Recovery & Rehabilitation Protocols

Protect the repair

• Boot & weightbearing: No weightbearing for weeks 0–2, in a CAM boot with two heel lifts or in a splint — not an ankle brace in this phase.
• Movement: Toe curls and toe spreads; keep the knee moving through its full range.
• Strength: Straight-leg raises and other exercises that do not involve the ankle.

Full weightbearing in the boot

• Boot & weightbearing: Full weightbearing in the boot. Start weaning the heel lifts in this phase — one review weans by week 5.
• Strength: Seated heel raises, plus plantarflexion, inversion and eversion against resistance.
• Training: Blood flow restriction (BFR) training, plus cycling in the boot, as cleared.
• Swelling: Elevation, ice, and other swelling-control measures as your therapy team advises.

Out of lifts, toward a shoe

• Boot & shoe: Being out of the lifts and moving toward a shoe by about 6 weeks is reasonable, as cleared.
• Range of motion: Active movement up and down to neutral only — never past it — plus side-to-side motion below neutral. Gentle assisted stretching, progressed slowly.
• Shoes: Consider a 1/8–1/4 inch heel cushion in shoes after 8 weeks.
• Care: Scar mobilization and wound-care guidance once the incision allows. Pool therapy is fine within your motion and weightbearing limits.
• Strength: Graduated resistance work (bands first, then weights) without going past neutral, plus gait retraining. Let pain be the guide — if it hurts, back off activity and weightbearing.

Heel-raise milestone

• Heel raises: Bilateral heel raises can start from about 6 weeks (GAIT consensus). Goal: a single-leg heel raise from flat ground by week 12.
• Caution: The tendon is still vulnerable. A sudden load — tripping, stepping up hard — can re-rupture it. Stay diligent with daily activities and exercises.
• Boot & brace: Wean out of the boot over about 4–5 days, then wear a compression ankle brace for extra stability and swelling control.
• Range of motion, strength & balance: Keep progressing all three. Add stationary bike, elliptical, and treadmill walking as tolerated; balance-board work progressing from seated, to standing with support, to standing free; gentle standing calf stretches.
• Therapy: Typically 1–2 visits per week, depending on how independently you can exercise and what equipment you have access to.

Strength, power, endurance

• Strength: Continue progressing range of motion, strength, and balance work, with emphasis on eccentric (lowering) strengthening and closed-chain exercises. Keep stretching and eccentrics at 12 weeks or later (GAIT consensus, 100% agreement).
• Running: Treat 12 weeks as a minimum biological floor for running, not a clearance criterion. Return to running is based on criteria — see the Return to Running protocol below — not on the calendar alone, and only with clearance.

Return to jogging and sport

• Jogging gate: 80% limb symmetry index (LSI) is a reasonable gate for jogging, with clearance.
• Sport clearance: Target 90–100% LSI, usually at 6+ months. Average return to sport is about 24 weeks in the GAIT consensus.
• Training: Add dynamic weightbearing exercise and sport-specific retraining as cleared.

Protect the wound

• Weightbearing & splint: Non-weightbearing in a well-padded splint with the ankle held in neutral (not pointed down). Use crutches, a walker, or a knee scooter.
• Swelling & wound: Keep the leg elevated above heart level, use ice around the splint, and keep the splint dry.
• Movement: Toe motion, plus full knee and hip range of motion.
• Strength: Straight-leg raises and hip and core work.
• Blood clot prevention: Follow your surgeon’s plan. Call right away if you notice calf pain or swelling, chest pain, or shortness of breath.

