Modified Brostrom-Gould Repair for Chronic Lateral Ankle Instability:

Post Op Protocol

Week 0-3:

Clinic Follow up on Post Op Day 1.
Dressing Change and Placement into Fixed Ankle Walker Boot for 6 weeks
Clinic Follow up on Post Op Day 14 for suture removal
Wear the Fixed Ankle Walker at all times, except when showering.
Wear the Fixed Ankle Walker Boot at night for 4 weeks.
Continue Ice/Cryotherapy as needed
Toe curls, toe spreads/extension, gentle foot movements in boot
Hip and knee strengthening exercises
Restrictions:
Non-weight bearing for 3 weeks.
Avoid plantar flexion greater than resting position for 4 weeks
No passive inversion or forceful eversion for 6 weeks
No swimming for 6 weeks.
No running, jumping, or ballistic activities for 3 months

Week 3 – 6:

Begin exercise bike with Fixed Ankle Walker Boot, no resistance.
Can sleep out of the Fixed Ankle Walker Boot at the beginning of Week 4.
Isometrics in multiple planes and progress to active exercises in protected ranges
Proprioception exercises, intrinsic muscle strengthening, manual resisted exercises
Soft tissue treatments daily and regular mobilization of intermetatarsal and midtarsal joints.
Minimize talocrural and subtalar mobilization

Week 6-12:

Clinic Follow up at week 6.
Progress to full weight bearing in Fixed Ankle Walker Boot.
Aircast splint for day-to-day activities for 8-12 weeks post-op
Cycling, aerobic machines in AirCast Splint as tolerated, and begin pool workouts in splint
Gradually increase intensity of exercises focusing on closed-chain and balance/ proprioception
Passive and active range of motion exercises into inversion and eversion cautiously

Month 3-6:

Clinic Follow up Month 3 and Month 6.
Progress back into athletics based upon functional status
Wear a lace-up ankle support for athletics

Modified Brostrom-Gould Repair for Chronic Lateral Ankle Instability:

Detailed Physical Therapy Post Op Protocol

The following post-operative rehabilitation protocol is adapted from the one used at the Brigham and Women’s Hospital and the Hospital for Special Surgery (HSS), where the modified Brostrom-Gould procedure is the preferred anatomical surgical procedure for the treatment of lateral ankle instability.

Progression to the next phase is based on Clinical Criteria and/or Time Frames as Appropriate.

Immediate Post Surgical Instructions and Home Exercise Program: Weeks 0 to 6:

Goals:

Edema control/reduction
Protect healing tissue.
Independent transfers and ambulation, non weight-bearing on involved lower extremity with use of optimal ambulatory assistive device

Physical Therapy interventions:

Proximal LE, upper extremity (UE) and core muscle strengthening exercises
Aerobic upper body conditioning
Transfer and gait training with optimal assistive device, non-weight-bearing on surgical lower extremity (LE) until independent
Identify patient’s goal for return to recreational and/or sport specific activities

Criteria for progression to Phase I:

Decreased pain
Decreased edema
Independence with home exercise program (HEP)
Independence with transfers and ambulation NWB on involved lower extremity

Phase I: Weeks 6 to 8:

Goals:

Protect healing tissue.
To protect the CFL from inversion and the ATFL from plantarflexion, the ankle is kept in Fixed Ankle Walker Boot
Progressive protected normalization of gait: After the initial 6 week immobilization period, progressive weight-bearing is initiated as tolerated, first with the involved ankle in a walking boot and then transitioned to protected ankle weight bearing in a semi-rigid ankle stirrup orthotic
Edema control and patient education regarding skin/wound care and prevention of infections
Pain reduction
Prevention of deconditioning
Prevention of scar adhesions and myofascial restriction

Precautions:

No passive, active-assisted or active inversion exercises
No active assisted or passive stretching into plantarflexion
Avoid standing or walking for extended periods of time

Physical therapy interventions:

Progressive weight-bearing as tolerated, with use of walking boot and appropriate assistive device.
Progress towards discontinuing boot and normalizing gait with commercially available semi-rigid pneumatic orthotic and assistive ambulatory device as needed
Edema control with use of modalities such as interferential current, cryotherapy
Joint mobilizations as identified by surgeon, adhering to indentified precautions and avoiding the tensioning of the CFL and ATFL
Stretches of gastrocnemius and soleus muscles
Cross training, including aquatics and upper body ergometer. For safety reasons, patient should ambulate to the pool with orthotic and assistive ambulatory device as needed
Submaximal isometrics (all planes except inversion)
Proprioception with activities involving bilateral stance
Soft tissue mobilization as indicated

Criteria for progression to Phase II:

Normalized gait without pain, with involved ankle protected in semi-rigid ankle stirrup, with or without appropriate assistive ambulatory device
Pain-free eversion against gravity

Phase II: Weeks 8 to 12:

Goals:

Restoring full ROM, by 12 weeks, at the latest
No edema post-activity
Normalized, pain-free gait on stairs and inconsistent surfaces, with or without ankle stirrup orthotic. Orthotic during gait may still be indicated in this phase in the event of persisting pain, edema and muscle weakness to promote normal gait mechanics and increased weight-bearing without assistive ambulatory device
5/5 strength all ankle muscle groups

Precautions:

Gentle AROM inversion as of week 9
Patient education regarding caution with pacing and progression of weight-bearing activities
To protect the ankle during progression of activities, patient should wear ankle stirrup orthotic (refer to gait goal above)
No plyometrics until week 11

