Lower Limb

Knee

Tape locking screw (TLS) short graft

The TLS short graft is a relatively new method of reconstructing a ruptured anterior cruciate ligament (ACL). The graft is harvested from a single hamstring tendon. Due to the strength of this graft, rehabilitation can be accelerated, which results in less muscle wasting, preservation of neuromuscular strength and an earlier return to work or sport.

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended.

After surgery

Our care is specifically tailored to each patient, which allows recognition and modified care for those patients who may progress slower than others.

Our rehabilitation protocols are ‘milestone driven’designed to provide rehab guidance for all of our patients. The aim is to limit unnecessary visits to the rooms and help to identify when specialist review is required.

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery
Physiotherapy/support
Phase I –early rehab

Goals:

  • Normal range of motion
  • Normal daily activities
Day 1 –7 The first phase of rehabilitation starts immediately after surgery. Before you leave the hospital, your physiotherapist will take you through some exercises including:

  • Bending the knee as far as possible and then straightening it out as far as possible
  • Contracting your quad and hamstring at the same time by pushing your foot firmly down into the bed and holding for 5 seconds
  • Walking, with or without crutches depending on your physiotherapist’s advice. Aim to walk around 10 m at a time
  • Double leg calf raises using a high table for support in front
  • Mini squats as far as comfortable and using support if needed

These exercises should continue at home. You should aim to do 10–15 repetitions of each, 3–5 times per day as long as you remain comfortable

It is recommended that you see your physiotherapist in the first week after discharge so they can assess your swelling and range of motion, and progress your rehabilitation program

Therapy and exercises:
  • Swelling and inflammation control
    • cryotherapy (ice)
    • analgesia as appropriate
    • elevation
  • Muscle stretching
    • knee flexion
    • knee extension
    • calf
    • hip
  • Muscle strengthening
    • straight leg raise
    • static quads
    • hip extension/abduction
    • standing hamstrings
    • bridging
    • calf raises
  • Other
    • exercise bike
    • walking

Milestones for progression to next phase

  • Walking 50 m with normal gait
  • Standing on operated leg with control for 20 seconds
  • Range of motion 0–120 degrees
Phase II –neuro-muscular rehabilitation

Goal:

  • Full every-day function
1 –6 weeks During this phase, you can expect the following.

Therapy and exercises:

  • Inflammation control
    • continue use of ice, compression and elevation, as needed
  • Muscle strengthening
    • lunges
    • squats
    • resistance training
    • core strengthening
  • Balance
    • single leg balance
    • walking figure 8/patterns
    • throwing catching
    • wobble board
    • clock-face toe touching
  • Other
    • walking increased distance
    • exercise bike/cross trainer

Milestones for progression to next phase

  • Full range of motion
  • Y-excursion balance test 90% of un-operated leg
  • Sit-stand 20 times without pain
Phase III – dynamic strengthening

Goal:

  •     Return to running
This phase and the next focus on building strength and fitness up to pre-op levels. By this stage the graft is healing well, but is weaker than in the early stages as it has yet to regain full blood supply.

The stronger and better at activating your muscles you are, the better protected the new ACL will be when it comes to returning to sports training. So in this phase, we add more resistance to strength training and begin to retrain the muscles that activate in an explosive and dynamic manner.

Therapy and exercises:
  • Inflammation control
    • continue use of ice, compression and elevation, as needed
  • Dynamic strengthening
    • single leg strengthening
    • dynamic lunges
    • increase resistance
    • hamstring resistance
  • Balance and control
    • walking on uneven surfaces
    • change-in-direction walking
    • jumping/hopping in a straight line
    • single leg catch/throw
  • Other
    • running – treadmill and road
    • return to trade/active job

Milestones for progression to next phase

  • Running 50% of pre-op distance with no pain
  • Single leg press 90% of un-operated side
  • Jump and hop 10 m in a straight line with no pain
Phase IV – Athletic rehab

Goal:

  • Return to sports training

If you are not wishing to return to competitive pivoting or contact sport, this stage of rehab should be all that is required for you to return to a fully active life.

In this phase, pivoting exercises are gradually increased but it’s important that these are always done under controlled conditions. Your physiotherapist will analyse the quality of your movements throughout this more rigorous training.

Therapy and exercises:

  • Plyometric
    • box jumps
    • single leg landing
    • hoping drills
    • cleans / jerks / kettlebells
  • Agility
    • slalom running
    • pivoting at controlled pace
    • un-anticipated change in direction
  • Physio
    • full cardio training
    • mental preparation for return to sports
    • address specific risk factors (e.g. landing technique, weakness in other areas such as hip/core)

Milestones for discharge or progression to next phase

  • Able to run pre-op distances with no pain
  • Hop tests 80% of un-operated side
  • Single leg press equal both sides
Phase V – Preparation for return to competitive sport

Goal:

  • Return to competitive sport

Sports training can begin in this final stage but, it should be done in a controlled manner and initially in a non-competitive environment.

