CAM Boot Discontinuation After Ankle Syndesmosis and Tibial Nail Fixation
Discontinue the CAM boot when clinical signs of healing have resolved—specifically when there is no pain, effusion, or increased temperature in the ankle—typically after 6-12 weeks of protected weight-bearing, with progression guided by serial clinical assessments rather than arbitrary time frames.
Weight-Bearing Protocol and Boot Use
Begin weight-bearing as tolerated immediately postoperatively using assistive devices (crutches or walker) to control load and maintain proper gait mechanics, provided there is no pain, effusion, or increased ankle temperature 1.
The CAM boot maintains physiologic syndesmotic motion even with significant ligamentous injury, making it an effective stabilization device during early weight-bearing 2.
Monitor at each visit for pain, effusion, and proper gait pattern as key indicators of healing progression 1.
Timeline for Boot Discontinuation
Most patients can discontinue the boot at 6-12 weeks after surgery, though this varies based on fracture pattern, fixation stability, and individual healing response 3, 4.
Do not allow weight-bearing if significant pain, swelling, or wound complications persist, as these indicate inadequate healing 1.
Full unrestricted weight-bearing is typically allowed at 8 weeks for combined tibial nail and syndesmotic fixation, with boot discontinuation following shortly after if clinical signs are favorable 5.
Clinical Decision-Making Algorithm
Week 0-2:
- CAM boot with assistive devices
- Isometric exercises if pain-free 1
- Active range of motion to prevent stiffness 1
Week 2-6:
- Progress weight-bearing as tolerated in boot
- Serial clinical assessments for pain, effusion, temperature 1
- Continue assistive devices until gait mechanics normalize
Week 6-12:
- Consider boot discontinuation if:
After Week 12:
- If pain, effusion, or abnormal gait persists, continue boot and reassess weekly
- Consider imaging to evaluate healing if clinical progress plateaus
Important Caveats
CAM boot inflation matters: Overinflation of boot cushions can cause external rotation forces on the fibula, potentially affecting syndesmotic reduction 6. Ensure proper fitting to avoid malreduction.
Early motion protocols show equivalent outcomes to prolonged immobilization in syndesmotic injuries, with functional scores (AOFAS 84-91, Olerud-Molander 46-90) showing no significant differences between approaches 3.
The boot does not prevent all instability: While it maintains physiologic motion in intact and injured syndesmoses during plantigrade weight-bearing 2, it may increase external rotation of the fibula under load 6.
Clinical signs trump arbitrary timelines: Pain, effusion, and temperature are more reliable indicators than fixed time periods for determining readiness to discontinue the boot 1.