Ten days into a mother's hospital stay after hip fracture surgery, a lot of family caregivers notice the same thing: her calf feels noticeably firmer than the other one, and pressing a finger into it leaves a dent that's slow to bounce back. Ask a nurse and you'll usually hear, get her moving her legs a bit, but rarely anything more specific than that — how many reps, how often per hour, or where normal swelling ends and a warning sign begins.
This guide is for anyone caring for an older adult who can't get up and walk on their own, whether from stroke-related hemiplegia, hip or knee surgery, or a chronic condition that's flared up. There are many kinds of in-bed exercise, but this guide focuses on exactly one goal — preventing deep vein thrombosis (DVT) and maintaining circulation in the legs — and walks through the exact technique for the ankle pump exercise, how a caregiver can perform it for someone who can't move on their own, and the stop signs you need to know.
One thing worth stating clearly up front: the ankle pump exercise is a supportive habit that helps lower clot risk, not a medical treatment that cures an existing clot or fully prevents one from forming. Compression stockings, intermittent pneumatic compression devices, and anticoagulant medication when prescribed are decisions for the care team to make separately — think of everything in this guide as self-care layered on top of that plan, not a replacement for it.
Why Bed Rest Puts the Legs at Risk
Why Bed Rest Puts the Legs at Risk
When Three Conditions Overlap
Conditions that favor clot formation generally fall into three categories. The first is stagnant blood flow: walking or moving the ankle contracts the calf muscles, which act as a pump pushing venous blood back toward the heart, and lying still shuts that pump down, letting blood pool in the leg veins. The second is damage to the vessel wall itself, which surgery, fractures, and even IV lines can cause through microscopic injury to the inner lining. The third is blood that clots more easily than usual, a tendency raised by dehydration, inflammation, and some cancer treatments. Risk climbs as these overlap, and an older adult on bed rest often has two or three of them at once.
Situations With Especially Elevated Risk
- Recent surgery for a hip or knee fracture
- Stroke-related hemiplegia that leaves one leg unable to move on its own
- Bed rest lasting more than 3 days without sitting up or walking independently
- Advanced heart failure or chronic lung disease that makes even light movement breathless and difficult
- Currently undergoing, or recently finished, cancer treatment
- Reduced food and fluid intake leading to dehydration, common in older adults
If two or more of these apply, that's a clear enough reason to start the ankle pump exercise today rather than waiting.
How to Measure Calf Circumference
Bedside nursing staff commonly use a simple self-check: measuring the calf circumference roughly 10 cm below the kneecap with a tape measure and comparing both sides. Measuring at the same time of day and the same spot matters, and if one side grows more than 2 to 3 cm overnight, that's a signal worth a closer look rather than routine swelling. This number isn't a diagnostic threshold, just a reference point for catching change early — if something feels off even when the number is ambiguous, it's safer to flag it to the care team right away.
Why Both Legs Need Attention
When caring for someone with hemiplegia, it's easy to focus entirely on the affected leg. But the leg that still moves freely isn't fully protected either — long periods of lying still reduce its muscle pump action too. The exercises below should be applied equally to both legs.
What to Confirm Before Starting
Checking three things with the care team beforehand makes this far safer. First, whether a DVT diagnosis has already been made. Second, if the person is on an anticoagulant like warfarin or rivaroxaban, whether recent bloodwork is stable. Third, whether there's a specific order restricting joint movement at a recent leg surgery site. If any of these apply, talk to the physician or physical therapist before starting the exercises below.
The Ankle Pump Exercise, Done Correctly
The Ankle Pump Exercise, Done Correctly
1. Ankle Pump Exercise (Basic, Self-Directed)
Starting Position: In bed, either raise the head of the bed to about 30 to 45 degrees or lie flat. Prop a thin rolled towel or small pillow under the knee so it bends slightly — this keeps the vein behind the knee from being compressed and is more comfortable. Let the heel rest naturally against the mattress.
