What Works
Ranked by how strong the evidence actually is, not by how commonly it is done.
Tier 1 — Strong evidence
Recognition and emergency screening HIGH
Compartment check, spine check, circulation check, open wound check, and a look at the other heel because bilateral injuries get missed. Getting this wrong costs a limb or a spinal cord. Getting the exercise dose wrong costs a few weeks.
Honest prognosis from the first appointment HIGH
Around one in three people treated surgically still scored in the impaired range on foot function questionnaires at an average of nearly five years. The severity of the original crush, measured on the first X-ray, predicts the two-year outcome regardless of what treatment follows. People do better when they are told this at the start rather than discovering it at month six.
Tier 2 — Moderate evidence
Early ankle and joint movement, once your surgeon permits it MODERATE
In the one group of 78 patients reporting exact timings, movement started at two weeks after fixation and the surgical correction held: heel angle 31.7 degrees at two weeks and 30.1 degrees at an average of nearly four years later. Ankle bend-up range recovered fully. Pointing the toes down and turning the sole inward did not.
What that group actually did
| Joint movement exercise | Started at 2 weeks. Brace removed for movement work whenever not walking |
| Forefoot weight bearing | Allowed at 2 weeks, in a brace or heel-off shoe |
| Walking without a crutch | Allowed at 4 weeks, as tolerated |
These are the timings one group of surgeons used and reported, not a schedule anyone has tested against an alternative. Your surgeon's instructions override all of it.
Earlier weight bearing, where the fixation allows it MODERATE
Across 72 studies, patients were grouped by when they started partial weight bearing: 0 to 4 weeks, 4 to 6, 6 to 8, and 8 to 12. Every measured outcome overlapped between the groups. Heel angle, heel height, function scores, pain, complications. A separate pooling of 20 studies and 1051 fractures found the surgical correction slipped by 0.4 degrees on average with a 13.9% complication rate. The fear that drove the standard rule, that loading collapses the repair, is not visible in the data that exists.
Not one of those studies was randomised. This is a consistent absence of detected harm, which is not the same as proof that it is safe.
Exercise Prescription
Everything below is standard practice rather than tested protocol, because no trial has ever randomised an exercise variable in this fracture. What the research does pin down is which losses persist: pointing the toes down and turning the sole of the foot inward. Bending the ankle upward tends to recover on its own. Those first two are where the effort belongs.
Home programme
| Toe wiggles and ankle pumps 20 reps, hourly while awake, from day one | Circulation and swelling control. Should never be sharp. |
| Knee, hip and glute work on the injured side 3 sets of 10, daily, from day one | Stops the whole leg wasting while the foot rests. |
| Slow ankle circles and alphabet 2 sets of 10 each direction, 2 to 3 times daily, once permitted | Stiffness and stretch are fine. Sharp pain means stop. |
| Turning the sole inward and outward 3 sets of 10, daily, once permitted | The movement most likely to stay stiff permanently. Be stubborn about this one. |
| Seated heel and toe raises 3 sets of 10, daily, once partial weight bearing is allowed | Effort, not sharp pain. |
| Standing calf raise, two legs then one 3 sets of 8 to 10, every other day, once full weight bearing is allowed | Aching calf is the point. No sharp heel pain. |
| Single-leg balance 3 x 30 seconds, daily, once full weight bearing is allowed | Wobbling is fine. Pain is not. Progress to eyes closed, then a cushion. |
The sets and repetitions follow standard practice. Nobody has run a trial comparing exercise doses for this fracture, so anyone quoting you a precise number with confidence is guessing.
Tier 3 — convention rather than evidence
Progressive loading, gait retraining, calf and foot strengthening. LOW No trial has randomised any exercise variable in this fracture. Included because the alternative is doing nothing, and because the persistent losses are measurable and worth chasing.
Heel-unloading orthosis. LOW A trial was designed and registered in 2018 to test exactly this. It has not reported results.
Primary joint fusion for the most severe pattern. LOW Across 9 studies and 142 patients, outcomes were not clearly different from reconstructing the bone, and 13.6% of the reconstruction group needed that fusion later anyway.
What Doesn't Work
- Adding hands-on treatment on top of exercise and gait training, for movement or balance gains. A double-blind trial of 72 patients after ankle and hindfoot fracture surgery compared real hands-on treatment against a convincing dummy version. Everyone was already doing exercise and gait training. Three sessions over 7 to 10 days produced no difference in range of movement, walking or balance. It is a specific add-on that did not add anything, rather than a verdict on rehabilitation.
- Defending the standard six-to-nine-week no-weight-bearing rule as evidence-based. The reviewers who studied it describe it as long-standing practice that was never adapted or tested. It may still turn out to be right. The two trials designed to settle it have not reported.
- Quoting the associated-injury rates from open fractures as if they applied to a simple closed one. The 14.5% spinal fracture figure comes from a high-energy open-fracture group at a major trauma centre. The reason to check the spine transfers to everyone. The number does not.
- Promising a full recovery. The data does not describe one, and saying so early is kinder than saying it late.
