What is the best course of treatment for a patient with post-surgical left ankle pain, limited range of motion, and mild swelling, who also requests medical shoes due to having wide feet?

Post-Surgical Ankle Rehabilitation with Limited ROM and Mild Swelling

Physical therapy with early exercise therapy is the cornerstone of treatment for post-surgical ankle pain with limited range of motion, and should be initiated as soon as possible to restore joint functionality. 1

Immediate Management Approach

Exercise Therapy (Primary Treatment)

• Start physical therapy immediately to recover joint functionality, as exercise therapy has the strongest evidence (Level 1) for improving outcomes after ankle injury 1
• Exercise should focus on:
  • Progressive weight-bearing exercises as pain allows 2
  • Range of motion restoration exercises 1
  • Proprioception and balance training to prevent future complications 2
• Home-based exercise programs are effective and can be self-administered 1

Functional Support During Rehabilitation

• Use a removable brace for 4-6 weeks rather than rigid immobilization, as this significantly reduces activity limitation and improves ankle dorsiflexion 1
• Functional support (brace or tape) is more effective than elastic bandages alone for reducing swelling and allowing earlier return to activities 2
• Important caveat: Removable immobilization increases risk of minor adverse events (RR 2.30), so patient compliance with controlled exercise protocols is essential 3

Manual Mobilization

• Manual joint mobilization combined with exercise therapy provides better outcomes than exercise alone 2
• Manual mobilization should only be used as an adjunct to exercise, not as standalone treatment 1

Pain and Swelling Management

NSAIDs for Symptom Control

• NSAIDs may be used to reduce pain and swelling (Level 2 evidence) 1
• Oral or topical NSAIDs reduce pain in the short term (<14 days) without significantly increasing adverse events 1
• Diclofenac shows superior results at days 1-2 compared to other NSAIDs for pain during motion 1

What NOT to Do

• RICE (Rest, Ice, Compression, Elevation) alone is NOT recommended as it has no evidence for positive influence on pain, swelling, or function 1
• Immobilization should NOT be used beyond 10 days, as prolonged immobilization is less effective than functional treatment 1, 2
• Ultrasound, laser therapy, and electrotherapy have no proven effectiveness 1, 2

Expected Recovery Timeline

• Return to light work: 3-6 weeks with mostly sitting work, limiting lifting to <10kg 1, 2
• Full return to former work: 6-8 weeks depending on task requirements 2
• Reassess at 4-6 weeks for improvement in pain, swelling, and function 2
• If symptoms persist beyond 8-12 weeks despite appropriate conservative management, consider specialist referral 2

Regarding Medical Shoes for Wide Feet

• There is no clear evidence on the role of shoe wear in treatment of ankle injuries 1
• The patient currently does not meet criteria for medical shoes per your organization's guidelines
• Standard wide-width footwear from commercial sources is appropriate for accommodating wide feet
• Focus should remain on functional rehabilitation rather than specialized footwear

Critical Pitfalls to Avoid

• Returning to full activities too quickly before adequate rehabilitation leads to recurrent injury 2
• Neglecting proprioceptive training increases risk of chronic ankle instability 2
• Prolonged immobilization (>10 days) significantly impairs recovery 1, 2
• Surgery is only indicated for chronic instability after failed comprehensive exercise-based physiotherapy, not for routine post-surgical rehabilitation 1, 2