Postoperative Rehabilitation Protocol Anterior Talofibular Ligament Reconstruction 

 

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Anterior Talofibular Ligament Reconstruction via Modified Brostrum-Gould Repair.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

 

* This protocol applies only to ATFL reconstruction.  If any other additional variables present (such as tendon augmentation or
peroneal tendon repair, revision procedure, patients with hyper-ligamentous laxity, and co-morbidities such as obesity and
advanced age) the therapist may need to take a more conservative approach or consult directly with our office for specific recommendations or alterations to protocol.

*Return to play is sport-specific.  Contact sports require a minimum 4-6 month rehabilitation period.  Any athlete wishing to resume play must undergo evaluation in the office prior to obtaining clearance. 

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

 

Phase 1- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity, and maximize the patient’s mobility with a goal of functional independence.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential. 

 

Goals: 

  1. Protect repair and promote soft tissue and wound healing
  2. Minimize atrophy of proximal lower extremity muscles
  3. Implement use of nonpharmacologic modalities to control pain and swelling such as cryotherapy, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wound for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment AROM/PROM, efficiency/safety/necessity of ambulatory assistive devices
  5. Assess for signs of DVT (Homan’s sign, calf circumference, Well’s Criteria), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Quadriceps, hamstring, and gluteal exercises OK 
  2. Supine passive hamstring stretches
  3. Straight leg raises (flexion,extension,ADDuction, ABDuction) 

Precautions:

  1. NWB at ankle joint
  2. Patient may remove splint/boot for bathing only

Phase II (Post-op Week 2-6)

Goals:

    1. Progress WB as tolerated in boot
    2. Decrease swelling/inflammation
    3. Protect repair and improve plantarflexion, dorsiflexion, eversion (PROM-->AAROM-->AROM)

    Assessment by Therapist:

    1. Monitor wound for signs of infection, dehiscence
    2. Monitor for signs/symptoms of DVT
    3. Assess use of narcotic and non-narcotic analgesics
    4. Assess pre-treatment and post-treatment PROM/AROM 


    Therapeutic Exercises:

    1. Continue Phase I exercises
    2. OK for upper body and proximal lower extremity strengthening exercises as tolearted
    3. Gentle gastroc stretching
    4. OK sub-maximal ankle isometrics other than inversion maneuvers
    5. Lumbopelvic strengthening exercises as necessary (clamshells, plank,etc) 

    Precautions:

    1. No ankle inversion until after 6 weeks post-op and second office visit

     

    Phase III (Post-op Week 6-12)

    Goals:

    1. Normalize gait pattern
    2. Restore full ROM
    3. Establish Home/Gym Exercise Plan in conjunction with therapist recommendations
    4. Return to work for professions not requiring manual labor, heavy lifting, climbing stairs, shifts requiring standing > 4 hours without breaks or steps > 5-10K per day

    Therapeutic Exercises:

    1. Continue Phase II exercises and progress resistance, strengthening, and repetitions as tolerated
    2. 4 way ankle theraband exercises
    3. Progress balance and proprioceptive exercises as appropriate
    4. Calf raises 
    5. Leg press, knee extension, hip ADDuctor/ABDuctor exercises
    6. Double limb standing on uneven surface (wobble/rocker board), Single limb balance with progression to uneven surface including perturbation training after week 9 if pain controlled and swelling resolved.  May also begin following exercises after week 9:
      1. Single leg calf raises
      2. Full depth squats
      3. Deadlift
      4. Resisted stepping
      5. Y-Balance/Star Balance
      6. Single leg balance with ball toss
      7. Step ups with single leg holds

    Precautions:

    1. No running, jumping, sprinting, cutting, pivoting, plyometrics before third office visit at 12 weeks

    Phase IV (Post-op Week 12-24 weeks)

    Goals:

    1. Maintain full ROM
    2. Continue Phase II and III exercises
    3. Start sport-specific drills at 16 weeks based on progress

    Therapeutic Exercises:

    1. Elliptical, stair climber
    2. Standing gastroc stretch and standing soleus stretch
    3. Hip hike
    4. Lateral lunges
    5. Interval running program
    6. Advance plyometrics and proprioceptive drills