Baby Steps: Learning to Walk Again After an Ankle Surgery
You wait weeks—or sometimes months—to hear the words: You can start putting weight on it.
You would think that would be the easy part.
It isn't always.
Here’s a video of my three week walking progression after ORIF surgery for a bimalleolar fracture and ruptured peroneal tendon.
FROM THE TRENCHES
For some people, the hardest part of learning to walk again isn’t the ankle. It’s convincing the brain that the ankle can be trusted. One woman from my Facebook support group described a “complete block” when she tried to take that first step. Her physical therapist put a bathroom scale under her injured foot so she could practice loading it while holding onto a chair or walker. Seeing the number on the scale helped her trust what she was doing.
Another started even smaller, standing near the bed or a sturdy chair and simply shifting her weight from her good foot to the healing one. She eventually progressed to holding the kitchen sink and walking in place.
Someone else’s therapist had her call out the names of fruits with every step—anything to stop her brain from thinking quite so hard about what her feet were doing.
And then there are those first unsupported steps. One woman remembers hers as the short trip from her bedroom to the shower: one slow step, pause, another slow step, pause.
Another gradually stopped relying on her crutches by carrying them while taking a step or two without actually using them. “It was a lot of brain training,” she said.
Someone who had spent 11 weeks non-weight-bearing described walking again as a “mind trip”; another was certain for a while that she would never walk without her crutches because her gait was so awkward. But she did.
Again and again, people described the same progression: shifting weight, taking a few protected steps, walking a little farther—and discovering that something that initially seemed almost impossible began to feel like walking again.
MY TAKE ON IT
My eagerness to walk allowed me to overcome my fear quickly. I got sore a lot; I scared myself a few times; and it certainly wasn’t pretty. I was shocked that it was actually hard to walk, that it was something I had to learn again. I had my husband film my progress every few days so I could see with my own eyes that I was getting better, not just imagining it.
As hard as it was for me, my fear level was fairly low. But I don’t think that’s necessarily the norm. The feedback I got from my fracture friends was that learning to walk again scared the heck out of many of them—maybe most of them. Combine that with the actual physical difficulty, and it’s a big mountain to climb.
Hooray, you can walk! Wait, that’s terrifying.
After weeks of protecting an injured ankle, keeping your foot off the ground becomes automatic. You’ve learned not to step on it. Every trip to the bathroom, every shower and every journey across the kitchen, you consciously make sure that foot doesn’t touch the floor. Your leg is fragile. You need to protect it. You’re broken.
Then one day somebody tells you to do exactly what you’ve trained yourself not to do.
For many people, learning to walk again is one of the strangest parts of ankle fracture recovery. The bone may be healed enough to bear weight, but the muscles are weaker, the ankle is stiff, balance has changed and the normal mechanics of walking can feel completely foreign.
And then there's your brain.
Being Cleared to Walk Doesn't Mean You Can Just Walk
Your surgeon may move you from non-weight-bearing (NWB) to partial weight-bearing (PWB), weight-bearing as tolerated (WBAT) or full weight-bearing (FWB). What those instructions mean—and how quickly you should progress—depends on your fracture, surgery and healing.
Follow the progression your own surgeon or physical therapist gives you. Don't decide that because somebody in an online group was walking at six weeks, you should be too.
First Comes Weight, Then Comes Walking
Walking doesn't necessarily begin with taking a step.
It may begin with simply standing.
Physical therapists often use controlled weight shifting to help people become accustomed to loading the injured leg again. Holding onto a counter, walker, parallel bars or another stable surface can allow you to gradually transfer weight from the uninjured leg to the healing one.
A bathroom scale can sometimes provide useful feedback when a specific amount of weight-bearing has been prescribed. Instead of guessing what 25 or 50 percent of your body weight feels like, you can actually see how much force you're putting through the foot.
This is something to discuss with your physical therapist, particularly if you have been given specific weight-bearing restrictions.
Those First Steps
Your first steps probably aren't going to look much like your old walk.
They may be slow. Awkward. Tiny.
You may put your foot down and pause before taking another step. You may lean heavily on a walker or crutches at first. You may discover that you're technically walking but still doing everything possible to avoid putting much weight through the injured side.
That's a beginning.
As confidence and strength return, the goal gradually changes from simply getting from Point A to Point B to walking with a more normal gait.
And those are two different things.
Crutches, Walkers and Canes Are Tools, Not Failures
There is no prize for getting rid of your walking aid first.
