Rehabilitation Guidelines for Total Ankle Replacement

Initial rehabilitation phase

0-4 weeks

Goals:

• To be safely and independently mobile with appropriate walking aid, adhering to weight bearing status
• To be independent with home exercise programme as appropriate
• To understand self management / monitoring, e.g. skin sensation, colour, swelling, temperature, circulation

Restrictions:

• Ensure that weight bearing restrictions are adhered to:
• Total Ankle Replacement (TAR):
• Non Weight Bearing (NWB) for 2 weeks in Back Slab
• Below Knee Plaster of Paris (BK POP) at 2 weeks. Progress to Full Weight Bearing (FWB) in POP.
• POP removed at 4 weeks. May require aircast boot. FWB.
• If any other surgical technique used ensure you check any restrictions with team as these may differ from TAR alone
• Elevation
• If sedentary employment, may be able to return to work from 4 weeks post-operatively, as long as provisions to elevate leg, and no complications

Treatment:

• Likely to be in POP
• Pain-relief: Ensure adequate analgesia
• Elevation: ensure elevating leg with foot higher than waist
• Exercises: teach circulatory exercises
• Education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned
• Mobility: ensure patient independent  with transfers and mobility, including stairs if necessary

Recovery rehabilitation phase

4 weeks – 3 months

Goals:

• To be independently mobile out of aircast boot
• To achieve full range of movement
• To optimise normal movement

Restrictions:

• Ensure adherence to weight bearing status.
• No strengthening against resistance until at least 3 months post-operatively of any tendon transfers if performed.
• Do not stretch any tendon transfers / ligament reconstructions if performed. They will naturally lengthen over a 6 month period

Treatment:

• Pain relief
• Advice / Education
• Posture advice / education
• Mobility: ensure safely and independently mobile adhering to appropriate weight bearing restrictions. Progress off walking aids as able once reaches FWB stage.
• Gait Re-education
• Wean out of aircast boot once advised to do so, and provision of plaster shoe as appropriate, if patient unable to get into normal footwear
• Exercises:   
• Passive range of movement (PROM)
• Active assisted range of movement (AAROM)
• Active range of movement (AROM)
• Strengthening exercises as appropriate
• Core stability work
• Balance / proprioception work once appropriate
• Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of tendon transfers / ligament reconstructions if performed.
• Review lower limb biomechanics. Address issues as appropriate.
• If tendon transfer performed, encourage isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful.
• Swelling Management
• Manual Therapy:
• Soft tissue techniques as appropriate
• Joint mobilisations as appropriate ensuring awareness of osteotomy sites and those joints which may be fused, and therefore not appropriate to mobilise
• Monitor sensation, swelling, colour, temperature, circulation
• Orthotics if required via surgical team
• Hydrotherapy if appropriate
• Pacing advice as appropriate

Intermediate rehabilitation phase

12 weeks – 6 months

Goals:

• Independently mobile unaided
• Wearing normal footwear
• Optimise normal movement
• Grade 5 muscle strength around ankle
• Grade 4 muscle strength of tendon transfers if performed

Treatment:

Further progression of the above treatment:

• Pain relief
• Advice / Education
• Posture advice / education
• Mobility: Progression of mobility and function
• Gait Re-education
• Exercises:   
• Range of movement
• Strengthening exercises as appropriate
• Core stability work
• Balance / proprioception work
• Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of transfers / ligament reconstructions if performed.
• Review lower limb biomechanics. Address issues as appropriate.
• If tendon transfer performed progress isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful.
• Swelling Management
• Manual Therapy:
• Soft tissue techniques as appropriate
• Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise
• Monitor sensation, swelling, colour, temperature, circulation
• Orthotics if required via surgical team
• Hydrotherapy if appropriate
• Pacing advice as appropriate

Final rehabilitation phase

6 months – 1 year

Goals:

• Return to gentle no-impact / low-impact sports
• Establish long term maintenance programme
• Grade 4 or 5 muscle strength of tendon transfers if performed

Treatment:

• Mobility / function: Progression of mobility and function, increasing dynamic control with specific training to functional goals
• Gait Re-education
• Exercises:   
• Progression of exercises including range of movement, strengthening, transfer activation, balance and proprioception, core stability
• Swelling Management
• Manual Therapy:
• Soft tissue techniques as appropriate
• Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise
• Pacing advice 

Failure to progress

If a patient is failing to progress, then consider the following:

