Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Section 5 - Athletic Shoes, Orthoses, and Rehabilitation

Chapter 28 - Principles of rehabilitation for the foot and ankle

Erin Richard Barill,David A. Porter







Cryotherapy/rest, ice, compression, and elevation (RICE)



Range of motion/mobilization



Protected weight bearing



Gait evaluation









Cardiovascular activities



Functional progression



Phases of rehabilitation



Rehabilitation of Achilles tendon repair



Rehabilitation after lateral ankle reconstruction



Rehabilitation of ankle fractures









Further reading



Rehabilitation Pearls

Every injury has a position that must be protected and an opposite motion that must be rehabilitated.

Every week of immobilization will add 2 weeks to the rehabilitation.

Once an athlete can use the StairMaster or elliptical machine 30 minutes 4 to 5 days a week without problems, he or she may start running.

A good surgery that is poorly rehabilitated will equal a poor result.

The athlete's goal is always 100% full function.


The foot and ankle often are injured during sporting events, recreational activities, and occupational accidents. Injuries to the foot and ankle may be acute or chronic in nature and often cause considerable disability in athletes. Garrick and Requa[1] reported that foot and ankle injuries represented more than 25% of the 1600 athletic injuries in their series. [0020] [0030] It has been suggested that the sprained ankle is the single most common injury in sports. [0020] [0040] [0050] [0060] [0070]

The foot and ankle serve as the junction of the body to the weight-bearing surface. This elegant collection of tissues, each with a variety of specialized functions, allows efficient, upright stance and locomotion.[8] Athletic populations have unique and strenuous demands. Even with minor injuries, improper or incomplete rehabilitation can lead to significant impairment. A detailed, focused approach to rehabilitation of the foot and ankle is crucial to the athlete. Fortunately, most competitive athletes have access to daily evaluation and monitoring of progress, as well as skilled assistance to help them comply with rehabilitation protocols. Recent technologic and procedural advances contribute greatly to the treatment of the competitive athlete. Principles of rehabilitation must continue to advance and keep up to date with technologic and procedural advances. A proper and advanced approach to rehabilitation can provide an environment conducive to a complete, full, and functional recovery.


Cryotherapy/Rest, Ice, Compression, and Elevation (RICE)

Initial treatment of acute foot and ankle injuries and postoperative ankles still follows the RICE principle. There are several cold agents to choose from, including the cold pack, ice bags, cold whirlpool, ice immersion, and the Aircast Cryocuff. The primary objective of ice is to reduce swelling and help manage pain. It has been found that pain is inhibited by cold through a decrease in nerve conduction velocity. As the temperature decreases, there is a corresponding decrease in sensory and motor nerve velocity, eventually causing synaptic transmission to be blocked.[9] In our experience, we have found the ankle and foot Cryocuffs to be effective because they combine compression and cold. In addition, elevation can help to reduce hydrostatic pressure and diminish edema. Physiologically, the application of cold agents also results in arteriolar vasoconstriction, a decrease in local metabolism, and an elevation in pain threshold.

The application of cold is most effective immediately after injury or within the first 72 hours. Hocutt et al.[10] found that patients with grade III ankle sprains that were treated with ice in the first day returned to functional activities such as running and jumping after 6 days, whereas those treated on the second day went 11 days before they could run or jump. In contrast, those who received heat in the first day had a recovery time of 14.8 days.

A contraindication to cryotherapy is individuals with hypersensitivity to cold. Cold should be avoided in patients with Raynaud's syndrome or peripheral vascular disease (see Chapter 10 ). Cold therapy also must be monitored closely in postoperative patients who have wet dressings because the combination of wet dressings with cold application can decrease the skin temperature to a dangerous level.


Range of Motion/Mobilization

There always has been an interesting rehabilitation dilemma between the need for early range of motion and the need to immobilize tissues to decrease swelling, protect injuries, and protect against pathologic motion. This section discusses the advantages of early motion.

Galileo first recognized the relationship between applied load and bone morphology. In 1892, Julius Wolff, a German anatomist, was the first to link these two vital concepts in his landmark thesis, “The Law of Bone Transformation.” Wolff explained that every change in the function of a bone is followed by certain definite changes in internal architecture and external confirmation in accordance with mathematical laws. Stated simply, “form follows function.”

Application of early motion on ligament healing demonstrates that the ligament hypertrophies to compensate for decreased tensile strength of the individual fibers. Obviously the amount of tension and stress must not overcome the ultimate load to failure of the tissue and must not lead to fatigue or plastic deformation. Wolff's law also may apply to these soft tissues, and physiologic stress may allow more functional and stronger healing of soft tissues. Experimental studies of ligaments after injury indicate that exercise and joint motion stimulate healing and influence the strength of ligaments after injury.[0110] [0120] [0130] [0140] [0150] [0160]

Some of the early research on restoration of early range of motion was performed in the hand and the knee. These historical papers revealed insight on how early range of motion decreases complications and actually enhances the healing process. Early mobilization may result in an earlier return to work and daily activity, less muscle atrophy, and better mobility compared with immobilization by casting.[0140] [0170] [0180] The value and benefit of early motion was investigated in the area of rehabilitation after flexor tendon repairs of the hand. The obvious need for full motion in the hand prompted investigation into safe rehabilitation practices, which would eliminate postoperative adhesions and stiffness but allow reliable healing of the tendon. Gelberman et al. [0190] [0200] noted an improved healing response, improved strength, and a more normal pattern of vascularity to the healing tendon with protective early mobilization. Several other studies also noted that early range of motion decreased adhesions around the repaired tendon and had a positive influence to the healing tissue. [0210] [0220] Early motion after flexor tendon repair has become standard today.