A walker or crutches can give you enough support to practice a normal stepping motion while controlling how much weight you place through the healing leg. Later, you may progress to one crutch or a cane before walking completely unsupported.
The timing is individual.
If giving up an assistive device leaves you with a pronounced limp or poor walking pattern, you may not be ready to stop using it. If you still need the device to walk correctly, using it a little longer may be more productive than limping without it.
Physical therapy can be especially useful here. A therapist can watch you walk and spot compensations that you may not even realize you're making.
WORTH KNOWING
Your fracture may be healed and you may still limp.
There are plenty of possible reasons.
Your ankle may not bend normally yet. (Mine still doesn’t bend normally.) Your calf may have lost considerable strength during immobilization.
Your injured leg may not be pushing you forward effectively. Pain or swelling may cause you to shorten the amount of time you spend standing on that leg.
And sometimes the limp has simply become a habit.
A normal walking pattern requires a surprisingly complicated combination of ankle motion, strength, balance and timing. All of those can be affected by weeks in a cast or boot.
This is one reason learning to walk again isn't just about accumulating more steps.
How you walk matters, too.
The Forgotten Calf
Take a look at both calves after several weeks of non-weight-bearing and you may be startled.
Muscle disappears quickly (in my case, like ice on hot pavement) when it isn't being used, and the calf plays an important role in walking. It helps control your body as you move over the foot and provides the push-off that moves you into the next step.
I remember I was thrilled that I lost five pounds while I was in a plaster cast. That was until the cast came off. I’m pretty sure the entire five pounds came from my calf. My leg looked like a stick. I was horrified.
Rebuilding that strength takes time.
Your physical therapist may eventually prescribe exercises such as calf raises, beginning with both legs and progressing as appropriate. Don't rush the progression; the right exercises and timing depend on your injury and stage of healing.
Your Ankle May Feel Very Strange
The first time your bare foot touches the floor after weeks in a cast or boot can be surprisingly unpleasant. Mine felt like it was puffed up, like the toes were balloons.
The bottom of your foot may feel hypersensitive. Your ankle may feel stiff, weak or vulnerable. Different surfaces can suddenly seem very noticeable. Even the sensation of your full body weight traveling through the foot can feel foreign.
Some people gradually become accustomed to those sensations simply through safe standing and walking. Your therapist may also recommend exercises or desensitization techniques if sensitivity is interfering with your progress.
The Boot Creates Another Transition
Getting permission to walk in a boot is one milestone.
Getting out of the boot can be another.
A walking boot is rigid and supportive. It also changes the mechanics of walking. When it finally comes off, your ankle suddenly has to do work that the boot has been doing for it.
Don't be surprised if walking without the boot initially feels harder or less secure even though getting rid of it seemed like something you had been waiting forever to do.
Depending on your injury, you may transition gradually from the boot to a supportive shoe rather than abandoning the boot in a single day.
Follow the plan you're given.
NOBODY TOLD ME...
There are alternatives to the standard walking boot. When I was able to start weight-bearing-as-tolerated, I was put in a CAM (Controlled Ankle Motion) boot, a big grey moonboot that went all the way up to the back of my knee. I was beyond eager to get outside and see my horses again, but the CAM had an open toe. It was almost impossible to keep my foot clean. Morning dew, manure, and shavings in the stalls made a barn visit a messy proposition. And Florida has fire ants. A lot of them.
Further, the cast added several inches to my bad leg, making walking even more awkward. I intended to be on uneven ground and I had no desire to fall again. I certainly didn’t want to fall under a horse.
I researched other possibilities online, and discovered the TayCo RecoverX Brace. This alternative to a walking boot is a lightweight, rigid brace that fits over your shoe.
Research at Ball State University’s Biomechanics Laboratory compared the TayCo XAB with a traditional orthopedic walking boot and regular athletic shoes during walking and stair climbing. The study found that both the TayCo brace and walking boot substantially restricted ankle motion, with similar overall ankle control. The walking boot, however, produced more changes in knee and hip movement than the TayCo brace. (3.)
There was a 30-day money-back guarantee and… I was in.
The brace gave me the protection I needed, and I could put it over my barn boot. I was much less awkward in it than the CAM.
Admittedly, I was rabid about getting to walk again. As soon as I was allowed to weight-bear I started on daily jaunts around the farm… at first just down the driveway, and then to the cul-de-sac. I didn’t dare venture off the pavement for several days. But within a week I was walking around the grass gallop track for the horses, soon logging about an hour a day.
