Everything You Need to Know About Foot and Ankle Surgery Recovery
You can start laying the groundwork for recovery from planned podiatric surgery well before the procedure itself.
Preparation extends beyond getting your house ready and setting up a support system; a pre-surgery diet and exercise program will aid in your recovery, making it less difficult and perhaps quicker than rehabilitation and recovery might otherwise be.
Most of Dr. Vora’s patients fall into one of two groups: Professional or amateur athletes who need foot or ankle repair surgery after injury, and older people who have chronic conditions or wear- and age-related problems that require surgical intervention.
In other words, his patients tend to be healthy, and many often have the procedure planned ahead of time so that they can do some preparatory work to make the rehabilitation as seamless and successful as possible.
We have broken this guide down into two main sections.
The first covers what healthy practices will make your post-operative recovery smooth. In this section, we look at smoking cessation, diet and prehabilitation.
The second sections attempts to align expectations with reality, and looks at how long rehabilitation actually takes. We’ve included a few physiotherapy schedules for common surgeries that can serve as a sort of checklist on your road to full recovery.
What to Do Before Surgery
Your surgeon might require a thorough medical evaluation, lab work and clearance by your primary care physician. It all depends on the type of surgery you’re having, your medical history, age and any risk factors.
If one or any of these evaluations are necessary, they should be completed at least two weeks prior to surgery. Make sure to be proactive in getting this accomplished so that your surgeon has all the information needed for a successful outcome. This will let you simply focus on healing.
If You Smoke, Stop
“Smoking increases the stress on the heart during anesthesia,” writes Dr. John Oyston, an anesthesiologist in Toronto. “Smoking increases the risk of breathing complications and wound infections after surgery. For many operations, especially plastic surgery or bone and joint surgery, smoking significantly reduces the chance of a successful operation.”
Dr. Oyston feels so strongly about the dangers of smoking (especially as it relates to smokers undergoing surgery) that he actually founded a website called Stop Smoking for Safe Surgery.
Many surgeons, Dr. Vora included, will ask that you cancel your elective procedure if you are unable to stop smoking. In fact, the risk factor is so high that you must not use any form of nicotine for at least two weeks prior to your surgery and during the entire healing process.
If you plan on smoking after the surgery, you should note that bones and ligaments take a long time to heal. For that reason, Dr. Oyston recommends an even longer postoperative smoke-free period, between 6 to 8 weeks to allow “most of the initial healing of a fracture or repair of a surgical incision through bone.”
He adds: “One rule of thumb is that if you still need to be in a cast, you should not be smoking. Bones go on remodelling themselves throughout life, breaking down in one area and reforming in another so the process of healing is never 100% complete.”
If you’re having trouble stopping in the first place, ask your doctor what smoking alternatives are acceptable until you can quit completely.
Weight Loss for Better Surgical Results and Post-Op Mobility
If you’re overweight, even a slight amount of weight loss before surgery will be beneficial to your rehabilitation. Trying to get around on crutches is simply more difficult when you have more pounds to carry.
But there are a couple of other reasons to drop some weight.
As Richard Novak, MD, a Stanford physician board-certified in anesthesiology and internal medicine, says: your anesthesiologist will thank you.
“Every anesthesia task can be more difficult to perform in an obese patient,” he writes. Extra body weight affects many aspects of anesthesiology, including placing an IV catheter and airway tube, inserting a needle for a regional block, and getting an accurate blood pressure reading.
“During surgery, an anesthesiologist’s job is to maintain the patient’s A-B-C’s of Airway, Breathing, and Circulation, in that order,” Dr. Novak writes. “All three tasks are more difficult in obese patients.”
Then there’s how fat tissue responds to trauma.
In 2013, researchers at Brigham and Women’s Hospital found that direct trauma greatly impacts the chemical balance of fat tissues located both near and away from the trauma site — these chemicals are known to communicate with nearby and distant organs. And in subjects with high-fat diets, that response to trauma is exaggerated and imbalanced.
The researchers also found that if you simply switch from a typical Western high-fat diet (containing 60 percent calories from fat) to a more normal diet (containing 10 percent calories from fat) a few weeks before surgery, the chemical balance of fat tissue will have a more normal response. This means decreased inflammation and fewer complication risks.
Now’s the Time to Eat Well, But Eat Wisely
By cutting out high-fat, high-sugar foods, including baked goods and fried foods, you’ve won half the battle. Replace those with portion-controlled, healthy choices including
- proteins (eggs, fish, nuts and lentils),
- raw fruits,
- vegetables and nuts,
- all washed down with copious amounts of water.
You will be on your way not only to losing weight but also to ensuring your body is healthy and your immune system strong.
