 
 
 
Massachusetts General Brigham Sports Medicine   
 
Rehabilitation Guidelines for Total Ankle Arthroplasty 
 
This protocol is intended to guide clinicians and patients through the post-operative course for an Achilles tendon repair. 
This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be 
based on the needs of the individual and should consider exam findings and clinical decision making. If you have 
questions, contact the referring physician.  
 
Total Ankle Arthroplasty Background 
The Total Ankle Arthroplasty, otherwise known as a Total Ankle Replacement, is performed as a treatment for end-stage 
ankle arthritis.  The arthritic surface of the distal tibia is removed along with the arthritic surface of the top of the talus. 
The resected bone is replaced with components with polyethylene surfaces that articulate to facilitate motion.  The 
longevity of an ankle replacement is less certain than that of a knee or hip replacement so it is typically done in older, 
low demand individuals.  The procedure preserves ankle motion in individuals who want to continue to perform low 
impact activities that would not be amenable to an ankle fusion.    
 
Post-operative Considerations 
This procedure results in a lot of pain and swelling.  It is normal for the foot and ankle to be swollen up to 6-12 months 
post-operatively. In the immediate post-operative period, the importance of elevation with the ankle above the heart 
for edema management should be emphasized.  The patient should be instructed to elevate for most of the day with a 
max of only 2-3 hours with the ankle below the heart in the first 2 weeks following surgery.  After that, elevation should 
be performed at regular intervals throughout the day as long as the swelling persists.  The procedure is not expected to 
increase ankle range of motion significantly but has been shown to effectively reduce pain over time.   The amount of 
ankle range of motion achievable with a total ankle arthroplasty is variable in the literature.   
 
If concomitant procedures such as tendon transfers are performed, strengthening of the foot and ankle against 
resistance as well as stretching of the involved musculature, should be avoided until 3 months post-op. 
 
If you develop a fever, intense calf pain, uncontrolled pain or any other symptoms you have concerns about you should 
call your doctor. 
 
 
PHASE I: IMMEDIATE POST-OP (0-2 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Demonstrate safe ambulation with assistive device. 
• Maintain strength of hip, knee and core. 
• Manage swelling with elevation “toes above nose.” 
Weight Bearing 
Walking 
• Non-weight bearing (NWB) on crutches in splint. 
 
Interventions 
Range of motion/Mobility 
• Supine passive hamstring stretch 
Strengthening 
• Quad sets 
• Straight leg raise 
• Abdominal bracing 
 
 
 
• Hip abduction  
• Sidelying hip external rotation-clamshell 
• Prone hip extension 
• Prone hamstring curls 
Criteria to 
Progress 
• Pain < 5/10 
• Patient compliant with proper elevation for most of the day. 
 
PHASE II: INTERMEDIATE POST-OP (3-5 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Continue to manage pain/swelling with elevation as well as modalities. 
• Increase range of motion of the foot and ankle. 
• Minimize the loss of strength of core, hips, knees. 
• Improve scar mobility once incision is healed. 
• Initiate some limited weight bearing in boot (standing only) for ADLs. 
Weight Bearing/ 
Precautions 
• When standing in place ONLY, may weight bear in the boot.  Maintain NWB while walking. 
• May remove boot to perform exercises and hygiene. 
• Keep boot on at night. 
• No foot/ankle strengthening against resistance or stretching of involved musculature until 3 
months post-operative if there are any tendon transfers. 
Additional 
Interventions 
*Continue with 
Phase I 
interventions 
Range of motion/Mobility 
• Initiate ankle passive range of motion (PROM), active assisted range of motion (AAROM) and 
active range of motion (AROM): 
- Ankle pumps  
- Ankle circles 
- Ankle inversion 
- Ankle eversion 
- Calf stretch with towel or calf stretch with strap 
- Seated heel-slides for ankle dorsi-flexion ROM  
• If stiff from boot immobilization, initiate great toe DF and PF stretching. 
• Scar mobilization once incision healed 
• Soft tissue mobilization as indicated 
 
Cardio 
• Upper body ergometer 
 
Strengthening 
• Lumbopelvic Strengthening: (ex:  abdominal bracing, planks and bridges in Achilles Boot) 
• Once able sit with foot flat on the floor in neutral (0 degrees) of ankle dorsi-flexion: 
- Seated heel raises 
- Seated toe raises 
- Seated arch doming 
- Seated great toe flexion with lesser toes extension 
- Seated great toe extension with lesser toes flexion 
- Seated toe piano 
- Seated toe abduction/adduction (spreads and squeezes) 
 
Suggested Modalities (with elevation) 
• Electrical stimulation for pain and swelling 
• Game ready™ cold/compression 
• Cold pack 
Criteria to 
Progress 
• Pain < 5/10 
• Decreased swelling. 
• Improving ankle ROM all planes. 
• Good tolerance with standing in place with 50% of body weight through the involved leg in boot. 
 
