If you have suffered alower-extremity fracture, you may need to undergoopen 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.Jeannot Olivet/Getty ImagesThere are times, however, when these “permanent” fixtures need to be removed, such as if they are causing pain, there is an infection, there is a new fracture, or there is injury to a nerve or blood vessel.If this happens, you will likely undergo a period of immobilization (wearing a brace or boot) once the hardware is removed, leading to a loss of strength, flexibility, and mobility. To compensate for this, yourorthopedic surgeonmay recommend a structured program of physical therapy.Baseline EvaluationsAfter 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 ofmuscle atrophy(wasting) and/or the loss ofrange of motionof a joint.If physical therapy is advised, you would undergo an evaluation to provide baseline measurements of some or all of the following:PainStrengthRange of motion (ROM)Gait cycleand stride lengthWeight-bearing status(how much weight you can bear without pain or loss of stability)Functional mobility(the ability to do the tasks involved in daily living independently)Surgical scar tissueThese measurements help the physical therapist formulate a rehabilitation plan and measure improvement as you progress through recovery.Treatment OptionsThe 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 of the injured extremity using various physical therapy techniques.Gait TrainingIf you have had hardware removed from a lower extremity like an ankle or knee, then you will most likely need awalkerorcrutchesafter your surgery. Your physical therapist can help progress from walking with two crutches to one crutch, to acane, and then to no assistive devices. This is part of a rehabilitative effort known asgait training.Gait training may also include side-stepping, stair-climbing, and navigating obstacles to target different muscle groups and enhance mobility.As you progress in your treatment, your physical therapist may incorporate exercise to aid with balance andproprioception(the body’s ability to sense location and movement of body parts), including aBAPS board.Jumping and plyometric (power) 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.Tips for Using CrutchesROM and Strength TraningThere may be loss of ROM if the limb is immobilized after hardware removal. To minimize the loss, the physical therapist may employ a variety of physical therapy exercises. Depending on the injury, these may include:Toe pointsAnkle pumpPassive 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 with a list of exercises to do at home.Scar MobilityAfter surgery, you will have a surgical scar where the surgeon cut through your skin and soft tissues to remove the hardware.Manual techniques likemyofascial releasecan 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 calledinstrument-assisted soft tissue mobilization (IASTM)that utilizes ergonomically shaped tools to mobilize scar tissue in a more targeted way.Scar Tissue Massage and ManagementPain ManagementAfter surgical removal of ORIF hardware, 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:Cryotherapy (cold therapy)Thermotherapy(heat therapy)Therapeutic ultrasoundTranscutaneous electrical nerve stimulation (TENS)In addition to physical therapy, your healthcare provider may provide you with medications to help control acute pain, ranging from over-the-counter Tylenol (acetaminophen) ornonsteroidal anti-inflammatory drugs (NSAIDs)to the short-term use of prescriptionopioids.How to Control Postoperative PainDuration of Physical TherapyYou 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 7 to 12 weeks you should be 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 VerywellPhysical 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.How to Find the Best Physical Therapist
If you have suffered alower-extremity fracture, you may need to undergoopen 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.
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 an infection, there is a new fracture, or there is injury to a nerve or blood vessel.
If this happens, you will likely undergo a period of immobilization (wearing a brace or boot) once the hardware is removed, leading to a loss of strength, flexibility, and mobility. To compensate for this, yourorthopedic surgeonmay 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 ofmuscle atrophy(wasting) and/or the loss ofrange of motionof 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 of 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 awalkerorcrutchesafter your surgery. Your physical therapist can help progress from walking with two crutches to one crutch, to acane, and then to no assistive devices. This is part of a rehabilitative effort known asgait training.
Gait training may also include side-stepping, stair-climbing, and navigating obstacles to target different muscle groups and enhance mobility.
As you progress in your treatment, your physical therapist may incorporate exercise to aid with balance andproprioception(the body’s ability to sense location and movement of body parts), including aBAPS board.Jumping and plyometric (power) 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.
Tips for Using Crutches
ROM and Strength Traning
There may be loss of ROM if the limb is immobilized after hardware removal. To minimize the loss, the physical therapist may employ a variety of physical therapy exercises. Depending on the injury, these may include:
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 with 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 soft tissues to remove the hardware.
Manual techniques likemyofascial releasecan 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 calledinstrument-assisted soft tissue mobilization (IASTM)that utilizes ergonomically shaped tools to mobilize scar tissue in a more targeted way.
Scar Tissue Massage and Management
Pain Management
After surgical removal of ORIF hardware, 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 Tylenol (acetaminophen) ornonsteroidal anti-inflammatory drugs (NSAIDs)to the short-term use of prescriptionopioids.
How to Control Postoperative Pain
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 7 to 12 weeks you should be 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.