Determine Whether You’re Deficient in Vitamins and Supplements
If you’re eating enough foods rich in vitamin C (the best are bell peppers, dark leafy greens, kiwis, broccoli, berries, citrus fruits, tomatoes, peas, and papayas), then you likely don’t need a supplement.
There are several reasons you want to get all of your daily recommended vitamin C, which is 90 mg for adult men and 75 mg for adult women:
- It acts as an antioxidant, helping to protect cells from the damage caused by free radicals.
- The body needs it to make collagen, a protein required to help wounds heal.
- It improves the absorption of iron from plant-based foods.
- It helps the immune system work properly to protect the body from disease.
Then there’s calcium and vitamin D.
Calcium is crucial for bone health, among other things, so you’ll want to include calcium-rich foods in your diet. The mineral is found in nuts, fruits and dark leafy greens.
Without vitamin D, your body can’t absorb calcium. Unfortunately, vitamin D is present in very few foods, although it’s added to others and is also available as a dietary supplement.
Exposure to sunlight is another way you can get vitamin D, but there are many factors that go into how much sun you’re getting, such as lifestyle, season, time of day, length of day, cloud cover, smog, skin melanin content and sunscreen.
Dr. Vora says that if you live in a place like Chicago, where there can be stretches of dreary days, you may not be getting an optimum amount of exposure to sunlight. He adds that even young patients who are not healing well after surgery can have a vitamin D deficiency.
A blood test is the only sure way to know whether you’re getting enough vitamin D, but you can read the Vitamin Council’s post “Am I Deficient in Vitamin D?” to see whether you might be deficient and should take a supplement.
Prehabilitation: Exercise Before Surgery
Dr. Vora says that nearly every patient he sees is treated preoperatively with some type of physical therapy in an effort to avoid surgery so that when it comes time for surgery, the prehabilitation will have already begun.
But the physio also prepares the patient for post-op recovery, in case surgery is required.
“We also want to make them safe during their recovery,” he says. “Physical therapy before surgery can impact an elderly patient’s safety after surgery. If someone’s non-weight-bearing, we want to make sure they’re safe during that time — it’s very challenging to learn how to be non-weight-bearing after surgery when there’s pain, and the stress of healing and all the other things that are going on.”
With that in mind, you should continue whatever exercise routine you usually follow. Maintain that routine for as long as possible, knowing that this depends on your injury, your condition, and whether the routine is in accordance with all doctor’s orders. If you can exercise safely, comfortably and within those parameters, you can do so up until you undergo the corrective procedure.
Almost anyone, no matter his or her condition, can take up balance exercises. These will be of value post-operatively, when you may be non-weight-bearing on one leg. These exercises are similar to tai chi, a form of movement training that has been found to improve balance and stability and reduce the incidence of falls.
One balance exercise is simply standing on one leg, arms relaxed at your side or up above your head. Another is to shift your weight completely from one leg to the other, with a 30-second hold between movements.
If you feel unsteady, use the back of a sturdy chair for support. Heel-to-toe walking is another balance exercise that can be useful, and those where you stand on one leg can be made more challenging by adding back and side leg raises.
“The injured joint ‘leads’ the movements,” advises tai chi instructor Chris Cinnamon, who used his training to recuperate after knee surgery.
“This principle means that the amount of movement in the injured joint sets the amount of movement in the rest of the body. Put another way, the uninjured parts only move as much as the injured part. Depending on the injury, this could mean the movements become very small. But they are balanced.”
Rehabilitation After Surgery
Chris says he started his own rehab as soon as he woke up from the knee surgery simply by massaging his legs from a supine position. The next day, he says he was able to work a modified version of Tai Chi Circling Hands, which incorporates relaxed, circular, whole body movements, with repeated weight shifts and hip turns.
Chris says he usually adheres to a 70% rule, which holds that, when you are healthy, you do no movement or practice greater than 70% of your maximum. To modify the exercise for his post-op condition, Chris reduced the rule to 50% of his new normal, the onset of pain. The goal is to move without pain, gaining the benefits of the movements, while relaxing nerves and soft tissue.
“The low impact, yet powerful movements of tai chi can be ideal for building leg strength, foot and ankle flexibility, and whole-body awareness, all of which can be immensely helpful in improving balance and recovering from any surgery affecting the hips, knees, ankles or feet.”
Motivation and Impatience
Dr. Vora emphasizes that patient compliance is important for a good end result He and his team spend a great deal of time with their patients to make sure they’re educated on their conditions and understand what is expected of them.
“People are motivated for different reasons: Young people and professional athletes want to get back to their sports, while elderly patients (especially if they’ve had this type of surgery before) know what they need to do to heal.