 
 
 
PHASE III: LATE POST-OP (6-10 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Initiate weight bearing during ambulation and normalize gait in walking boot using a shoe 
leveler as needed for the uninvolved side. 
• Good tolerance with transition from walking boot to supportive sneaker with/without assistive 
device. 
• Continue to control edema as weight bearing and activity level progresses. 
• Continue to progress ankle ROM. 
• Initiate foot/ankle resistive strengthening (unless tendon transfers have been performed) 
Weight Bearing/ 
Precautions 
• Week 6:  Transition to WBAT in walking boot. 
• Week 7:  Begin to wean boot by spending small amounts of time in supportive sneaker for 
weight shifting and short distances on level surfaces. 
• Week 8:  Transition to supportive sneaker for all ambulation.  May still use assistive device if 
needed. 
• No foot/ankle strengthening against resistance or stretching of involved musculature until 3 
months post-operative if there are any tendon transfers. 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
Range of motion/Mobility 
• Begin gentle standing gastrocnemius stretch and soleus stretch once out of the boot 
• Gentle stretching of proximal muscle groups as indicated: (Examples: standing quad stretch, 
standing hamstrings stretch, kneeling hip flexor stretch, piriformis stretch)  
• Ankle/foot mobilizations and as indicated 
• Scar mobilization and soft tissue mobilization as indicated 
 
Cardio 
• Stationary bicycle  (initially in boot and then progress to sneaker once out of boot) 
• May begin swimming and pool walking at post-op week 8 if incision is fully healed, fully weaned 
from boot and able to get safely in/out of the pool. 
 
Strengthening 
• Begin 4-way ankle with resistance band – do not begin this until 3 months post-op if any 
tendon transfers performed 
• Lumbopelvic strengthening: bridges on physioball, bridge on physioball with roll-in, bridge on 
physioball alternating 
• Gym equipment: hip abductor machine, adductor machine, hip extension machine, roman chair, 
knee extension machine and hamstring curl machine   
Criteria to 
Progress 
• Decreased swelling 
• No pain during/after exercise. 
• Good tolerance with transition from boot to supportive sneaker with/without the need for 
assistive device (<3/10 with walking/weight bearing) 
 
PHASE IV: TRANSITIONAL (11-13 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Normalize gait in supportive sneaker. 
• Safely progress strengthening.  
• Promote proper movement patterns. 
• Improve balance/proprioception. 
• Minimize post exercise pain/swelling. 
Weight Bearing/ 
Precautions 
• Full weight bearing in supportive sneaker. 
• No foot/ankle strengthening against resistance or stretching of involved musculature until 3 
months post-operative if there are any tendon transfers. 
Additional 
Interventions 
*Continue with 
Phase II-III 
interventions 
Range of motion/Mobility 
• Ankle/foot mobilizations as indicated 
• Continue AROM/AAROM/PROM activities per prior phases as needed   
• Scar mobilization 
• Standing ankle dorsiflexion stretch on step 
 
 
 
 
Cardio 
• Stationary bike, pool walking, swimming 
 
Strengthening 
• Progress intensity (strength) and duration (endurance) of exercises 
• Gym equipment:  Leg press machine 
• Romanian deadlift, bilateral mini squats progressing to bilateral squats 
 
Balance/proprioception 
• Double limb standing balance activities on stable surfaces progressing to eyes closed 
• Double limb standing balance utilizing uneven surface (wobble board, foam, etc)  
Criteria to 
Progress 
• Minimize post-exercise pain/swelling  
• Normal gait in supportive sneaker without need for any assistive device 
 
PHASE V: TRANSITIONAL (14-16 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Safely progress strengthening.  
• Initiate single limb standing exercises. 
• Promote proper movement patterns. 
• Avoid post exercise pain/swelling. 
Weight Bearing 
• Weight bearing as tolerated in supportive sneakers  
Additional 
Interventions 
*Continue with 
Phase II-IV 
interventions 
Range of motion/Mobility 
• Standing ankle DF mobilization on step 
 
Cardio 
• May implement pool jogging in addition to previously recommended cardio 
 
Strengthening 
• Begin bilateral heel raises, bilateral squats 
• Seated calf machine 
 
Balance/proprioception 
• Begin single limb balance exercises on level surfaces (ex:  single leg balance). 
Criteria to 
Progress 
• No increased swelling post-exercise that exceeds pre-exercise baseline. 
• No pain during or after exercise. 
• Good tolerance with addition of single limb exercises. 
 