Over the past 2 decades, there have been significant studies in the area of rehabilitation after knee injury and surgery. The focus of knee rehabilitation has centered on obtaining full symmetrical range of motion following a knee injury or surgery. Obtaining full knee extension was one of the most important criteria in allowing the anterior cruciate ligament to heal anatomically and yet still avoid a knee flexion contracture. Close observation of patients who were doing well demonstrated that early range of motion was not detrimental to the ligament (and in fact could be advantageous to proper ligament healing/strengthening) while allowing an earlier and safe return to function.[23] Early motion and weight bearing led to a significant decrease in muscle atrophy and decreased complications from arthrofibrosis with an earlier return to function.

Robert Salter and associates[24] investigated the effect of joint motion on cartilage nutrition. Early continuous passive motion in synovial joints allows and promotes cartilage nutrition and health. Salter et al.[24] demonstrated that small cartilage defects actually could heal with continuous motion, further supporting the benefit of motion on articular cartilage nutrition and healing.

These advances in hand and knee rehabilitation gave us reason to approach the foot and ankle with a similar approach. Thus early mobilization of the foot and ankle following injury is our currently favored treatment method when applicable. This method specifically avoids or reduces immobilization. We have followed the principle that unnecessarily protracted immobilization can prolong the recovery period. Early mobilization can expedite the return to work and resumption of athletic activity while potentially decreasing the risk of complications.

Eiff et al.[17] used a prospective randomized study to determine which treatment for first-time ankle sprains, early mobilization or immobilization, is more effective. They reported that, in first-time lateral ankle sprains, although both immobilization and early mobilization prevent late residual symptoms and ankle instability, early mobilization allows earlier return to work and may be more comfortable for patients. Active and passive range of motion is useful to regain motion in cardinal and diagonal planes. Passive range of motion allows the muscles to relax while working the mobility of the joint. Active range of motion requires independent muscle action and incorporates muscle re-education. It is important to work range of motion in the direction opposite of the mechanism of injury (i.e., we allow dorsiflexion and eversion and avoid plantarflexion and inversion initially after a grade II or III lateral ankle sprain). Once the injury has healed, range of motion should include all directions.

In addition to active and passive range of motion, joint mobilization should be incorporated in the rehabilitation program. Accessory movements, termed joint play, are not volitional but accompany voluntary movements or occur passively in response to the ground or other forces. The amount of joint play is a function of ligament and soft-tissue compliance as well as bony configuration.[25]Mobilization techniques involve oscillation, distraction, and gliding movements of the joints in the planes of accessory motions. The range of mobilization is always advanced in a graded manner but always stays within the physiologic limits of the joint.[25]

There is much discussion with regard to immediate, short-term protection of ankle injuries. Some of the more common methods consist of elastic wrapping, taping/strapping, semirigid pneumatic ankle brace, nonrigid functional ankle brace, and a removable walking boot. A device we like is the Aircast walking boot with built-in Aircast Cryocuff ( Fig. 28-1 ). The device allows patients to weight bear immediately, work on range of motion by removing the boot, and use a continuous cold/compression device. Once the ankle has healed, a more functional brace is used for return to activity (2-4 weeks after injury). We particularly stress the use of the boot at night for the first 3 to 4 weeks to keep the foot and ankle complex in a 90-degree dorsiflexed position during sleep, when the relaxation of muscular control and the forces on the heel passively place the complex in a plantarflexed and inverted position. The rigid boot counteracts this position.


Figure 28-1  Aircast Cryocuff and walking boot.




Protected Weight Bearing

Early weight bearing has been shown to increase the stability of the lateral ankle ligaments after injury while decreasing the amount of muscle atrophy. Protected weight bearing provides a safe and earlier return to activity when appropriate by decreasing joint stiffness, muscular strength deficits, and proprioception dysfunction ( Fig. 28-2 ). We favor a postoperative protocol that allows for early weight bearing whenever possible. We recognize there are times when this is not possible such as in hindfoot fusions. However, in the sports population, early weight bearing can have such a positive impact that we try to tailor our surgical and nonoperative approach to allow early protected weight bearing.


Figure 28-2  Patient wearing Aircast walking boot.