It is wise to continue a certain amount of strength and dynamic training alongside any sport specific session to maintain the muscle strength and the control you have built up. A major factor in return to competitive sport is your confidence in the reconstructed knee. Once you feel you may be ready, discuss this with your physiotherapist and if they agree you must make an appointment to see your surgeon

Exercises:

  • General
    • full strength training
    • full fitness / running training
    • ongoing plyometrics
  • Sport specific
    • sprinting
    • pivoting at pace
    • un-anticipated change in direction at full speed
    • sports drills
    • jumping and landing in sports context
  • Other
    • kinematic evaluation and training
    • neuromuscular control after fatigue
    • patient specific risk factor identification and training
    • Returning to competitive sport is a great achievement after ACL reconstruction but it also carries with it inherent risk. There is ongoing debate and numerous studies that try to standardise a return to sport criteria but there is little consensus.

Before considering a return to high level competitive sport, it is recommended that you undergo a comprehensive return to sport assessment by a specialised APA Sports Physiotherapist.

Knee arthroscopy

This is general advice about caring for your knee after an arthroscopy. It does not replace specific medical advice about your condition and how best to care for it.

Managing your pain

During your arthroscopy, at least two small cuts were made on either side of your kneecap to allow a tiny camera and instruments into your knee joint.

Local anaesthetic has been injected around the cuts and into the knee to minimise discomfort after the procedure. The numbing effect last between 5 and 12 hours. When it wears off, your knee may be uncomfortable. Pain relief tablets work best when your pain is starting, so it’s best to take them early rather than waiting for the pain to worsen.

Unless you have been advised something different, take paracetamol first. You will have been prescribed stronger pain tablets take you can also take if needed. If you have been prescribed Panadeine Forte®, note that this contains paracetamol, so you cannot take this and other medications containing paracetamol such as Panadol®, Panamax® or Panadol Osteo® at the same time.

Looking after your dressings

The cuts on your knee have been closed with clear dissolvable stitches under the skin. These do not need to be removed. Over the cuts, white tape and waterproof adhesive dressings have been placed. You can shower with these dressings as long as the seal remains intact. Before you go home, the staff will give you replacement adhesive dressings, which you can use if the seal is broken. If you do need to change the dressings, don’t take off the white tape underneath.

A bandage will also be on your knee. Leave this on for 24 hours to help keep the swelling down.

Controlling swelling

It is normal for there to be some swelling for 2–4 weeks after knee arthroscopy. For the first 3 days after your surgery, keep your leg elevated as much as possible and take things easy.

Try to ice your need as much as possible for the first week. Keep ice applied for 20 minutes at a time, with at least 20 minutes rest between icings.

Using crutches

Unless you have been advised otherwise, you can bear full weight on your knee and crutches are for comfort only. Crutches are only needed for a few days, if at all.

Post-op exercises

To get the best results after surgery, perform the following exercise 3–4 times each day.

Returning to activities

The timings given here are general. They may differ depending on your knee condition.

Activity When you can expect to be able to do the activity
Return to work Sedentary job 1–2 weeks

Manual job 2–4 weeks

Driving 5–7 days
Exercise bike 1–2 weeks
Swimming 2–4 weeks
Gym 2–4 weeks
Sport 3–8 weeks

 

biking

Patellofemoral Stabilisation

Patellofemoral stabilisation encompasses procedures such as medial patellofemoral ligament (MPFL) reconstruction, lateral release and tibial tubercle transfer (TTT).

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended.

After surgery

Our care is specifically tailored to each patient, which allows recognition and modified care for those patients who may progress slower than others.

Our rehabilitation protocols are ‘milestone driven’designed to provide rehab guidance for all of our patients. The aim is to limit unnecessary visits to the rooms and help to identify when specialist review is required.

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Phase I – Initial rehabilitation

Goals:

  • Minimise swelling and inflammation (control bleeding in the joint)
  • Start quadriceps muscle training
  • Walk unaided
Day 1 –7 The first phase of rehabilitation starts immediately after surgery. During the first week, you can expect the following.

