CHAPTER 30

Ankle Arthroscopy
Tom Burton, Danny Arora, Benjamin Cornell, Lisa Maxey, Richard D.
Ferkel

The first arthroscopic inspection of a cadaveric joint was performed by

Takagi in Japan in 1918.1 In 1939 he reported on the arthroscopic
examination of an ankle joint in a human patient. 1 With the advent of
fiberoptic light transmission, video cameras, instruments for small
joints, and distraction devices, arthroscopy has become an important
diagnostic and therapeutic modality for disorders of the ankle.
Arthroscopic examination of the ankle joint allows direct visualization
during stress testing of intraarticular structures and ligaments about
the ankle joint. Various arthroscopic procedures have been developed
with less attendant morbidity and mortality to patients. 2-6 With the
advent of better, smaller joint arthroscopes and instrumentation, and
the introduction of more efficient noninvasive distraction devices, ankle
arthroscopy is now state of the art. It has become a standard
procedure in many institutions as a diagnostic and therapeutic tool for
the practicing surgeon.

SURGICAL INDICATIONS AND CONTRAINDICATIONS

Foot and ankle arthroscopy has become a valuable adjuvant to the

diagnosis and treatment of an increasing amount of disorders.
Diagnostic indications (Box 30-1) for ankle arthroscopy include
unexplained pain, swelling, stiffness, instability, hemarthrosis, locking,
and abnormal snapping or popping.

Operative indications for ankle arthroscopy include loose body

removal, excision of anterior tibiotalar osteophytes, dbridement of
soft tissue impingement and arthrofibrosis, and treatment of
osteochondral lesions and ankle instability. Other indications include
arthrodesis for posttraumatic degenerative arthritis and treatment for
ankle fractures and postfracture defects.

Absolute contraindications for ankle arthroscopy include

localized soft tissue or systemic infection, and severe
degenerative joint disease (DJD). With end-stage DJD, occasionally
successful distraction may not be possible, precluding visualization of
the ankle joint. Relative contraindications include complex regional
pain syndrome (CRPS), moderate DJD with restricted range of motion
(ROM), severe edema, and tenuous vascular supply.

PATIENT EVALUATION

Successful outcomes following ankle arthroscopy depend on accurate

diagnosis and concise preoperative planning. It is important to
understand the nature of the patients complaint and gather the
following information: date of injury, duration and severity of
symptoms, provocative events, previous injuries and presence of any
redness, swelling, instability, stiffness, locking, or popping. A general
medical examination should be obtained, with special attention to
rheumatologic disorders. The physical examination should include:
inspection, palpation, ROM, and special tests. The contralateral side
should always be inspected for comparison. Stability of the ankle and
the subtalar joint should be evaluated. Often, a local anesthetic agent
can be injected into a specific joint to aid in diagnosis.

Routine blood tests should be performed to check for systemic and

rheumatologic conditions and infection. Aspiration of the ankle joint
and analysis of the joint fluid can be helpful in distinguishing
inflammatory from septic conditions of the ankle joint.

Routine radiographs (anteroposterior [AP], lateral, and mortise view)

should be obtained for all patients. Stress radiographs can provide
useful information when instability is suspected. Computed
tomography (CT) and/or magnetic resonance imaging (MRI) are often
helpful in evaluating soft tissue and bony disorders about the foot and
ankle. Threephase bone scans can also aid in distinguishing soft tissue
from bony pathology.

SURGICAL TECHNIQUE
Ankle arthroscopy is usually performed in one of four ways: (1) in the supine
position, (2) with the knee bent 90 over the end of the table, (3) in the
decubitus position, or (4) in the prone position for posterior ankle arthroscopy.
The method of choice is a surgeons preference, while taking into account
specific surgical circumstances. Different types and sizes of arthroscopic
equipment can be used depending on surgeons preference and availability of
equipment. The procedure described is that used most commonly by the
senior author of this chapter; a more detailed description of ankle arthroscopy
can be found in his textbook.BOX 30-1 Surgical Indications and
Contraindications
Indications
Loose bodies
Anterior tibiotalar osteophytes
Soft tissue impingement
Osteochondral lesions
Synovectomy
Lateral instability
Arthrodesis
Ankle fractures
Contraindications
Infection*
Severe degenerative joint disease*
Complex regional pain syndrome
Moderate degenerative joint disease
Severe edema
Tenuous vascular supply
Relative contraindications.
*Absolute contraindications.

Positioning

The patient is taken to the operating room and placed in the supine
position. The hip is flexed to 45, and the thigh is placed onto a well-
padded support placed proximal to the popliteal fossa and distal to the
tourniquet. The lower extremity (LE) is then prepared and draped so
that good access is available posteriorly. A tourniquet is applied as
needed. A noninvasive distraction strap is placed over the foot and
ankle. Distraction is used to separate the distal tibia from the talus so
that at least 4mm of joint space opening is obtained (Fig. 30-1).
Without distraction, the surgeon has difficulty positioning the
arthroscopic instruments in the ankle without scuffing the articular
cartilage; visualizing the central and posterior portions of the ankle
also is difficult without adequate joint separation. The distraction
device is carefully positioned so as not to injure the neurovascular
structures, and approximately 30 to 40lb of force is placed across
the ankle for no more than 60 to 90 minutes. Before applying the
distraction strap, the surgeon should identify and outline the dorsalis
pedis artery, the deep peroneal nerve, saphenous vein, tibialis anterior
tendon, peroneus tertius tendon, and superficial peroneal nerve and its
branches on the skin with a marker. Identification of the superficial
peroneal nerve and its branches is facilitated by inverting and plantar
flexing the foot and flexing the toes.

