This is a standard program; any unusual circumstances noted by MD or therapist should be clarified and protocol modified as warranted.
RN pre-screen for “Red Flag” patient referral to PT pre-op.
- No previous ortho surgery
- Bilateral surgery
- Previous failure
- over 65
- co-morbidities including UE injury/dysfunction
PT pre-op visit
- Assess current level of function (ADLs/Mobility), ability to manage post-op restrictions, use of assistive devices.
- Screen PMH, condition of UEs and contralateral LE
- Home Environment: Modifications needed, assistance available, SNF or HH needs.
- Teach post-op mobility restrictions.
- Gait training: NWB on surgical foot unless otherwise indicated. Must be able to transfer and walk maintaining precautions.
Examples of potential gait devices:
- Crutches, walker, wheelchair, knee scooter, “Peg-leg”.
- Patient to obtain equipment and bring to hospital.
- General post-op exercise program: ROM, strengthening for UEs, uninvolved leg; AROM/Isometrics gluts, hip, knee, toes of surgical leg unless contraindicated by procedure or condition.
- Relaxation techniques and edema management.
- Avoid excessive elevation; arterial circulation can be compromised leading to compartment syndrome. 6-10 inches above heart (1-2 pillows) is sufficient.
- Family/Caregiver training as needed.
- NWB on surgical foot.
- Bed “rest” with leg elevated 8-10 inches*. Up as tolerated.
- CAM boot or posterior foot splint.
- Exercise training for HEP:
- POD 1: Bed exercises for joints above surgical sites. Toe AROM to tolerance.
- POD 2: Early AROM ankle, toes.
- Up in chair with nursing assist for lunch and dinner not to exceed 1 hour. Limited time with extremity dependent. Keep foot elevated while sitting and during transfer.
- Gait training (NWB surgical foot). Family/caregiver training as needed. D/C from hospital.
- POD 4-7: Patient to begin early subtalar AROM when surgical incision sealed (clear with M.D.) Begin gentle PROM toes. Continue with previous exercises. *Excessive elevation may increase risk of compartment syndrome; 6-10 inches above heart is sufficient.
- NWB on surgical foot MD visit: Sutures out. Continue.
- Pt. teaching: Edema control.
- Desensitization techniques prn. Beginning scar massage.
- Continue with previous exercises for HEP
- AROM ankle, STJ, toes, gentle active assist, passive ROM (stretch) toes with MT stabilized. Can swim (but not walk in water) as soon as wound is healed. No aggressive kicking.
- NWB on surgical foot*. MD visit: X-ray.
- Pt. teaching: Scar mobilization.
- Continue/reinforce previous exercises for home exercise program. Monitor range of motion.
- Home exercise program, strengthening, conditioning uninvolved extremities. *Small incision repair may begin 50% WB as early as 6 weeks post-op. (Extensile ORIF: NWB until 12 weeks).
- Exercise training for HEP:
- Ankle, subtalar, forefoot, toe ROM. OK to use lightweight resistance band .
- Ankle, subtalar isometrics.
- gentle towel calf stretch
- Scar tissue mobilization. Desensitization techniques. Measure range of motion ankle, STJ, toes.
- Gait training (ORIF) in CAM boot: Progressive weight bearing over one month- 50lbs for 2 weeks followed by 2 weeks @ 100 lbs until FWB. OK to slow progression if painful.
- Wean off assistive device. Wean off CAM walker when comfortably FWB (by 16-17 weeks). Shoe modification if needed.
- Begin balance and proprioception training when FWB.
- Conditioning: Pool therapy, stationary bike, low impact endurance training. Home exercise program.
- Progression of gait.
- Ankle, subtalar, forefoot isometric, isotonic strengthening with tubing/theraband resistance (no free weights).
- Soft tissue, gentle joint mobilization 5 months:
- Advanced balance, proprioceptive work, closed chain exercises. Sample exercises for home exercise program: Progressive stretching. Single leg stance activities. Step-ups, stairs. Foam standing/wobble board/Baps. 6 months:
- Ankle, subtalar stretching.
- Joint mobilization.
- Advanced gait training, maximize quality of gait.
- Higher impact activities O.K.
- Ankle, STJ strength-endurance training.
- Functional LE testing: Timed SLS. SL squat
- measure knee angle. SL heel raise
- measure distance of heel to floor, count reps. Timed walk.
- Assess shoes/orthotics.