Weight bearing status:

  • Weight bearing as tolerated with the support of two crutches and a range of motion (ROM) brace, locked at 0–30 degrees of flexion

Range of motion:

  • ROM brace locked at 0–30 degrees of flexion

Therapy and exercises:

  • Swelling and inflammation control
    • cryotherapy (ice)
    • non-steroidal anti-inflammatories (NSAIDS)
    • elevation
    • ankle pumps
  • Muscle retraining
    • quadriceps isometrics
    • straight leg raises
    • hip adduction
  • Flexibility
    • hamstring stretches
    • calf stretches

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Phase II – the acute rehabilitation phase

Goals:

  • Control swelling and inflammation
  • Gradual improvement in range of motion
  • Quadriceps strengthening (especially the vastus medialis [VMO] muscle)
During this phase, you can expect the following.

Weight bearing status:

  • Discontinue crutches when appropriate
  • Weight bearing as tolerated with ROM brace locked to a comfortable flexion limit

Range of motion:

  • At least 60 degrees of flexion (week 2)
  • At least 90 degrees of flexion (week 4
  • Full flexion (week 6–8)
  • NB rate of progress is based on swelling/inflammation
Therapy and exercises:
  • Inflammation control
    • continue use of ice, compression and elevation, as needed
  • Muscle retraining
    • electrical muscle stimulation to quads
    • quad setting isometrics
    • straight leg raises (flexion)
    • hip adduction
    • knee extension 60–0 degrees, pain-free arc
    • bicycle* (stationary, in brace) if range of motion/swelling permits
    • proprioceptive training*
  • Flexibility
    • continue hamstring and calf stretches
    • initiate quadriceps muscle stretching
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Phase III – Moderate protection

Goals:

  • Eliminate any joint swelling
  • Improve muscle strength and control without exacerbation of symptoms
  • Functional exercise movements
  • Wean off brace
6 –12 weeks To advance to this phase you need to have:

  • minimal inflammation and pain
  • near full range of motion
  • strong quadriceps contraction

Once you’ve achieved these criteria, over the next 6 weeks, you can expect the following.

Therapy and exercises:

  • Inflammation control
    • continue use of ice, compression and elevation, as needed
  • Muscle retraining
    • continue muscle stimulation to quadriceps (if needed)
    • quadriceps setting isometrics
    • 4-way hip machine (hip adduction, abduction, extension, flexion)
    • lateral step-ups, if able
    • front step-ups, if able
    • squats against wall* (0–60 degrees)
    • knee extension (90–0 degrees), pain-free arc
    • bicycle
    • pool program* (walking, strengthening, running)
    • proprioceptive training
  • Flexibility
    • continue all stretching exercise for lower extremity
Phase IV – Minimal protection

Goals:

  • Achieve maximal strength and endurance
  • Functional activities and drills
12 –16 weeks To advance to this phase, you need to have:

  • full, non-painful range of motion
  • no swelling or inflammation
  • a knee extension strength that is 70% of your other knee

During the next 4 weeks, you can expect:

Therapy and exercises:
  • Inflammation control
    • continue use of ice as needed
  • Muscle strengthening
    • wall squats (0–70 degrees) pain-free arc
    • vertical squats* (0–60 degrees)
    • leg press
    • forward lunges
    • lateral lunges
    • lateral step-ups
    • front step-ups
    • knee extension pain-free arc
    • hip strengthening (4 way)
    • bicycle
    • Stairmaster®
    • proprioception drills
    • sport specific functional drills (if you’re a competitive athlete)
    • jogging program
  • Flexibility
    • continue all stretching exercise for lower extremity
Phase V – Return to activity phase

Goal:

  • Functional return to work and/or sport
16 –20 weeks To be able to advance to this phase you need to have:

  • full, non-painful range of motion
  • an appropriate level of strength (>80% of your other leg)
  • a satisfactory clinical examination

During this phase, you can expect the following.

Exercises:

  • Functional drills
  • Continue jogging/running program
  • Strengthening exercises (selected)
  • Flexibility exercises

*If you are able to perform pain free

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Time after surgery
Physiotherapy/support
Phase I – Initial rehabilitation (0 –6 weeks)

Goals:

  • To be safely and independently mobile with appropriate walking aid, adhering to weight bearing restrictions
  • To be independent with a home exercise program, as appropriate
  • To understand self-management and monitoring (e.g. skin sensation, colour, swelling, temperature)
Day 1 –2 weeks Immediately after surgery, you will:

  • be fitted with a moon boot that holds your foot in flexion (2–3 wedges or 30 degrees)
  • be taught exercises to help your circulation
  • be required to elevate your leg (nose above nose) as much as possible
  • learn how to monitor sensation, colour, circulation, temperature and swelling of your foot/ankle (and what to do if you’re concerned)
  • be given adequate pain relief

You will have a wound review at 2 weeks and then you’ll be referred for outpatient physiotherapy

2 –6 weeks During this time, you’ll start bearing weight (up to around 50%). You can also expect the following.