An intriguing area of research that is revealing to us is the investigation of weightlessness. Costill et al.[26] examined the effect of a 17-day space flight (essentially, total weightlessness) on muscle. They reported that there was an 11% decrease in peak muscle power, a decrease in muscle fiber diameter, and a 21% decrease in force when the muscle was contracted at peak power velocity. More specifically, Costill et al.[26] examined single muscle fiber changes after weightlessness. The single fiber diameter decreases were 20% after 17 days suspended leg weightlessness (for example crutch-assisted nonweight bearing) and demonstrated similar profound muscular atrophy.

Research suggests that early loading of damaged soft tissue can enhance collagen fiber realignment and healing. [0130] [0140] [0160] [0270] [0280] Using a removable Aircast walking boot allows the patient to progress to weight bear immediately after injury. Being in a walking boot instead of an ankle cast allows the patient to take the boot off to begin rehabilitation activities. The walking boot provides more support than elastic wrapping, taping, and other semirigid bracing systems, and it also allows the patient the ability to apply cold compression simultaneously.


Gait Evaluation

The evaluation of a patient's gait immediately after injury and before return to activity can provide a clinician with valuable information on how abnormalities in ambulation contribute to the rehabilitation and prevention of injuries. Often abnormal gait mechanics can predispose the other joints of the lower extremity and back to overload and pain. Restoring normal gait after acute injuries can help to prevent these abnormal mechanics and significantly reduce the amount of time required for return to normal function. It is important that a clinician evaluates the entire lower extremity and its function during gait.

Normal gait is composed of two phases, a stance phase (60%) and a swing phase (40%). The stance phase is composed of five categories, including initial contact (heel strike), loading response (foot flat), midstance (single leg support), terminal stance (heel off), and pre-swing (toe-off). The swing phase consists of initial swing (acceleration), midswing, and terminal swing (deceleration). [0290] [0300] [0310]

In acute injuries, a clinician will notice gait abnormalities because of pain, decreased range of motion, strength deficits, and lack of proprioception. The majority of the time, a patient will present antalgic with a decreased stance phase. If a patient is unable to walk without antalgia, a clinician should educate the patient on normal gait mechanics using assistive devices; for example, crutches. A patient may discontinue assistive devices when he or she can walk normally. It is extremely important that as clinicians we correct gait immediately to prevent abnormal gait habits from becoming permanent. It is likely that some failure to return to full strength return after a lower-extremity injury is related to adaptive gait changes that become permanent in unloading the injured extremity.

In chronic injuries or before return to activity, a clinician should take a closer look at lower-extremity biomechanics and gait abnormalities to facilitate return to function while preventing future problems. Observation of gait should include lateral, anterior, and posterior view. It is important to observe and evaluate the foot, ankle, knee, and hip/pelvis position and biomechanics during the gait cycle. Treatment of gait deviations includes flexibility, strengthening, and proprioception. An orthotic can be an excellent adjunct to rehabilitation if the gait deviation is a result of abnormal biomechanics and structural problems within the foot.



Muscle strengthening should be initiated once the patient has recovered 95% to 100% of the range of motion of that joint. Initiating strengthening too early can cause an increase in joint stiffness, therefore decreasing the function of the joint. Working isometrically, isotonically, or isokinetically can achieve strengthening. Isotonic strengthening, which is most commonly performed, uses concentric and eccentric contractions. Concentric contraction causes muscle shortening, whereas in an eccentric contraction the muscle lengthens while maintaining a load. Both phases are extremely important and should be included in a comprehensive rehabilitation program.

There are several methods of strengthening, including weights, Thera-Band, and water resistance. Thera-Band is a useful tool to provide resistance in all directions of the foot and ankle. It has different levels of resistance to allow the athlete to progress. Once the athlete can complete 3 sets of 15 repetitions through a full range of movement, the next level of resistance should be started. This same concept can be used with ankle weights.



Many rehabilitation programs often fail to pay attention to proprioception deficits. Proprioception is the ability of the body to vary the forces of muscles in response to outside forces. Muscles, tendons, and joint receptors provide this information, which affects posture, muscle tone, kinesthetic awareness, and coordination. [0290] [0300] When an individual is injured, the proprioceptive input to that joint is altered and diminished. Diminished proprioception can lead to a recurrence of injury because of the joint's decreased ability to respond to outside forces.

Proprioception can be improved with a number of treatment techniques. Early weight bearing can help to decrease the amount of proprioception loss. A patient can practice standing with equal weight on both feet, progressing to single leg stance. A biomechanical ankle proprioception system (BAPS) board or kinesthetic awareness trainer (KAT) can be used as a patient advances through rehabilitation ( Fig. 28-3 ).


Figure 28-3  Biomechanical ankle proprioception system (BAPS) board for balance and range of motion.




Cardiovascular Activities

During the rehabilitation program it is extremely important to keep the patient active. If the patient becomes sedentary, the cellular metabolism levels will decrease and the individual will lack energy, and may experience both diminished desire and blunted motivation because of a form of depression seen after injury in athletes. This consequently can then present a challenge for recovery and rehabilitation. Early in the rehabilitation, we feel that it is vital to start a sensible regimen of low-resistance exercise bike or pool therapy training 3 to 4 days a week for 10 to 15 minutes with a progression by 5 to 10 minutes of training per session per week. If the bike is used, then a walking boot or protective brace is used. Pool therapy is not initiated until the sutures are removed and the wound is fully healed. By initiating early activity during the rehabilitation program, the cellular metabolism will be maintained. The early exercise also provides psychological benefits for the athlete. Physically it allows an active blood flow to the involved extremity, and psychologically it helps to keep the patient motivated and counteracts the potential for depression.

