Recovering from a wrist or ankle fracture: pain-related fear, catastrophising and pain influences outcome
I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated!

This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets like little else. BUT, in a fracture, we have a nice clear-cut incident that begins the process of recovery, a well-known pathophysiology, and a well-understood recovery process from a biophysical perspective, so it provides us with a great opportunity to see what the risk factors are for longterm pain and disability.


I’ll just briefly describe the methodology here – 79 participants were sequentially recruited to the study if they had a distal fracture, were aged between 18 – 70 years, without any other fractures and not experiencing dementia. Nine dropped out and these were older and female. Each participant completed a modified Fear Avoidance Beliefs Questionnaire, completing this in respect of their beliefs about pain before their injury; the Pain Catastrophising Scale, numeric rating scale for pain before the injury, expected recovery at six months, and actual recovery at six months. Mobility and strength were also tested a time one and six months later.

Pain and worry reduced over time, as expected. Pain level started at 4 (ranging between 0 – 8), and dropped at T2 and T3. The number of people reporting no pain or no worry increased from T1 to T3 from 4% to 46% and from 30% to 57%.
69% of patients thought they should be fully recovered within six months when they were first asked. 36% thought this at T2, but the percentage who actually thought they were fully recovered at T3 were only 29%. That means that although most people thought they would be recovered within 6 months, actually less than 1/3 actually were. I certainly didn’t expect that!

Mobility and strength ratings at T3 showed 45% were not fully recovered at six months if they had a wrist fracture, while 33% of people with ankle fractures were not fully recovered. And yes, they do describe the processes used to measure mobility and strength.

Looking at fear-avoidance and catastrophising, there was a bit of work to get the groups divided into high and low levels of fear.
The proportion of patients with low fear at T1 and T2 was 54%, while for catastrophising was 56%. 29% of the participants had a high fear and pain profile at T2. What this lead to, after looking at an odds ratio analysis examining the relationship between fear and catastrophising, was that higher fear-avoidance beliefs increased the risk for pain , but high fear wasn’t significantly related to future self-rated recovery, mobility or strength. For catastrophising, there was a relationship only for strength.

What can we conclude?
OK, apart from the small sample size, and the need to use the strength of the noninjured limb as a substitute for the fractured one at T1, and the authors suggest that taking more frequent repeated measures might have helped; we can conclude a couple of interesting things:

  1. People over-estimate how rapidly they will recover from distal fractures, and expect to be fully recovered within six months, when 2/3 of people won’t be
  2. Higher-than-average scores, or increasing scores on pain-related fear and catastrophising are linked with future pain and recovery levels.  This is similar to the repeated findings in back pain and other types of pain, so shouldn’t be unexpected.
  3. As catastrophising and pain-related fear drop over time, this could mask those who are at risk of failing to recover.

Linton and colleagues suggest that close monitoring of fear-avoidance beliefs and catastrophising over the first few weeks of recovery would help health professionals intervene with psychological input designed to reduce fear and normalise expectations.  In other words, reassure patients that it’s normal for distal fractures to take a lot longer than 6 months to fully settle down.

One problem with this for me is that I don’t know anywhere in New Zealand where fear-avoidance and catastrophising is measured in people who have distal fractures! Most orthopaedic departments are singularly lacking in psychologists, and provided the fracture is uniting, patient’s fears and worries rarely get a look-in!  I can’t speak for GP’s who might have some ongoing input with a person who has a distal fracture, but I’d expect that unless the person attends and asks for help, their worries and fears won’t be identified.  This then means the physiotherapist who might be involved to help improve function (and maybe the occupational therapist) are the ones who may be left trying to address the patient’s fears.

Do we need to introduce another layer of psychological input delivered by psychologists for this group of people?

I think not – I do think maybe occupaitonal therapists and physiotherapists could be mindful of the natural healing process, the time it takes to recover, and be aware of how fear-avoidance and catastrophising interact to produce disability – and start to structure graded activities to increase the  confidence a person can have in their own ability to move.  And perhaps encouraging gradual return to functional activities rather than ‘exercises’ per se could be a better approach.  No gadgets please OT’s!  Learning to use the limb, attending to fear and catastrophising and addressing these quickly are well within the clinical skills of occupational therapists, physiotherapists, nurses and GP’s – so watch, listen and respond, even in these acute and so-called ‘simple’ injuries.

