For this patient encounter reflection, I am looking back on the many treatment sessions that I’ve had with a patient who is 7 months post-op ankle reconstruction using a Brostrom-Gould procedure. I actually evaluated this patient back when I was a student at UVA, so I’ve seen his journey through PT from the beginning until now. Initially when I began treating him again this September, he was doing great and had progressed to tolerating most weightbearing exercises, had improved his ankle ROM, improved his peroneal strength, and was ready in my mind to progress towards plyometrics. The patient is 41 y.o. and a father of two (8 & 9 years old) and one of his main goals is to be able to play basketball with his kids. The patient had a long history of chronic ankle instability which ultimately led to the surgery, but he previously had no other serious injuries or surgeries to his ankles. As I began to implement plyometrics, I started light with step downs onto a half bosu and total gym hopping unweighted, but this ended up increasing the patient’s pain significantly over the span of a week. Due to this response, I regressed all the way back to ankle isometrics as this was the only exercise he could tolerate. Over the last couple weeks, it has been much of the same where we’ve started to progress slightly but ultimately had to regress again due to his pain.

I’ve had many conversations with the patient about expectations following a surgery like this including the expectation of some pain and discomfort with the interventions we perform as he progresses. Where I feel caught up some with this patient is that whenever we progress just slightly, his response is more than I would expect, with his pain sitting around a 6-7/10. Reflecting back on the interventions I provided, I feel that perhaps I progressed too quickly towards plyometrics and I should’ve increased the intensity of his isotonic ankle strengthening prior to implementing any plyometric based exercise, even if it is primarily unweighted. I feel that given his surgical timeline, plyometrics should begin to be incorporated around that 6 month timeframe, but he simply wasn’t ready for it and needs more strength and stability at the ankle before we can progress to dynamic loading.

I also feel that I should’ve set better expectations for the level of pain he can expect with therapy as we progress the intensity of his exercises. Something I often hear said to patients by clinicians is that the exercise shouldn’t increase their pain past a 5 or 6/10. I agree this is a good number because it ensures the patient understands some discomfort is expected with the interventions provided, but it shouldn’t be excessive. However, I feel I could do a better job at explaining this to the patient early on so that it isn’t a surprise or hindrance to progress later on in rehab. I’d be curious to hear from anyone else what kind of explanations they use when educating patients on how much pain is expected.

I’m also curious about experiences with post-op ankle surgeries and when/how plyometrics were implemented into the plan of care. Where do you start? How do you ensure the patient is ready to accept that load through their ankle without flaring them up?