Arthroscopic Portal Placement

The surgeon uses three primary portals or access areas to insert the
arthroscope and instrumentation (Fig. 30-2). These include the
anteromedial, anterolateral, and posterolateral portals. Accessory
portals can be used as needed but are rarely required. Portals are
made by nicking the skin only, then with the use of a clamp spreading
through the subcutaneous tissue and into the ankle joint. The surgeon
must take great care to avoid injuring the neurovascular and tendinous
structures.

The anteromedial portal is established first and a 2.7-mm, 30 oblique

small joint videoscope is inserted. The surgeon establishes the
anterolateral portal under direct vision, using extreme care to avoid
injuring the superficial peroneal nerve branches. The arthroscope is
then positioned in the posterior portion of the ankle so the
posterolateral portal can be made just lateral to the Achilles tendon,
entering the ankle beneath the posterior ankle ligaments.

In recent years, techniques have been developed for arthroscopy in the

prone position, using the posterolateral and posteromedial portals. This
allows access for treatment of a variety of problems, including
osteochondral lesions of the talus (OLT), os trigonum, and flexor
hallucis longus tendinitis or tears.2
7-10
The senior author of this chapter occasionally uses this position.

Arthroscopic Examination

A 21-point arthroscopic examination of the ankle is performed to

ensure a systematic evaluation.2 After completing the arthroscopic
evaluation, the surgeon identifies the pathology and treats it
accordingly, using small joint instrumentation ranging in size from 2.0
to 3.5mm. These instruments include baskets, knives, intraarticular
shavers, and burrs. Scar tissue is removed using baskets and an
intraarticular shaver. Synovectomy is performed with an intraarticular
shaver (Fig. 30-3). OLT are carefully evaluated and, if they are found to
be loose, excised with a ring curette and banana knife. The surgeon
can use transmalleolar or transtalar drilling, and/or microfracture
techniques, to promote fibrocartilage formation and new circulation in
the avascular area (Fig. 30-4). Acute ankle fractures can be evaluated
arthroscopically; the surgeon can perform percutaneous screw
insertion while monitoring fracture reduction arthroscopically (see
Chapter 29).

After the procedure is performed, the wounds are closed with a

nonabsorbable suture, and a compression dressing and posterior splint
are applied.

Postoperative Plan

The patient remains nonweight bearing on crutches for 1 week. The

splint and the stitches are then removed. If an osteochondral lesion
has been treated with one of the previously mentioned methods, the
patient may be required to be non-weight bearing for 4 to 6 weeks.
During this time, the patient is initially in a removable splint and is
allowed to exercise the ankle actively to promote new fibrocartilage
formation. The type of arthroscopic procedure performed and
individual patient goals determine weight-bearing status and
rehabilitation.

SOFT TISSUE IMPINGEMENT

Ankle sprains are one of the most common injuries in sports. One
inversion sprain occurs per 10,000 persons per day. It has been
estimated that 10% to 50% of patients will have some degree of
chronic ankle pain.

The primary cause of chronic ankle pain after an ankle sprain is soft
tissue impingement. This can occur along the syndesmosis, the
syndesmotic interval between the tibia and fibula, or the medial,
lateral, and/or posterior gutters. Most commonly it is located
anterolaterally given the common occurrence of a common inversion
ankle sprain.11 Diagnosis is done by careful history, physical
examination, and selective injections. MRI can also be very helpful in
assessing the problem (Fig. 30-5).12

The sequence of lateral ankle pain after a sprain can be explained as

shown in Fig. 30-6.

A distraction device may be necessary to identify some of the synovial

pathology involving the posterolateral corner of the ankle, because
such identification can be sometimes difficult. The inflamed synovium,
thickened adhesive bands, osteophytes, and loose bodies are dbrided
arthroscopically using motorized shavers and burrs, graspers, and
baskets (Fig. 30-7).

Postoperatively, patients are splinted for 1 week, and then put into a
CAM (controlled angle motion) walker for 2 to 3 weeks. Subsequently,
they wear a soft ankle brace and begin formal physiotherapy. Return to
activity or sport is allowed only after all rehabilitation goals are
achieved.

Arthroscopic treatment of anterolateral soft tissue impingement of the

ankle has been proven successful at alleviating chronic ankle pain after
an inversion sprain. Numerous authors have reported a good to
excellent outcome in approximately 80% to 85% of patients.11,13,14

OSTEOCHONDRAL LESIONS

Controversy persists regarding the cause, treatment, and prognosis of

osteochondral and chondral lesions of the ankle. OLT comprise 4% of
all osteochondral defects. Males are slightly more predominant than
females between the ages of 20 to 30 years. Medial talar dome lesions
are more common than lateral.

