 
 
Rehabilitation Protocol for Ankle Fracture with ORIF 
  
This protocol is intended to guide clinicians through the post-operative course for an ankle fracture with ORIF. This 
protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on 
the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected 
outcomes contained within this guideline may vary based on surgeon’s preference, additional procedures performed, 
and/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult 
with the referring surgeon. 
  
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician.  
  
Considerations for the Post-operative Ankle ORIF 
Many different factors influence the post-operative ankle ORIF rehabilitation outcomes, including rate of healing, 
complexity of the fracture and/or need for hardware removal. It is recommended that clinicians collaborate closely with 
the referring physician regarding the timeframes for progression.  Patients with less complex fractures may progress 
more quickly through the phases of these guidelines. 
 
If the patient develops a fever, unresolving numbness/tingling, excessive drainage from the incision, 
uncontrolled pain or any other symptoms you have concerns about, the referring physician should be contacted.  
 
 
PHASE I: IMMEDIATE POST-OP (0-6 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Demonstrate safe ambulation with prescribed weight bearing precautions  
• Able to maintain weight bearing status per surgeon with transfers and stairs 
• Manage swelling 
• Perform ADLs in a modified independent manner or with minimal assistance 
• Increase range of motion of foot and ankle 
• Minimize the loss of strength in the core, hips, knees, and upper extremities 
• Patient Education: 
• Modifications for ADLs 
Precautions  
• No joint mobilizations near fracture site or that require stabilizing over the fracture site 
• NO instrument assisted soft tissue mobilization (IASTM) over fracture sites until at least 6 
weeks post-op 
Weight Bearing 
• Weight bearing status per surgeon 
• Boot/cast per surgeon 
Interventions 
Swelling Management  
• Ice, compression, elevation  
• Retrograde massage (avoid pressure on healing fracture sites) 
 
Gait Training 
• Gait training on level surfaces and stairs with emphasis on weight bearing precautions  
 
Range of motion/Mobility 
• Initiate ankle passive range of motion (PROM), active assisted range of motion (AAROM) and 
active range of motion (AROM)  
- Ankle pumps  
- Ankle circles 
 
 
- Ankle inversion 
- Ankle eversion 
- Seated heel-slides for ankle DF ROM  
• If stiff from boot immobilization, initiate toe stretching (by patient or by therapist)  
• Foot joint mobilizations may be performed if indicated during this time per therapist discretion 
- AVOID pressure on healing fracture sites or hardware. 
• May begin gentle scar mobilization once incisions are healed    
 
Cardio 
• Upper body ergometer 
 
Strengthening (in boot/splint) 
• May perform upper body strengthening with weights if modified for weight bearing precautions 
• Lower extremity gym equipment (Ex:  hip abductor and adductor machine, hip extension 
machine, roman chair) 
• Proximal/core strengthening (maintain precautions) 
- Quad sets 
- Straight leg raise 
- Abdominal bracing  
- Hip abduction 
- Clamshells 
- Prone hip extension 
- Prone hamstring curls 
• Ankle: 
-  Seated heel raises 
-  Seated toe raises 
-  Seated arch doming 
-  Exercises for foot intrinsic muscles to minimize atrophy while in boot 
 
Proprioception 
• Joint position re-training 
Criteria to 
Progress 
• Pain <3/10 
• Minimal swelling (recommend water displacement volumetry or circumference measures such 
as Figure 8). 
• Increased ankle ROM 
• Cleared by surgeon to progress to weight bearing as tolerated (WBAT) or full weight bearing 
(FWB) 
• Independence with daily home exercise program 
 
PHASE II: INTERMEDIATE POST-OP (7-12 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Manage swelling 
• Full range of motion of foot and ankle 
• Safely progress strengthening 
• A normalized gait pattern on all surfaces (wean from boot/brace when healing is adequate) 
• Minimize the loss of strength in the upper extremities, core, hips, and knees 
• Gradually return to regular activities if ROM, strength, and gait pattern are sufficient 
Precautions 
• No joint mobilizations near fracture site or that require stabilizing over the fracture site 
Weight Bearing 
• Progress to FWB per surgeon 
• Wean boot per surgeon 
Additional 
Interventions 
*Continue with 
Phase I 
interventions as 
indicated 
Range of motion/Mobility 
• Continue ankle AROM/PROM exercises and toe stretching as needed 
• Progress to standing ankle dorsiflexion stretch on step 
• Gentle stretching of proximal muscle groups as indicated: (Ex: standing quad stretch, standing 
hamstrings stretch, Thomas hip flexor stretch, piriformis stretch)  
• Standing gastrocnemius and standing soleus stretching once weaned from boot and talocrural 
joint mobility is normalized 
 
 
• May begin gentle ankle mobilizations at the discretion of the therapist once fracture is 
radiographically healed or clearance is given by surgeon.  
 
