Brostrom Postoperative Protocol

The surgical repair after a lateral ligament reconstruction of the ankle can be variable. Options for repair include the ligament only or could include peroneal tendon and bone work in the form of osteotomies. The repair itself could include soft tissue only or augmentation with either allograft or a suture-like material. Frequently, there can be injuries to the articular cartilage and this may affect the return to play timeline as well. Obviously, these nuances will affect what the recovery may look like. Below is a rough guideline as to what the recovery may look like. Obviously, this could be adjusted based on additional procedures that are performed at the time of surgery. Please contact us if there are questions on specifics of the rehabilitation.

Checklist of Ankle Procedure Performed:

• o Ankle Arthroscopy with Debridement
• o Collateral ligament reconstruction (Brostrom/Gould)
• o Peroneal Tendon Repair –
• o Repair of Osteochondral Lesion
• o Open reduction internal fixation of syndesmosis/high ankle sprain

Big Picture:

• 0 to 2 weeks: Non weight bearing in a splint, elevate and minimize swelling.
• 2-6 weeks: transition to a postoperative boot – progressive weight bearing for 6 weeks but may begin range of motion exercises
• 6 weeks: Wean out of boot into lace up ankle brace with tennis shoe.
• 12 weeks: cleared to begin a return to sport program

Phase 1: Weeks 0-2:

• NWB for first two weeks –
• (Dr. Strasser: Splint and NWB for first 2 weeks)
• No Inversion until 6 weeks
• Control swelling with modalities and elevation
• Goal: minimize swelling and promote skin healing –

Phase 2: Weeks 2-6 (Gradual progression to Full weight bearing)

• Precautions: No inversion until 6 weeks
• Stirrup Splint (AirCast or similar) or Boot on at all times (weight bearing and sleeping)
• No wobble board
• Begin: Scar mobilization (dry, circular patterns)
• Massage to posterior, anterior, and lateral compartments
• Mobilization of mid-tarsal and inter-metatarsal joints
• Mobilize ankle PF/DF
• Exercises: Stationary Bike 5-20 minutes
• · Active assisted range of motion to at least 10° dorsiflexion and 30° plantarflexion
• · Isometric activation of the peroneus longus, brevis and tertius
• · Ankle isometrics to 10° of dorsiflexion and 30° of plantarflexion
• · Seated active dorsiflexion to 10° and plantarflexion to 30° with rockerboard
• · Upper body strengthening activities as tolerated (seated or supine)

Weeks 6-12:

· Discontinue cam walking boot

· Transition into lace-up figure-8 ankle brace or air cast based on comfort

• · PT modalities as needed to reduce residual pain and swelling
• · Advance to full active range of motion in all directions
• · Mobilizations as needed to address specific motion restrictions
• · Scar mobilization as needed
• · Standing BAPS exercise: level 1 or 2
• · Single-limb static standing balance on firm surface
• · Sagittal and coronal plane weight shifting on rocker board
• · Multi-directional ankle strengthening with resistance band
• · Double-limb calf press (body weight only)
• · Rhythmic stabilization in all directions
• · Single-limb standing on affected leg while pulling against resistance band with unaffected leg (sagittal plane)
• · Wall squats
• · Single-limb stepping (4″ step)
• · Treadmill walking
• · Stationary cycling

Weeks 12-

Precautions: None (Air-Cast or lace up ankle brace for athletic activities)

• · Cleared to begin a return to play program (may be longer if osteochondral injury or peroneal tendon pathology)
• · PT Modalities as needed
• · Continue use of lace-up figure-8 brace
• · Mobilizations as needed
• · Double-limb and single-limb leg press
• · Shallow and deep-water exercise or swimming
• · Upper body strengthening activities as tolerated
• · Stationary cycling
• · Standing BAPS exercise: level 3 or 4
• · Single-limb static standing balance on foam mat
• · Single-limb standing balance on wobble board or disc
• · Double-limb and single-limb calf press
• · Resisted lunges
• · Lunges onto BOSU
• · Single-limb balance with Plyoball toss (front facing)
• · Medicine ball toss standing on wobble board with wide base of support
• · Single-limb standing on affected leg on foam mat while pulling against resistance band with unaffected leg (four directions)
• · Interval running

Weeks 16 -24

Precautions: Return to normal/sport activities (longer if ankle OCD cartilage procedure)

• Brace for sport for the remainder of the season
• · Maintain full motion of ankle and all uninvolved joints
• · Mobilizations as needed
• · Advance weight/resistance as tolerated for previous OKC and CKC exercises
• · Treadmill running
• · Elliptical trainer for cross training
• · Standing BAPS exercise: level 3 or 4
• · Single-limb static standing balance on foam mat with perturbation such as multidirectional reaching
• · Resisted lunges onto BOSU
• · Single-limb balance with Plyoball toss (side facing)
• · Medicine ball toss standing on wobble board with narrow base of support
• · Box jumps
• · Double-limb and single-limb plyometric hops
• · Straight line sprints
• · Shuttle run
• · Crossover and cutting drills
• · Sport specific drills

References:

1) Reider, Bruce, et al. “Ankle Sprains, Fractures, and Chondral Injuries.” Orthopaedic Rehabilitation of the Athlete: Getting Back in the Game, Elsevier/Saunders, Philadelphia, PA, 2015.