“Everyone gets impatient during recovery. But when you set expectations, it’s a little easier. For example, if an athlete knows he can bike or swim (but not run) six weeks after surgery, then he has realistic expectations. We let them do things when it’s safe — so we let someone swim 3–4 weeks after an ankle replacement if it’s a young patient with a Jones fracture. An athlete knows that at 2–3 weeks, we’ll let her get on an anti-gravity treadmill or swim in a pool so she can rehab quicker.”
“As long as they know what to expect beforehand (and even with impatience), they tend to be pretty good.”
To give you an idea of what to expect, we’ve listed rehabilitation guidelines and reference timelines specific to a few of the more common types corrective surgeries below.
Achilles Tendon Rupture Repair
There’s no cast after this procedure, and you’ll be able to move your ankle up and down immediately after surgery. Swelling can be controlled using compression stockings, ice and elevation, and you can expect physical therapy to begin 2–3 weeks post-op.
Use those first weeks for rest and recovery, during which time you’ll be in a non-weight-bearing boot, moving to a protected weight-bearing boot after one month for another 4 weeks. To get around, you’ll need to use an assistive device such as a knee walker, crutches or scooter at all times for safety.
Even when you sleep, you’ll be required to wear a controlled ankle motion boot until 8 weeks post-surgery.
It’s at this 8-week point when things start to move more quickly, as you slowly transition to a regular shoe and can begin activities such as driving, biking and swimming. At Week 16, if all is progressing as it should, you can begin higher-impact activities such as running.
Once you’re able to come up and down on your toes (single heel rise) on the surgical side, or you can hop on the surgical foot (single leg hop), you may return to sports and all activities. This can take six months to a year.
Ankle and Foot Fusions
Depending on which joint is being fused, you may be non-weight-bearing for up to 10 weeks in a cast or boot, followed by six weeks of protected weight-bearing in a boot.
If you’re in a cast, physical therapy will only start once its removed, at about six weeks. Otherwise, physical therapy usually starts the third week after surgery to maintain hip and knee range of motion; to improve strength in the core, hip and knee; and also to learn the safe use of crutches and/or a knee walker.
Weeks 6 through 10, depending on how you’re healing, you will begin a gradual progression to full weight-bearing in a walker boot as well as using a stationary bike in the boot. All the while, you’ll be increasing your core, hip and knee strength.
Depending on the degree of fusion, you should be full weight-bearing in regular shoes at about Week 12. During this time, you may be provided with an ankle brace, work on muscle stimulation and gait retraining, and will progress to exercises such as standing presses and leg presses.
From Weeks 13–16, you should gain a full range of motion in non-fused joints, and you’ll be approaching a restoration of near normal strength.
There’s no cast with an ankle fracture, and you’ll begin moving the ankle up and down immediately after surgery so it doesn’t get stiff. Swelling is controlled by wearing a compression stocking, and by elevating the foot and icing the ankle.
You’ll spend the first four weeks post-op in a non-weight bearing in boot, followed by four weeks of protected weight-bearing in a boot. Physical therapy begins 2–3 weeks after the procedure. Expect to be wearing regular shoes and driving at about two months after surgery.
When you get to the three-month mark, you should be ready to begin gentle running and other higher impact activities. You can return to sports and all activities once you’re able to do a single heel rise on the surgical side, or you can do a single leg hop on the surgical foot. This final step may take as much as six months to a year.
It’s a Long Road to Recovery, Not a Race
It’s important to remember that whatever surgery you’ve had, it can take as long as a year to make a full recovery, though you will be back on your feet much earlier than that. It’s not unusual to have swelling as well as intermittent aches and pains during that time.
Be tenacious when it comes to your recovery, and do everything as much as you can:
- Rest, elevate and ice in the early weeks.
- Allow yourself mood swings and watch for signs of depression.
- Stay involved and entertained to alleviate boredom.
- Eat mindfully.
- Do your daily physical therapy exercises faithfully.
- Be patient with the healing process.
Not all recoveries are the same. Some take longer, some take a lot less. This is because there is such a diversity of conditions and procedures.
And just as each surgery is unique, each patient is unique. While the guidelines for recovery above are generally applicable, there are always exceptions to the rules. For instance, Dr. Vora saw one pro soccer player, who had a minimally invasive surgical procedure done on his ankle, back on the field about six weeks post-op.
No matter how long the recovery takes, though, it’s worth it.
There’s another patient Dr. Vora recalls who lived for decades with ankle pain. His daily commute to work took so much out of him that by weekends all he could do was try to recover.
Then, he finally had an ankle replacement. After a full recovery, he’s no longer in pain and can do things that were very nearly impossible not so long ago such as walk to the train and play with his grandkids after work.
In other words, the procedure allowed him to reclaim the quality of his life.