Cardio 
• Stationary bicycle  (in boot if not yet weaned) 
• Treadmill walking once boot is weaned and gait normalized 
 
Strengthening 
• Continue Phase I exercises 
• Isometrics for ankle planes that are not near full active range of motion (AROM). 
• Ankle exercise with resistance bands once near full ankle AROM: 
- Ankle dorsiflexion with resistance 
- Ankle plantar flexion with resistance 
- Ankle eversion with resistance 
- Ankle inversion with resistance 
• Once boot is weaned begin standing calf raise progression: 
-  Bilateral standing heel raises (25% body weight thru involved leg)  
-  Bilateral standing heel raises (50% equal weight through both legs)  
-  Bilateral standing heel raises (75% body weight thru the involved leg)  
• Knee Exercises for additional exercises and descriptions  
• Gym equipment (ex:  seated hamstring curl machine and hamstring curl machine, leg press 
machine, hip abductor and adductor machine, hip extension machine, roman chair ) 
• Lumbopelvic strengthening: (ex:  bridges on physioball, bridge on physioball with roll-in, bridge 
on physioball alternating 
• Progress intensity (strength) and duration (endurance) of exercises 
 
Balance/proprioception  
• Double limb standing balance utilizing uneven surface (wobble board)  
• Single limb balance - progress to uneven surface as able  
Criteria to 
Progress 
• No swelling/pain after exercise 
• Normalized gait in supportive sneaker 
• AROM equal to contralateral side 
• Progressing strength of lower extremities 
• Return to all activities (except sports) 
• Joint position sense symmetrical (<5 degree margin of error). 
 
PHASE III: LATE POST-OP (13-16 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Good balance and control on the involved leg in all planes 
• Safely progress strengthening  
• Promote proper movement patterns  
• Avoid post exercise pain/swelling 
Weight Bearing/ 
Precautions 
None if healing is complete 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions as 
indicated 
Range of motion/Mobility  
• Joint mobilizations as indicated 
  
Cardio  
• Stationary bicycle, treadmill walking 
 
Strengthening  
• Seated calf machine or wall sit with bilateral calf raises  
• Unilateral heel raises (once heel raise progression in Phase II completed) 
• **The following exercises are to focus on proper pelvis and lower extremity control with emphasis 
on good proximal stability:  
- Hip hike  
 
 
- Forward lunges 
- Bilateral squats progressing to single leg progression (below)  
- Single leg progression: partial weight bearing single leg press, slide board 
lunges: retro and lateral, step ups and step ups with march, lateral step-ups, step downs, single 
leg squats, single leg wall slides  
  
Balance/proprioception  
• Single limb balance on uneven surfaces (ex: balance disc, Bosu, ½ foam roll) 
Criteria to 
Progress 
• Good balance and control of the involved leg in all planes with single and double leg exercises 
 
PHASE IV: TRANSITIONAL (17-20 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Progress to plyometrics and sports specific movement patterns 
• Progress to low impact fitness activities 
Additional 
Interventions 
*Continue with 
Phase II-III 
interventions as 
indicated 
Cardio 
• Elliptical, stair climber, treadmill walking 
 
Plyometrics   
• Initiate Beginner Level plyometrics:  
- Once able to perform 3 sets of 15 of bilateral standing heel-raises with equal weight 
bearing progress to rebounding heel raises bilateral stance.    
- Once able to perform 3 sets of 15 unilateral heel raises progress 
to rebounding unilateral heel raises.  
- Once able to demonstrate good performance/tolerance with rebounding heel raises 
then initiate hopping in place bilateral stance.  Progress as able to unilateral hopping in 
place. 
Criteria to 
Progress 
• No swelling/pain after exercise  
• Standing Heel Rise test > 90% of uninvolved  
• No swelling/pain with 30 minutes of fast-paced walking  
• Good tolerance and performance of Beginner Level plyometrics  
• Psych Readiness to Return to Sport (PRRS)  
 