There are many possible causes for OLT. Trauma is believed to play a
major role, but there are also instances where atraumatic
presentations are possible, secondary to idiopathic avascular necrosis.
The diagnosis of OLT requires a high index of suspicion because
symptoms may be mild and imaging is not readily available. Patients
may present in an acute traumatic setting, complaining of persistent
ankle pain (i.e., inversion ankle sprain), or may have a chronic
complaint of ongoing ankle pain. The literature has shown that the
location of pain is not correlative with the location of the lesion,
therefore adding to the vague nature of the condition. Other common
symptoms include stiffness, deep aching pain, swelling, clicking,
locking, or even instability.

OLT that do not respond to conservative treatment are treated

arthroscopically. Most chronic OLT in adults are loose and have to be
excised. The osteochondral lesion bed is then microfractured and/or
drilled. Occasional they can be pinned back (Fig. 30-8).

Postoperatively, patients are splinted for 1 week in neutral position.

Once the portal incisions have healed (approximately 1 to 2 weeks),
ROM exercises are begun, since early motion appears to facilitate
cartilage healing. Patients remain nonweight bearing for 6 to 8 weeks,
depending on the size of the lesion. Usually by 4 to 6 weeks, patients
start physical therapy in the pool and then progress to land exercises.
Cutting, shear stress, or impact activities are avoided for 6 months.

Arthroscopic treatment of OLT has proven to be comparable with open

surgery, with less morbidity and less recovery time. Ankle arthroscopy
has proven to be one of the most reliable methods in classifying OLT.
Recently, clinical management of articular cartilage defects has
generated significant research interest in the orthopedic world.
Attempts to stimulate a hyaline cartilage response have included
transplantation of various cells, including periosteal and perichondral
tissues, woven carbon-fiber pads, and osteochondral autografts/
allografts.

In addition, chondrocyte transplantation has been studied extensively

now in the United States. With further research, it is hoped that
osteochondral defects can be successfully covered by articular
cartilage instead of fibrocartilage replacement.9

OVERALL SURGICAL OUTCOMES

Numerous papers have been published regarding the outcome of

arthroscopic surgery of the ankle. Results vary depending on the type
of procedure and the study that was undertaken. 15-23 In general, a large
percentage of patients should achieve a successful outcome depending
on the nature of the pathology. Expectations after surgery include a full
ROM, strength, and full function. The preoperative ROM, strength, and
severity of the pathologic condition heavily influence the results.

COMPLICATIONS

All arthroscopic procedures have potential complications. 24 The most

common complications in foot and ankle arthroscopy are injuries to the
neurovascular structures, especially the superficial peroneal nerve. 8
The overall complication rate has varied with the transition from
invasive to noninvasive distraction. Current complication rates are
between 6.8% and 9%.25,26 The physical therapist should report to the
physician any problems they note after surgery. Sometimes, excessive
massage over the portals can even irritate the nerves and cause
tingling and numbness. In general, we wait 2 to 3 weeks to initiate
physical therapy after ankle and foot arthroscopy to avoid wound
problems and increased pain while the soft tissues are healing.

THERAPY GUIDELINES FOR REHABILITATION

Several factors must be considered in planning a successful

rehabilitation program for the postoperative ankle arthroscopy patient.
Rehabilitation guidelines can vary greatly for the same injury
depending on the patients age, severity/ chronicity of injury, healing
rate of tissue, general medical health, and previous level of activity.
The physician, physical therapist, and patient must work together as a
team to create an appropriate, effective, and efficient treatment plan
that will allow the patient to optimize his or her recovery. The phases in
each of the following rehabilitation protocols may overlap 1 to 3 weeks
depending on the factors mentioned previously and individual
progress.

The physical therapist should consider the following 6 basic principles

when planning an ankle rehabilitation protocol:

1. Protect the healing tissue. What tissues were directly and indirectly
affected during the procedure? Was the tissue healthy or frayed?
2. It is not just about strengthening. Control of acute symptoms and
restoration of normalized mobility need to be addressed before
embarking on an ankle strengthening regimen. Incorporation of
proprioceptive training in conjunction with the patients strengthening
program will improve overall outcomes.
3. Minimize the effects of immobilization.
4. Encourage a neutral subtalar position during exercise to optimize
functionally efficient training. This may require orthotics.
5. The ultimate goal of rehabilitation is to optimize the patients
function, minimize pain, and restore the patient to a reasonable and
acceptable quality of life.
6. Take into account the whole patient. The ankle is just one part of the
patients kinetic chain. It is this kinetic chain that needs to be
addressed in optimizing outcomes. Putting a plan of care that includes
the patients UEs, trunk, core, and LEs will improve successful return to
function. Recognizing and addressing any dysfunctions within the
kinetic chain will improve functional outcomes and lessen future
problems.

The following rehabilitation program was designed for a patient who

has chronic pain because of a recurring inversion sprain suffered
during the basketball season. The patient underwent an arthroscopic
procedure to dbride the anterolateral soft tissue because of
impingement.

