Physiotherapy Protocol


Phase 1 (0 – 2 weeks) Protection and mobility

Rest with leg elevation

Rehabilitation goals:

  • Protection of the post-surgical compartment
  • Minimize post-operative swelling
  • Positioning of limb (elevated)
  • Restore normal ankle and knee range of motion
  • Non-antalgic gait


  • Avoid any impact activity including running, jumping or hopping (6-8 weeks)
  • Avoid any activity that will increase swelling


  • Lying: Ankle pumps – Active range of motion (AROM) of the ankle begins immediately to maintain tissue extensibility as they heal and present post-operative contractures. Progress: use of thera-band for controlled ankle dorsiflexion and plantarflexion
  • Supine: straight leg raises: Eg: 4×15
  • Elevation, gentle compression and icing as needed
  • Gentle distal to proximal massage to assist venous return and swelling control

Phase 2: (2 – 4 weeks) Light strengthening

Rehabilitation goals

  • Lower extremity circumference within 1 cm of uninvolved side
  • Minimize muscle atrophy and flexibility deficits in involved compartment
  • Full flexibility/mobility of gastrocnemius/ankle
  • Incision well healed
  • Single leg stance control


  • Avoid eccentric loading
  • Avoid post-activity swelling by limiting prolonged weight-bearing activity as appropriate; if swelling occurs, manage with rest, ice, elevation and compression


  • Gentle scar massage
  • Gentle Hamstring, Gastrocnemius and Soleus stretching
  • Neural mobilisations in involved compartment
  • Standing: Proprioceptive exercises. Progress to single leg standing from a level/firm to soft/unstable surface.
  • Gait drills: begin with forwards, sideways and backwards walking
  • May commence gentle stationary bike work (once wound has healed)
  • May commence gentle swimming or water walking once wound has FULLY healed

Phase 3 (4 – 6 weeks) progression of strengthening

Rehabilitation goals:

  • Prevent post-operative recurrence of symptoms with all activity
  • Tolerate 10-15min of continuous aerobic exercise without the onset of symptoms/pain
  • Normal 5/5 ankle strength and pain free
  • Proper lower extremity control and alignment
  • No pain with single leg functional movements
  • No residual swelling 12-24 hours following all physical activity
  • No pain 1-2 hours following activity (including impact exercises)


  • Avoid friction over scar
  • No running until 6-8 weeks post-operatively
  • Avoid pain with exertional activity


  • Standing: Gently increase stretching and neural mobilisations
  • Lower extremity myofascial stretching and foam rolling
  • Progression of lower extremity closed-chain functional strengthening including mini lunges, step-backs and mini single squats
  • Single leg calf raises: slow and controlled eg 4×10 (continuous)
  • Progress gait drills
  • Initiate plyometric exercises (focus on lower extremity control and alignment at hip, knee and ankle). Example: at 6 weeks begin with 2 feet to 2 feet (jumping), progressing from 1 foot to the other foot (leaping) and then 1 foot to the same foot (hopping). Focus on landing technique and deceleration mechanics
  • May begin elliptical trainer as tolerated
  • Light jogging may commence at 6-8 weeks. Starting on a level surface, gentle interval style. Avoid hills and speed work. Consider progression of multi-planar activity for sport specificity.

Phase 4: (8-12 weeks) Impact/Sport Training

Rehabilitation goals:

  • Proper dynamic neuromuscular control and alignment with eccentric and concentric multi-plane activities including impact for return to work/sports
  • Within 90% of pain free plantar flexion and dorsiflexion strength


  • Avoid pain with any exertional activity
  • Avoid post-activity swelling


  • Progressive strengthening exercises using higher stability and neuromuscular control with increased loads and speeds, along with combined movement patterns; begin with low velocity, single plane activities and progress to multi-plane high velocity
  • Begin with strides and slow jogging forward and backwards, side to side and diagonals.
  • Integrate movements and positions into exercises that stimulate functional activities
  • Initiate sport specific training
  • Patient may return to sport/work if they have met the above criteria
  • Precautions: to reduce the risk of re-injury when returning to sport or high demand activities as appropriate; if collision/contact sport, may consider protective padding over area of scar tissue