POSSIBLE PROBLEM	ACTION
Swelling	Ensure elevating leg regularly Use ice as appropriate if normal skin sensation and no contraindications Decrease amount of time on feet Pacing Use walking aids Circulatory exercises If decreases overnight, monitor closely If does not decrease overnight, refer back to surgical team or to GP
Pain	Decrease activity Ensure adequate analgesia Elevate regularly Decrease weight bearing and use walking aids as appropriate Pacing Modify exercise programme as appropriate If persists, refer back to surgical team or to GP
Breakdown of Wound e.g inflammation, bleeding, infection	Refer to surgical team or to GP
Transfer not activating	Start working in NWB gravity eliminated position with AAROM and then build up as able Biofeedback Ensure adequate analgesia as appropriate Ensure swelling under control as appropriate Ensure foot neutral when mobilising to avoid excessive shear. Consider orthotics referral via surgical team if unable to keep neutral Refer back to surgical team if no improvement
Numbness / altered sensation	Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team or GP If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned

Summary of evidence for physiotherapy guidelines

A comprehensive literature search was carried out to identify research relating to surgery for tibialis posterior tendon dysfunction and subsequent rehabilitation. After reviewing the articles and information, the physiotherapy guidelines were produced on the best available evidence.

• Ali et al (2007) “Intermediate results of Buechel Pappas unconstrained uncemented Total Ankle Replacement for osteoarthritis” The Journal of Foot and Ankle Surgery 46, (1): 16-20
• Buechel et al (2004) “Twenty-year evaluation of cementless mobile-bearing Total Ankle Replacements” Clinical Orthopaedics and Related Research 424, 19-26
• Coetzee J & Castro M (2004) “Accurate measurement of ankle range of motion after Total Ankle Arthroplasty” Clinical Orthopaedics and Related Research 424, 27-31
• Conti S & Wong YS (2001) “Complications of Total Ankle Replacement” Clinical Orthopaedics and Related Research 391, 105-114
• Griesberg J & Hansen S (2003) “Total Ankle Arthroplasty in the advanced flatfoot” Techniques in Foot and Ankle Surgery 2, (3): 152-161
• Knecht et al (2004) “The Agility Total Ankle Arthroplasty” The Journal of Bone and joint Surgery 86-A, (6): 1161-1171
• Kobayashi et al (2004) “Ankle arthroplasties generate wear particles similar to knee arthroplasties” Clinical Orthopaedics and Related Research 424, 69-72
• Kotnis et al (2006) “The management of failed ankle replacement” The Journal of Bone and Joint Surgery 88-B, (8): 1039-1047
• Lalonde K & Conti S (2006) “Ankle arthritis: current status of ankle replacement versus fusion and other treatment modalities” Current Opinion in Orthopaedics 17, (2): 117-123
• Mendolia et al (1005) “Lond term (10-14 years) results of the Ramses Total Ankle Arthroplasty” Techniques in Foot and Ankle Surgery 4, (3): 160-173
• Spirt et al (2004) “Complications and failure after Total Ankle Arthroplasty” The Journal of Bone and Joint Surgery 86-A, (6): 1172-1178
• Tochigi et al (2005) “The effect of accuracy of implantation on range of movement of the Scandinavian Total Ankle Replacement” The Journal of Bone and Joint Surgery 87-B, (5): 736-740
• Valderrabano et al (2006) “Sports and recreation activity of ankle arthritis patients before and after Total Ankle Replacement” The American Journal of Sports Medicine 34, (6): 993-999

Sumber :

Royal National Orthopaedic Hospital In association with the UCL Institute of Orthopaedics and Musculoskeletal Science

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Ankle Sprain Rehabilitation Exercises

As soon as you can tolerate pressure on the ball of your foot, begin stretching your ankle using the towel stretch. When this stretch is too easy, try the standing calf stretch and soleus stretch. 

Towel stretch

Sit on a hard surface with one leg stretched out in front of you. Loop a towel around your toes and the ball of your foot and pull the towel toward your body keeping your knee straight. Hold this position for 15 to 30 seconds then relax. Repeat 3 times. 

Standing calf stretch

Facing a wall, put your hands against the wall at about eye level. Keep one leg back with the heel on the floor, and the other leg forward. Turn your back foot slightly inward (as if you were pigeon-toed) as you slowly lean into the wall until you feel a stretch in the back of your calf. Hold for 15 to 30 seconds. Repeat 3 times and then switch the position of your legs and repeat the exercise 3 times. Do this exercise several times each day. 

Standing soleus stretch

Stand facing a wall with your hands on a wall at about chest level. With both knees slightly bent and one foot back, gently lean into the wall until you feel a stretch in your lower calf. Angle the toes of your back foot slightly inward and keep your heel down on the floor. Hold this for 15 to 30 seconds. Return to the starting position. Repeat 3 times. 