Foot position:

Your moon boot will be adjusted to reduce the flexion of your foot:

  • weeks 2–4 (3 wedges or 30 degrees)
  • weeks 4–6 (2 wedges or 20–30 degrees)
  • week 6+ (neutral position)

Therapy and exercises:

  • Inflammation control
    • use of ice and elevation
  • Exercises
    • active dorsiflexion exercises to neutral and inversion/eversion below neutral
    • gentle active plantarflexion
    • knee/hip exercises, as necessary
    • non-weight bearing fitness work
    • hydrotherapy within range of motion and weight being status (when your wound is well healed)
Phase II – Recovery rehabilitation

Goals:

  • To be independently mobile out of the boot
  • To achieve full range of motion
  • Muscle strength improving
  • Optimise normal movement
6 –8 weeks During this time, you will:

  • bear weight as tolerated
  • receive pain relief advice and education
  • receive posture advice and education
  • wean out of the boot and back into normal footwear
  • receive gait re-education
  • achieve safe and independent mobility without a walking aid

Foot position:

  • moon boot in neutral position (no wedges)

Therapy and exercises:

  • Inflammation control
    • use of ice and elevation, as needed
  • Exercises
    • dorsiflexion stretching (slowly)
    • graduated resistance exercises (closed chain to open chain to functional)
    • proprioception and gait training
    • fitness exercise full weight bearing
    • hydrotherapy
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisation as appropriate
    • monitoring of sensation, swelling, colour and temperature
    • pacing as appropriate
8 –12 weeks Your therapy will continue but during this time you can expect to:

  • wean off the boot
  • return to crutches or stick as necessary during gait re-education (then wean off those)
  • continue to progress your range of motion, strength and proprioception
Phase III – Intermediate rehabilitation

Goals:

  • Independent mobility (unaided)
  • Optimise normal movement
  • Return to normal activities
12 weeks + From here, you will:

  • continue to progress range of motion, strength and proprioception
  • retrain strength, power, endurance and control
  • introduce dynamic exercises including plyometric training
  • commence sport-specific training

Therapy and exercises:

  • Exercises
    • range of movement
    • progress strengthening of calf muscles
    • core stability work
    • balance and proprioception work (i.e. use of wobble boards, gym ball, Dyna cushion®)
    • stretches of tight structures as appropriate
    • sports-specific exercises
    • exercises to address any lower limb biomechanical issues as needed
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisation as appropriate
    • monitoring of sensation, swelling, colour and temperature
    • pacing as appropriate

Milestones for discharge:

  • Independently mobile unaided
  • Muscle strength – plantarflexion grade 5 with no pain
  • Return to low-impact activity/sports
Phase IV – Final rehabilitation

Goals:

  • Return to high impact sports (if you’ve set this as a goal)
  • Normal plantarflexion activity
  • Single leg stand 10 seconds, eyes open and closed
  • To be able to do multiple heel raises
  • Establish long term maintenance program
6 months + From here, you will:

  • work on progressing your mobility and function, increasing dynamic control with specific training to functional goals
  • continue gait re-education
  • receive pacing advice

Therapy and exercises:

  • Exercises
    • sports-specific/functional exercises
    • exercises to address any lower limb biomechanical issues as needed

 

Milestones for discharge:

  • Independently mobile unaided
  • Good proprioceptive control on single leg stand on operated limb
  • Return to normal functional level
  • Return to sports (if this is your goal)

Failure to progress

If your rehabilitation is not progressing as expected, your physiotherapist may perform or recommend one or more of the following actions.

Possible problem Action
Foot swelling Ensure leg is being elevated regularly

Use ice as appropriate (if normal skin sensation and no contraindications)

Decrease amount of time on feet

Use walking aids

Circulatory exercise

If the swelling decreases overnight, then monitor closely

If the swelling doesn’t decrease overnight, refer back to surgeon or GP

Swelling of calf If accompanied by pain, refer urgently to emergency department or surgeon to rule out deep vein thrombosis (DVT)
Pain Decrease activity

Ensure adequate analgesia

Elevate regularly

Decease weight bearing and use walking aids as appropriate

Modify exercise program as appropriate

If persistent, refer back to surgeon

Breakdown of wound (e.g. inflammation, bleeding, infection) Urgent referral back to surgeon
Suspected re-rupture Refer back to surgeon

Ensure exercises not too advanced

Numbness or altered sensation Review immediate post-op status if possible

Ensure swelling is under control

If new onset or increasing, refer urgently back to surgeon

If static, monitor closely, but inform surgeon and refer back if the problem worsens or if concerned

Foot and ankle fractures

Some fractures can be managed without surgery, but others require surgery to achieve the best possible outcome. Fractures and injuries to joints have a high risk of developing arthritis – surgery aims to reduce this risk but sadly the damage was done at the time of the initial injury.