Movement Sequence: Pull the toes up toward the shin as far as comfortable and hold for 2 seconds. Then point the toes the other way so the sole faces the foot of the bed, and hold for another 2 seconds. Think of it as pressing and releasing a car's gas pedal. One full back-and-forth counts as one rep.
Breathing: Inhale while pulling the foot up, exhale while pushing it down. Holding the breath while exerting force can cause a momentary spike in blood pressure, so anyone with high blood pressure or heart disease should pay particular attention to breathing through each rep.
Sets, Reps, and Frequency: Count 10 reps as one set. Aim for one set every 1 to 2 hours while awake, for a daily target of 8 to 10 sets. If starting from scratch, 5 reps per set for the first few days is enough before building up to 10.
Common Mistakes and Corrections: The most common mistake is barely moving the ankle joint while just wiggling the toes — the top of the foot should visibly lift toward the shin. Bending and straightening the knee to move the whole leg is another common error; that works the quadriceps, not the ankle pump, so the knee should stay still while all the movement comes from the ankle joint. Forcing past a point of resistance is also a mistake to avoid.
Stop Signs: If a new tightening pain appears in the calf during the exercise, or one leg becomes noticeably more swollen and warm to the touch right after, stop immediately and notify the care team. If sudden shortness of breath or chest pain accompanies this, that's an emergency — beyond simply stopping the exercise, call emergency services right away.
2. Ankle Circles (Supplementary Circulation Exercise)
Starting Position: Same base position as above, but propping a low pillow under the heel so the foot hovers slightly off the mattress makes it easier to trace a full circle.
Movement Sequence: Imagine the big toe as a pencil tip and trace 5 large circles clockwise, then 5 counterclockwise. The arc traced by the inner and outer ankle bones should be visibly large for the joint to be considered fully engaged.
Breathing: No need to match it precisely to the movement — just breathe naturally, using roughly 3 to 4 seconds per circle as a pace guide.
Sets, Reps, and Frequency: Adding 3 to 4 rounds a day between ankle pump sets is enough. Unlike the ankle pump, there's no need to repeat this on a strict hourly schedule.
Common Mistakes and Corrections: A common error is wiggling just the toes while the circle traced gets progressively smaller. Lightly holding the shin still with the other hand makes it easier to confirm the circle is coming from the ankle joint itself.
Stop Signs: If a sharp pain shows up only in one direction, skip that direction and continue with the other. If swelling increases overall, respond using the same criteria as the basic ankle pump exercise.
If Wearing a Brace or Splint
If a brace is required after an ankle fracture or surgery, the rule is to fit the exercise into whatever windows the brace can safely come off. Never remove a brace on your own without the care team's approval to exercise. Most braces still allow toe joint movement even while worn, so doing a short version within that limited range is better than skipping the exercise entirely.
What About Overnight?
There's no need to wake someone up specifically for the ankle pump exercise. But if they're already waking for a nighttime repositioning or bathroom need anyway, that's a good moment to fit in one extra set. Don't sacrifice sleep quality just to hit a daily set target.
When Someone Can't Move on Their Own: A Caregiver's Guide
When Someone Can't Move on Their Own: A Caregiver's Guide
An older adult who is unresponsive, or who has lost the use of one leg to hemiplegia, doesn't have to miss out on the benefits of the ankle pump entirely. A caregiver or care aide can perform a passive range-of-motion version that replaces much of the effect.
3. Caregiver-Assisted Ankle Pump
Starting Position: Sit in a chair beside the bed or on the edge of the bed. Use one hand to cradle and support the heel from underneath, and rest the other hand lightly on the top or sole of the foot.
Movement Sequence: Using the hand on the sole, push slowly toward the top of the foot to guide dorsiflexion, stopping the moment resistance is felt and holding for 2 seconds. Then gently press the toes the other way to guide plantarflexion, holding again for 2 seconds. Never force past a point where the movement feels stiff or blocked.
Breathing: Let the person breathe at their own natural pace. If their face tenses or they make a sound of discomfort during the movement, stop your hand at that exact point.