I still wasn’t allowed to ride for four more weeks due to the severe tendon injury I had on top of the bimalleolar fracture, but my recovery was excellent. This isn’t to say I walked normally at first, or even that I walk entirely normally now. Nevertheless, I get to enjoy the things I love to do again.
Swelling May Have Something to Say About This
It certainly had something to say when I was on my feet for too long. As your activity increases, your ankle may swell more.
That doesn't necessarily mean you've damaged something. A recovering ankle can remain prone to swelling for a long time, particularly after you've been upright or walking more than usual.
But your ankle can also tell you when you've made too large a jump in activity.
Instead of going from almost no walking to spending an entire day on your feet, increasing activity gradually gives your body a chance to adapt.
I was not very good at this. I tended to stay on my feet until discomfort forced me to stop. I scared myself a few times, worried that maybe I’d really injured myself, but my surgeon had assured me that if I didn’t fall or land on the leg in an uncontrolled way, I wasn’t going to hurt it.
Definitely get guidance from your health professionals: you don’t want to go backwards in your healing journey.
What Physical Therapy Can Do
Physical therapy isn't only about exercises.
This is one stage where having somebody actually watch you move can be enormously valuable.
A physical therapist can work on ankle range of motion, strength and balance, but can also help retrain the mechanics of walking. They can determine whether you're ready to reduce your reliance on a walker, crutches or cane and identify problems such as shortening your stride, avoiding the injured side or failing to push off normally.
Some clinics have parallel bars, which can provide a particularly reassuring place to practice those early steps.
If you're struggling to make the transition to walking, tell your therapist. Fear and lack of confidence are problems they can work with, too.
A Few Things Worth Remembering
Being cleared to bear weight and feeling comfortable bearing weight may not happen on the same day.
Don't compare your walking timeline with somebody else's.
Use your walker, crutches or cane for as long as you need them to walk safely and as normally as possible.
Increase distance gradually rather than proving you can walk by massively overdoing it on the first good day. (Note to self: read this one twice.)
Expect some awkwardness.
Pay attention to gait, not just distance.
Strength, range of motion, balance and confidence all have to recover.
Ask for help if you're having trouble progressing rather than simply forcing your way through it.
ASK YOUR SURGEON OR PHYSICAL THERAPIST
Exactly how much weight am I allowed to put on my injured leg?
Should I increase weight-bearing gradually or can I bear weight as tolerated?
Should I be walking in the boot, a brace or a regular shoe?
How do I know when I'm ready to stop using two crutches, one crutch, a walker or a cane?
How much pain or swelling after walking is expected?
Is my limp something I should actively work on now?
Are there exercises I should do before trying to increase my walking distance?
Are there movements or surfaces I should still avoid?
What symptoms mean I should stop and call you?
When to Call Your Doctor
Some discomfort, stiffness and swelling can accompany the return to weight-bearing, but new or worsening symptoms shouldn't automatically be dismissed as part of learning to walk.
If you have sudden or severe pain, an inability to bear weight after previously progressing, concerning incision changes or significant new swelling, contact your doctor right away.
Watch for Signs of a Blood Clot
A deep vein thrombosis (DVT) is a blood clot, usually in the leg. Contact your doctor promptly if you develop:
New or unexplained swelling, especially in one leg
Calf or leg pain or tenderness
Warmth in the affected area
Redness or discoloration of the skin
A clot can travel to the lungs and cause a pulmonary embolism (PE). Seek emergency medical care immediately for unexplained shortness of breath, chest pain (especially pain that gets worse when you breathe deeply or cough), coughing up blood, a rapid or irregular heartbeat, lightheadedness or fainting.
One Step Really Is a Big Deal
Walking is something most of us did without thinking about it—until suddenly we couldn't.
That's why those first few steps can feel so enormous.
They aren't graceful. They may happen with both hands wrapped around a walker, or with a physical therapist standing six inches away, or during the world's slowest trip from the bed to the bathroom.
But they're steps.
And after weeks or months spent thinking about everything you can't do with that leg, learning to walk again is one of the first times recovery begins to feel less like waiting to heal and more like getting your life back.
3) Dickin, D. Clark, et al. “Comparison of Walking and Stair Climbing Using a Walking Boot or an Ankle Brace to Measure Joint Stabilization.” Ball State University Biomechanics Laboratory.