Linton, S., Buer, N., Samuelsson, L., & Harms-Ringdahl, K. (2010). Pain-related fear, catastrophizing and pain in the recovery from a fracture Scandinavian Journal of Pain, 1 (1), 38-42 DOI: 10.1016/j.sjpain.2009.09.004


  1. I think it would be tremendously helpful to know to expect that healing is unlikely to be complete by 6 months post distal fracture. I’d have expected that once the cast came off that some time would be required to regain the strength in that limb, but I doubt that most people would expect six months. The feeling of not doing as well as expected can be trouble.
    Knowing what to expect, and that what one is experiencing is “normal” is very helpful in the healing process. I suspect that many Dr.s don’t really realize the steps in healing past the “taking the cast off and getting some excersize” part either…

    1. Hi there! Yes I was amazed at how long ‘normal’ is! I’d never thought of it being that long, and ‘innoculation’ against expecting things to be completely settled earlier I think would make an enormous difference, especially in people who are worried about their health. Exercising/using the limb is a vital part of healing, and it seems that if you’re worried that it hasn’t ‘healed’ then you won’t use it as much – so this could be really helpful information. Thanks for your comments, it’s always nice to know people are out there reading my waffle!

  2. How is this for funny…I fractured my distal radius a few months ago and after my cast came off I had crps symptoms occuring-and it was ME who had to reassure my OT hand therapist that it was going to settle and come right. I think she had more anxiety about it than I did.

    But I didn’t realise that it was ‘normal ‘for it to take longer than 6 months to fully recover…I shall now give myself a break about taking way too long to get back to normal.

    1. Isn’t it amazing how the personal knowledge we get can be so helpful when we’re informing the health care providers!! Good on you for letting your OT know that everything is fine – now maybe you can take it a bit easier on yourself?!! I hope your exams and everything have gone OK. cheers Bronnie

  3. A nice blog highlighting the role of Pain Management strategies ‘even’ with acute presentations. The ability to identify those ‘at risk’ patients (and then act on that information) is where I would like to see more energy poured.
    I think Linton and others are doing some great work in identifying the characteristics, but are we seeing this translated into change in the GP’s, fracture clinics, OP physios etc? I don’t think so – and wonder why not. The information has been there around LBP and risk factors for years.

    Is this about politics and funding – high risk patients would require more input, therefore more cost, and STILL take longer to rehab.

    What about culture? How many orthopaedic doctors, PT’s and OT’s are willing to embrace a seemingly seismic shift in approach?

    And skills? I know what physio’s leave with on qualifying re: psychosocial influences (little) and so to shift away from what you are comfortable with (and often highly skilled in) is unlikely to happen from the ‘bottom up’.

    A pessimistic response perhaps, but to even it up (a little) I see one or two great new physios and students coming through our pain management service each year and moving on to other areas with a bucketload of new skills and confidence to use them in a wide variety of clinical settings.
    It’s perhaps more evolution than revolution (which is hard for an impatient person like me) but I may have to be in for the long haul!

    Thanks for spreading the word – you are prolific and quality which is inspiring!


    1. After an absence of a few weeks, it’s always good to get revved up by you Penelope!
      I wonder if the fact that ‘what gets measured/monitored gets done’ is part of why so few acute ‘physical’ clinicians look at psychosocial factors – you can’t count when you talk to someone about their anxiety, but you can count how many sessions of ultrasound you give! And lack of confidence, and the need to feel like you’re ‘curing’ someone might also play a big part. I think it also demonstrates the pervasiveness of the body/mind division that our society holds onto.
      Yes, way more students are coming through with interest and skill in managing psychosocial factors, would that the old hands could also watch and learn!
      BTW prolific yes, quality=variable. You haven’t seen Friday Funnies yet!

  4. I think this is great information! I realize we’re talking about something totally different, but I broke my toe about ten months ago and it wasn’t healing, I ended up with surgery to put a pin/screw/plate thing in. Ten months later, it’s still not totally healed and it’s hard not to worry. I think a little education goes a long way. I’m lucky enough to have a physical therapist who did social work and she’s just great, she’s aware of my anxiety and reminds me that since it hasn’t healed, it’s normal to have some swelling and redness so it doesn’t necessarily mean RSD spread. That goes a long way when waiting for my body to finish the healing process.

    I wonder if social workers could be used in the role of assisting in monitoring for fear and such. We may not understand all the medical stuff, but maybe we could get an idea of their expectations and the doctor’s expectations. We can also make sure they have a support system and are able to get that reassurance once they leave the hospital or clinic. If we’re doing a psychosocial assessment, then that might be something to consider.

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