Controversially, I trialled my own specific rehabilitation programme that went against standard recommendations.
What I discovered was that it is possible to significantly and safely speed up recovery time. In this article I’ll explain why I think advanced rehabilitation is important in physiotherapy and an overview of how I achieved my speedy recovery.
Why would you want to speed up recovery?
Common sense would dictate that speeding up recovery will increase the risk of further injury during rehab. Though this isn’t something I necessarily agree with, my own experience proving that it can be done safely, there’s got to be a good reason to challenge the agreed safe orthopaedic guidelines. The most compelling reason is to minimise significant and costly disruption to people’s lives.
The typical demographic that suffers from tibial fractures are sporty younger and middle aged adults. Injury tends to be caused by contact sports like skiing, snowboarding, fell racing and similar.
This is a group who are desperate to rehabilitate and get into fitness as early as possible. Not least to keep up with their responsibilities. Often they’ll have young and active families and need to get back to work as soon as they can.
The prolonged period of immobilization can affect all areas of an adult’s life. If we can speed up recovery then patients can get back to normal activity and independence quicker and minimise the disruption an injury will have on their lives.
The prescribed safe timetable for recovery for a well-aligned fracture of the tibia and fibula
From an orthopaedic surgical perspective this is the typical safe time frame for recovery for an average tibia and fibula fracture.
Step 1 Immobilise all fractures (depending on the type of fracture the treatment will vary) and check x-rays for healing and alignment at 4,8 and 12 weeks for undisplaced fractures.
Step 2 When pain free and somewhere between 12 and 16 weeks start to encourage full weight bearing activity and a gradual progression to activity.
Step 3 6-12 months prepare a return to sport programme.
Step 4 12 months return to contact or skiing activity.
So how do you improve function, allow early muscle rehabilitation, restore balance and proprioception that so quickly goes whilst patients are placed in a cast?
Well, the first 8 weeks are extremely painful and a cast is unavoidable for safe healing of the fracture and to ensure the fracture does not become displaced. It is just after 8 weeks, when pain has settled a bit that is the crucial moment where you have the opportunity to speed things up.
During the first four weeks after injury, patients with proximal factures are usually placed in an above knee cast to limit lower limb rotation that can dislodge the fracture site. Toe touching is possible, but any weight through the leg is not possible; you are stuck with two crutches to help mobilise. However, upper limb, core stability and fit ball sitting and hip strengthening is to be encouraged.
At four weeks the cast can be reduced after x-ray to a below knee or patella loading cast. These don’t really work as putting load through the patella is just too painful, but it does give more freedom of knee movement, more function for activities and sitting is more comfortable. You can start swimming using a ‘Limbo’ or similar waterproof aid around the cast. Walking is promoted, but be careful not to over-do it as it’s very painful if you do – trust me I know! Keep up with your routine for general conditioning as this will help to stabilise the affected leg.
After eight weeks
Pain stays strong until eight weeks and then starts to settle. If you experience this then you have a strong case to ask for an aircast removable walking brace. I did it against standard orthopaedic recommendations – they were worried the fracture site might move under the early loading pressure, but under the right guidance this is the only opportunity there is to accelerate your early rehabilitation. Ask for a brace otherwise you will be back in a cast for a further 4-6 weeks with no chance to get started with rehabilitation.
How? Well the brace can encourage early loading and weight bearing activity – walking. This is called closed kinetic chain activity and any CKC exercise can:
- Promote bone growth and consolidation;
- Allow better circulation;
- Reduce swelling;
- Improve muscle function;
- Start early strengthening of weakened muscle groups;
- Improve tendon, ligament and soft tissue mobility and flexibility – the ankle and knee gets very tight during immobilisation and this helps to improve the tissue several months before normal practice.
- Improved proprioception, balance and single leg standing.
What type of exercises can be done?
The literature is varied and non-specific on the type of exercises you can and can’t do. There is little or no information about the detail of exercise and when to start. In my experience the following program helps reduce fracture site pain and restores early muscle function:
There are limited centres with a Wattbike (we have one!) and a physiotherapist will have to devise a programme for you, but they are excellent tools for rehabilitation. It can give you direct feedback on the output of the affected leg compared to your normal leg. A programme is started, normally with three, five and ten minute duration to start. This bike is used by Olympians to improve performance and recovering patients can use it to gain significant advanced in their training.
CKC work for quads, calf ankle and knee activity. You will also benefits from aerobic activity with upper limb strengthening.
Hip, knee, ankle stretches and muscle work
Take the brace off and wear an ankle air cast for ankle stretches. Try ball wall squats, mini squats with support and hill and slope walking to encourage calf and ankle activity.
Encourage loading in and out of the braces and supports (walking, balancing) to benefit from gradual weaning off the appliance so by 12 weeks you are ready for increased gym and functional activity.
Normally by 12 weeks you’d still be in a cast! (And would have a long way to go before you started your rehab). The longer you are in the cast the longer the period of recovery. So what happens next? A twelve weeks x-ray to check bone healing and confirmation of the next stage of recovery, early progression now with further rehabilitation.