Research findings: walking two weeks after ankle surgery is safe for many

After surgery for a broken ankle, standard practice typically advises avoiding walking (delayed weight-bearing, or DWB) for six weeks, though some surgeons recommend walking as early as two weeks post-operatively (early weight bearing, or EWB). The weight-bearing in ankle fractures trial aimed to determine the clinical and cost effectiveness of these two strategies (early versus delayed weight-bearing). 

What’s new? 

The study involved 561 adults who had surgery for a broken ankle at 23 hospitals in the UK. Half were encouraged to walk two weeks after surgery, the others to wait six weeks. The groups had similar characteristics, most participants (64 per cent) were women, and their average age was 50 years. 

The main outcome at four months was a measure of ankle function, including symptoms (such as pain and stiffness) and the ability to put weight on the ankle (for example climbing stairs). 

Scores within six points (out of 100) of each other were considered equal. 243 in the two-week group and 237 in the six-week group provided data for this outcome. At four months, the two-week group: 

• had similar ankle function (score: 66) to the six-week group (61).
• had a similar likelihood of complications (16 per cent) as the six-week group (14 per cent).
• had a similar number of unplanned surgeries due to complications (eight per cent) as the six-week group (six per cent).
• cost the NHS and social services less (£725) than the six-week group (£785 in 2021/22 costs). 

Ankle function was similar between groups for different ages, sexes, and types of ankle surgery. After one year, there was no difference between groups in ankle function. 

People in the two-week group had slightly (but not significantly) less time off work in the six weeks after surgery. This saved society an average of £722 per person. Years of life in good health were also higher for the two-week group. 

Interviews with 29 participants found that recovery took longer than people expected. They were unsure if their symptoms were normal; many wanted more information: ‘Even a little leaflet would be good…To say you’re getting back on your feet.’ 

People valued spending time with physios but access to physiotherapy varied between hospitals. For most, pain did not greatly limit their recovery, but the fear of pain and injury did: 

When you’ve been in the cast for a few weeks and then you get transferred into the boot…it is quite frightening.

Why is this important? 

The study suggests that walking two weeks after surgery for a broken ankle is as safe as waiting six weeks and costs less. This means people could return to normal activities earlier.

Clinicians could inform patients of the findings when discussing their rehabilitation. Policymakers could consider ways to encourage more clinicians to recommend a two-week waiting period; from 2019 to 2021, just 11 per cent of people were recommended this approach.  

The authors stress that surgeons considered that many people (42 per cent of the 2,218 assessed) needed to wait for the full six weeks after surgery before walking; these people were therefore ineligible for inclusion in this study. 

This means the findings may be less generalisable to people with more serious fractures. In addition, many people in the six-week group (38 per cent) did not wait the full period before walking, which may have affected the findings. 

Charli Robertson, EDB representative for the Association of Chartered Physiotherapists in Sports and Exercise Medicine says:

‘Positive outcomes regarding early loading of soft tissue injuries have been noted for some time, and it is encouraging to see further support for early weight bearing within ankle fracture populations. Early mobilisation has offered many benefits and continues to be tested in practice. 

‘As with everything within our profession, rehab is a constant balance of risk versus reward and as such the findings here should be approached with pragmatism when applying them to our patients. 

‘A wide range of people were included within EWB and DWB groups, and details of who ‘did better’ is not specified. EWB may not be best for someone with a trimaleolar high force fracture, poorly controlled diabetes and post-injury anxiety; but it might be for the weekend triathlete with a unimaleolar fracture following a step off a curb on a run.

Emma Lee, a senior oprthopaedic practitioner at York and Scarborough Teaching Hospital NHS and ATOCP committee member, says:

‘Often as clinicians we need to weigh up the risk between independence and function, and protecting bone healing. This study provides evidence to support early weightbearing for patients following surgery for a broken ankle. For many patients, this could mean the difference between going home and needing either inpatient rehab or a temporary care home placement. I feel this will enhance patient’s wellbeing and quality of life, as well as reduce pressure on the NHS and social sector. 

'Participants in the study had an average age of 50 and most were female. Individualised treatment, particularly for those with less clinical representation, needs to be taken into consideration when planning fracture management. 

'This study highlights the importance of informed choice, and patient education to reassure and advise on what to expect. If adopted, early weightbearing could create consistency in management nationally, reduce confusion for patients, and increase confidence for clinicians.’

Access the full NIHR evidence summary.