Physiotherapy after ankle surgery

In today’s blog, I will explain the type of post-operative physiotherapy/rehabilitation for an ankle syndesmosis/high ankle sprain injury, following a tightrope ankle stabilisation surgery.

We will talk about some exercises that we would typically like to see throughout the different stages of rehabilitation and key milestones along the way.

But first, a quick overview of an ankle syndesmosis injury and what a tightrope fixation surgery involves.

Syndesmosis injuries or high ankle sprains are typically caused by excessive external rotation or a combination of rotation and dorsiflexion of the ankle. Majority of the time these occur during sporting activities that involve sudden changes in direction, pivoting, or direct trauma to the lower leg.

When it comes to these syndesmosis injuries we have 3 different grades.

Grade 1: Partial Tear of the AITFL (Anterior-inferior Tibio-fibular Ligament)

  • Conservatively managed with no surgery

Grade 2a (stable): Full Tear of the AITFL +/- interroseous membrane, PITFL (Postero-inferior Tibio-fibular ligament).

  • Conservatively managed with no surgery

Grade 2b (unstable): Full Tear of the AITFL +/- interroseous membrane, PITFL (Postero-inferior Tibio-fibular ligament).

  • Requires surgical management

Grade 3: Full Tear of AITFL, PITFL, Interosseous Membrane and TL

  • Requires surgical management

The two main types of surgery include an open reduction internal fixation (ORIF) and tightrope fixation surgery. An ORIF involves the use of screws to fixate the tibia and fibula, whereas the tightrope involves the passing of a flexible and adjustable suture material through the tibia and fibula, providing necessary stability between the two bones.

The nature of this surgery allows for controlled and earlier mobilisation, reducing the risk of stiffness and muscle atrophy associated with prolonged immobilisation. With the absence of screws there is no need for a second surgical procedure for screw removal, allowing athletes to focus on their rehabilitation and return to their sport more efficiently.

Now let’s have a look at the different phases for tightrope fixation surgery:

Phase 1: Protected Weight Bearing Phase

The first phase of post-op rehab is protected weightbearing phase. Following surgery you will be typically be placed in a CAM/long walker boot for 6 weeks. Sometimes you will be placed in a backslab cast and NWB (non-weight-bearing) for 2 weeks with crutches. Again, with any post-op injury not specific to the ankle, each surgeon will have different parameters and guidelines but the general consensus is 6 weeks in a boot to protect the injured site and allow the patient and site of injury to heal. During these early phases you will come out of the boot to work on ankle range of motion/mid-foot and foot intrinsic exercises, whilst maintaining regular elevation and relative rest for swelling and pain. Otherwise the boot will stay on outside of physiotherapy or work in the gym/clinic.

Some Key Milestones to hit in this phase is:

  • Knee to Wall (KTW): 0cm

For a tightrope fixation, the benefit of this type of surgery is early weightbearing. So when not in the boot and during physiotherapy, we can start to load the foot with some Isometric Plantar-Flexion exercises in supine, seated calf raises from plantar-grade or with heels elevated in plantar flexion, single leg strength work on the opposing side. The boot, pending symptoms can come off around the 3-4 week mark for some conditioning work on the bike, which will also facilitate range of motion at the ankle. It is important to note that you will need to avoid pushing the ankle in dorsi-flexion (DF), as this will stress the site of injury and surgical site. Once you can progress to the next stage and the boot comes off then we can start to build tolerance and push range of motion if tight through some passive mobilisation techniques around the ankle and mid-foot region.

Other things to work on can include: gait mechanics, balance/proprioceptive exercises, ankle mobilisations if ankle is very stiff (not in early phases of loading)

Phase 2: Load Introduction and Strength Accumulation Phase

After the boot comes off at the 6 week mark, you should have some improvement with knee to wall, swelling, pain and range of motion. The goal is to build to full weight-bearing, pending symptoms above, as it will be an adjustment after coming out of the boot.

We continue working and exposure in the sagittal plane with movements focused at getting the ankle comfortable in a lunge position. This is when we start to expose the body to bigger compound movements as we have allowed the ankle sufficient time for healing to take place. We start to build out strength through deadlifts/squats/any triple extension movements and if still lacking we can continue to work on ankle DF specific mobilisations.

Some key milestones:

  • 70% strength of contralateral side with single leg calf raises. This can be done for repetitions and with a metronome or if your clinic has access to force plates/decks you can measure force output side to side.

Phase 3: Return to Performance (RTP) + Return to Run (RTR)

Example of parameters for this phase to begin is:

  • Full Ankle DF ROM
  • SL CR 100% – typically 30 reps side to side // or symmetry on force deck testing
  • Seated CR 1.5 x BW

Some drills that we can incorporate in this phase start to build into sagittal and frontal plane (lateral based movements) as tolerable.

E.g. paloff press progressions from double stance → split stance → addition of unstable environments.

We can then continue to build into run mechanic drills such as wall-frame marches, single leg stepdowns,etc. Once running we need to build volume from a linear standpoint whilst also getting comfortable with some COD drills, expect some reactive drills and continued exposure to repeated hops along the way.

For those who are getting back to sport this phase can vary in time pending confidence and general conditioning.

In Summary:

To reiterate this is a small snapshot of what you can expect with post-operative rehabilitation following ankle surgery (more specific to the ankle syndesmosis). The extent of the injury will dictate the length of rehabilitation/recovery. However for majority of post-operative ankle syndesmosis injuries they will typically be in a boot for 6 weeks and the weight bearing status of these will vary. Once out of the boot, rehabilitation can progress fairly quickly pending critera of pain-free activity, range of motion and strength milestones.

Return to play can take anywhere from 3 – 6 months, sometimes earlier pending the patient/injury/sport. The earlier time frame is largely due to the accelerated and frequency of rehabilitation.

So next time you are thinking about getting surgery, think about the rehab involved and if you are an athlete who is wanting more specific rehabilitation, come book an appointment with us as the team at BeFit Training Physio would love to help you get back to what you love doing!


  • Bart Lubberts, Pim A D van Dijk, Nathan Donovan, C Niek van Dijk, James D Calder, Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in functional outcomes: a systematic review, Journal of ISAKOS, Volume 1, Issue 4, 2016, Pages 192-197, ISSN 2059-7754,
  • Latham, A. J., Goodwin, P. C., Stirling, B., & Budgen, A. (2017). Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ open sport & exercise medicine, 3(1), e000175.


Jamie Cheok – BeFit Training Physio Coogee

Jamie Cheok – BeFit Training Physio Coogee

Jamie Cheok is a physiotherapist based in Coogee in the Eastern Suburbs of Sydney. Jamie has successfully treated musculoskeletal problems on the basis of a thorough assessment and diagnosis coupled with evidence-based rehabilitation programs tailored to the needs and goals of each individual. To book a consultation, click the link below.

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