Ankle Ligament
Reconstruction Pre Operative
Education Program
Prepared By
Dr. Mark Glazebrook MD, MSc., PhD., FRCS(C)
QEII HSC
Daniela Rubinger BScPT, MCPA
Citadel Physiotherapy Ltd.
Introduction
Ankle Ligament Reconstruction is a surgical treatment for chronic ankle joint instability
designed to improve pain and function. For the patient to obtain the maximum benefit, it
is important that they fully understand the ankle anatomy, reason for surgery, surgical
procedure and rehabilitation process. This booklet will provide all necessary information
to allow the patient to make an educated and thorough recovery from surgery.
Ankle Anatomy
The hindfoot has two joints; the ankle joint and the subtalar joint (Figure 1). The ankle
joint is composed of 3 bones, the tibia which forms the superior and medial, portion of
the ankle; the fibula which forms the lateral, and the talus which forms the inferior
portion of the ankle joint. The ankle joint is responsible for up and down motion of the
foot.
Beneath the ankle joint is the second part of the ankle, the subtalar joint, which consists
of the talus on top and calcaneus on the bottom. The subtalar joint allows side to side
motion of the hindfoot foot.
The ends of the bones in these joints are covered by articular cartilage. The articular
cartilage provides a cushioned surface for the bones of the ankle joint to slide by each
other during foot up and down movement.
There are many major ligaments of the ankle which connect the tibia to the fibula on the
front of the ankle, the fibula to the calcaneous on the outside of the ankle and the tibia to
the talus and calcaneous on the inside of the ankle. These ligaments provide stability to
the ankle.
Ankle Sprain
Ankle sprains commonly occur when the ligaments are stretched more than normal
resulting in a partial or complete tear of the ligament. This ligament damage results in
abnormal excessive movement in the ankle due to loss of ankle stability.
Ankle Sprains can be sprains are divided into several groups depending on the severity of
damage to the involved ligament.
Grade I Sprain - A Grade I (First Degree) sprain is the most common. The
ligaments are over-stretched, and damaged microscopically, but not torn. The
ligament damage has occurred without any significant instability developing.
Grade II Sprain - A Grade II (Second Degree) injury is more severe and
indicates that the ligament has been more significantly damaged, but there is no
significant instability. The ligaments are often partially torn.
Grade III Sprain - A Grade III (Third Degree) sprain is the most severe. This
indicates that the ligament has been significantly damaged, and that instability has
resulted. A grade III injury means that the ligament has been torn.
Ankle Instability
Ankle injuries are extremely common, and the vast majority of ankle sprains recover
fully within six weeks of injury. Occasionally, if the ligaments are severely disrupted,
patients may suffer weakness or giving way of the ankle beyond this period.
What are the symptoms?
Most people with ankle instability complain of one or more of the following:
- The ankle gives way on uneven ground, playing sport or even just walking
- Pain with each episode, which recovers quickly
- Feeling of instability or weakness in the ankle
- Swelling or puffiness
Surgical Procedure
Mark to do….
Rehabilitation Process
Rehabilitation following ankle ligament reconstruction surgery should begin prior to the
surgery with the education of the client and proper preparation to ensure that everything
is in place for a successful rehabilitation process.
Important things to consider:
 You will be encouraged to attend a Pre-operative Physiotherapy appointment.
This will consist of a session in which the physiotherapist will educate you on the
surgical procedure and the rehabilitation process.
 Prior to the surgery you will also be fitted with a walking cast called a boot
walker (Figure 3). This specific type of ankle brace will be required to be worn
for the first 6-8 weeks post surgery.
 You will be non-weight bearing for the first 2 weeks so you will require crutches
for mobility.
Polar Care Unit
It maybe possible to use this during the initial two weeks post op. Let me know what you
think.
Cast Boot/ Boot Walker
Figure 3
The cast boot is designed to immobilize the foot and ankle
and lower leg while allowing safe ambulation. The
reinforced nylon shell provides maximum rigidity while
the wrap around liner with Velcro straps provides comfort.
There is a large rocker bottom for improved weight
transfer during gait.
Post Operative Protocol
The following protocol has been developed for the post – operative rehabilitation of the
Ankle Ligament Reconstruction patient.
Week 1-2
Goals
- Rest and recovery from surgery
- Control swelling and pain
- Increase ADL
General Considerations
- NWB in boot
- Sutures removed at approximately 10 days
- Encourage ADL
- Rest and elevation to control swelling
- Control pain
- Hip and knee range of motion exercises
Week 3-6
Goals
- Allow healing while maintaining upper body, core, hip and knee strength
and ROM
Protocol
- FWB in walker boot at all times
-
Massage for swelling
Elevation to control swelling
Gentle AROM ankle PF/DF/eversion and toe flexion/extension
Stationary bicycle with boot
Core exercises – abdominal recruitment, bridges on ball, arm
pulleys/theraband diagonal patterns
Hip AROM and strengthening (clam, side lift, glut max. SLR)
Knee AROM and strengthening ( SLR, theraband press or leg press
machine)
Stretching – Glut max, glut. Med, piriformis, erectus femoris, hamstrings
Week 7-10
Goals
- WB in boot with pain and swelling control
Protocol
- WB in boot
- Stationary bicycle
- AROM – begin inversion and eversion; continue with PFDF, toe flex/ext.
- Continue with core exercise, hip strengthening and knee strengthening
exercises. Progress to standing.
- Manual mobilizations to joints not part of ligament reconstruction
Week 11-12
Goals
- Full ROM
Protocol
- Wean from boot walker
- Control swelling and pain with elevation and modalities as needed
- AROM in WB
- Manual mobilizations as required
- Muscle stimulation to intrinsics, invertors/evertors if required.
- Gait retraining
- Continue strengthening core, hips and knees
- Proprioceptive training – balance board, uneven surfaces, etc.
Week 13-16
Goals
- Full ROM in WB
- Good single leg stance
- Near full strength in lower extremity
Protocol
- Proprioceptive training
o Single leg stance on uneven surface with resistance to arms or
NWB leg
o Double stance on balance board, Sissel, Fitter
o Single leg WB on balance board, Sissel, Fitter
-
o Single leg WB on balance board, Sissel, Fitter with resistance to
arms NWB leg
Strength – toe raises, lunges, squats, hopping, skipping, running at
approximately 14 weeks
Manual mobilization if required
Week 16+
Goals
- Full functional return to work and or activity
Protocol
- Continue to build endurance
- Work specific or activity specific retraining
- Pylometric training