Phase I (surgery to 2 weeks after):
Splint/Boot: Locked 20-30 degree plantarflexion for two weeks
Weight-bearing: Touchdown weight-bearing (TDWB) with crutches
Cardiovascular: Upper body circuit training
Patient Precautions:
- Keep elevated.
- Keep incision/splint clean and dry.
- DO NOT push through the pain.
Progression Criteria:
- Two weeks post-op.
- No wound complications.
Phase II (2-6 weeks after surgery):
Physical therapy appointments begin one to two visits per week.
Goals: Protection of repair and achieve active dorsiflexion (DF) to neutral
Precautions:
- Post-op weeks 2-3: boot at 20 degrees, sleep in boot, TTWB with crutches, no active DF.
- Post-op weeks 3-4: boot at 10 degrees, sleep in boot, TTWB with crutches.
- Post-op weeks 4-6: If the pt can reach neutral PF/DF comfortably, then neutral boot with small heel lifts, sleep in boot, WBAT (based on pain, swelling and wound) with crutches and boot, active DF to neutral.
Therapeutic Exercises:
- Ankle range of motion (ROM) respecting precautions.
- Pain-free isometric ankle inversion, eversion, DF and submaximal PF.
- Open chain hip and core strengthening.
- Cardiovascular upper extremity circuit training.
Progression Criteria:
- Six weeks post-op.
- Pain-free active DF to 0 degrees.
- No wound complications. If you have a concern, please consult with Dr. Roe.
Phase III (6-8 weeks after surgery):
Physical therapy appointments are once a week.
Goals:
- Normalize gait on level surfaces without boot or heel lift.
- Single leg stance with good control for 10 seconds.
- Active ROM between 5 degrees of DF and 40 degrees of PF.
Precautions:
- Slowly wean from boot. Begin by using one to two-inch heel lifts in tennis shoes for short distances on level surfaces and gradually remove heel lifts during the fifth through the eighth week depending on symptoms.
- Avoid overstressing the repair (avoid large movements up and down, forceful PF while in a dorsiflexed position, aggressive passive ROM, and impact activities).
Therapeutic Exercises:
- Frontal and sagittal plane stepping drills (side-step, crossover step, grapevine step).
- Active ankle ROM.
- Gentle gastroc/soleus stretching.
- Static balance exercises (begin in two-foot stance, then two-foot stance on balance board and gradually progress to single-leg stance).
- Two-foot standing nose touches.
- Ankle strengthening with resistance bands.
- Low velocity and partial ROM for functional movements (squat, step back, lunges).
- Hip and core strengthening.
- Pool exercises if the wound is completely healed.
- Cardiovascular upper extremity circuit training.
Progression Criteria:
- Normal gait mechanics without the boot.
- Squat to 30 degrees knee flexion without weight shift.
- Single leg stance with good control for 10 seconds.
- Active ROM between 5 degrees of dorsiflexion and 40 degrees of plantarflexion.
Phase IV (8 weeks after surgery):
Physical therapy appointments are once every one to two weeks.
Goals:
- Normalize gait on all surfaces without boot or heel lift.
- Single leg stance with good control for 10 seconds.
- Active ROM between 15 degrees of DF and 50 degrees of PF.
- Good control and no pain with functional movements, including step-up/down, squats and lunges.
Precautions:
- Avoid forceful impact activities.
- Do not perform exercises that create movement compensations.
Therapeutic Exercises:
- Frontal and transverse plane agility drills (progress from low velocity to high, then gradually add in sagittal plane drills).
- Active ankle ROM.
- Gentle gastroc/soleus stretching.
- Multi-plane proprioceptive exercises – single-leg stance.
- One-foot standing nose touches.
- Ankle strengthening – concentric and eccentric gastroc strengthening.
- Functional movements (squats, step backs, lunges).
- Hip and core strengthening.
- Cardiovascular: stationary bike, StairMaster, swimming.
Progression Criteria:
- Normal gait mechanics without the boot on all surfaces.
- Squat and lunge to 70 degrees knee flexion without weight shift.
- Single leg stance with good control for 10 seconds.
- Active ROM between 15 degrees of dorsiflexion and 50 degrees of plantarflexion.
Phase V (usually 4 months after surgery):
PT appointments are once every one to two weeks.
Goals:
- Good control and no pain with sport/work-specific movements, including the impact.
Precautions:
- Post-activity soreness should resolve within 24 hours.
- Limit post-activity swelling.
- Avoid running with a limp.
Therapeutic Exercises:
- Impact control exercises beginning with two feet to two feet, progressing from one foot to the other, and then one foot to the same foot.
- Movement control exercises beginning with low velocity, single plane activities and progressing to higher velocity, multi-plane activities.
- Sport/work-specific balance and proprioceptive drills.
- Hip and core strengthening.
- Stretching for patient-specific muscle imbalances.
- Cardiovascular: replicate sport/work-specific energy demands.
Progression Criteria:
- Dynamic neuromuscular control with multi-plane activities, without pain or swelling.