How to Find the Best Physical Therapist
14 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Rasouli MR, Viola J, Maltenfort MG, Shahi A, Parvizi J, Krieg JC.Hardware removal due to infection after open reduction and internal fixation: trends and predictors.Arch Bone Jt Surg. 2015;3(3):184–192Thune 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-2016-014560Gouk C, Ng SK, Knight M, Bindra R, Thomas M.Long term outcomes of open reduction internal fixationversusexternal fixation of distal radius fractures: a meta-analysis.Orthop Rev (Pavia). 2019;11(3):7809. doi:10.4081/or.2019.7809Ji LL, Yeo D.Cellular mechanism of immobilization-induced muscle atrophy: a mini review.Sports Med Health Sci.2019;1(1):19-23.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:10.1155/2016/5250672Mass General Brigham.Rehabilitation protocol for ankle fracture with ORIF.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 instability.J Sport Rehabil. 2017;26(1):1-7. doi:10.1123/jsr.2015-0045Davies G, Riemann BL, Manske R.Current concepts in plyometric exercise.Int J Sports Phys Ther.2015 Nov;10(6):760-86.Corewell Health.Gait and balance training.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-2019-030877Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D.Effectiveness of various methods of manual scar therapy.Skin Res Technol.2023;29(3):e13272. doi:10.1111/srt.13272Kim J, Sung DJ, Lee J.Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.J Exerc Rehabil. 2017;13(1):12-22. doi:10.12965/jer.1732824.412Robinson 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.0226227Horn R, Kramer J.Postoperative pain control. In:StatPearls [Internet].
14 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Rasouli MR, Viola J, Maltenfort MG, Shahi A, Parvizi J, Krieg JC.Hardware removal due to infection after open reduction and internal fixation: trends and predictors.Arch Bone Jt Surg. 2015;3(3):184–192Thune 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-2016-014560Gouk C, Ng SK, Knight M, Bindra R, Thomas M.Long term outcomes of open reduction internal fixationversusexternal fixation of distal radius fractures: a meta-analysis.Orthop Rev (Pavia). 2019;11(3):7809. doi:10.4081/or.2019.7809Ji LL, Yeo D.Cellular mechanism of immobilization-induced muscle atrophy: a mini review.Sports Med Health Sci.2019;1(1):19-23.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:10.1155/2016/5250672Mass General Brigham.Rehabilitation protocol for ankle fracture with ORIF.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 instability.J Sport Rehabil. 2017;26(1):1-7. doi:10.1123/jsr.2015-0045Davies G, Riemann BL, Manske R.Current concepts in plyometric exercise.Int J Sports Phys Ther.2015 Nov;10(6):760-86.Corewell Health.Gait and balance training.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-2019-030877Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D.Effectiveness of various methods of manual scar therapy.Skin Res Technol.2023;29(3):e13272. doi:10.1111/srt.13272Kim J, Sung DJ, Lee J.Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.J Exerc Rehabil. 2017;13(1):12-22. doi:10.12965/jer.1732824.412Robinson 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.0226227Horn R, Kramer J.Postoperative pain control. In:StatPearls [Internet].
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Rasouli MR, Viola J, Maltenfort MG, Shahi A, Parvizi J, Krieg JC.Hardware removal due to infection after open reduction and internal fixation: trends and predictors.Arch Bone Jt Surg. 2015;3(3):184–192Thune 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-2016-014560Gouk C, Ng SK, Knight M, Bindra R, Thomas M.Long term outcomes of open reduction internal fixationversusexternal fixation of distal radius fractures: a meta-analysis.Orthop Rev (Pavia). 2019;11(3):7809. doi:10.4081/or.2019.7809Ji LL, Yeo D.Cellular mechanism of immobilization-induced muscle atrophy: a mini review.Sports Med Health Sci.2019;1(1):19-23.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:10.1155/2016/5250672Mass General Brigham.Rehabilitation protocol for ankle fracture with ORIF.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 instability.J Sport Rehabil. 2017;26(1):1-7. doi:10.1123/jsr.2015-0045Davies G, Riemann BL, Manske R.Current concepts in plyometric exercise.Int J Sports Phys Ther.2015 Nov;10(6):760-86.Corewell Health.Gait and balance training.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-2019-030877Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D.Effectiveness of various methods of manual scar therapy.Skin Res Technol.2023;29(3):e13272. doi:10.1111/srt.13272Kim J, Sung DJ, Lee J.Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.J Exerc Rehabil. 2017;13(1):12-22. doi:10.12965/jer.1732824.412Robinson 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.0226227Horn R, Kramer J.Postoperative pain control. In:StatPearls [Internet].
Rasouli MR, Viola J, Maltenfort MG, Shahi A, Parvizi J, Krieg JC.Hardware removal due to infection after open reduction and internal fixation: trends and predictors.Arch Bone Jt Surg. 2015;3(3):184–192
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
Gouk C, Ng SK, Knight M, Bindra R, Thomas M.Long term outcomes of open reduction internal fixationversusexternal fixation of distal radius fractures: a meta-analysis.Orthop Rev (Pavia). 2019;11(3):7809. doi:10.4081/or.2019.7809
Ji LL, Yeo D.Cellular mechanism of immobilization-induced muscle atrophy: a mini review.Sports Med Health Sci.2019;1(1):19-23.
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
Mass General Brigham.Rehabilitation protocol for ankle fracture with ORIF.
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 instability.J Sport Rehabil. 2017;26(1):1-7. doi:10.1123/jsr.2015-0045
Davies G, Riemann BL, Manske R.Current concepts in plyometric exercise.Int J Sports Phys Ther.2015 Nov;10(6):760-86.
Corewell Health.Gait and balance training.
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
Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D.Effectiveness of various methods of manual scar therapy.Skin Res Technol.2023;29(3):e13272. doi:10.1111/srt.13272
Kim J, Sung DJ, Lee J.Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.J Exerc Rehabil. 2017;13(1):12-22. doi:10.12965/jer.1732824.412
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
Horn R, Kramer J.Postoperative pain control. In:StatPearls [Internet].
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