enrolled after sustaining a bimalleolar or trimalleolar ankle fracture or fracture dislocation (OTA/AO codes 44A, 44B, and 44C) and undergoing surgical treatment at our institution. Either a treating surgeon or member of the orthopaedic team identified patients with ankle fractures at admission to the inpatient hospital or at clinic for follow-up. A complete history and physical, radiographic analysis, and review of the medical record were performed to screen for eligibility. Inclusion criteria include: bimalleolar or trimalleolar ankle fracture or ankle fracture-dislocation necessitating open reduction and internal fixation, open or closed fracture, patient fluent in English, and age 18 and older. Patients were excluded if they had a previous injury or pre-existing osteoarthritis of the affected ankle, retained hardware from a previous surgery around the ankle, history of inflammatory arthropathy, traumatic brain or spinal cord injury precluding weight bearing on the lower extremities, and patients with Gustillo-Anderson type 3B and 3C open fractures.
2.2 Data collection
Patients were identified at either their initial consultation or the first postoperative visit and baseline demographic and injury data were recorded. Injury anteroposterior, mortise, and lateral radiographs were reviewed, and fractures were classified by the Lauge-Hansen and AO/OTA system.[26,27] The initial displacement of the talus was also assessed on injury films and fractures were classified as dislocated if there was complete displacement of the talus away from the intact weight-bearing surface of the distal tibia.
The primary outcomes of this study were ankle function as assessed on the Foot and Ankle Ability Measure (FAAM) scale, a self-report measure that captures overall physical performance among patients with foot, ankle, and leg injuries or disorders, and the Short Form Musculoskeletal Functional Assessment (SFMA) Score, a self-report measure that assesses the impact of musculoskeletal injuries or conditions on functioning and daily activities. Patients were followed at clinic appointments at standard postoperative intervals of 2 weeks, 6 weeks, 3 months, and subsequently based on patient individualized recovery and treating surgeon preference. Primary and secondary outcomes were assessed at 6-months postoperatively by a telephone interview or at a 6-month clinical visit if the patient was still requiring direct physician care. Physical therapy data was also collected by telephone interviews as well as from chart review. All data collected was stored in a secure database for analysis.
2.3 Operative intervention
The patient's treatment course was unaltered by enrollment in the study. Patients underwent open reduction and internal fixation using standard fracture fixation techniques based on the discretion of the attending surgeon. All patients were placed in a well-padded splint until their 2-week follow-up appointment at which point they were transitioned into a cast or removable walker boot. All patients were kept nonweightbearing for a minimum of 6 weeks postoperatively.
2.4 Physical therapy
Patients were either prescribed formal supervised physical therapy or were treated with surgeon-directed rehabilitation after their operative treatment based on the practice patterns of the attending surgeon and/or patient preference. For patients prescribed formal therapy, timing of commencement of clinic-based, supervised physical therapy was at the discretion of the treating surgeon (<2 weeks N = 2, 2–6 weeks N = 29, 7–12 weeks N = 7, >12 weeks N = 2) and not based on a predetermined protocol. The duration of therapy was variable depending on each patient's individual improvement and/or compliance. There was no standardization of the physical therapy and the specific exercises, frequency and duration was variable based on the treating surgeons’ prescription and the therapist's interpretation of patient needs.
Patients who underwent surgeon-directed rehabilitation (Home-PT) were given initial instruction on ankle range of motion at the time of cast/splint removal. Patients were directed to complete home exercises to achieve range of motion, strength and continual guidance was given at each subsequent visit. Patients receiving Home-PT were occasionally transitioned to formal PT if the surgeon was dissatisfied with the recovery process.
2.5 Statistical analysis
Baseline comparison between the 2 study groups was performed using Student t tests and chi-square analyses for continuous and categorical variables respectively. The principal analysis compared scores on the FAAM and SMFA scales. Multivariate regression analyses with FAAM and SMFA scores as the dependent variables, a dichotomous variable indicating injury type, and age were performed to adjust for the significant difference in mean age between the 2 groups. A P value of less than .05 was considered statistically significant.