There are multiple surgical techniques that we use to achieve the best alignment and positioning. The expected outcomes from surgery are:

  • Improved function / mobility
  • Improved strength
  • Return to full activities
  • Full recovery may take up to 1–2 years
After surgery

Our care is specifically tailored to each patient, which allows recognition and modified care for those patients who may progress slower than others.

Our rehabilitation protocols are ‘milestone driven’designed to provide rehab guidance for all of our patients. The aim is to limit unnecessary visits to the rooms and help to identify when specialist review is required.

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

postop8
lower3
Time after surgery – Physiotherapy/support
Phase I – Initial rehabilitation (0 –6 weeks)

Goals:

  • To be safely and independently mobile with appropriate walking aid, adhering to weight bearing restrictions
  • To be independent with a home exercise program, as appropriate
  • To understand self-management and monitoring (e.g. skin sensation, colour, swelling, temperature)
Day 1 –6 weeks Immediately after surgery, you will:

  • be fitted with a walker boot or plaster
  • be taught exercises to help your circulation
  • be required to elevate your leg (nose above nose) as much as possible
  • learn how to monitor sensation, colour, circulation, temperature and swelling of your foot/ankle (and what to do if you’re concerned)
  • be given adequate pain relief

During this phase, you will have X-rays to monitor fracture healing

Phase II – Recovery rehabilitation

Goals:

  • To be independently mobile out of boot or plaster (depending on surgeon decision)
  • To progress weight bearing (if appropriate – check with the surgeon)
  • To work on range of movement
  • Muscle strength improving
  • Optimise normal movement
6 –12 weeks During this time, you will:

  • receive pain relief advice and education
  • receive posture advice and education
  • work on achieving safe independent mobility, without walking aid
  • receive gait re-education
  • have X-rays to monitor fracture healing

Therapy and exercises:

  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisation as appropriate
    • monitoring of sensation, swelling, colour and temperature
    • hydrotherapy as appropriate
    • pacing as appropriate
  • Mobility
    • your physiotherapist will ensure that you can manage to move around independently, including using stairs if necessary
Phase III – Intermediate rehabilitation

Goals:

  • To be independently mobile unaided
  • Optimise normal movement
  • Return to normal activities
12 weeks –6 months During this time, you will receive ongoing advice and education about:

  • pain relief
  • posture
  • gait
  • mobility

You may still require further X-rays to check fracture healing

Therapy and exercises:

  • Exercises
    • range of movement
    • progress strengthening of calf muscles
    • core stability work
    • balance and proprioception work (i.e. use of wobble boards, gym ball, Dyna cushion®)
    • stretches of tight structures as appropriate
    • sports-specific exercises
    • exercises to address any lower limb biomechanical issues as needed
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisation as appropriate
    • monitoring of sensation, swelling, colour and temperature
    • pacing advice as appropriate

Milestones for discharge:

  • Independently mobile unaided
  • Full muscle strength
  • Return to low-impact activity/sports
Phase IV – Final rehabilitation

Goals:

  • Return to high impact sports (if you’ve set this as a goal)
  • Full range of motion
  • Single leg stand 10 seconds, eyes open and closed
  • To be able to do multiple heel raises
  • Establish long term maintenance program
6 months + From here, you will:

  • work on progressing your mobility and function, increasing dynamic control with specific training to functional goals
  • continue gait re-education
  • be advice on whether the screws and plates will need to be removed

Therapy and exercises:

  • Exercises
    • sports-specific/functional exercises
    • exercises to address any lower limb biomechanical issues as needed
    • pacing advice

Milestones for discharge:

  • Independently mobile unaided
  • Good proprioceptive control on single leg stand on operated limb
  • Return to normal functional level
  • Return to sports (if this is your goal)

Failure to progress

If your rehabilitation is not progressing as expected, your physiotherapist may perform or recommend one or more of the following actions.