Weight in the boot, motion out of it

• 2-week visit: Splint and stitches come off, the wound is checked, X-rays are taken, and your track is confirmed.
• Weightbearing (standard track): Weightbearing as tolerated in a removable walking boot, using crutches as needed and weaning off them as pain allows.
• Weightbearing (protected track): Stay non-weightbearing in the boot.
• Boot use: Take the boot off for exercises, hygiene, and sleep if your surgeon allows. Wear it for all standing and walking.
• Range of motion: Ankle pumps, ankle alphabet, ankle circles, seated balance-board work, and towel calf stretches (hold 20 seconds, rest 20 seconds) with the knee straight, the knee bent, and the foot turned in each direction.
• Foot strength: Towel scrunches with the toes (10–15 repetitions) and picking up marbles or a small ball (15 repetitions).
• Therapy: Soft-tissue and gentle joint mobilization, scar mobilization once the incision has fully healed, and swelling control.
• Fitness: Upper-body exercise, and stationary cycling with the boot on once cleared.

Out of the boot

• 6-week visit: X-rays to confirm healing.
• Weightbearing: Full weightbearing. Move from the boot to a supportive shoe, with an ankle brace if needed, over about 1–2 weeks. Protected-track patients start weightbearing as tolerated in the boot now and progress from there.
• Range of motion: Active and passive dorsiflexion, plantarflexion, inversion, and eversion. Progress to standing calf stretches.
• Strength: Isometrics in all directions, progressing to resistance bands. Start double-leg heel raises.
• Gait: Gait retraining to normalize heel-toe walking without a limp.
• Fitness: Stationary bike, and pool work once the wound has fully healed.

Strength and balance

• Strength: Progress resistance. Move from double-leg to single-leg heel raises, and add step-ups, squats, and lunges.
• Balance: Single-leg stance progressing from a firm surface to foam to eyes closed, plus balance board or wobble board.
• Fitness: Elliptical, and treadmill walking built up toward brisk walking (about 3.5 mph).

Return to running

• Jogging can start once all of these are met: surgeon clearance, healing on X-ray, pain-free walking with a normal gait, near-full ankle motion, single-leg balance, and repeated single-leg heel raises compared with the other side.
• Training: Walk–jog intervals, plyometrics starting with double-leg hops, and agility drills.

Return to sport

• Sport-specific drills: Cutting, jumping, and sport drills.
• Clearance criteria: At least 90% of the other side’s motion and strength, no pain (≤2/10) with sport movements, and no instability with hopping, jumping, or cutting. Most athletes return around 4–6 months, and contact or high-demand sports often take longer.
• Recovery timeline: Some stiffness and limited ankle motion are common up to 12 months after surgery.

Protected weightbearing

• Support: Removable walking boot or functional ankle brace. If the patient is too painful to stand for X-rays, a short-leg splint or cast for up to about 1 week, then a weightbearing X-ray and a switch to the boot or brace.
• Weightbearing: Weightbearing as tolerated in the boot or brace once the mortise is confirmed congruent on a weightbearing X-ray. Crutches for comfort only, weaned as pain allows.
• Imaging: Weightbearing AP, mortise, and lateral X-rays at the first follow-up (about 1–2 weeks), then at about 6 weeks. Any medial clear space widening means surgical review.
• Pain and swelling: Ice, compression, and elevation.
• Exercise (out of the boot, seated or lying, pain-free): Ankle pumps, ankle alphabet, toe curls, towel gathers (10–15 repetitions), ball pick-ups between the toes (15 repetitions). Hip and knee strengthening, and upper-body or one-leg cardio.

Wean support, restore motion

• Support: Wean out of the boot from about week 3 as pain and gait allow. Change to a lace-up ankle brace for walking and activity.
• Weightbearing: Full weightbearing. Work on a normal walking pattern with no crutches.
• Range of motion: Towel calf stretches, 20-second holds with 20 seconds of rest (straight back, turned each way, and with the knee bent). Standing calf stretches as tolerated. Seated balance board.
• Therapy: Soft-tissue and joint mobilization as needed.
• Strength: Resistance bands in all directions. Double-leg heel raises when pain-free.
• Balance: Single-leg stance, progressing from eyes open to eyes closed.
• Fitness: Stationary bike.