Our experience with and observation of clinical healing and postoperative wound healing have proven that it is important to progress the patient's activity gradually. Increasing the time increments of 10 minutes a week on a bike will allow the patient to be working approximately 30 minutes per session in a 3-week span ( Table 28-1 ). Typically, low-impact, weight-bearing exercise will be introduced when the athlete is able to walk normally in a protective device and regular shoe. The rehabilitation program will begin replacing one day of bike with a StairMaster/elliptical machine ( Fig. 28-4 , A and B). We allow an additional day of StairMaster or elliptical each successive week until the athlete has been converted to StairMaster or elliptical 4 to 6 days per week. The athlete will continue to increase low-impact, weight-bearing exercise as tolerated. We have found that when an athlete can work out on the StairMaster or elliptical machine 4 to 5 days a week for 30-plus minutes, it is safe to initiate running. Running should gradually replace StairMaster/elliptical each week. It is important to give the athlete a set of running guidelines that allows for a gradual progression of activity ( Table 28-2 ).

Table 28-1   -- Increase Exercise Capacity Program (with boot/postoperative shoe/brace on)

   Exercise 10 minutes on a stationary bike 3 days a week.

   Exercise 20 minutes on a stationary bike 4 days a week.

   Exercise 30 minutes on a stationary bike 4 days a week.

•Once you are able to ride the bike 30 minutes a day for 4 days a week, then you may start replacing one of your days of biking per week with 1 day of StairMaster or elliptical trainer. You will do the StairMaster or elliptical for the same amount of time you normally would ride the bike.





Figure 28-4  (A) Patient performing StairMaster with Aircast walking boot. (B) Patient performing StairMaster with ankle stabilizing orthosis (ASO) brace.



Table 28-2   -- Running Progression




Week no.








Total minutes





































Previously running 30-45 minutes per day.

Subtract times from time spent on low-impact aerobic training.





Functional Progression

A functional progression is a series of sport-specific skills that increase in the level of difficulty that an athlete must complete before he or she can safely return to competition. Yamamoto and Fragi described a functional progression in the rehabilitation of injured West Point cadets. [0320] [0330] The emphasis in this program was placed on restoring agility through dynamic exercise after knee injury. Kegerreis et al.[34] added specific movement patterns and skills to the program and introduced the importance of addressing the psychological needs of the injured athlete. They also addressed the scientific principles that play an important role in the functional progression and the need to break down sport-specific functions to be addressed in the order of difficulty.

The functional progression is vital to a complete sport-specific rehabilitation program. It serves as the key element in advancing the athlete from clinical rehabilitation to athletics. Each sport has certain demands and skills that stress the foot and ankle differently. It is extremely important that the athlete advance one step at a time without pain or apprehension. Once the athlete has completed the list of activities in order without pain or apprehension, he or she may return to full sport activity.

There are several physical and psychological benefits that the functional progression will address. The functional progression promotes healing through the application of Davis’ law and Wolfe's law, which were discussed earlier. It is important that the healing tissue be stressed in the way required of it before injury so that the tissue will be ready to fully accept preinjury activity requirements. As described in Davis’ law and Wolfe's law, injured tissue and bone stressed in this controlled manner will lead to further tissue and bone healing and strength. In addition, the functional progression breaks up the monotony of traditional rehabilitation and allows the athlete to begin performing activities related to function. Psychologically it allows the athlete to increase self-confidence and mentally prepares him or her to return to sport. As the athlete completes each step, confidence will increase and apprehension will decrease, allowing the athlete to enter the competitive environment at the level of function needed for playing standards ( Table 28-3 ).

Table 28-3   -- Functional Progression—Court Sports

Begin with step one. If you can do this exercise without pain or limping, you may proceed to the next step. It is very important that you perform each exercise correctly, without apprehension. When you have successfully completed each step of the functional progression, you may then attempt to return to your sport. You should wear the Aircast, Swedo, knee brace, or tape as instructed.

Heel raises injured leg—10 times

Walk at fast pace—full court

Jumping on both legs—10 times

Jumping on the injured leg—10 times

Jog straight—full court

Jog straight and curves—2 laps

Spring: ½, ¾, full speed—baseline to ¼ court

Run figure eights: ½, ¾, full speed-baseline to ¼ court

Triangle drills: sprint baseline to ½ court, backward run to ½ court, defensive slides along baseline, both directions

Cariocas (cross-over drill) ½, ¾, full speed—½ court

Cutting ½, ¾, full speed—full court




Phases of Rehabilitation

The cornerstone to appropriate rehabilitation is an accurate diagnosis, so that an appropriate rehabilitation program can be established efficiently and safely. For any injury or condition, the rehabilitation can be divided into three general phases. Each phase has specific goals, and, although there is a time frame assigned to each phase, advancement from one phase to another should be based on the patient's achieving the prescribed goals rather than on time. A clinician must be willing to adapt and modify the exercise program for each patient. There are a variety of rehabilitative techniques to choose from; each can have benefit to the patient. As a clinician, it is important to stay up to date with current rehabilitative trends.

