Post Surgical Physiotherapy for Active 69-Year-Old with Ankle Replacement
History
More and more people are staying active through advancing age, and this case is a fine example. Physical activity does not have to decrease after major surgery, in fact, it may be even more important to schedule it into everyday life. Our client is a 69-year-old female with arthritis that eventually led to a knee replacement in 2019 and a more rare surgery, ankle replacement in 2024. She reports that at her baseline health she walks a lot and completes all activities of daily living independently. She is seeing the Physiotherapist to support a full recovery from surgery to ensure that she returns to her baseline functioning. She also wants to learn how to better manage her arthritis for preventative care. Our client complains of pain in the ankle and calf of the surgical leg. She is presently performing Pilates exercise and practicing arm and hip strengthening at home. In the past she enjoyed swimming and cycling, but she had been experiencing chronic ankle pain due to arthritis which runs in the family.
Assessment
First Visit
Our client is 6-weeks post surgery. She is independent, strong, fit and agile with transfers. To walk, she is using a 2 wheeled-walker and is only allowed 25% of her weight through her ankle. She is walking short distances and can move in bed and around her apartment adequately. She is experiencing pain and tightness in the tibialis posterior muscle and tendon found deep in the calf. This muscle is a key stabilizer supporting the medial arch of the foot. The client describes her gait as “feeling like she is walking more on the outer edge of her foot” with an inverted ankle. She is tight in the achilles tendon. The full body assessment allows the Physiotherapist to address all areas that may contribute to gait and balance problems. There is also tightness in the calf muscles of the surgical leg – the gastrocnemius and tibialis posterior including the tendons. Minimal swelling is observed.
Treatment
First Visit
Our Physiotherapist provides Soft Tissue Massage to tibialis posterior as well as massage for the achilles tendon. Calf stretches are performed and a thorough review of hip strengthening and core Pilates exercises is done. Gait training both forwards and backwards using the walker is practiced with hands-on postural correction. Seated ankle range of motion in all directions including plantarflexion, dorsiflexion, inversion and eversion is repeated 2 sets of 10 repetitions. After this work improved ankle mobility is seen and our Client is walking with a more neutral and centered ankle.
Assessment and Treatment
Second Visit
Our Client reports inner ankle and calf pain in the tibialis posterior tendon and muscle after a longer than usual walk. Her operated ankle is inverted with a high arch, compressed on the inner arch by the tibialis posterior muscle and tendon. She also has a shortened plantar fascia (supportive band of connective tissue on the sole of the foot). All the calf muscles are short, tight and tender to touch. Again, she feels as though she is walking on the outer edge of her foot in supination.
Treatment and exercises are the same as the previous sessions with Deep Tissue Massage given to the Tibialis Posterior muscle and the plantar fascia. After the session the ankle is more neutral, the foot feels more relaxed and gait is more even and stable with the walker.
Assessment and Treatment
Third Visit
Our Client is able to wean off her boot and start walking with running shoes. Through daily exercise and support, she has good mechanics with her gait and the ankle appears stable and in neutral alignment. The calf muscles are tight but improving slowly. The ankle is reaching dorsiflexion of 5-10 degrees before treatment and 10-15 degrees after treatment. This visit consists of more deep tissue massage for affected muscles and walking with the 2 wheeled walker using sneakers and cues for gait correction. A visit to the gym in the building to use the bike, elliptical and rowing machine is made to begin the strengthening program and improve aerobic fitness. One legged stance is practiced at the walker to increase weight bearing tolerance through the operated ankle. Our client is supervised and advised not to overdo the walking while transitioning to running shoes. She is to keep within the limits of her pain and tolerance levels.
Fourth Visit
We observe that Our Client is walking well with her running shoes. She is using the gym bike, elliptical and rower for heart and lung health, and to build strength and endurance. She has progressed from the walker to using walking poles for walking longer distances.
Treatment continues with Soft and Deep Tissue Massage for short, tight calf muscles and all plantar muscles of the foot. The metatarsophalangeal joints (MTP – the joints between the bones of the foot and the ones of the toes) are mobilized and the arch of the foot is lengthened to create space in the mid foot. Calf stretching in standing is demonstrated and performed for regular at-home care too.
Outcome
Total Ankle Replacement can require 5-6 months of Physiotherapy depending on the individual circumstances. Our Client will continue with us until she feels she is ready to return to her pre-surgical level of activity. She is well on her way to a full recovery. As with any Physiotherapy Program Post Surgery, the main areas to focus on are:
Pain and Swelling Control:
Massage and compression are the primary ways in which our Physiotherapists will help with pain and swelling. Elevating the ankle when seated, using ice when needed and avoiding overdoing weight bearing exercises such as walking are key.
Regaining Range of Motion:
Inflammation and swelling after surgery and immobilization in a boot will cause stiffness in the ankle joint. Loss of joint mobility and contracted tissues will mean loss of balance and walking ability, so the Physiotherapist employs massage, passive stretching, manual mobilization techniques and range of motion exercises.
Gait Training and Balance:
After ankle surgery, you are required to be non-weight-bearing for at least 6 weeks. Muscles around your ankle will have weakened, you may walk with a limp and your balance will be off. There is usually a transition from crutches or walker to walking independently again, first with a boot and then with well-fitted walking or sport shoes. Your physiotherapist is the one to help you regain proprioception or a sense of balance and movement awareness in your ankle joint. Careful foot placement and mobilization with hands-on therapy helps in finding stability again. (Dynamic standing balance exercises are progressed week to week)
Building Strength:
The first weeks of rehabilitation will involve gentle strengthening exercises to help our client stand, walk and climb stairs with confidence. Isometrics like static holds to gently turn on muscles are used until you are ready for more of a challenge with resistance bands and standing balance exercises. Generally it is advised to avoid high impact sports with ankle arthroplasty, but our client can return to her long walks, swimming and pilates to stay healthy and fit.