Some broken ankles, where the bones stay in line and all the ligaments are intact, are stable and will heal without surgery. They will need a boot, but the bones can heal well on their own.
Other times, the bone pieces shift out of place, or the whole ankle is unstable and needs to be stabilized surgically with plates or screws. The name for that surgery is open reduction and internal fixation. It means the bones are opened and exposed and put back in line, then held in a way that allows the bone to heal. The bones can be held with a plate and screws, or with a thin rod passed down the bone through a smaller cut.
First, the outer bone will be fixed in length and rotation to re-establish the width of the ankle joint. Then the connection between the two bones in the lower leg is examined and fixed if needed. Next, the inner side of the ankle will be fixed. Images will be taken during the surgery and at the end to make sure the bones are lined up well.
How long the surgery takes says little about how long the recovery will take. The bones heal on their own timetable, and then strength and balance get rebuilt.
Surgery here is about restoring the joint's alignment. Even slightly out-of-line healing leads to uneven wear and cartilage damage down the road, trading a fixable break for long-running ankle pain. Few injuries reward delay less than a displaced fracture.
A high ankle sprain is actually a very different kind of ankle sprain. It occurs above the ankle joint, where the two bones of the lower leg are connected by a fibrous joint just above the ankle, called the syndesmosis.
Because of its location in the syndesmosis and the disruption of its binding, it behaves entirely differently from a sprained (or rolled) ankle. The term high is, in this case, very literal.
The shin bone and the fibula (the thinner bone on the outside of the lower leg) lie next to each other and join to the ankle bone. The syndesmosis attaches the bottoms of these two bones together. When this structure tears, the two bones spread apart under weight, and the joint no longer fits together properly.
The usual mechanism is when the foot is planted and rotates outward while the body rotates over it. This is seen commonly in collision sports and skiing.
It can also occur if the foot is driven forcefully upwards and the bones are separated from underneath.
It feels similar to a rolled ankle, except the pain sits higher up the leg, not over the bony knob of the ankle. It's hard to put weight on the leg. The ankle may feel loose. There will also be pain upon squeezing your calf or upon rotating your foot outward.
An x-ray can show bones out of place or broken bones.
A stress view (the foot is rotated during the x-ray) can sometimes show gaps which are not seen in the regular x-rays.
Sometimes a scan is necessary to more fully view bones or surrounding soft tissue.
More mild injuries heal without the need for surgery. Treatment is usually a boot or a brace. No weight at first, then weight returns in stages.
Sometimes the bones can't stay together without surgery and need to be held together while the ligaments heal. This surgery might place a screw through both bones, or link two small buttons with a strong suture passed through the bone; the suture version leaves the bones a little of their natural movement.
Rehabilitation is harder work than recovering from a simple sprain and recovery is measured by what your ankle can do rather than how many weeks have passed.
A sprained ankle is more likely to sprain again, and that mechanism is the place to start. Repeated sprains cause the ligaments on the outside of the ankle not to spring back after being stretched. Over time this loose feeling in the joint can lead to the ankle rolling in benign circumstances or on normal ground. Left alone, that looseness wears down the cartilage lining the joint, toward arthritis. In addition, a sprained ankle loses the ability to correctly feel where it is in space and so corrective reflexes to prevent rolling occur later than they should. Bracing and balance retraining solve this for most people: the training rebuilds the late reflexes, and the brace props the ankle while improving the sense of control. Occasionally injections join the conservative plan, and the alternatives to cortisone injections are worth understanding before any needle is chosen. If, after a real trial of brace and exercises, the ankle still gives way, it is time to discuss a surgical option.
Ligament repairs usually involve shortening and re-attaching the ligaments to make them tight again. In a Brostrom repair, the surgeon overlaps the stretched ligament and sews it together to restore its original length. There are variations of this. In one, a strip of nearby tissue is used to buttress the repair. The other technique lays a flat suture over the repair to bear the load as the ligaments heal. These repairs can be done through a standard incision, a smaller incision, or arthroscopically through a camera and small portals.
The deltoid (medial) ligament is a fan of tissue on the inside of the ankle. The repair typically involves stitching the ligament back together, but in some cases, it may need to be attached to the bones with special anchors. If the ligament tissue is not adequate, a piece of tendon can be used to replace the ligament. Injuries to the inner side of the ankle rarely happen in isolation and will often require an adjacent procedure as well.