Preoperative Phase

GOALS: Restore functional ROM; normalize gait; apply corrective

orthoses to improve mechanical neutrality; gait train with the
appropriate assistive device(s), taking into consideration postoperative
weight-bearing status; create patients initial postoperative home
exercise program (HEP) to bridge the gap from surgery to initiation of
formal postoperative rehabilitation with surgeons input; educate
patient as to what the next few months will entail and answer any
questions the patient may have (Table 30-1)

Phase I: Acute Phase

Initial Postoperative Examination

Palpation
Incision site
Local muscles and tendons (gastrocnemius, soleus, Achilles tendon)
Check for pitting edema
Dorsalis pedis pulse
Active range of motion (AROM)/passive range of motion (PROM)
measurements
Dorsiflexion, plantar flexion, inversion, eversion
Hallux dorsiflexion
Knee and hip joints Girth measurements
Figure 8 or volumetric measure Strength of uninvolved LE muscles
Quadriceps
Hamstrings
Hip flexors
Hip extensors
Hip abductors
Hip adductors
Hip internal rotators
Hip external rotators
Abdominals
Functional disability measure
Lower extremity functional scale
Foot and ankle disability index Tests requiring caution
Weight-bearing tests if nonweight bearing
Strength testing if patients irritability is high

TIME: Week 1 Postoperative

GOALS: Protect the healing tissue; control postoperative pain and
swelling; initiate HEP; maintain patients overall level of fitness (Table
30-2)

Postoperatively, the patient will be in a splint and have weight-bearing

restrictions. The patient should follow all postoperative instructions
unless told otherwise by the surgeon. Elevation and intermittent icing
(including cryopneumatic device) will help control postoperative
swelling and pain. The patients HEP can be initiated based on the
program designed preoperatively. This may include upper extremity
(UE) AROM/resistive exercises, trunk and core training, isometric
strengthening of the glutes, and quads and hamstrings bilaterally with
AROM exercises for the uninvolved side.

Phase II: Early Rehabilitation

TIME: Weeks 2 to 5 Postoperative

GOAL: Decrease inflammation and pain; increase ankle ROM; restore
soft tissue flexibility/mobility; restore normal gait; progress weight-
bearing and non weight bearing exercises; maintain patients general
cardiovascular fitness (Table 30-3)

The splint can be removed under the surgeons directive. Patient can
progress to weight bearing as tolerated (WBAT) and eventually full
weight bearing (FWB) as long as there is no evidence of compensation.
If the surgical sites are closed/ dry/healed and the surgeon has
approved, initiate pool therapy when available. Pool therapy should
include normalized gait, weight-bearing exercises, balance, and deep
water cardiovascular exercises. Land therapy may also begin
progressing through AROM exercises, exercise bike, beginning weight-
bearing exercises, and passive resistance exercises. Care needs to be
taken to not progress the patient too quickly, which could lead to an
unwanted inflammatory response and probable setback. General
physical fitness should continue to be addressed. PROM, A/AROM,
AROM, and joint mobilization can be initiated to address the patients
restricted ROM at the ankle and the surrounding joints. The soft tissue
will need to be addressed as well, since it is an integral component of
normal joint function Balance activities can also be progressed as the
patient is able to tolerate when on land.

Start with static positioned exercises such as single-limb stance (SLS)

and progress by varying the standing surfaces
(pads/towels/trampoline) and adding dynamic activities such as the
PlyoBack.
The following are some ideas to address the goals for phase 2.

Decrease Inflammation and Pain

Ice and elevate. The incorporation of compression is also very

helpful. This can be found in devices like the Game Ready and
CryoCuff.
Electrical stimulation.
Kinesio tape.
Soft tissue mobilization. This can help with concomitant spasms that
are not uncommon after surgery or injury. Lymphedema techniques can
also assist with inflammation.
Phonophoresis/iontophoresis. The use of ultrasound or electricity to
drive medication into the affected area. Oftentimes this can be a
steroid. This will need to be cleared by the surgeon. Introduction of
medications into an area too soon in the postoperative phase can
slow/deter healing.
Active ankle pumps and circles.
Grade I to II forefoot, midfoot, and hindfoot joint mobilization.
Sustained stretching techniques after ankle and foot mobilization can
be used as a beginning technique to stretch the joint capsule. The
gentle oscillations involved with grade I and II mobilizations can assist
in decreasing swelling and pain. Grade III and IV mobilizations can be
used to improve limited joint ROM once pain and swelling have been
reduced. The following are a few recommendations for accessory joint
mobilizations:
Forefoot and metatarsal anterior and posterior glides
Talar rock (for calcaneal movement)
Anterior glide of the talocrural joint (to increase plantar flexion)
Posterior glide of the talocrural joint (to increase dorsiflexion) (see
Fig. 29-8)
Distraction of the talocrural joint (increase joint play in the mortise)
(see Fig. 29-6) and subtalar joint (see Fig. 29-8)
Medial and lateral subtalar glides (to increase eversion and inversion)
(Fig. 30-9)

Restore Normal Gait

As the patient transitions to partial weight bearing (PWB), WBAT, and

FWB, emphasis on proper heel to toe patterning should be made. This
will limit compensatory patterning as the patient transitions off of
assistive devices. This should carry over into the pool with his or her
aquatic program and on land. It needs to be noted that normalizing
ROM and strength not only in the involved foot and ankle, but in the
proximal lower quarter of the surgical side as well as the nonsurgical
side will lessen the possibility of a compensated patterning. Use of
orthotics can be considered to assist in supporting the foot in a
mechanically correct position.