Physical therapy interventions:

Week 9:
Sitting: Ankle AROM exercises into all planes of motion straight plane movements and combined movements with alphabet, circles, BAPS or rocker board and foam roller
Standing: BAPS board
Gait training on level and inconsistent surfaces
Continue edema control
Continue ROM exercises
Standing BAPS board
Mobilizations as indicated
Stretches of gastrocnemius, soleus and tibialis posterior
Soft tissue mobilizations as indicated
Proprioception activities involving unilateral stance; eyes open, eyes closed, external perturbations, foam block, rocker board, ball toss, reaching, Star Balance Excursion Test1
Strengthening: foot intrinsics, progressive resisted ankle exercises in all planes of motion with elastic tubing2, core stabilization, bilateral heel raises

Week 10: Progress strengthening of all major muscle groups supporting the ankle with use of closed and open kinetic chain exercises, unilateral eccentric heel raises, rhythmic stabilization; use of StairMaster and Elliptical, treadmill, and VersaClimber for muscle endurance

*Week 11:Plyometrics with bilateral and unilateral jumps
*Plyometrics Progression during Phase II 3
Horizontal leg press jumps
Lateral Jumping bilaterally over a line
Up and over a 4-inch box
Jumps in series in multiple planes: four quadrant box jumps
Bilateral jumps:
Up to a 4-inch box then to a 6-inch box
Vertical jumps in place
Jumps up to and down from first a 4-inch box then to a 6-inch box
Vertical jumps in series
Depth jumps up and down from 8-inch to 12-inch boxes
Unilateral jumps may be initiated with the same progression pattern as outlined above with bilateral jumps

If there is any discomfort with the initial plyometric exercises, delay them until the patient is able to perform at least 10 repetitions pain-free. Edelstein and Noonan suggest beginning with 10 repetitions of one plyometric activity, then progressing towards up to 3 of the plyometric activities, for a maximum of 2 sets of 10 repetitions. They also recommend not overloading a patient with high repetitions of plyometrics and a full strengthening program on the same day. Their practice is to start the treatment session with an active warm up followed by the plyometrics program.

Criteria for progression to the Phase III:

Full active and passive ROM
No residual edema or pain after activity
Normalized gait without assistive device on level surfaces, stairs and inconsistent surfaces, with orthotic or assistive device

Phase III: Weeks 12 to 16:

Precautions:

Continue use of brace (lace-up, sport brace or standard stirrup) during sports for 6 months, for increased stability and proprioception
Patient to be independent with activity progression and/or modification in general, and especially in the event of onset of pain or swelling

Physical therapy interventions:

Initiate jogging with progression to running
Strengthening: testing: dynamometry, isokinetic, functional *
increased workload, resistance and intensity in progressive resisted exercises
Endurance: jumping rope (bilateral, alternating and unilateral skips)
Proprioception: see Phase II and add sport-specific drills
Plyometrics: see progression outlined in phase II
Return to sports functional progression and testing

The multiple hop test has been proven to be a reliable test for measuring the dynamic postural control in patients with chronic lateral instability (CAI).4 Some authors have found that reports of subjective instability in CAI were more reliable for determining functional ability than most of the functional tests5-7. However, the tests are still used as benchmarks for functional progression. They should be combined with subjective feedback regarding pain and apprehension and tailored to the patient’s specific needs.

*Return to Sport Functional Progression and Clinical Testing:3

Retro jog
Side shuffles
Carioca
Bilateral bounding (A-P then lateral)
Run
Unilateral quadrant jumps
Jog-sprint-jog
Sprint-jog
Sprint-stop
Figure eights
Unilateral bounding (A-P then lateral)
45-degree cuts
Single-leg hop test for time and distance8
Multpile Hop Test4
90-degree cuts
Shuttle run test

Sport-specific activities:

Single skill activities, progressed to multitasking skills and changes of direction
Add defensive player or coach to drills
Practice drills with team
Scrimmage with team
Return to play

Criteria for discharge from skilled therapy:

Running to sprinting
Multiplane activities
Regain full cardiovascular and muscular endurance
Strength ≥85% limb symmetry through functional testing
No apprehension with high level activity, and with direction changes
Return to full sport and high level activities

Author: Marie-Josée McKenzie, PT 1/ 2010

REFERENCES

Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simplifying the star excursion balance test: Analyses of subjects with and without chronic ankle instability. J Orthop Sports Phys Ther. 2006;36:131-137.
Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. J Orthop Sports Phys Ther. 2009;39:246-255.
Edelstein J, Noonan D. Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Chapter 39: Lateral Ankle Reconstruction. Philadelphia: Mosby, Inc.; 2006.
Eechaute C, Vaes P, Duquet W. The dynamic postural control is impaired in patients with chronic ankle instability: Reliability and validity of the multiple hop test. Clin J Sport Med. 2009;19:107-114.
Mattacola CG, Dwyer MK. Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. 2002;37:413-429.
Munn J, Beard DJ, Refshauge KM, Lee RW. Do functional performance tests detect impairment in subjects wiht ankle instability? J Sports Rehabil. 2002:40-50.
Worrell TW, Booher LD, Hench KM. Closed kinetic chain assessment following inversion ankle sprain. J Sports Rehabil. 1994:197-203.
Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop Relat Res. 1990;(255):204-214.