Sets, Reps, and Frequency: 10 reps make one set, with 6 to 8 sets a day being reasonable. Pairing this with routine repositioning, which typically happens every 2 hours, makes it much easier to remember consistently.
Common Mistakes and Corrections: The most dangerous mistake is a caregiver pushing hard to force a bigger range of motion — stop the moment resistance appears. Repeating only one leg instead of alternating both is another common oversight; both legs need the same attention.
Stop Signs: If the person shows signs of pain — grimacing, moaning, or pushing the leg away with their hand — or if one leg in particular is unusually swollen or firm, get it checked by the care team before continuing the assisted exercise.
Combining With Compression Stockings or Pneumatic Devices
If compression stockings or an intermittent pneumatic compression (IPC) device has been prescribed, it's fine to do the ankle pump exercise on top of them. Multiple clinical guidelines commonly recommend pairing mechanical prevention with active muscle pump action, since the two work in a complementary way. That said, if the foot or toes swell or change color while wearing the stockings, the compression level may be off — check back with the nursing staff.
Why Pairing This With Repositioning Helps
Pressure-relief repositioning to prevent bedsores usually happens on a roughly 2-hour cycle. Folding the ankle pump into that same moment makes it a single routine that's easier for a caregiver to remember, and the older adult tends to accept it more readily since it happens alongside a position change they're already used to. Adding a checkbox for the ankle pump next to the repositioning log noticeably cuts down on missed sessions.
When Multiple Family Members Take Shifts
When care is split across several family members on rotating shifts, relying on a verbal handoff about whether the ankle pump was done is an easy way for sessions to slip through the cracks. Taping a simple sheet by the bed for logging the time and a checkmark, and making it a habit to check the last logged time at every shift change, makes it immediately obvious how many hours have gone by without a session.
Week-by-Week Progression and the Research Behind It
Week-by-Week Progression and the Research Behind It
A study by Chandrasekaran and colleagues conducted in Australia (ANZ Journal of Surgery, 2009) measured how much ankle pump and hip pump exercises raised peak blood flow velocity in the popliteal vein among healthy adults, comparing the results against an intermittent pneumatic compression (IPC) device commonly used in hospitals. The increase in velocity produced by active ankle and hip pump exercises turned out to be statistically indistinguishable from what the IPC device produced. That said, this was a short-term study on a relatively small group of healthy volunteers, and it measured blood flow velocity as a surrogate marker rather than actual clot incidence — a limitation that makes it hard to assume the same magnitude of effect in older, bed-bound patients carrying multiple underlying conditions.
The UK's National Institute for Health and Care Excellence (NICE) published hospital VTE prevention guideline NG89 (issued 2018, updated since), which specifies that all admitted patients should be assessed for clot risk early after admission, and that patients classified as at-risk should receive mechanical prevention such as compression stockings or an IPC device, alongside leg exercises and early mobilization to the extent movement is possible. Notably, this recommendation is built mostly on trials that combined mechanical devices with exercise, and doesn't offer a standalone effect size for leg exercise alone. In other words, the guideline's intent is for the ankle pump exercise to function as one piece of a broader prevention strategy, not a stand-alone measure.
| Timeframe | Goal | Method | Criteria to Advance |
|---|---|---|---|
| Start of bed rest to Day 3 | Acute phase; confirm a safe range of motion | Caregiver-assisted ankle pump 6–8 times a day, with self-directed attempts alongside if possible | Tolerates the movement pain-free, with no increase in morning swelling the next day |
| Day 4 through Week 1 | Transition to self-directed ankle pump | Attempt 5–10 reps independently; combine with assistance if difficult | Completes 10 reps independently, pain-free |
| Week 2 | Establish the ankle pump; add ankle circles | 8–10 sets a day plus 3–4 rounds of ankle circles | Meets the daily set target for 3 consecutive days, with calf circumference staying roughly even on both sides |
| Weeks 3–4 | Sit at the edge of the bed; prepare to stand | Maintain ankle exercises; add seated leg dangling and similar movements as directed by the care team | Can sit at the bed's edge without dizziness, and standing produces no leg swelling or pain |
Don't advance to the next stage just because time has passed if the table's criteria haven't been met. The transition to sitting and standing in weeks 3 to 4 in particular should always go through the judgment of the care team or physical therapist.