Phase I

Phase one emphasizes pain modulation and inflammatory control of the soft tissues. Controlling pain and inflammation will allow patients to be better able to perform their rehabilitation exercises. Restoration of normal range of motion and joint accessory motions, including glide, roll, and spin, are stressed in this phase. Early return of pain-free range of motion will enhance the rehabilitative process and allow the patient to begin isolated and functional rehabilitation exercises in phase II with greater effectiveness. Once a patient has minimal pain and has normal to near normal range of motion, he or she may be advanced to phase II .

Phase II

Once inflammation is decreased, pain has subsided, and range of motion is near normal, phase II may begin. Foot and ankle flexibility with functional strengthening are initiated and are the focus of this phase. In addition, cardiovascular conditioning and proprioceptive training also are started at this time. The goals of this particular phase are to improve flexibility, restore strength, and begin light, sport-specific functional training. A patient may be progressed to phase III when he or she is ready for a gradual return to activity and participation in sports.

Phase III

Emphasis in phase III is on functional return to activities of daily living (ADLs) and previous activity/sport participation. Advanced activity-specific exercise should be implemented with special attention to mechanics of the activity. Proper mechanics, as well as maintenance of flexibility and strength, can prevent further chance of reinjury. To ensure safe return to sport, athletes should perform a functional progression. External supports such as braces, straps, taping, and orthotics may be used at this time to allow the patient to participate in his or her activity pain free.


Rehabilitation of Achilles Tendon Repair

The rehabilitation after an Achilles repair is an example of progression toward a more functional recovery. Recently, rehabilitation after an Achilles repair has progressed from long-leg casting to short-leg casting to the use of intermittent immobilization and early weight bearing. Mandelbaum et al.[35] have established an accelerated rehabilitation protocol for the Achilles repair. Their protocol involves early range of motion at 72 hours and early weight bearing at 2 weeks postrepair. This functional approach allows the competitive athlete to return to sports more quickly without a reported increase in complications.

At Methodist Sports Medicine, more than 75 acute Achilles repairs have been performed over the past 8 years using an ankle-block anesthetic, no casting, intermittent immobilization with a removable boot, and cryotherapy. Patients have been full weight bearing by 2 weeks, and range of motion is started at the first postoperative visit, along with a bike program and sitting toe raises. We use the concept that early-protected range of motion and weight bearing encourage strong tendon healing and protect against disuse atrophy. The re-rupture rate has been consistent with that of less accelerated protocols (<2%). This is an example of our rehabilitation program.

Immediately postoperatively the patient is placed in an Aircast walking boot with a built-in Cryocuff. The walking boot also has one 9⅙; - inch felt heel lifts placed inside to put the foot/ankle in a slight equines position for healing. (We will use two heel lifts if the repair is 3-8 weeks after the tear.) The patient is instructed to be nonweight bearing for the first 5 to 7 days and is appropriately trained in axillary crutch use for walking and negotiating stairs. This decreases the risk of early postoperative swelling and allows appropriate initial wound healing.

The immediate postoperative protocol consists of rest, elevation, and continuous daytime Cryocuff use. The patient also is instructed to wiggle toes and perform leg lifts every 3 to 4 hours in the first postoperative week.

Dressing changes and rehabilitation will begin 1-week postoperatively. Physical therapy will consist of a home exercise program, gradual progression of weight bearing, and a light bike program to maintain cellular metabolism. Biking is performed with the ankle immobilized in the boot. The home exercise program includes toe curls ( Fig. 28-5 A ), active plantarflexion, resistive-band plantarflexion ( Fig. 28-5, B ), and sitting calf raises ( Fig. 28-5 C ). We use the concept of early-protected motion and resistance training, which encourages stronger tendon healing and protects against disuse atrophy. Exercises are performed at a higher frequency with a low load (see phase I exercise prescription) to continuously stimulate the tendon to heal. It is extremely important to avoid ankle dorsiflexion activity or a heel cord stretch to protect the tendon from overstretching.



Figure 28-5  (A) Towel toe curls. (B) Resisted plantarflexion using Thera tubing. (C)Single-leg balance for proprioception.



Partial weight bearing is started at 1 week with a gradual progression to full weight bearing at 2 to 3 weeks postoperatively. The first week of rehabilitation allows partial weight bearing in the walking boot with axillary crutches and the amount of weight bearing is increased as tolerated by pain and swelling. After the first week, the patient may begin using one crutch under the opposite arm and then progress to full weight bearing when the athlete is able to walk normally.

A bike program is initiated in the first week using the walking boot. The program consists of 10 minutes three times the first week and increases by 10 minutes per week and to 4 days over the first month. We progress this slowly to give the incision/wound time to heal without increasing the moisture or swelling to the ankle. Once clinical wound healing has occurred, a patient can be more aggressive with cardiovascular activity.