Increase Ankle Joint ROM and Restore Soft Tissue Flexibility

The use of joint mobilization and soft tissue mobilization combined with
exercise is an effective way to improve ROM and soft tissue function.
As would be expected, a patient who has had an injury or surgery and
is splinted or immobilized can quickly develop restrictions in the soft
tissues and joints at and around the affected area. The following
techniques should be considered if deemed safe to the surgical area:

Joint Mobilizations. Progressing to grade II to III joint mobilizations will

help restore normalized joint function and decrease capsular
restriction.
Soft tissue mobilization to reduce any soft tissue restrictions
including adhesions, spasm, edema.
Gastroc/soleus, FHL, anterior tib, hamstring, quads, glutes, and hip
flexor stretching in weight bearing and nonweight bearing.
AROM exercises in all planes.

Increase Strength

It is important to progress slowly in a well-paced manner to avoid

aggravating the ankle. Aggravation of symptoms could require a 1 to 2
week delay. This can be avoided by making the patient aware that over
activity with exercises and or functional weight bearing could lead to
irritation and overstressing the healing tissues. Adding a few exercises
at a time, working at minimal resistances, and progressing with each
success by either adding new exercises or progressing the
resistance/repetitions of their present exercises is one method of
lessening the risk of any exacerbations. The following are a few
examples:

Manual resistance exercises in all planes. Resistance is mild

progressing to moderate.
Intrinsic muscle strengthening (towel curls, marble pick up) to
stabilize the metatarsophalangeal joints during propulsion.
Windshield wipers.
Active resistive exercises using elastic bands (progress from lightest
to heavier) (Fig. 30-10).
Very low resistance leg presses and total gym within painminimized
ranges.
Incorporate weight bearing toe ups/heel ups.
Continue UE, trunk, and proximal lower quarter exercises.
Incorporate beginning cardiovascular exercises with the exercise bike
at low resistance.

Increase Proprioception

Strengthening the stabilizing muscle groups will offer improved support

through movement and increased safety on surfaces that are less
stable. It will also offer improved reaction when loss of balance occurs.
The following are some examples to help improve this:

SLS exercises (see Fig. 28-5). Beginning with static flat surface SLS
progressing to the use of variable firmness balance pads. With success,
progression to dynamic SLS activities such as using the rebounder and
Thera-Band. The BAPS (Biomechanical Ankle Platform System) Board
can be used in sitting as a mild weight-bearing AROM exercise program
and progressed to FWB in stance (see Fig. 28-6).

Maintain Cardiovascular Fitness

It is important to support and progress the overall fitness of the patient

while in rehab. A patients general fitness level is important to his or
her ability to sustain activity in a safe, mechanically correct manner. If
a body part fatigues but the activity continues, other areas of the body
must work harder to sustain that activity. This can lead to overuse
issues and potentially to injury. The following are ideas to help sustain
fitness:

Stationary (exercise) bike. There are standard and recumbent

options.
Upper body ergometer.
Deep water pool running/bicycling.
High repetition, lower resistance exercises progressed in a manner of
a push followed by a pull exercise without a break between the
alternating sets.
The elliptical is an excellent piece of equipment (once the patient is
allowed FWB) that trains a patient in a more functional way with
minimal impact.
There is a variety of unweighting equipment that can be used in
conjunction with a treadmill.

Increase Patient Knowledge and Awareness

By educating the patient, the physical therapist is involving the patient

as an active participant in his or her own care. The therapist can
empower the patient by having a dramatic effect on his or her
response to therapy, including how to avoid exacerbations and how to
progress with each success. The following are ways to increase a
patients knowledge and awareness:

Allow the patient a safe enough environment to ask questions.

Encourage an open line of communication.
Give specific instructions concerning the pathology of an injury, how
healing occurs, precautions and limitations with activities to avoid flare
ups, what to do for themselves in the case of a flare up, keys to
progression, expectations/goals with treatment, why each component
of the treatment is chosen, and the importance of consistency in
treatment.

Phase III: Advanced Rehabilitation

TIME: Weeks 6 to 8 Postoperative

GOALS: Alleviate pain and swelling; normalize functional ROM;
normalize functional strength; normalize functional proprioception
(Table 30-4)

At this point, the patient should be progressing well with therapy. ROM
and strength should be to a point that the patient is able to walk with a
near normal gait pattern and progressing with the exercise program
that should consist of a variety of weight-bearing and nonweight-
bearing exercises.

Alleviate Pain and Swelling

Modalities specific to the issue(s) being treated should continue. Work

with the patient to help problem solve if there are mechanical
dysfunctions or behaviors that may be precipitating the patients
symptoms. The patient is far enough into the healing phases to
consider iontophoresis or phonophoresis (it should still be cleared by
the surgeon as to not interrupt any anticipated healing). Encourage the
patient to continue using home applied modalities such as ice.
Modification of activities may need to continue with some refining.