PHASE V: EARLY to UNRESTRICTED RETURN TO SPORT (5+ MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
• Gradual return to higher impact activities (jogging, running, jumping) 
• Gradual return to activities with multi-planar on uneven surfaces (hiking)  
• Safely initiate sport specific training program  
• Symmetrical performance with sport specific drills  
• Good lower extremity mechanics with plyometrics, agility, and running gait 
• Safely progress to full sport  
Additional 
Interventions 
*Continue with 
Phase II-IV 
interventions 
Running  
• Interval walk/jog program - Return to Running Program (Phase 1) 
• Return to Running Program (Phase 2)  
  
Plyometrics and Agility   
• Criteria to progress to the Agility and Plyometrics Program:  
- Good tolerance/performance of Beginner Level Plyometrics in Phase VI above   
- Completion of Phase 1 Return to Running Program (walk/jog intervals) with good 
tolerance.  
Criteria to 
Progress 
• Clearance from MD and ALL milestone criteria below have been met.  
- Completion of the Return to Running Program without pain/swelling.  
- Functional Assessment  
- Lower Extremity Functional Tests should be ≥90% compared to contralateral side for 
unilateral tests.    
Revised 10/2021 
 
 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
References: 
 
Dehgan N, et al.  Early Weightbearing and Range of Motion vs. Non-Weightbearing and Immobilization after Open Reduction and Internal Fixation of Unstable 
Ankle Fractures: A Randomized Controlled Trial.  J Orthop Trauma. 2016 Jul;30(7):345-52. 
 
Keene D, et al. Early Ankle Movement vs Immobilization in the Post-operative Management of Ankle Fracture in Adults: A Systematic Review and Meta-
Analysis. J Orthop Sports Phys Ther. 2014 Sep;44(9):690-701, C1-7. 
 
MGH Orthopedics Foot and Ankle Service.  Physical Therapy Guidelines for Ankle Fracture with Surgery.  
https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/foot-ankle/PT-guidelines-ankle-fracture-with-ORIF-final.pdf 
 
Schubert J, 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 Ankle Int. 2020 June;41(6):658-665. 
 
Smeeing DPJ, et al.  Weight-bearing or non-weight-bearing after Surgical Treatment of Ankle Fractures: A Multi-Center Randomized Trial. Eur J Trauma Emerg 
Surg.  2020 Feb;46(1):121-130. 
 
Smeeing DPJ, et al.  Weight bearing and Mobilization in the Post-operative Care of Ankle Fractures:  A Systematic Review and Meta-Analysis of Randomized 
Controlled Trials and Cohort Studies.  PLoS One.  2015; 10(2): e0118320  
 
 
 
 
 
Functional Assessment 
 
Patient Name:    
 
 
 
 
 
MRN:    
 
 
Date of Surgery:   
 
 
 
 
 
Surgeon:   
 
 
 
 
 
 
Concomitant Injuries/Procedures:   
 
 
 
 
 
 
                 
                
Ready to jog?  
 
YES 
 
NO 
Ready to return to sport? 
YES 
 
NO 
Recommendations:   
 
 
 
 
 
 
 
 
 
 
  
Examiner:   
 
 
 
 
                                                                                  
 
 
 
 
Pain is recorded as an average value over the past 2 weeks, from 0-10.  0 is absolutely no pain, and 10 is the worst pain 
ever experienced. 
 
Standing Heel Rise test is performed starting on a box with a 10 degree incline. Patient performs as many single leg heel 
raises as possible to a 30 beat per minute metronome. The test is terminated if the patient leans or pushes down on the 
table surface they are using to balance, the knee flexes, the plantar-flexion range of motion decreases by more than 50% 
of the starting range of motion, or the patient cannot keep up with the metronome/fatigues. 
 
Hop testing is performed per standardized testing guidelines.  The average of 3 trials is recorded to the nearest 
centimeter for each limb. 
 