Possible problem Action
Foot swelling Ensure leg is being elevated regularly

Use ice as appropriate (if normal skin sensation and no contraindications)

Decrease amount of time on feet

Use walking aids

Circulatory exercise

If the swelling decreases overnight, then monitor closely

If the swelling doesn’t decrease overnight, refer back to surgeon or GP

Swelling of calf If accompanied by pain, refer urgently to emergency department or surgeon to rule out deep vein thrombosis (DVT)
Pain Decrease activity

Ensure adequate analgesia

Elevate regularly

Decease weight bearing and use walking aids as appropriate

Modify exercise program as appropriate

If persistent, refer back to surgeon

Breakdown of wound (e.g. inflammation, bleeding, infection) Urgent referral back to surgeon

Bunion (hallux valgus deformity) surgery

Bunion surgery is generally reserved for bunions that are severe and impacting on function.

There most frequent surgical procedure used involves a medial incision over the joint. Then the first metatarsal is cut into a Z shape (Scarf osteotomy) using a surgical saw. The first metatarsal is shifted laterally back onto the sesamoids, which also corrects the deformity. The bones are then held together with screws.

The expected outcomes from surgery are:

  • Deformity correction
  • Improved function
  • Reduced pain
After surgery

Our care is specifically tailored to each patient, which allows recognition and modified care for those patients who may progress slower than others.

Our rehabilitation protocols are ‘milestone driven’designed to provide rehab guidance for all of our patients. The aim is to limit unnecessary visits to the rooms and help to identify when specialist review is required.

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery
Physiotherapy/support
Phase I – Initial rehabilitation (0 –6 weeks)

Goals:

  • To be safely and independently mobile with appropriate walking aid and footwear (i.e. heel wedge shoe)
  • To be independent with a home exercise program, as appropriate
  • To understand self-management and monitoring (e.g. skin sensation, colour, swelling, temperature)
Day 1 –6 weeks Restrictions:

  • You will be full weight bearing in a heel wedge shoe for the first 4–6 weeks, progression from here will depend on X-ray results
  • Your consultation may request that you wear a splint to promote hallux alignment

Therapy and exercises:

  • Inflammation and pain control
    • heel wedge shoe
    • analgesia as needed
    • using ice and elevating leg (toes above the nose)
  • Exercises
    • circulation exercises and passive range of movement of metatarsal-phalangeal joint (MTPJ) from 2 weeks (note the difference between the motion at MTPJ and inter phalangeal joint)
  • Education
    • you will be taught how to monitor sensation, colour, circulation, temperature, swelling (and advised about what to do if concerned)
  • Mobility
    • your physiotherapist will ensure that you can manage to move around independently, including using stairs if necessary

Milestones to progress to next phase:

  • Wearing trainers comfortably (1 oversize if necessary) at 6 weeks as per consultant advice
  • Managing swelling
  • Wound healing well
  • Adequate analgesia
  • Team to refer to outpatient physiotherapy if MTPJ range severely restricted
Phase II – Recovery rehabilitation

Goals:

  • To be returning to normal footwear
  • To aim for full range of movement of MTPJ
  • Optimise normal movement
  • Walking comfortably
6 –12 weeks Restrictions:

  • No impact exercise (e.g. jogging, aerobics)
  • Continue to wean into normal footwear

Therapy and exercises:

  • Inflammation management
  • Treatments
    • pain relief advice and education
    • posture advice and education
    • gait re-education
    • pacing as appropriate
  • Exercises
    • active and passive range of movement of hallux (AROM, PROM)
    • strengthening exercises of the foot and ankle as appropriate
    • exercises to teach you to find and encourage appropriate foot and ankle positioning in weight bearing
    • balance and proprioception work once appropriate
    • stretches of tight structures as appropriate (e.g. Achilles tendon)
    • exercises to address any kinetic chain issues as needed
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisations as appropriate particularly MTPJ and mid foot
    • monitor sensation, swelling, colour and temperature
    • orthotics if required
    • hydrotherapy if appropriate
    • pacing advice as appropriate
  • Mobility
    • your physiotherapist will ensure that you can manage to move around as independently as before surgery

Milestones to progress to next phase:

  • Full range of movement MTPJ
  • Mobilising in normal footwear
  • Tolerating weight bearing through hallux in standing and in gait
  • Improving toe-off

Failure to meet milestones:

  • Refer back to surgeon

Continue with outpatient physiotherapy if still progressing

Phase III – Final rehabilitation

Goals:

  • To be independently mobile unaided
  • Optimise normal movement
  • Return to normal activities
12 weeks –6 months Therapy and exercises:

  • Treatments
    • pain relief advice and education
    • posture advice and education
    • gait re-education
    • pacing as appropriate
  • Exercises
    • active and passive range of movement toes, foot and ankle as appropriate
    • promotion of independence with self-mobilisations of the MTPJ
    • balance and proprioception work (i.e. use of wobble boards, gym ball, Dyna cushion)
    • stretches of tight structures as appropriate (e.g. Achilles tendon) if decreased toe-off
    • exercises to address any kinetic chain issues as needed
    • sports specific rehabilitation

Milestones for discharge:

  • Independently mobile unaided
  • Return to full function

 

Failure to progress

If your rehabilitation is not progressing as expected, your physiotherapist may perform or recommend one or more of the following actions.