The second phase of rehabilitation begins approximately 6 weeks after repair. At this time, an increase in weight-bearing exercise is allowed, and proprioception retraining with an emphasis on normal gait is initiated. Athletes at this time are instructed in a program to wean out of the boot into an athletic shoe with one9⅙; - inch felt heel lift. Our goal is to wean the patient out of the boot over 2 weeks with normal pain-free gait ( Table 28-4 ).

Table 28-4   -- Wean out of Boot/Postoperative Shoe

Week 1: Wear your boot/postoperative shoe from 8 AM to 4 PM.

Wear the brace/shoe insert/steel shank after 4 PM.

Week 2: Wear your boot/postoperative shoe every Monday, Wednesday, and Friday from 8AM to 4 PM. After 4 PM, wear the brace/shoe insert or steel shank. Wear your brace/shoe insert/steel shank all day Tuesday, Thursday, Saturday, and Sunday.

Week 3 and beyond:Wear your brace/shoe insert/steel shank every day of the week.

You should wear the boot if you are doing excessive walking.



Exercises in the second phase consist of balance, standing calf raises, and elliptical/StairMaster progression. Single-leg balance ( Fig. 28-6 ) is first initiated barefoot on a hard surface with a goal of approximately 60 seconds. Once that is achieved, balance is progressed to a soft surface with other possible variations (i.e., ball toss). Patients will begin bilateral calf raises ( Fig. 28-7 ) with a progression to single calf raises. Thera-Band exercise is performed in all directions to incorporate the entire ankle. However, dorsiflexion past neutral is not allowed. Once completely out of the boot, 1 day of elliptical/StairMaster may be substituted for the bike each week, so that over a 4-week period the athlete transitions into full cardiovascular workouts with a StairMaster/elliptical 4 to 5 days a week. It is important to avoid passive dorsiflexion or Achilles tendon stretching to protect the Achilles repair from stretching out. We have found that normal dorsiflexion will return naturally without being aggressive with dorsiflexion motion.


Figure 28-6  Single-leg balance for proprioception.




Figure 28-7  Bilateral calf raise.



The final phase of rehabilitation starts approximately at the 3-month mark. Patients will continue to work on balance, ankle strength, and unilateral calf raises. At this time, full lower-extremity strengthening will be initiated. Exercise will include stepdowns ( Fig. 28-8, A ) leg press ( Fig. 28-8, B ), knee extensions ( Fig. 28-8, C ), and hamstring curls that can be advanced per patient tolerance. Weighted calf raises typically are initiated around 4 months.


Figure 28-8  (A) Stepdown for balance and strengthening. (B) Leg press using single leg. (C) Knee extension machine for quadriceps strengthening.



Once an athlete is capable of using a StairMaster/elliptical machine for 30 minutes 5 days a week, he or she may begin light jogging (usually at 3-4 months after the repair). It also is important to begin sport-specific skills, such as shooting a basketball or hitting a tennis ball. Agility drills should be advanced gradually per patient tolerance. Before return to sport, the patient should successfully complete a functional progression to ensure a safe return to competition. Return to sports normally occurs at 5 to 8 months after surgery.


Rehabilitation After Lateral Ankle Reconstruction

The treatment and rehabilitation after acute ankle sprains begins by positioning the ankle in a position that reapproximates the torn ligament ends (neutral dorsiflexion with weight bearing). The application of a removable walking boot with an Aircast Cryocuff and immediate weight bearing place the ankle mortise in its most stable position. Early range of motion, Achilles stretching, and peroneal strengthening is started immediately after injury. However, plantarflexion and inversion will result in separation and possible elongation of the injured ligaments and therefore should be avoided. Once the ligaments have healed, then advancing the rehabilitation is safe.

A similar approach can be used following a lateral ankle reconstruction. For the reliable athlete with close medical monitoring and sturdy tissue at the time of reconstruction, there may be a place for intermittent immobilization with early weight bearing and specific range-of-motion exercise. Overall the objective is to obtain as “normal” an ankle as possible. This is an example of our rehabilitation program.

Immediately after surgical reconstruction, the athlete is placed in an Aircast walking boot with a Cryocuff placed inside the boot. Dressing changes and rehabilitation will begin 3 days postoperatively. The clinical goals in the first phase of rehabilitation (4 weeks) consist of restoring full eversion and dorsiflexion, normalizing gait, increasing calf flexibility, and beginning light strengthening. Physical therapy will consist of a home exercise program, progression to full weight bearing, a light bike program, Cryocuff, and desensitization massage. Competitive athletes with training room availability use on-site athletic trainers’ and physical therapists’ expertise.

The home exercise program consists of range of motion exercises and strengthening with Thera-tubing ( Fig. 28-9, A and B ) in the directions of eversion and dorsiflexion. Over the first 4 weeks, the patient is instructed to avoid inversion and plantarflexion to protect the integrity of the newly reconstructed ligaments. It also is important to begin Achilles tendon stretching using a towel ( Fig. 28-10 ) with progression to a stair stretch. Exercises are performed at a high frequency with a low load to stimulate the ligament to heal without creating swelling or reinjury. The Cryocuff will be used to help control swelling and inflammation and is most helpful in the first week after surgery.