Eighty patients were enrolled in the study. Forty patients sustained bi or tri-malleolar ankle fractures while 40 patients had bi or tri-malleloar ankle fracture dislocations. Consecutive patients were enrolled in each group of ankle fractures and fracture dislocations. The baseline characteristics and patient demographics of the cohorts were/were not different between the Formal-PT and Home-PT groups (Table 1). The average age was 52 in the formal-PT group and 51 in the Home-PT group (P = .680), 77% in the formal-PT group vs 66% of patients in the Home-PT group were female (P = .274). Supervised rehabilitation Formal-PT was prescribed for 38 (47.5%) patients while 42 (52.5%) received exercise instruction from the physican or advanced care practitioner at a clinic visit (Home-PT). Of the patients who were initially prescribed physical therapy, 34 of 38 patients (89.5%) attended at least 1 session. No specific reason could be ascertained for the nonattendance of the remaining 4 patients. For the patients who attended physical therapy, the number of sessions ranged from 1 to 36 (mean = 16).
Of the patients enrolled, there were 39 bimalleolar and 41 trimalleolar fractures. Prescription of physical therapy did not differ based on injury characteristics, mechanism, or demographics in the patient population. However, 57% of patients with private insurance were prescribed Formal-physical therapy compared with 7% of patients without private insurance (P = .033).
3.1 Outcome scores
At 6 months postoperatively outcome scores showed mean FAAM score of 69.7 for the Formal-PT patients compared to 70.9 for Home-PT patients (P = 0.868). The SMFA scores for Formal PT patients were 20.1 compared to 24.4 in Home-PT group (P = .454), and no significant differences were identified in any of the subscale scores (Table 2).
There were no differences in rates of complications between patients receiving Formal-PT and those receiving Home-PT. Rates of complications were rare and equivalent in both groups (Table 3).
3.3 Direct patient costs
Costs of physical therapy were calculated by taking the average cost for 15 minutes of physical therapy charged within our health care system—$125.81 average per patient/session. The average cost multiplied by therapy attendance was used to create estimates for the total cost of therapy per patient. Because of the wide range of therapy sessions attended, the cost per patient ranged from $125.81 to $4500. Cumulatively, the total cost of supervised rehabilitation was approximately $62,401 for our patient cohort.
3.4 Practice model differences
Physician and practice-specific differences were observed between phyisican subset groups (Table 4). Patients treated within the private practice model had a higher likelihood to be prescribed physical therapy compared to those treated in a hospital-employed practice (84% vs 19%; P < .001). This finding correlates with a higher percentage of these patients having private insurance (69% of patients in hospital-employed practice with insurance vs. 97% of private-practice patients; P < = .001).
Formal physical therapy compared to physician-directed therapy provided similar scores on the FAAM and SMFA outcome measures for our patients. Our study found a significant difference between the rate of prescription of formal therapy for insured patients compared to their unisured counterparts.
A number of studies have looked at physical therapy specifically after ankle fractures. Lin et al compared physical therapy including ankle joint manual therapy in addition to standard supervised physical therapy and showed there was not added benefit to manual therapy. There was, however, a higher cost in the manual therapy group. Nillson et al reported a randomized trial that compared patients in a personalized training model to a group that received usual care consisting of whatever the surgeon decided was best. There was a small benefit to those patients in the training model group despite a high uptake of physical therapy in the control group. These authors conclude there may be a small functional bennefit to a personalized training program after ankle fractures in young patients. Moseley et al compared patients with a postoperative equinus contracture who received either passive stretching for 6 minutes a day or passive stretching for 30 minutes a day or usual care with no specific stretching. All groups improved their functional outcome 3 months after the cast removal and all groups had similar ankle range of motion following 3 months of treatment. Most recent, Mosely et al conducted a randomized controlled trial comparing outcomes among patients with isolated and uncomplicated ankle fractures randomized to a supervised exercise program and advice vs advice alone. There were no significant differences between patients in the 2 groups on measures of activity limitation or quality of life.
The cost-effectiveness of physical therapy following fracture has been investigated for other anatomic areas. Ring et al conducted a randomized controlled trial comparing patients after fixation of a distal radius fracture who received exercises supervised by an occupational therapist to exercises done independantly under the direction of the treating surgeon. The patients in each group had similar functional outcome and range of motion. A systematic review of the treatment of upper extremity injuries found very heterogenous conclusions about the efficacy of supervised exercise after operatively and nonoperatively managed distal radius and proximal humerus fractures.