Possible problem Action
Foot swelling Ensure leg is being elevated regularly

Use ice as appropriate (if normal skin sensation and no contraindications)

Decrease amount of time on feet

Use walking aids

Circulatory exercise

If the swelling decreases overnight, then monitor closely

If the swelling doesn’t decrease overnight, refer back to surgeon or GP

Swelling of calf If accompanied by pain, refer urgently to emergency department or surgeon to rule out deep vein thrombosis (DVT)
Pain Decrease activity

Ensure adequate analgesia

Elevate regularly

Decease weight bearing and use walking aids as appropriate

Modify exercise program as appropriate

If persistent, refer back to surgeon

Breakdown of wound (e.g. inflammation, bleeding, infection) Urgent referral back to surgeon
Suspected re-rupture Refer back to surgeon

Ensure exercises not too advanced

Numbness or altered sensation Review immediate post-op status if possible

Ensure swelling is under control

If new onset or increasing, refer urgently back to surgeon

If static, monitor closely, but inform surgeon and refer back if the problem worsens or if concerned

Ankle Instability Surgery

Ankle instability surgery is generally reserved for people with chronic ankle instability who have failed to respond to conservative treatment.

The surgical technique used will depend on the severity of the ankle instability and the quality of the lateral ligament complex. Surgery tends to include one or more of the following:

  • Ankle arthroscopy to assess and address any problems within the ankle joint. This includes removing scar tissue and dealing with cartilage damage or loose bodies.
  • Primary anatomical (non-augmented) repair. This is carried out by reattaching torn ligaments in order to regain lateral ankle stability. A Brostrom repair is the common technique used in an anatomical repair, reinforced with the Gould modification.
  • Occasionally, augmentation with tendon grafts or synthetic ligaments are required. Repair of unstable peroneal tendons (at the outer side of the ankle) and tears of these tendons may be required.

The expected outcomes of surgery are:

  • Improved function and mobility
  • Improved pain relief with decreased analgesic requirements
  • Improved ankle-hind foot complex stability
  • Decreased requirement for orthotics
  • Return to full sporting activity
  • Full recovery may take up to 12 months
After surgery

Our care is specifically tailored to each patient, which allows recognition and modified care for those patients who may progress slower than others.

Our rehabilitation protocols are ‘milestone driven’designed to provide rehab guidance for all of our patients. The aim is to limit unnecessary visits to the rooms and help to identify when specialist review is required.

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery
Physiotherapy/support
Phase I – Initial rehabilitation (0 –6 weeks)

Goals:

  • To be safely and independently mobile with appropriate walking aid, adhering to weight bearing restrictions
  • To be independent with a home exercise program, as appropriate
  • To understand self-management and monitoring (e.g. skin sensation, colour, swelling, temperature)
Day 1 – 6 weeks Restrictions:

  • For the first 2 weeks you will be non-weight bearing (NWB) in a moon boot (foot in neutral position). You will have a wound review in the rooms and then be referred for outpatient physiotherapy, aiming to start at week 3
  • At week 3 you should progress to 50% weight bearing. You’ll begin range of motion exercises – initially from the ankle dorsiflexed (DF) 10 degrees (ankle to ceiling) to plantarflexion (PF) 20 degrees (ankle to the floor). Avoid inversion/eversion
  • At week 4 you should be fully weight bearing in the boot. Continue similar range of motion. Avoid inversion/eversion
  • During weeks 5 to 6, your range of motion increases to DF 20 degrees and PF 40 degrees. Avoid inversion/eversion
  • At 6 weeks you should be fully weight bearing and can start to wean out of the boot

Therapy and exercises:

  • Inflammation and pain control
    • walker boot or plaster
    • analgesia as needed
    • using ice and elevating leg (toes above the nose)
  • Exercises
    • circulation exercises
  • Education and support
    • you will be taught how to monitor sensation, colour, circulation, temperature, swelling (and advised about what to do if concerned)
  • Mobility
    • your physiotherapist will ensure that you can manage to move around independently, including using stairs if necessary

Milestones to progress to next phase:

  • Out of boot
  • Progress to partial or full weight bearing (PWB, FWB)
  • Team to refer to physiotherapy if required to review safety of mobility (including stairs if necessary)
  • Adequate analgesia
Phase II – Recovery rehabilitation

Goals:

  • To be independently mobile out of the boot or plaster
  • To achieve full range of movement
  • To achieve muscle strength of eversion grade 4 or 5 on Oxford scale
  • Optimise normal movement
6 –12 weeks Restrictions:

  • No balance exercises until eversion grade 4 or 5 on Oxford scale achieved
  • Do not formally stretch repair – it will naturally lengthen over a 6-month period
  • No impact exercise (e.g. jogging, aerobics)

Therapy and exercises:

  • Treatments
    • pain relief advice and education
    • posture advice and education
    • gait re-education
    • pacing as appropriate
    • swelling management
  • Mobility
    • your physiotherapist will ensure that you can manage to move around independently without a walking aid
  • Exercises
    • active assisted range of movement (AAROM)
    • active range of movement (AROM)
    • resisted inversion and eversion exercises with progression
    • encourage isolation of evertors without overuse of other muscles.
    • biofeedback likely to be useful
    • strengthening exercises of other muscle groups as appropriate
    • core stability work
    • exercises to teach you to find and maintain sub-talar neutral
    • balance and proprioception work once appropriate
    • stretches of tight structures as appropriate (e.g. Achilles Tendon), not of repair
    • exercises to address any lower limb biomechanics issues as needed
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisations as appropriate particularly sub-talar joint
    • monitor sensation, swelling, colour and temperature
    • orthotics if required (bracing or taping acceptable)
    • hydrotherapy if appropriate
    • pacing advice as appropriate

Milestones to progress to next phase:

  • Muscle strength: eversion grade 4 or 5 on Oxford scale
  • Full range of movement
  • Mobilising out of boot
  • Neutral foot position when weight bearing/mobilising
Phase III – Intermediate rehabilitation

Goals:

  • To be independently mobile unaided
  • Optimise normal movement
  • Return to normal activities
Therapy and exercises:

  • Treatments
    • pain relief advice and education
    • posture advice and education
    • gait re-education
    • pacing as appropriate
    • progression of mobility and function
  • Exercises
    • range of movement
    • progress strengthening of evertors
    • core stability work
    • balance and proprioception work (i.e. use of wobble boards, gym ball, Dyna cushion)
    • stretches of tight structures as appropriate (e.g. Achilles tendon)
    • exercises to address any lower limb biomechanics issues as needed
    • sports specific rehabilitation
  • Manual therapy
    • soft tissue techniques as appropriate (e.g. scar massage)
    • joint mobilisations as appropriate particularly sub-talar joint
    • monitor sensation, swelling, colour and temperature
    • orthotics if required (bracing or taping acceptable)
    • hydrotherapy if appropriate
    • pacing advice as appropriate

Milestones for discharge:

  • Independently mobile unaided
  • Muscle strength: eversion grade 5 on Oxford scale
  • Returned to low-impact activity/sports
Phase IV – Final rehabilitation

Goals:

  • Return to high impact sports (if you’ve set this as a goal)
  • Normal evertor activity
  • Single leg stand 10 seconds, eyes open and closed
  • To be able to do multiple heel raises
  • Establish long term maintenance programme
6 months + Therapy and exercises:

  • Treatments
    • progression of mobility and function
    • gait re-education
    • pacing advice
  • Exercises
    • sports specific rehabilitation
    • addressing any specific issues

Milestones for discharge:

  • Independently mobile unaided
  • Good proprioceptive control on single leg stand on operated limb
  • Return to normal functional level
  • Return to sports (if this is your goal)
  • Grade 5 eversion strength

 

Failure to progress

If your rehabilitation is not progressing as expected, your physiotherapist may perform or recommend one or more of the following actions.

Possible problem Action
Foot swelling Ensure leg is being elevated regularly

Use ice as appropriate (if normal skin sensation and no contraindications)

Decrease amount of time on feet

Use walking aids

Circulatory exercise

If the swelling decreases overnight, then monitor closely

If the swelling doesn’t decrease overnight, refer back to surgeon or GP

Swelling of calf If accompanied by pain, refer urgently to emergency department or surgeon to rule out deep vein thrombosis (DVT)
Pain Decrease activity

Ensure adequate analgesia

Elevate regularly

Decease weight bearing and use walking aids as appropriate

Modify exercise program as appropriate

If persistent, refer back to surgeon

Breakdown of wound (e.g. inflammation, bleeding, infection) Urgent referral back to surgeon
Suspected re-rupture Refer back to surgeon

Ensure exercises not too advanced

Numbness or altered sensation Review immediate post-op status if possible

Ensure swelling is under control

If new onset or increasing, refer urgently back to surgeon

If static, monitor closely, but inform surgeon and refer back if the problem worsens or if concerned