Benefits of Physical Therapy After Fracture Hardware Removal

If you have suffered a lower-extremity fracture, you may need to undergo open reduction internal fixation (ORIF) to repair the break. This involves non-removable, internal hardware like metal pins, plates, rods, or screws to help support and stabilize the bone.

Physical therapist assessing ankle mobility.
Jeannot Olivet/Getty Images

There are times, however, when these "permanent" fixtures need to be removed, such as if they are causing pain, there is a severe infection, or the bone hasn't healed as hoped.

If this happens, you will likely undergo a period of immobilization once the hardware is removed, leading to a loss of strength, flexibility, and mobility. To compensate for this, your orthopedic surgeon may recommend a structured program of physical therapy.

Baseline Evaluations

After fixation hardware has been removed, you will most likely be wearing a cast or removable immobilizer to help stabilize the healing bone. Any time that a limb is immobilized for a prolonged period of time, there will inevitably be some level of muscle atrophy (wasting) and/or the loss of range of motion of a joint.

If physical therapy is advised, you would undergo an evaluation to provide baseline measurements of some or all of the following:

These measurements help the physical therapist formulate a rehabilitation plan and measure improvement as you progress through recovery.

Treatment Options

The most common reason for hardware removal after a fracture is pain or the loss of mobility and ROM. Physical therapy would therefore likely focus on regaining ROM around the injured extremity using various physical therapy techniques.

Gait Training

If you have had hardware removed from a lower extremity like an ankle or knee, then you will most likely need a walker or crutches after your surgery. Your physical therapist can help progress from walking with two crutches to one crutch and finally to a cane. This is part of a rehabilitative effort know as gait training.

Gait training may also include side-stepping, stair-climbing, navigating obstacles, and retro walking (walking backward) to target different muscle groups and enhance mobility.

As you progress in your treatment, your physical therapist may incorporate exercise to aid with balance and proprioception (including a BAPS board). Jumping and plyometric (agility) training may be necessary if you are planning to return to high-level sports and athletics.

The goal of gait training is to be able to walk independently with optimal mechanics and no assistive device.

ROM and Strength Traning

If internal hardware was removed due to the restriction of ROM, there may be further loss of ROM once the limb is immobilized. To minimize the loss, the physical therapist may employ passive physical therapy exercises in which there is no weight-bearing. Depending on the injury, these may include:

  • Toe points
  • Ankle pump
  • Passive knee flexion (bending)
  • Hip abduction (pressing outward) or adduction (pressing inward)

After the cast or immobilizer is no longer needed, resistance training and weight-bearing exercises may be added, increasing in intensity and duration week on week. In addition to in-office exercises, your physical therapist will provide you a list of exercises to do at home.

Scar Mobility

After surgery, you will have a surgical scar where the surgeon cut through your skin and muscles to remove the hardware.

Manual techniques like myofascial release can aid with healing and help reduce the amount of scar tissue that develops. The excessive buildup of scar tissue can lead to tissue contraction and the formation of adhesions (in which tissues stick together).

There is also a technique called instrument-assisted soft tissue mobilization (IASTM) that utilizes ergonomically shaped tools to mobilize scar tissue in a more targeted way.

Pain Management

After ORIF surgical removal, you may experience pain and swelling around the surgical site. Your physical therapist can use various treatments and modalities to help manage postoperative pain including:

In addition to physical therapy, your healthcare provider may provide you with medications to help control acute pain, ranging from over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) to the short-term use of prescription opioids.

Duration of Physical Therapy

You can expect to start physical therapy a few weeks after your hardware removal surgery. ROM and strength gains can usually be made quickly, and within 4 to 6 weeks you should nearer to your preoperative level of function.

Every injury is different and everyone heals at different rates. Speak with your healthcare provider to find out what you should expect with your specific condition.

A Word From Verywell

Physical therapy after ORIF hardware removal can be extremely beneficial in restoring ROM, strength, agility, and endurance. By staying motivated and working hard with your physical therapist, you can increase your chances of returning to full functional mobility even in older adults.

13 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Gouk C, Ng SK, Knight M, Bindra R, Thomas M. Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: a meta-analysis. Orthop Rev (Pavia). 2019 Sep 24;11(3):7809. doi:10.4081/or.2019.7809

  2. Thune A, Hagelberg M, Nasell H, Skoldenberg O. The benefits of hardware removal in patients with pain or discomfort after fracture healing of the ankle: a systematic review protocol. BMJ Open. 2017;7(8):e014560. doi:10.1136/bmjopen-2016-014560

  3. Ji LL, Yeo D. Cellular mechanism of immobilization-induced muscle atrophy: a mini review. Sports Med Health Sci. 2019;1(1):19-23.

  4. Jung HG, Kim JI, Park JY, Park JT, Eom JS, Lee DO. Is hardware removal recommended after ankle fracture repair? Biomed Res Int. 2016;2016:5250672. doi:10.1155/2016/5250672

  5. Schroder J, Truijen S, Van Criekinge, Saeys W. Feasibility and effectiveness of repetitive gait training early after stroke: A systematic review and meta-analysis. J Rehabil Med. 2019 Feb 1;51(2):78-88. doi:10.2340/16501977-2505

  6. Cain MS, Garceau SW, Linens SW. Effects of a 4-week biomechanical ankle platform system protocol on balance in high school athletes with chronic ankle instabilityJ Sport Rehabil. 2017;26(1):1-7. doi:10.1123/jsr.2015-0045

  7. Davies G, Riemann BL, Manske R. Current concepts in plyometric exercise. Int J Sports Phys Ther. 2015 Nov;10(6):760-86.

  8. Keene DJ, Costa ML, Tutton E, et al. Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study. BMJ Open. 2019;9(11):e030877. doi:10.1136/bmjopen-2019-030877

  9. Zanier E, Bordoni B. A multidisciplinary approach to scars: a narrative review. J Multidiscip Healthc. 2015;8:359-63. doi:10.2147/JMDH.S87845

  10. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical applicationJ Exerc Rehabil. 2017;13(1):12-22. doi:10.12965/jer.1732824.412

  11. Robinson A, McIntosh J, Peberdy H, et al. The effectiveness of physiotherapy interventions on pain and quality of life in adults with persistent post-surgical pain compared to usual care: a systematic review. PLoS One. 2019;14(12):e0226227 doi:10.1371/journal.pone.0226227

  12. Horn R, Kramer J. Postoperative pain control. In: StatPearls [Internet].

  13. Carneiro MB, Alves DPL, Mercadante MT, et al. Physical therapy in the postoperative of proximal femur fracture in elderly: literature review. Acta Ortop Bras. 2013 May-Jun;21(3):175-8. doi:10.1590/S1413-78522013000300010

By Brett Sears, PT
Brett Sears, PT, MDT, is a physical therapist with over 20 years of experience in orthopedic and hospital-based therapy.