Our study has found a significant cost associated with physical therapy. Due to the variability of patient's individual health care insurance and the continual trend with high-deductible plans to shift additional cost to patients, the personal financial implications associated with physical therapy should be carefully discussed with patients. We found an average cost of $125.81 per patient therapy session and total average cost of $2012.96 per patient for therapy. Using this information, physicians should carefully discuss these financial expectations with their patients when postoperative therapy is to be prescribed.
4.1 Study limitations
This study has several limitiations. As this was a prospectivie observational study, the assignment of patients to the Formal-PT vs Home-PT groups was at the discretion of the surgeon or the demand of the patient. Despite the disparity in prescribing habits showing less formal physical therapy prescription for lower socioeconomical status patients, the results do not show inferior outcomes in this group. It is also possible that the outcome measures selected for the study, the FAAM and the SMFA, are not sensitive enough to detect differences between patients who receive Formal-PT as compared to patients participating in Home-PT. There may also be differences between these groups in return of motion, return to work, or other outcome measures that were not assessed in this study. However, this study did offer the unique ability to examine a diverse patient population and a variety of practice patterns through the inclusion of patients treated at both academic and private practice clinics. While this study was likely underpowered to detect differences between these populations, it does add to the literature by demonstrating that patients with operative ankle fractures have similar outcomes with Home-PT as they do with Formal-PT as measured by the FAAM and the SMFA, 2 common measures used to assess physical function following lower-extremity injury. These data can be used to guide the development of prospective randomized trials which can determine the utility of Formal-PT in this population and identify subgroups which may benefit from Formal-PT.
Our study failed to find a difference in patient-reported outcome scores between the 2 treatment groups and a significant cost associated with physical therapy. We also found significant bias toward prescription of physical therapy in privately insured patients. Based on this study, the authors cannot support a ubiquitous prescription of clinic-based, supervised phyical therapy for all patients with operative ankle fractures. Patients should be made aware of the direct costs associated with physical therapy to allow them to participate in a shared decision-making process related to the utilization of postoperative PT resources. This study can be foundational to the design of a prospective randomized controlled clinical trial to assess the role of physical therapy in ankle fracture care and objectively determining the subgroup of ankle fractures that may benefit from formal PT.
1. Beris A, Kabbani K, Xenakis T, et al Surgical treatment of malleolar fractures. A review of 144 patients. Clin Orthop Relat Res. 1997;341:90–98.
2. Davidovitch R, Walsh M, Spitzer A, et al Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int. 2009;30:728–733.
3. Egol K, Tejwani N, Walsh M, et al Predictors of short-term functional outcome following ankle fracture
surgery. J Bone Joint Surg Am. 2006;88:974–979.
4. Ackerman I, Bennell K. Predictors of short-term functional outcome following ankle fracture
surgery. Austral J Physiother. 2004;50:25–30.
5. Ko V, Naylor J, Harris I, et al One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am. 2013;95:1942–1949.
6. Goodwin P, Morrissey M, Omar R, et al Effectiveness of supervised physical therapy
in the early period after arthroscopic partial meniscectomy. Phys Ther. 2003;83:520–535.
7. Di Paola J. Disability, impairment, and physical therapy
utilization after arthroscopic partial meniscectomy in patients receiving workers’ compensation. J Bone Joint Surg Am. 2012;94:523–530.
8. Jokl P, Stull P, Lynch J, et al Independent home versus supervised rehabilitation following arthroscopic knee surgery: a prospective randomized trial. Arthroscopy. 1989;5:298–305.
9. Grant J, Mohtadi N, Maitland M, et al Comparison of home versus physical therapy
-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. Am J Sports Med. 2005;33:1288–1297.
10. Bong M, Di Cesare P. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg. 2004;12:164–171.
11. Becker D, Yun H, Kilgore M, et al Health services utilization after fractures: evidence from Medicare. J Gerontol A Biol Sci Med Sci. 2010;65:1012–1020.
