The non-surgical protocol I’ve been following

Physiotherapy Protocol
March 2002

    0-2 WEEKS

Surgical group: bulky dressing/splint
NWB with crutches
Non-operative group: aircast boot with 2 cm heel lift [24/7]
NWB with crutches

2-4 WEEKS *from this point on, both groups should be treated the same*
-aircast boot with 2 cm heel lift
-protected weight-bearing with crutches
-active plantar and dorsi flexion to neutral, inversion /eversion below neutral-
-modalities to control swelling
-incision mobilization/modalities as indicated
-knee/hip exercises as appropriate
-NWB fitness/cardio work
-Hydrotherapy (within motion and weight-bearing limitations.

    4-6 WEEKS

-aircast boat with 2 cm heel lift
-WBAT [Weight Bearing As Tolerated]
-continue treatment as per 2-4 weeks

    6-8 WEEKS

-aircast boot
-D/C [Discontinue] heel lift
-dorsiflexion stretching, slowly
-graduated resistance exercises (OKC, CKC, functional)
-proprioceptive and gait retraining
-modalities as indicated
-incision mobilization, as indicated
-fitness/cardio to include WBAT

8-12 WEEKS
-wean off boot
-return to crutches/cane as necessary; then wean off
-continue to progress ROM, strength, proprioception

-continue to progress ROM, strength, proprioception
-retrain strength, power, endurance
-increase dynamic WB exercise, include plyometric training
-sport specific retraining

[Permanent link . As explained at , this is an OCR version of the rehab protocol used in the U. of W. Ontario's randomized trial of 145 complete-AT Rupture patients, comparing surgery to non-operative treatment. This version, which I was given by my surgeon at Toronto's Sports Medicine Specialists, was faxed to him by the people who did the study at UWO. As of July 2010, the versions of the study's protocol posted online differ from this in a couple of details, and seem to be in error. Most importantly, the online version calls for the complete withdrawal of the 2cm heel lifts by two weeks into treatment. I've discussed that with my own surgeon and with one of the study co-authors, and they both agree with me that bringing the ankle to the "neutral" position that quickly (esp. with no surgery) seems much too fast.

My own preference for an "ideal" rehab protocol would start with this one, but I would edit it in two regards: (1) With all due regard for the Aircast boot and the fine company (which co-sponsored the UWO study), I would use a hinged boot, that can be set to allow unlimited plantarflexion while preventing dorsiflexion. And (2) the sudden and immediate withdrawal of all heel lifts, scheduled for 6 weeks, should be replaced with a slightly more gradual withdrawal, at least over a few days. Concerning "(1)" above, I have no strong or evidence-based opinion on when the boot should be allowed to hinge, esp. for non-operative patients. Personally, I went into a hinged Donjoy MC Walker boot at 7 weeks, and weaned off it very gradually starting at 8 weeks. E.g. I continued to use it for several weeks for bicycling, going out in crowded places, and other higher-risk activities, while wearing 2 shoes at home and in other safe places. The new VacoCast (or VacoPed) hinged boot has received rave reviews from a number of users, and also deserves a look. -- Norm Rubin, aka "normofthenorth" at]