Figure 28-9  (A) Resisted eversion using Thera tubing. (B) Resisted dorsiflexion using Thera tubing.




Figure 28-10  Achilles/calf stretch with towel.



Partial weight bearing is started immediately after surgery with progression to full weight bearing in the next 7 to 10 days in the walking boot. A bike program is initiated the first week postreconstruction with the walking boot. The program will advance each week as the incision/wound has had time to heal. Once clinical wound healing has occurred, a patient can be more aggressive with cardiovascular activity.

Desensitization massage is an important part of the early rehabilitation program. Because of the highly innervated foot and ankle, the patient often will experience some surface hypersensitivity after surgery. It is important to stimulate this nerve tissue with light massage and tactile stimulation to reeducate and desensitize the tissue to normal pressure and touch. This can be accomplished with a light massage 3 to 5 minutes several times a day.

The second phase of rehabilitation begins 1-month postoperatively. At this time patients are instructed to wean out of the boot into a stirrup ankle brace ( Fig. 28-11 ). Our goal is to wean the athlete out of the boot within 2 weeks and obtain a normal, pain-free gait (see Table 28-4 ).


Figure 28-11  Patient using active ankle brace.



Exercises in the second phase include range of motion/strengthening in all four directions, aggressive heel-cord stretching ( Fig. 28-12 ), calf raises, and proprioception exercise. Dorsiflexion and inversion strengthening still are performed with Thera-tubing. Aggressive peroneal strength ( Fig. 28-13 ) is accomplished by having the athlete lie in a lateral position with ankle weights hung over the end of the foot and the toes pointed to isolate the peroneal tendons. The athlete then everts the foot and ankle to strengthen the tendons. We have found this to be a very effective means of maximizing peroneal strength. Bilateral calf raises are initiated with progression to single calf raise. We like to have the patient work on eccentric phase of calf raise by going up on both and lowering slowly on the injured side. Once the patient has no difficulty with the eccentric phase of the exercise, he or she may add the concentric phase of the exercise. Proprioception exercise ( Fig. 28-14 ) should begin with one-foot balance, with progression of balance with opposite hip/leg exercise. Cardiovascular exercise should be advanced from the bike to StairMaster/elliptical machine (4-6 weeks after surgery) and eventually to light jogging (6-10 weeks after surgery).


Figure 28-12  Aggressive Achilles/calf stretch on step.




Figure 28-13  Aggressive peroneal strengthening with cuff weight.




Figure 28-14  Single-leg balance for proprioception using opposite hip strengthening with Thera tubing.



There are several other ways to strengthen the ankle postoperatively, including Cybex/Biodex ( Fig. 28-15 ) and the multiaxial machine. As long as the emphasis is on pain-free strengthening involving dorsiflexion, eversion and plantarflexion these exercise follow the same clinical guideline set in this phase. The final phase of rehabilitation (2 months) should focus on advance strengthening of the entire lower extremity and sport-specific agility drills. The final goal of this phase is return to sport after finishing a sport-specific functional progression.


Figure 28-15  Cybex isokinetic strengthening for inversion/eversion.



Exercises in the final phase will continue to focus on ankle strengthening, flexibility, and proprioception activity. Advanced lower-extremity exercise can include leg press, knee extension, and hamstring curls as tolerated. Sport-specific skills, such as kicking a soccer ball, ball handling drills, or catching a football should be implemented at this time. The intensity of these activities can be increased as tolerated. Before return to sport, the patient should successfully complete a sport-specific functional progression program to ensure safe return to competition. Return to sports participation is 10 to 12 weeks.


Rehabilitation of Ankle Fractures

The treatment and rehabilitation after acute displaced ankle fractures in the athlete can be particularly exciting with the ability to anatomically and rigidly fix bony fractures and anatomically repair torn ligaments. Displaced fractures should be treated with anatomic open reduction and internal fixation. We have progressed from short-leg casting and nonweight bearing to the use of intermittent immobilization, early range of motion, and protected weight bearing. The goal of rigid, stable, internal fixation is to allow a more functional recovery. This is an example of our rehabilitation program.

Immediately after surgery, the patient is placed in an Aircast walking boot with a Cryocuff for cold and compression. Early immobilization consists of rest, elevation, and continuous daytime Cryocuff use. Patients are instructed to stay down as much as possible to help decrease swelling. Nonweight bearing with axillary crutches is initiated initially after surgery to reduce the risk of immediate postoperative swelling. The patient should also wiggle the toes and perform leg lifts every 3 to 4 hours while awake.