Strength and function

• Imaging: Weightbearing X-rays at about 6 weeks to confirm healing and alignment.
• Support: Lace-up brace for higher-demand activity as needed. Stop the brace by about 8–12 weeks.
• Strength: Progressive resistance, single-leg heel raises, step-ups, and squats/lunges.
• Balance: Balance board and unstable surfaces.
• Fitness: Elliptical. Treadmill walking, building toward brisk walking.

Return to running and sport

• Running: Start jogging once pain-free walking, near-full motion, and good single-leg control are in place, usually not before about 8–12 weeks.
• Sport: Progress to agility, hopping, and sport-specific drills.
• Return-to-sport criteria (time alone is not enough): At least 90% of motion and strength compared with the other side; pain no higher than 2/10 with sport movements; no instability on hop, jump, and cutting tests.
• Return to work: Based on job demands. Desk work is often possible within days to weeks.

Before you start: readiness checklist

Your clinician or therapist should confirm all of these:

• No pain with daily activities, and no tenderness at the injury site (for bone injuries).
• Pain-free brisk walking for 30 minutes, with a normal walking pattern.
• Full, pain-free range of motion that matches the other side.
• Strength close to the uninjured side. Your therapist will test this and set your target.
• Good control on a single-leg squat and step-down (step heel-touches), with no pain.
• Imaging or surgeon sign-off, if your injury needs it (for example, high-risk stress fractures or after surgery).

Hop progression (mechanics first)

Work through these in order:

• Two-leg hops in place, then forward and backward.
• Single-leg hops in place, then forward and backward.
• Side-to-side hops, then lateral bounds.
• Triple hops, then scissor hops and box hops.
• Move to the next level only when you land softly and in control, and you have no increase in pain or swelling that day or the next morning. Before you start running, you should be able to do 10–20 single-leg hops on the injured leg without pain.

Walk-run program (5 phases)

• How often: 2–3 days per week, with at least 1 rest day between run days. Cross-training such as cycling or swimming is fine on other days.
• Each session: A 5–10 minute dynamic warm-up first. Do about 30 minutes of walk-run intervals (6 rounds) at an easy, conversational pace on a flat, even surface.
• Phase 1: 4 min walk / 1 min run × 6 rounds = 30 min.
• Phase 2: 3 min walk / 2 min run × 6 rounds = 30 min.
• Phase 3: 2 min walk / 3 min run × 6 rounds = 30 min.
• Phase 4: 1 min walk / 4 min run × 6 rounds = 30 min.
• Phase 5: 30 min continuous running.
• When to advance: Complete at least 3 sessions at a phase with no increase in pain or swelling during the run, later that day, or the next morning. Your therapist may ask you to do up to 6 sessions at a phase.

Know when to back off

• Stop the run if you have sharp pain, pain that keeps building while you run, or pain that makes you limp or change how you run. Contact your clinician before your next session.
• Mild soreness (3/10 or less) that is gone by the next morning is OK. Repeat the same phase; do not move up.
• Pain above 3/10, or pain that lasts into the next day: rest until the pain is gone, then restart one phase lower.
• Call your clinician right away if you have pain at rest, pain at night, new swelling, or a tender spot on the bone.

After 30 minutes of continuous running: rebuild mileage

• Build distance before speed. Increase your total weekly running a little at a time, often about 10% per week. Go no higher than 20% per week, and only if you have no symptoms.
• Add speed work and hills only once you are back to about 50–60% of your pre-injury weekly mileage. Add one hard session per week to start.
• Keep at least 1 full rest day each week.
• Return to normal training at about 75–80% of your pre-injury mileage, as long as you have no symptoms.

Prevent it from happening again

• Talk with your care team about anything that may have contributed to the injury, such as training errors, worn-out shoes, running form, strength deficits, sleep, and, for bone stress injuries, eating enough and menstrual health.
• Keep doing your strength exercises 2 times a week throughout this program.