Impact of physical therapy timing on fear of falling and outcomes in elderly patients with ankle fractures

OBJECTIVE: Fear of falling (FOF) after ankle fracture surgery significantly hinders rehabilitation in elderly patients, yet the optimal timing for physical therapy (PT) remains debated. This study examines how PT initiation time affects FOF and functional recovery. METHODS: In this single-center retrospective cohort study, we analyzed 2,816 patients (aged ≥ 65) with ankle fractures (2014-2023), stratified into early (≤ 2 weeks post-operation) and conventional PT (>2 weeks) groups. Primary outcomes were changes in FES-I and AOFAS scores; secondary outcomes included complication rates and time to resuming daily activities. Propensity score matching controlled for confounders, and interaction analysis assessed the moderating effect of fracture type (Weber classification). RESULTS: At 12 months, the early PT group showed significantly lower FES-I scores (median 19 [IQR 17-23] vs. 17 [IQR 22-27], P < 0.001), and higher AOFAS scores (85.5 [78-92] vs. 77 [70-86], P < 0.001). Weber type B fractures benefited most, with early PT yielding greater FES-I improvements (2.8-point difference; 95% CI 1.8-3.8, P < 0.001) and AOFAS gains (10.0 points; 95% CI 8.4-11.6, P < 0.001). Complication rates were similar (9.2% early vs. 11.8% conventional, P = 0.078), but early PT had lower deep vein thrombosis incidence (3.5% vs. 5.7%, P = 0.035). CONCLUSION: Early PT significantly reduces FOF and enhances functional recovery, particularly in Weber type B fractures. We recommend individualized PT protocols based on fracture type and bone density. TRIAL REGISTRATION: Retrospectively registered.