If Progress Stalls by Week 2
If independent completion of 10 reps still isn't happening after 2 weeks, check three things. First, whether 8 to 10 sets a day are genuinely happening every day. Second, whether pain is causing every attempt to stop below 5 reps. Third, whether something beyond simple muscle weakness — worsening paralysis or increasing numbness — has newly developed. If all three check out and progress is still stalled, a rehabilitation medicine evaluation will help set the next stage more safely than continuing to guess.
A Progression Example
Take an 82-year-old two days out from hip fracture surgery. Because of surgical-site pain, the first two days involved only the caregiver-assisted version, done 6 times a day. By day 3, pain had dropped to about 4 out of 10, enough to attempt a few self-directed toe pulls, but reaching only 5 or 6 reps before struggling. Rather than pushing to force all 10 reps independently, the better approach was doing as many as possible alone and filling in the rest with the assisted version. A week in, 10 independent reps were completed pain-free, and ankle circles were added starting in week 2. Small, incremental gains like this over several days are the normal pattern — there's no need to feel rushed just because a full day's target wasn't met right away.
When to Avoid This Exercise, and Signs That Need Immediate Medical Attention
When to Avoid This Exercise, and Signs That Need Immediate Medical Attention
When to Avoid Starting This Exercise (Contraindications)
- An acute DVT has already been diagnosed and anticoagulant treatment hasn't yet had time to take effect (don't start this on your own until the care team confirms it's safe)
- A physician has specifically ordered restricted joint movement right after a leg fracture or surgery
- An open wound, severe pressure sore, or acute infection such as cellulitis is present on the leg
- Heart failure has acutely worsened, causing significant shortness of breath
- Pain is severe enough that a safe response to movement can't be confirmed
Signs During or Right After Exercise That Call for Immediate Medical Care (Red Flags)
- One calf is noticeably more swollen than the other, tender to press, and warm to the touch (suspected DVT)
- Sudden shortness of breath, chest pain, or cold sweat appears (suspected pulmonary embolism — a piece of the leg clot breaking off and blocking a lung vessel is a medical emergency, so call emergency services immediately)
- The skin on the leg turns pale or bluish
- The leg suddenly loses sensation or can no longer be moved
This routine does not replace a physician's diagnosis or prescription. If any contraindication above applies, talk to the care team before starting. If a red-flag symptom appears, don't just pause the exercise — notify the care team or seek emergency care immediately.
Can This Be Combined With Other Preventive Measures?
This exercise isn't mutually exclusive with compression stockings, intermittent pneumatic compression, or anticoagulant medication when prescribed. Combining multiple preventive measures is, in fact, the standard approach. Which of these to use, and how to combine them, is a decision for the care team managing the person's overall condition — the ankle pump exercise described here should be understood as self-care layered on top of that broader plan.
Three Things Family Members Can Check Daily
- Gently cupping both calves by hand to compare firmness and temperature
- Confirming and logging whether the target number of ankle pump sets was completed
- Checking for any noticeable change in leg swelling or skin color compared to the day before
What to Keep in Mind After Recovery
Even after bed rest ends and walking resumes, it's worth keeping up 2 to 3 sets of the ankle pump exercise a day for a while rather than stopping outright. Early in recovery, walking volume usually isn't yet enough for the calf muscle pump to work as actively as it once did. Once walking distance and duration increase enough to fully engage the calf muscles again, it becomes natural to scale back the ankle pump exercise from there.
Don't Forget Hydration
Hydration is just as easy to overlook as the exercise itself. Older adults eating less often stop feeling thirsty on schedule, which makes it easy to fall short of daily fluid needs — and thicker blood makes the clotting-tendency factor described earlier even more pronounced. Unless fluid intake has specifically been restricted for a kidney condition or heart failure, it helps to write the care team's recommended daily fluid target right next to the ankle pump checklist and track both together.