PHASE VI: ADVANCED POST-OP (4-6MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
• Safely progress strengthening.  
• Promote proper movement patterns. 
• Minimize post exercise pain/swelling. 
• Good tolerance with progression to single limb strengthening 
• Progress single limb balance/proprioception to unstable surfaces. 
Additional 
Interventions 
*Continue with 
Phase II-V 
interventions 
Cardio 
• Elliptical, stair climber, walking on treadmill 
 
Range of motion/Mobility 
• Continue per prior phases as needed 
 
Strengthening 
• If able to perform bilateral standing heel raises with 75% of body weight shifted through the 
involved (plantar flexion through range available – it is expected to be reduced), progress to 
eccentric calf raises (bilateral raises, unilateral lowering) on level surface followed by 
progression to unilateral heel-raises. 
 
 
 
• **The following exercises to focus on proper pelvis and lower extremity control with emphasis on 
good proximal stability: 
- Hip hike 
- Forward lunges: Begin leading with injured leg only then progress to leading with 
uninjured leg 
- Lateral lunges 
- Single leg strengthening progression: partial weight bearing single leg press, slide 
board lunges: retro and lateral, step ups, step ups with march, lateral step-ups, step 
downs, single leg squats, single leg wall slides 
 
Balance/proprioception 
• Progress unilateral balance activities to unstable surfaces 
Criteria to 
Progress 
• No increased swelling/pain with 30 minutes of fast-paced walking 
• Standing Heel Rise test > 90% of uninvolved in available ankle range 
• 5/5 ankle strength (in available range) and lower extremity strength 
• Single leg balance on level surface > 30 seconds 
 
PHASE VII: EARLY to UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
• Safely initiate low impact sport specific training program. 
• Safely progress to low impact full sport participation once cleared by MD.  Patients participating 
in no impact sports may begin prior to this phase. 
Additional 
Interventions 
*Continue with 
Phase III-VI 
interventions 
• Continue strengthening and progress cardiovascular endurance. 
• Progress to higher level balance and proprioceptive exercises. 
• Initiate sports specific training – low/no impact 
Criteria to 
Progress 
• Clearance from MD (timeframes will vary depending on the sport) 
• Psych Readiness to Return to Sport (PRRS) 
• Functional Assessment (examples for low impact sports – i.e. golf, yoga, etc) 
- Y-Balance Test 
- Star Excursion Balance test 
Recommendation 
• Patients with total ankle arthroplasty should not return to any sport, occupation or 
activity with repetitive, high impact to the lower extremity. 
   Revised 1/2023 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
References: 
 
1. 
Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot and Ankle International. 2013 
May;34(5):645-56 
 
2. 
Coetzee JC, Castro M. Accurate Measurement of Ankle Range of Motion after Total Ankle Arthroplasty. Clinical Orthopaedics and Related Research. 
2004 July;424:p 27-31 
 
3. 
Johns WL, Sower CB, Ross D, Thordarson DB, Jackson JB, Gonzalez TA.  Return to Sports and Activity After Total Ankle Arthroplasty and 
Arthrodesis:  A Systematic Review.  Foot & Ankle International. 2020 Aug;41(8):916-929 
 
4. 
MGH Orthopedics Foot and Ankle Service.  Physical Therapy Guidelines for Total Ankle Arthroplasty. 
https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/foot-ankle/pt-guidelines-total-ankle-arthroplasty-final.pdf 
 
 
 
 
 
 
 
 
Psychological Readiness to Return to Sport 
 
Patient Name:    
 
 
 
 
 
MRN:    
 
 
Surgery:  
 
 
 
 
  
 
Date of Surgery:   
 
 
 
 
Surgeon:   
 
 
 
 
 
 
 
Please rate your confidence to return to your sport on a scale from 0 – 100 
Example: 
0 = No confidence at all 
 
 
50 = Moderate confidence 
 
 
100 = Complete confidence 
 
1. My overall confidence to play is _____ 
2. My confidence to play without pain is _____ 
3. My confidence to give 100% effort is _____ 
4. My confidence to not concentrate on the injury is _____ 
5. My confidence in the injured body part to handle demands of the situation is _____ 
6. My confidence in my skill level/ability is _____ 
Total: _____ 
Score:_____ 
 
Examiner: ________________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic Training. 2009;44(2):185-18. 