You can do the next 5 exercises when your ankle swelling has stopped increasing. 

Ankle range of motion

Sitting or lying down with your legs straight and your knee toward the ceiling, move your ankle up and down by pointing your toes toward your nose, then away from your body; in toward your other foot and out away from your other foot; and in circles. Only move your foot and ankle. Don't move your leg. Repeat 10 times in each direction. Push hard in all directions. 

Resisted ankle dorsiflexion

Sit with one leg out straight and your foot facing a doorway. Tie a loop in one end of elastic tubing. Put your foot through the loop so that the tubing goes around the arch of your foot. Tie a knot in the other end of the tubing and shut the knot in the door. Move backward until there is tension in the tubing. Keeping your knee straight, pull your foot toward your body, stretching the tubing. Slowly return to the starting position. Do 3 sets of 10. 

Resisted ankle plantar flexion

Sit with your leg outstretched and loop the middle section of the tubing around the ball of your foot. Hold the ends of the tubing in both hands. Gently press the ball of your foot down and point your toes, stretching the tubing. Return to the starting position. Do 3 sets of 10. 

Resisted ankle inversion

Sit with your legs out straight and cross one leg over your other ankle. Wrap elastic tubing around the ball of your bottom foot and then loop it around your top foot so that the tubing is anchored there at one end. Hold the other end of the tubing in your hand. Turn your bottom foot inward and upward. This will stretch the tubing. Return to the starting position. Do 3 sets of 10

Resisted ankle eversion

Sit with both legs stretched out in front of you, with your feet about a shoulder's width apart. Tie a loop in one end of elastic tubing. Put one foot through the loop so that the tubing goes around the arch of that foot and wraps around the outside of the other foot. Hold onto the other end of the tubing with your hand to provide tension. Turn the foot with the tubing up and out. Make sure you keep your other foot still so that it will allow the tubing to stretch as you move your foot with the tubing. Return to the starting position. Do 3 sets of 10. 

You may do the rest of the exercises when you can stand on your injured ankle without pain.

Heel raise

Balance yourself while standing behind a chair or counter. Using the chair to help you, raise your body up onto your toes and hold for 5 seconds. Then slowly lower yourself down without holding onto the chair. Hold onto the chair or counter if you need to. When this exercise becomes less painful, try lowering on one leg only. Repeat 10 times. Do 3 sets of 10. 

Step-up

Stand with the foot of your injured leg on a support (like a small step or block of wood) 3 to 5 inches high. Keep your other foot flat on the floor. Shift your weight onto your injured leg on the support straighten your knee as the other leg comes off the floor. Lower your leg back to the floor slowly. Do 3 sets of 10. 

Balance and reach exercises 

1. Stand upright next to a chair with your injured leg farthest from the chair. This will provide you with support if you need it. Stand just on the foot of your injured leg. Try to raise the arch of this foot while keeping your toes on the floor. 
2. Keep your foot in this position and reach forward in front of you with the hand farthest away from the chair, allowing your knee to bend. Repeat this 10 times while maintaining the arch height. This exercise can be made more difficult by reaching farther in front of you. Do 2 sets. 
3. Stand in the same position as above. While maintaining your arch height, reach the hand farthest away from the chair across your body toward the chair. The farther you reach, the more challenging the exercise. Do 2 sets of 10. 

Jump rope

Jump rope landing, on both legs, for 5 minutes, then on only one leg at a time for 5 minutes. 

Wobble board exercises

1. Stand on a wobble board with your feet shoulder width apart. Rock the board forwards and backwards 30 times, then side to side 30 times. Hold on to a chair if you need support. 
2. Rotate the wobble board around so that the edge of the board is in contact with the floor at all times. Do this 30 times in a clockwise and then a counterclockwise direction. 
3. Balance on the wobble board for as long as you can without letting the edges touch the floor. Try to do this for 2 minutes without touching the floor. 
4. Rotate the wobble board in clockwise and counterclockwise circles, but do not allow the edge of the board to touch the floor. 
5. When you have mastered exercises A through D, try repeating them while standing on only one leg (your injured leg). 
6. Once you can do these exercises on one leg, try to do them with your eyes closed. Make sure you have something nearby to support you in case you lose your balance. 

Written by Tammy White, MS, PT, and Phyllis Clapis, PT, DHSc, OCS, for RelayHealth. Published by RelayHealth. 

© 2009 RelayHealth and/or its affiliates. All Rights Reserved.

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