Dressing changes and rehabilitation will begin 1 week postoperatively. If stable bone alignment is demonstrated on radiographs, range-of-motion exercises are started. Range of motion should be initiated in a manner that does not put tension on an injured or repaired ligament. For an isolated lateral fibula or stable bimalleolar fracture, range of motion can include all directions. If the patient has a medial ligament injury, dorsiflexion with eversion should be avoided until the ligament is healed. Range of motion and light tubing exercises are guided by pain and should be performed several times a day in high repetitions (15-20); towel stretch for the Achilles and manual plantarflexion stretch can be started (20 seconds, 5 repetitions) if there is no contraindicating ligament injury. The home exercise program will consist of toe curls (see Fig. 28-5, A ), range of motion in appropriate directions, resistive band in appropriate directions, desensitization massage, and a light bike program wearing the boot ( Fig. 28-16 ).


Figure 28-16  Stationary bike using Aircast walking boot.



Partial weight bearing is started at 1 week, with progression to full weight bearing in the walking boot in 2 weeks (if the fracture is stable and does not involve a weight-bearing surface). Patients are instructed to use axillary crutches and increase weight bearing as tolerated. After the first week of partial weight bearing, the patient may begin using one crutch under the opposite arm and eventually progress to full weight bearing over the next week. Once a patient can walk normally with the walking book (typically within 3 weeks), we begin weaning the patient out of the boot and into a stirrup brace (Fig. 28-17 ) and regular shoe over the next 2 weeks. Patients with highly comminuted fractures and those with weight-bearing joint injury or significant cartilage injury do not follow this same protocol.


Figure 28-17  Patient using Aircast stirrup brace.



The second phase of rehabilitation begins approximately 1 month after surgery. At this time, an increase in weight-bearing exercise, proprioception, and gait training with an athletic shoe is initiated. Exercises consist of progression of Thera-Band activities to include directions originally avoided because of ligament complications. Standing calf stretching, balancing exercises, double to single leg calf raises, and elliptical/StairMaster progression are included during this phase. Thera-Band exercise should continue to be high repetitions (15-20) in all directions. Single leg balance is first initiated in a regular shoe and then progressed to bare foot on a hard surface. Our goal is approximately 60 seconds. Balance can be advanced by use of a soft surface and balance board ( Fig. 28-18 ). The patient should work aggressively with calf stretching using a stair or an incline board for 3 minutes three times a day. Bilateral standing calf raises should be initiated with progression to single-leg calf raises ( Fig. 28-19 ). Once completely out of the boot, elliptical or StairMaster progression should be substituted for the bike with use of the brace and athletic shoes (see Fig. 28-4, B ). Patients typically are given a home exercise program to be performed two to three times a day. Athletes who have athletic training resources should work under the guidance of the athletic training staff.


Figure 28-18  Single-leg balance for proprioception on Thera disk.




Figure 28-19  Unilateral calf raise.



The final phase of rehabilitation (2 months) should focus on advance strengthening of the entire lower extremity and sport-specific agility drills. The final goal of this phase is the return to sport after finishing a sport-specific functional progression program.

Exercises in the final phase will continue to focus on ankle strengthening; flexibility; and proprioception activity; and advanced lower-extremity exercise, including leg press, knee extension, and hamstring curls as tolerated and indicated. Sport-specific skills, such as kicking a soccer ball, ball handling drills, or catching a football should be implemented at this time, increasing the intensity of these activities as tolerated. Return to sports can be as early as 4 weeks after rigid fixation of an isolated fibula fracture to 8 to 10 weeks after a bimalleolar and equivalent repair. Fractures that require fixation of the syndesmosis can take 4 to 6 months before return.



The athlete will desire and in most instances demand 100% strength, 100% motion, and 100% function. This is a challenge for the surgeon, therapist, and trainer. The understanding of muscle function and its need for motion with controlled resistance to return to functional ability has shown us that our rehabilitation must take this into account. We have discussed our principles of rehabilitation and some specific approaches for athletes and their injuries. We also have tried to relate the basics of science understanding that underlie our principles and specific approaches. The area of rehabilitation of the foot and ankle will continue to progress as we understand more clearly the appropriate use of weight bearing, early motion, and function resistance. Also, as our understanding of proper anatomic repair and reconstruction advance, our rehabilitation must and will advance also. This is an exciting time in the treatment of athletes with foot and ankle injuries. We hope that this chapter both encourages you and challenges you in your treatment of your athletes.



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Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Copyright © 2007 Mosby, Inc.

Further reading

Clanton CO: Athletic injuries to the soft tissues of the foot and ankle.   In: Coughlin MJ, Mann RA, ed. Surgery of the foot and ankle,  St Louis: Mosby; 1999.

Kern-Steiner R, Washecheck HS, Kelsey DD: Strategy of exercise prescription using an unloading technique for functional rehabilitation of an athlete with an inversion ankle sprain.  J Orthop Sport Phys Ther  1999; 29:282.

Pugia ML, et al: Comparison of acute swelling and function in subjects with lateral ankle injury.  J Orthop Sport Phys Ther  2001; 31:348.

Rozzi SL, et al: Balance training for persons with functionally unstable ankles.  J Orthop Sport Phys Ther  1999; 29:478.

Smith LS, et al: The effects of soft and semi-rigid orthoses upon rearfoot movement in running.  J Am Podiatr Med Assoc  1986; 76:227.