Your surgeon sets every milestone, and the x-rays drive the timing, but the healing stages after ankle surgery come in a fixed order. The stages below are a shape, not a schedule.
Immediately post-op the ankle will be in a splint or cast, with the foot square and the leg elevated.
Elevation is easy to underrate: swelling slows everything else, and keeping the leg up is what opens the door to the next steps.
When the leg can take weight again depends on what the x-rays show, not on elapsed time, though some forms of fixation allow weight sooner than others. It comes down to which bone broke and how it was held together.
The longer it remains immobile, the longer it takes to get it moving again.
Therapy works motion first, stiff to loose. Strength and balance follow once the ankle can be loaded.
Milestones depend on what the leg can do, not on the date. Your first goal is to walk without help and without looking at your feet. Next goal is to handle stairs and uneven ground, then high impact exercise if needed for your lifestyle.
How fast bone heals rides on the soft tissue around the fracture, glucose control, smoking, and how closely the rehab protocol is followed. In some cases a biologic adjunct added at surgery can support the repair.
Walking in the boot usually comes sooner than people expect, walking without it later, and walking without a thought about it is the final stage. Whether a biologic belongs in that picture is a regenerative medicine conversation of its own.
Ankle surgery is not one operation but a collection of them, and which is appropriate depends on what part has failed; the grid below organizes them that way. An achilles tendon rupture carries a page of its own, and for the arthritic ankle the joint preservation frame, keeping motion rather than fusing or replacing, shapes which of these even gets discussed.
Most breaks here are ankle fractures, stabilized with a plate and screws or a rod.
A more severe type of ankle fracture is the pilon fracture. This is where the lower shin bone is driven straight into the joint surface below. This type of fracture is usually treated in two stages.
When a patient has repeated sprains of the inside or outside of the ankle, they can be repaired or reconstructed.
Syndesmotic tears require stabilization while they heal. Syndesmotic tears can occur with fractures or by themselves.
Treatment is available for bruises or divots in the cartilage covering the ankle bones. These can be smoothed out or stimulated to try and heal. Bigger lesions can be filled with a plug of bone and cartilage.
More advanced arthritis requires different treatment, which might involve realigning the joint, fusing the joint or even replacing the joint.
Behind the outer ankle bone, peroneal tendons can be damaged by splitting, or slipping out of their groove. They can be repaired or rerouted surgically.
The tarsal tunnel is a passageway on the inner side of the ankle. A nerve can be squeezed in this tunnel and be released surgically.
Deciding which of these a given ankle needs is what the training is for. Completed three advanced orthopedic fellowships. Active member of the Arthroscopy Association of North America (AANA).
Half the patients who walk through our Atlanta door have been told they need surgery; the other half arrive with no information at all. The next step is the same for both: request an appointment and have the ankle looked at properly.
If pain is limiting the way you train, work, sleep, or move, an evaluation can turn uncertainty into a practical next-step plan.
Book an appointment →Explain what you want to return to, not only what hurts.
Look for the combination of findings that best explains the symptoms.
Understand the likely cause, whether imaging helps, and what comes next.
Atlanta Sports Medicine Institute helps active patients understand what may be driving their symptoms and compare appropriate treatment paths. The experience should be precise, understandable, and tied to the activities each patient wants to return to.
Elevation counts for more than most people think. The answers people give afterward are consistent: the recovery deserves more attention than the operation, and recovery runs on x-rays rather than the calendar, which is easier to accept before surgery than during it. Swelling is what slows everything else down, and stiffness gives way before mobility returns.
With a high ankle sprain you can often limp on the leg even while the two lower leg bones separate under stress, which is why many of these injuries get missed or picked up late. The ability to put weight on your injured ankle does not mean it is stable. Only an examination and specific x-ray views can tell whether the ankle is stable.
The first days after surgery will be your sorest days. A good plan for dealing with that pain, not winging it, is key. A typical pain-relief plan involves the nerve block done at the time of surgery, oral medications after surgery and elevation of your leg. Elevation is as helpful a tool as any in the early days. After that the road differs for everyone, and the plan you set with your team is the guide.
Tell us what is bothering you and we will get you in front of the right person.
