Phases of Physiotherapy:-

• Initial Immobilization Phase (e.g., 4-8 weeks in a cast or boot):
  • Goals: Protect the healing ligaments and soft tissues, control pain and swelling, prevent joint stiffness in adjacent areas.
  • Interventions:
    • R.I.C.E. principles: Rest, Ice, Compression, Elevation to manage swelling.
    • Non-weight bearing: Using crutches or a walker.
    • Exercises for unaffected joints: Maintain strength and range of motion in the knee, hip, and core.
    • Isometric exercises (in cast/boot): Gentle muscle contractions without moving the joint (e.g., quadriceps sets, gluteal sets, toe curls/spreads) to maintain muscle tone and promote circulation.
    • Upper body conditioning: To maintain overall fitness.
• Early Mobilization and Controlled Weight-Bearing Phase (Weeks 4-12, post-immobilization):
  • Goals: Restore pain-free range of motion, begin gentle strengthening, improve proprioception, gradually introduce weight-bearing.
    • Manual Therapy:
      • Gentle Joint Mobilizations: Once cleared by the surgeon, the physiotherapist will start with gentle, pain-free mobilizations of the subtalar joint and surrounding foot and ankle joints (talocrural, midfoot) to restore arthrokinematics (joint play) and reduce stiffness. These are typically low-grade mobilizations (Grade I-II) initially. The goal is to regain the crucial pronation/supination motion of the subtalar joint.
      • Soft Tissue Mobilization: Gentle massage and release techniques for tight muscles (e.g., calf muscles, tibialis posterior, peroneals) and fascial restrictions that may have developed due to injury or immobilization. This helps reduce pain and improve flexibility.
  • Active and Passive Range of Motion (AROM/PROM): Gradually introduce exercises to move the ankle and foot through their full range of motion, focusing on subtalar inversion/eversion, ankle dorsiflexion/plantarflexion.
  • Gentle Stretching: For calf muscles (gastrocnemius, soleus) and other tight structures.
  • Early Strengthening (non-weight bearing to partial weight-bearing):
    • Theraband exercises: For ankle dorsiflexion, plantarflexion, inversion, and eversion.
    • Foot intrinsic muscle strengthening: Toe curls, marble pickups to support the arch.
    • Gluteal and hip strengthening: To improve proximal stability and support lower limb mechanics.
  • Proprioception/Balance Training (non-weight bearing to partial weight-bearing):
    • Sitting balance exercises (e.g., pointing foot to targets).
    • Progress to standing balance with support, then without support.
    • Single leg stance on stable surfaces.
  • Gait Training: Re-education on a normal walking pattern, gradually progressing from partial to full weight-bearing with assistive devices (crutches/walker) as tolerated. Emphasis on restoring a smooth heel-to-toe pattern.
• Intermediate Strengthening and Proprioception Phase (Weeks 12 onwards):
  • Goals: Progress strength, endurance, and balance, prepare for more functional activities.
    • Advanced Manual Therapy:
      • Higher-grade joint mobilizations (Grade III-IV): As tolerated and indicated, to further improve joint mobility and address any persistent stiffness.
      • Myofascial Release Techniques: Deeper soft tissue work to release any remaining restrictions and improve muscle function.
      • Mobilization with Movement (MWM): Combining patient-active movement with passive accessory glides by the therapist to address movement restrictions and pain.
    • Progressive Strengthening:
      • Weight-bearing exercises: Calf raises (double leg to single leg), squats, lunges, step-ups.
      • Closed-chain exercises: Emphasizing functional movements of the lower limb.
      • Plyometric preparation (low-level): Gentle hopping, jumping drills on stable surfaces (only if appropriate and no pain).
    • Advanced Proprioception/Balance Training:
      • Balance exercises on unstable surfaces (e.g., foam pad, wobble board, BOSU ball).
      • Single-leg balance with perturbations (e.g., catching a ball, reaching).
      • Dynamic balance exercises (e.g., walking on uneven surfaces, tandem walking, balance beam).
    • Sport-Specific or Activity-Specific Drills: Gradually introducing movements relevant to the patient’s desired activities or sports (e.g., agility drills, cutting, pivoting, running progression).
• Return to Activity/Sport Phase:
  • Goals: Achieve full functional return, minimize risk of re-injury.
    • High-level plyometrics and agility: Jumping, bounding, multi-directional drills.
    • Strength and Conditioning: Ongoing program to maintain strength, power, and endurance.
    • Taping: Ankle taping for support during return to higher-impact activities, especially initially, to enhance proprioception and provide external stability.