Restore Normalized ROM

The patient should be near normal ROM at this point with the goal to
achieve normalized ROM during this phase. Mobilizations should
continue combined with a strong soft tissue mobilization program and
stretching program. ROM during this phase can be made more
aggressive with the use of body weight for stretching. Muscle energy
can be an effective technique to improve ROM. Continue with general
LE ROM as well. Stretching before and after a workout can be very
effective. Help the patient in realizing that the efforts made outside of
therapy (under the therapists guidance) will not only bridge the gap
between treatments, but continue his or her progress.

Improve Strength

As the patient is able to tolerate, progress the resistances in the

therapeutic exercise program:

Proprioceptive neuromuscular facilitation (PNF) for the ankle and the

lower quarter to progress to moderate and maximal resistances.
Increase elastic band resistance.
Add resistance to Windshield wipers and towel curls.
Concentric and eccentric gastrocnemius/soleus training in weight
bearing. Increase resistance by either holding onto weights, resistance
bands, or weight vests. If using a leg press machine, increase weight.
Step up/downs. Add resistance and increase heights of steps (see Fig.
28-15).
Increase resistance and time on exercise bike, elliptical, treadmill.
Okay to incorporate elevation.
Closed kinetic chain exercises using elastic bands, sports cord (start
with light resistance and progress) (Fig. 30-11)
Front and side LE lunges (add weight as tolerated).
Lateral steps, lateral shuffles, lateral sidestep with elastic band.
Slide board.
Continued ongoing UE and trunk strengthening and conditioning.

Improve Proprioception and Balance

Balance and proprioception become more important in this phase

because the patient is getting nearer to returning to sport. With that in
mind, modifications in the stability of the base of support should be
added (i.e., wobble boards, Dyna- Disc, etc.). Additionally,
perturbations to balance using manual contact or external loads such
as weight or bands will challenge the patients balance strategies.

SLS varied surface static and dynamic including uninvolved side

resistive exercises
BAPS board
Wobble boards
DynaDisc
Trampoline for balance weight shifting
Varied position on incline board (Fig. 30-12) Continue with
precautions and limitations with activities, rate of progression, and
specific goals.

Phase IV: Specificity of Sport

TIME: Weeks 9 to 12 Postoperative

GOALS: Provide sport-specific training to allow return to the required
physical demands of the sport and the athletes specific position;
independent home and gym exercise program (HEP, GEP) (Table 30-5)

This final phase of rehab is critical to the success of the athletes return
and is oftentimes an area not included in his or her rehabilitation. It is
often heard that an athlete can return to play when he or she has full
strength and ROM. The problem is full strength and full ROM does not
imply readiness to return to a sport safely and successfully. This safety
and readiness comes with sport- or position-specific training. As the
athlete prepares to return to sports, he or she will need to be
progressed through a grouping of higher-level activities to recreate the
expected stresses, forces, and movements for his or her sport and
position.
It is important to note that an athlete before starting this
phase of their rehabilitation should be:
Pain free
Without swelling
Full ROM
Full strength
Good proprioception

During this phase, the athlete will be working on advanced

strengthening/proprioceptive/conditioning training. The exercises need
to be tailored not only for the physical requirements of the sport, but
also the physical requirements of the position. A football kicker would
require a much different training regimen than a football offensive
lineman. That said, the following exercises and progressions are useful
for rehabilitating a basketball player:

Running on a treadmill
Vary the speeds from jogging to sprint (if available).
Vary the elevations.
Consider lateral shuffle and carioca.
Jogging to sprint on flat hard surface
Resisted running (chute, sport cord)
Bilateral jumping
Agility drills (progressing to sport-specific surface and to competition
speeds) (see Fig. 28-12)
A skip (high knees skip)
B skip (high knees skip with knee extension)
Carioca
Back pedaling
Figure 8 drills
Cutting drills
Plyometrics all directions
Trampoline work
Four-square hopping (single limb) (Fig. 30-13)
Sports drills
Dribbling
Lay ups
Shooting
Boxing out
Pick and rolls
Videotaping the athlete playing and reviewing the tape with him or
her to discuss any noted areas of weakness or biomechanic issues that
could predispose him or her to further reinjury or new injury (Correct
these areas to remove weakness and mechanical issues).
In review, the athlete can be guided in returning to sports activities
with some basic progressions:
Nonweight-bearing exercises
PWB exercises
Full weight-bearing exercises
Stable surface balance training
Walking
Weight-bearing balance board training (start with bilateral and go to
unilateral)
Stepping in all planes
Cariocas
Rebounder jogging
Jogging
Running
Bilateral jumping and hopping
Backpedaling
Figure 8 running
Cutting and twisting
Plyometrics
Single-leg hopping and jumping

The program should be challenging for the athlete while keeping in

mind where that patient is in the healing cycle. Stresses should be
progressed when the physiology will allow for it and as the patient is
able to demonstrate success. Continue to train the athlete into the
physical requirements of his or her sport and position. Safe and
successful return is the ultimate goal.