 
 
Operative Limb 
Non-operative 
Limb 
Limb Symmetry 
Index 
Range of motion (X-0-X) 
 
 
- 
Pain (0-10) 
 
 
- 
Standing Heel Rise test 
 
 
 
Hop Testing 
 
Single-leg Hop for Distance 
 
 
 
Triple Hop for Distance 
 
 
 
Crossover Hop for Distance 
 
 
 
Vertical Jump 
 
 
 
Y-Balance Test 
 
 
 
Calculated 1 RM (single leg press) 
 
 
 
Psych. Readiness to Return to Sport (PRRS) 
 
 
 
Return to Running Program 
 
This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients 
should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or 
meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical 
decision making. If you have questions, contact the referring physician.  
 
PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Day 
1 
2 
3 
4 
5 
6 
7 
Week 1 
W5/J1x5 
 
W5/J1x5 
 
W4/J2x5 
 
W4/J2x5 
Week 2 
 
W3/J3x5 
 
W3/J3x5 
 
W2/J4x5 
 
Week 3 
W2/J4x5 
 
W1/J5x5 
 
W1/J5x5 
 
Return 
to Run  
Key: W=walk, J=jog 
**Only progress if there is no pain or swelling during or after the run 
 
PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Week 
Sunday 
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
1 
20 min 
 
20 min 
 
20 min 
 
25 min 
2 
 
25 min 
 
25 min 
 
30 min 
 
3 
30 min 
 
30 min 
 
35 min 
 
35 min 
4 
 
35 min 
 
40 min 
 
40 min 
 
5 
40 min 
 
45 min 
 
45 min 
 
45 min 
6 
 
50 min 
 
50 min 
 
50 min 
 
7 
55 min 
 
55 min 
 
55 min 
 
60 min 
8 
 
60 min 
 
60 min 
 
 
 
Recommendations 
• Runs should occur on softer surfaces during Phase I 
• Non-impact activity on off days 
• Goal is to increase mileage and then increase pace; avoid increasing two variables at once 
• 10% rule:  no more than 10% increase in mileage per week 
 
 
 
 
Agility and Plyometric Program 
 
This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric 
exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the 
Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the 
individual and should consider clinical decision making. If you have questions, contact the referring physician.  
 
PHASE I: ANTERIOR PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for pre-sports conditioning 
Agility 
• Forward run 
• Backward run 
• Forward lean in to a run 
• Forward run with 3-step deceleration 
• Figure 8 run 
• Circle run 
• Ladder  
Plyometrics 
• Shuttle press: Double leg
alternating leg
single leg jumps 
• Double leg:  
- Jumps on to a box
 jump off of a box
 jumps on/off box 
- Forward jumps, forward jump to broad jump 
- Tuck jumps 
- Backward/forward hops over line/cone 
• Single leg (these exercises are challenging and should be considered for more advanced 
athletes): 
- Progressive single leg jump tasks 
- Bounding run 
- Scissor jumps 
- Backward/forward hops over line/cone 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
PHASE II: LATERAL PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for the Level 1 sport athlete 
Agility 
*Continue with 
Phase I 
interventions 
 
• Side shuffle 
• Carioca 
• Crossover steps 
• Shuttle run 
• Zig-zag run 
• Ladder 
Plyometrics 
*Continue with 
Phase I 
interventions 
• Double leg:  
- Lateral jumps over line/cone 
- Lateral tuck jumps over cone 
• Single leg(these exercises are challenging and should be considered for more advanced 
athletes): 
- Lateral jumps over line/cone 
- Lateral jumps with sport cord 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
 
 
 
PHASE III: MULTI-PLANAR PROGRESSION 
Rehabilitation 
Goals 
• Challenge the Level 1 sport athlete in preparation for final clearance for return to sport 
Agility  
*Continue with 
Phase I-II 
interventions 
• Box drill 
• Star drill 
• Side shuffle with hurdles 
Plyometrics 
*Continue with 
Phase I-II 
interventions 
• Box jumps with quick change of direction 
• 90 and 180 degree jumps  
Criteria to 
Progress 
• Clearance from MD 
• Functional Assessment 
- ≥90% contralateral side 
• Achilles Tendon Rupture Score (ATRS) 
• Psych Readiness to Return to Sport (PRRS) 
 
 
 