12. Lin C-W, Donkers N, Refshauge K, et al Rehabilitation for Ankle Fractures in Adults. Chichester, UK: John Wiley & Sons, Ltd; 1996.
13. Bruder A, Taylor N, Dodd K, et al Exercise reduces impairment and improves activity in people after some upper limb fractures: a systematic review. J Physiother. 2011;57:71–82.
14. Mosely A, Beckenkamp P, Haas M, et al EXACT Team. Rehabilitation after immobilzation for ankle fracture
: the EXACT randomized study. JAMA. 2015;2015:1376–1385.
15. Darter B, Nielsen D, Yack H, et al Home-based treadmill training to improve gait performance in persons with a chronic transfemoral amputation. Arch Phys Med Rehabil. 2013;94:2440–2447.
16. Ravaud P, Giraudeau B, Logeart I, et al Management of osteoarthritis (OA) with an unsupervised home based exercise programme and/or patient administered assessment tools. A cluster randomised controlled trial with a 2x2 factorial design. Ann Rheum Dis. 2004;63:703–708.
17. Lim H, Moon Y, Lee M. Effects of home-based daily exercise on joint mobility, daily activity, pain, and depression in patients with ankylosing spondylitis. Rheumatol Int. 2005;25:225–229.
18. Shirado O, Doi T, Akai M, et al Multicenter randomized controlled trial to evaluate the effect of home-based exercise on patients with chronic low back pain: the Japan low back pain exercise therapy study. Spine (Phila Pa 1976). 2010;35:e811–e819.
19. Valdes K, Naughton N, Burke C. Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture. J Hand Surg Am. 2015;40:1110–1116.
20. Holmgren T, Oberg B, Sjoberg I, et al Supervised strengthening exercises versus home-based movement exercises after arthroscopic acromioplasty: a randomized clinical trial. J Rehabil Med. 2012;44:12–18.
21. Ismail M, El Shorbagy K. Motions and functional performance after supervised physical therapy
program versus home-based program after arthroscopic anterior shoulder stabilization: a randomized clinical trial. Ann Phys Rehabil Med. 2014;57:353–372.
22. Hohmann E, Tetsworth K, Bryant A. Physiotherapy-guided versus home-based, unsupervised rehabilitation in isolated anterior cruciate injuries following surgical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1158–1167.
23. Moffet H, Tousignant M, Nadeau S, et al In-home telerehabilitation compared with face-to-face rehabilitation afte total knee arthroplasty: a noninferiority randomized clinical trial. J Bone Joint Surg Am. 2015;97:1129–1141.
24. Fischer D, Tewes D, Boyd J, et al Home based rehabilitation for anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 1998;347:194–199.
25. Grant J, Mohtadi N. Two-to 4-year follow-up to a comparison of home versus physical therapy
-supervised rehabilitation programs after anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38:1389–1394.
26. Kellam JF, Meinberg EG, Agel J, et al Introduction: Fracture and Dislocation Classification Compendium-2018: international comprehensive classification of fractures and dislocations committee. J Orthop Trauma. 2018;32 (suppl 1):S1–s10.
27. Tartaglione JP, Rosenbaum AJ, Abousayed M, et al Classifications in brief: Lauge-Hansen classification of ankle fractures. Clin Orthop Relat Res. 2015;473:3323–3328.
28. Martin R, Irrgang J, Burdett R, et al Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26:968–983.
29. Swiontkowski M, Engelberg R, Martin D, et al Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999;81:1245–1260.
30. Lin C, Moseley A, Haas M, et al Manual therapy in addition to physiotherapy does not improve clinical or economic outcomes
after ankle fracture
. J Rehabil Med. 2008;40:433–439.
31. Nilsson G, Jonsson K, Ekdahl C, et al Manual therapy in addition to physiotherapy does not improve clinical or economic outcomes
after ankle fracture
. BMC Musculoskelet Disord. 2009;10:118–111.
32. Moseley A, Herbert R, Nightingale E, et al 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;86:1118–1126.
33. Souer JS, Buijze G, Ring D. A prospective randomized controlled trial comparing occupational therapy with independent exercised after volar plate fixation of a fracture of the distal part of the radius. J Bone Joint Surg Am. 2011;93:1761–1766.