Before ending the formal rehabilitation program, the physical therapist

should review proper training technique as it applies to the athletes
HEP. The athlete needs to be independent in his or her program.

If the athlete is part of a team that has training staff, with the athletes
approval, discuss the ongoing training program with the team trainer
for consistency during this transition. Speed and duration of these
exercises should meet what is expected for the sport or activity to
ensure a safe return. If the patient has increased swelling or pain that
lasts more than a day or two with these activities, then the patient is
not ready to return to that particular level of play. Be sure to
communicate with the surgeon the athletes status in the discharge
note. Be sure to comment on the HEP and that the training staff has
been contacted.

TROUBLESHOOTING

It is not uncommon after ankle surgery to have soreness, numbness,

and tingling over the portal sites. There may also be residual swelling
and discoloration. Physical therapy can begin within 1 to 3 weeks
postoperatively. If the therapy is too aggressive too soon, significant
swelling and pain may develop and lead to loss of motion, loss of
strength, decreased functional ability, and diminished confidence. It
will take time to reverse this and it can delay therapy for 2 to 3 weeks
or more. Although it is desirable to achieve weight bearing early in the
rehabilitation process, caution should be taken in removing assistive
devices if the patient is continuing to walk with an antalgic gait. Some
patients may require special precautions depending on the surgery
performed, the tissues involved, and the normal physiologic healing
that is expected. The physical therapist should review the operative
notes and discuss any precautions with the surgeon.

Complications can occur in ankle arthroscopy as with any surgery. It

was previously discussed that a 6.8% to 9% complication rate exists.
The most common of these complications is injury to the surrounding
nerves, with injury to the superficial peroneal nerve accounting for the
most frequent complication seen with ankle arthroscopy. There would
be transient or permanent numbness on the dorsum of the foot
extending into the toes. The therapist should notify the surgeon
immediately if:
Drainage, redness, swelling, increased pain is evident at any of the
surgical sites.
Patient develops a fever.
Abnormal redness, swelling of the lower leg is seen.
Lack or loss of sensation develops.
Sudden inability to tolerate therapy, HEP, function is evident.
Patient stops attending therapy.
Patient is noncompliant to any part of or all of rehabilitation.

Be sure that the athlete/patient always has a progress note when

returning to the physician. This will allow the surgeon to know where
the patient is in rehabilitation, any gains made, any issues that exist,
and any recommendations to consider with his or her ongoing care.
Keep the lines of communication open always.

CONCLUSION

Therapy for the postoperative ankle should follow an agreed upon plan
set up by the surgeon. Sticking to a program that allows for
progression of a patient taking into account the physiologic healing
that is occurring will allow for a wellprogressed rehabilitation with a
minimal amount off exacerbations. Progressing the patient with
success and making sure the patient has met all goals before
progressing to the next phase of rehabilitation will continue steady,
forward progress. Only when the athlete/patient has successfully
returned to full functional ROM/strength/proprioception in a pain
minimized/alleviated state and is able to meet thenecessary physical
requirements of normal activities should he or she be allowed to return
to normal activities (whether it be professional sports or gardening at
home). Do not forget the other three-fourths of the patient when
rehabilitating the surgical ankle. Remember, the patient will need to be
able to perform all required functions of his or her normal activities,
which means the need to be fully functional and strong. The patient
must also exhibit sustained endurance. Lastly, and perhaps most
importantly, if there are any questions or issues that come up, talk with
the surgeon. This open line of communication is paramount to the
patients/athletes ultimate outcome.

CLINICAL CASE REVIEW

1 Paul had arthroscopic ankle surgery for an excision of an anterior

tibiotalar osteophyte. He had surgery 7 weeks ago and has returned to
working as a store manager. He is on his feet most of the day. He is
anxious about recovering quickly and doing his usual routine. During
his last visit he complained of increased soreness at times. The pain
has not been decreasing, and swelling persists. During his home
exercises, Paul works hard on the resisted exercises. How can the
therapist help Paul to progress?

Paul was told that progressing his function or exercising too

aggressively could lead to increased symptoms and potential delays in
his progress. Pauls physician was able to write a prescription for
compression stockings to help with the swelling and Paul was advised
to sit and elevate his leg whenever possible. Paul was put on an icing
regimen to elevate and ice three times a day as well. Pauls HEP was
reviewed, with adjustments to resistances and repetitions to lessen the
likelihood of irritation. Steady progress staying below the threshold of
symptoms and exacerbations will keep Paul progressing with his
therapy/function with minimal delays and setbacks.

2 Christine is a 32-year-old woman who underwent an ankle

arthroscopy procedure for dbridement of soft tissue impingement 5
weeks ago. Since then her physical therapy has consisted of massage,
ultrasound, AROM and PROM exercises, resisted exercises,
cryotherapy, and a HEP. Her main complaint is pain during gait, while
descending stairs, and during attempts to squat partially. Dorsiflexion
is limited, and minimal swelling persists. What treatment may be
particularly helpful to Christine?
Mobilization of the talocrural joint was performed with an AP
movement applied to the talus while stabilizing the distal tibia. Distal
fibular mobilizations were performed as well to assist with the talus
ability to move into the ankle mortise. This was followed by stretching
and ROM exercises to reinforce dorsiflexion. The increase in ROM to
15 with this treatment addition reduced her pain dramatically with
gait, stairs, and squatting.

