Weight-bearing Status After Foot & Ankle Surgery



  • Restriction of weight-bearing following foot and ankle surgery is commonly used to protect the surgical site and allow soft tissues and wounds to settle
  • However, not all patients are able to comply with this instruction and, at the very least, find it inconvenient
  • This can lead to delayed hospital discharge and increased length of stay
  • In addition, non-weight-bearing (NWB) and casting can potentially lead to a higher risk of complications such as muscle atrophy and venous thromboembolic events
  • Therefore, earlier weightbearing and rehabilitation would be advantageous if they do not increase adverse outcomes of surgery
  • There has been increasing interest in this issue, both in the elective and trauma situation


1st MTPJ fusion

  • Post-operative weightbearing status and splints have been variously described, with use of surgical shoes, cast boots and heel or flat weightbearing
  • A recent systematic review found 17 articles with suitable criteria where weightbearing was initiated within 2 weeks of surgery encompassing 898 arthrodesis
  • Pooling these results showed a total of 57 described non-unions (6.35%)
  • This compares with an earlier systematic review showing a non-union rate of 5.4% when weightbearing status was not a criteria of the review
  • Caution is required, however, as none of the studies were controlled trials comparing post-operative weightbearing status; the definition of non-union was varied between trials; the groups were heterogenous
  • Overall, however, it is suggested that early weightbearing may not result in an adverse outcome, and may be a suggested avenue for further investigation


1st TMTJ fusion

  • Traditionally accompanied by cast immobilisation and non-weightbearing status for 6 weeks
  • Some studies have reported on earlier weightbearing ranging from partial to full weightbearing within 2 weeks of surgery
  • A recent systematic review found 7 suitable papers with early weightbearing protocols, with a total of 443 arthrodesis; 16 (3.61%) non-unions were described
  • Again, caution is recommended as no studies were controlled trials comparing post-operative weightbearing and there is significant heterogenicity of the papers
  • However, early weightbearing for this procedure has shown promising results and may be a consideration for further study


Ankle fusion

  • Post-operative regimens vary, but typically involve immobilisation in cast, non-weightbearing for 6 weeks
  • A recent systematic review looked at the evidence for weightbearing encompassing 60 studies deemed suitable for review, with a total of 2426 ankle arthrodesis
  • Only 1 study compared outcomes of weightbearing status and was retrospective in nature
  • The studies were grouped dependent on length of time kept non-weightbearing: 0-1 week, 2-3 weeks, 4-5 weeks, 6 weeks and beyond
  • Overall union rate was 93%
  • There were comparable union rates, complication rates and time to union between groups
  • However, caution again is required on study interpretation due to the highlighted heterogenicity of the groups, the consistency of reporting between the studies and the overall lack of high-quality evidence
  • The results of early weightbearing are promising and would be a valuable area for a further high-quality study


Ankle fractures

  • Ankle fracture management has been an area of increased interest in recent years
  • Early and immediate weightbearing and early range of motion have both been proposed to improve outcomes, both separately and in combination
  • Benefits suggested include improved range of motion, and early return to work
  • A Cochrane review in 2012 found 30 trials that met the criteria to be assessed following surgical management of ankle fractures
  • It concluded that the evidence was limited, due to heterogenicity and bias, however early weightbearing may show an improvement in ankle range of motion
  • However, a further systematic review in 2016 indicated that active mobilisation and early weightbearing was advantageous and resulted in an earlier return to work, without increasing complications
  • Overall, there is a trend towards early weightbearing and early range of motion; further evidence is likely to be produced as study protocols for randomised control trials looking at weightbearing status and exercise in the post-operative period have been recently submitted



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RoukisTS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. JFootAnkleSurg2011;50(6):710–713

Crowell A, Van JC, Meyr AJ. Early Weightbearing After Arthrodesis of the First Metatarsal-Medial Cuneiform Joint: A Systematic Review of the Incidence of Nonunion. J Foot Ankle Surg. 2018 Nov-Dec;57(6):1204-1206. doi: 10.1053/j.jfas.2018.06.011. Epub 2018 Sep 22. PMID: 30253966

Potter MJ, Freeman R. Postoperative weightbearing following ankle arthrodesis: a systematic review. Bone Joint J. 2019 Oct;101-B(10):1256-1262. doi: 10.1302/0301-620X.101B10.BJJ-2019-0207.R1. PMID: 31564155

Lin CW, Donkers NA, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012 Nov 14;11:CD005595. doi: 10.1002/14651858.CD005595.pub3. PMID: 23152232

Smeeing DPJ, Houwert RM, Briet JP, Kelder JC, Segers MJM, Verleisdonk EJMM, et al. (2015) Weight-Bearing and Mobilization in the Postoperative Care of Ankle Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Cohort Studies. PLoS ONE 10(2): e0118320. doi:10.1371/journal.pone.0118320

Khojaly R, Mac Niocaill R, Shahab M, Nagle M, Taylor C, Rowan FE, Cleary M. Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture. Trials. 2021 May 27;22(1):369. doi: 10.1186/s13063-021-05319-0