3 Jessica is a 40-year-old woman who had an ankle arthroscopy done

with the removal of a loose body from an osteochondral lesion 9 weeks
ago. She was nonweight bearing for 5 weeks and has been in therapy;
progress with exercise has decreased because of pain during many of
the closed chain exercises, such as SLS, double heel lifts, minisquats,
and walking more than 8 minutes on the treadmill. What type of closed
chain exercises can Jessica do to progress with her strengthening?

The therapist explained that any activities that cause prolonged pain
and swelling need to be put on hold and techniques reviewed with the
physical therapist. Any changes and modifications can be made so the
exercise is successful. If success is not able to be achieved, the
exercises that are symptomatic should be stopped until such time that
the patient is able to perform without symptoms. Jessica was able to
perform the following exercises without issue: forward lunges,
backward lunges, lateral lunges, and single heel raises performed on a
leg press machine set at 75lb. She could backward walk and lessen
the time on the treadmill. Use of a pool for gravity-minimized exercises
is ideal in this situation as well. As her tolerance improved, she was
able to progress her therapeutic exercises successfully and without
exacerbation.

4 Rebecca is a 45-year-old mother of young children. She underwent

ankle arthroscopy surgery for a synovectomy 5 weeks ago. When she
is on her feet for more than a couple of hours, she has prolonged
soreness. Yesterday, she was on her feet for several hours in the
afternoon and intermittently for the rest of the day. Today, she is in for
treatment. She has minimal to moderate swelling and complains of
minimum to moderate levels of pain with weight-bearing activities.
What type of treatment should Rebecca receive today?

When pain and/or swelling limits the progress of rehabilitation, the

intensity of rehabilitation needs to be modified. The therapist, in this
case, focused on controlling pain and decreasing swelling. Joint
mobilizations using glides and distraction maneuvers were performed
on the talocrural joints. Gentle PROM was performed. AROM and
resisted exercises were placed on hold because of the pain and
swelling. Soft tissue mobilization was performed to assist with swelling
and to address any soft tissue/fascial restrictions. Ice packs with
compression was performed as well. The patient was encouraged to
avoid any known aggravating factors. The patients swelling and pain
lessened and the patient was able to get back on track.

5 Jennifer is a 22-year-old ballet dancer. She underwent arthroscopic

ankle surgery 10 weeks ago for posterior soft-tissue impingement. She
has begun to resume dance practice but still feels some pinching
discomfort in her posterior ankle when in an en pointe (on toes)
position. What treatment may be particularly helpful to Jennifer at this
stage of her rehabilitation?

A mobilization technique was performed at the talocrural joint. A

posterior to anterior (PA) glide was applied to the talus, while
stabilizing the distal tibia, to increase plantarflexion. To address the
end range position needed for ballet, the mobilization was performed
in an end range plantarflexion position with a grade IV technique to
improve capsular stretching. Following treatment, Jennifer was able to
go en pointe with significantly less pinching in her posterior ankle.

6 James is a 30-year-old recreational soccer player. Because of multiple

ankle sprains over many years of playing, he suffered an osteochondral
lesion of his medial talus. He underwent arthroscopic loose body
dbridement 9 weeks ago. He has been jogging without symptoms for
up to 15 minutes on a treadmill or a track. Over the weekend, he went
out to run on the soccer field and began to feel soreness. He states he
did no cutting, only running straight up and down the field. What can
be done to help James achieve his goal of returning to soccer when he
is unable to run on grass pain free?

Despite James pain-free running on flat surfaces, the grass poses a

new challenge because of its inherent instability. James may need to
spend more time working on his ankle proprioception during dynamic
activities before running on grass. Running on level ground with small
changes in direction will provide his ankle the stimulus to control the
lateral movements of the subtalar joint. He may also be able to
achieve his goal by breaking down the task and doing shorter jogs on
the grass with rest before discomfort to allow his body to adjust to the
new situation.

7 You have been seeing Sharon in physical therapy for 1 week following
her surgery for ankle arthroscopy 2 weeks ago. Today she is
complaining of worsening pain and redness along her surgical portals.
Upon inspection you notice localized edema, erythema, and warmth
along the surgical portal. In addition, there is a small amount of yellow
exudate from the wound. How should your physical therapy plan
change based on todays findings?

You should immediately contact the surgeon as there is a chance that

the wound has become infected.

8 For 2 weeks following arthroscopic surgery for synovitis of his ankle,

Bill complains of numbness and tingling along his lateral foot. He
noticed it to be more pronounced after splint removal and the onset of
weight bearing 1 week ago. He often feels it when pointing his toes
during his active ROM exercises. What other objective testing should
you perform at this time to help in your treatment of Bill?

Decreased neural mobility in the foot and ankle can occur following
any immobilization. Straight leg raise or slump testing should be
completed to determine if this might be causing Bills symptoms.