A few facts to keep in mind:

1. During the first 10 weeks after surgery, there is an increased risk of recurrence of injury.
   1. This is the reason for casting and religious use of the tall boot
2. The pain of injury and surgery repair is different than the pain of re-strengthening after surgery.
3. Isometric exercises (or contractions of muscle groups), are extremely beneficial for improving post-operative results and decreasing complications following surgery.
4. Athlete or not, this is a 9 to 16-month recovery. The higher the competition the longer it takes.
5. There is an increased risk of blood clots (DVT) with Achilles surgery so take a baby Aspirin (81mg) once or twice a day while in splint or cast if you are not on other blood thinners.

Postoperative Protocol:

Surgery until initial postop appointment (Surgery Date- 14ish days):

• A splint is placed on the leg in the operating room and should be kept in place until the initial postoperative visit. The splint allows for anticipated swelling following the procedure. Weight-bearing is NOT permitted, and even hazardous, while in the splint. 
• Quadriceps and hamstring exercises as well as isometric calf exercises (calf contraction without moving foot) can be started on postop day 1.

First postop visit (Approximately 2 weeks):

• A cast is placed on the first postoperative visit and will remain on for 2-4 weeks, depending on Dr. Mitchell's confidence in the repair, and post-operative healing.
• DO NOT get the cast wet, or stick anything down your cast, as it may cause lacerations or increase risk of infections.
• During this time quadriceps and hamstring exercises and isometric calf exercises should be continued.

Second postop visit (4-6 weeks after surgery):

• The cast will be removed, and you will be given a tall walking boot. You will slowly transition to full weight-bearing in the boot.
• Single-leg calf raises should NOT be attempted at this time.
• No walking out of the boot at this time but you may take it off to stand in the shower.
• Do not dorsiflex above neutral.
• Gradual Thera-Band exercises, with the lightest resistance, can be started at this time as well – See picture below

Third postop visit (10-12 weeks after surgery):

• You will gradually transition out of the boot and into regular shoes.
• Take a shorter steps, and walk slower at first. This will allow you to focus on trying to make your walking symmetric and balanced.
• Walking in front of a mirror, if available, can be helpful. Watch shoulder motion and foot position for symmetry. Proper walking mechanics now leads to better performance later as the stride opens up.
• Elliptical machine, treadmill, and stationary bike are okay at this time.
• Physical therapy prescription will be given at this appointment
• No dorsiflexion stretch above 90° until 12 weeks post operatively and don’t stretch aggressively until 6 months postop as you can lengthen repair until then.

Approximately 5 months postop:

• Transition from double leg calf raises to single-leg calf raises.
• This is the earliest people typically return to jogging. The patient has to be able to walk 20 feet on their tiptoes without heel dip and be able to do a single-leg calf raise prior to jogging.
• More aggressive athletic activities that involve jumping and more explosive movement can start around 9 months at the earliest.
  • This is dependent on your PT progress and Dr. Mitchell’s discretion.

Your surgery with Dr. Mitchell is scheduled as follows:

DATE: ARRIVAL TIME:
LOCATION: HonorHealth Piper Surgery Center
9007 E Shea Blvd Bldg. A
Scottsdale, AZ 85260

(Surgery time is subject to change and you will be notified on any changes.)

IMPORTANT PRE-OPERATIVE INSTRUCTIONS

1. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT BEFORE SURGERY OR YOUR SURGERY WILL BE CANCELLED!!!!!! This includes water and ice.
2. Surgery Prep: On the morning of your surgery, please wash your foot/ankle with Hibiclens before going to the surgery center. This can be purchased at any pharmacy or store (i.e. Walmart, Target, CVS, Walgreens). Do not apply lotion the night before and the morning of surgery.
3. Medications:
   1. ACEIs and ARBs: Blood pressure medications can interact with the anesthetic. Both should be held 24 hours prior to surgery and resumed as normal after leaving the surgery center. Examples include: Lisinopril, Lotensin, Ramipril, Olmesartan, Losartan, Valsartan.
   2. NSAIDs: STOP ALL non-steroidal anti-inflammatory medications 7 days prior to surgery. You may resume taking NSAIDs in the evening after your surgery. Inflammation is part of healing and NSAIDs can lead to more bruising and swelling but you may resume if necessary. Examples include, but are not limited to: Naprosyn, Aleve, Advil, Indocin, Voltaren, Motrin, Aspirin, Ibuprofen, Feldene, and Daypro. If you are unsure, please call with any questions. You CAN take Celebrex within 7 days of surgery. DO NOT STOP taking your steroids.
   3. Weight Loss: If you are taking any weight loss medications or herbal supplements, it is imperative that you DISCONTINUE those two weeks before surgery. Examples: weight loss: Phenteramine, Redux, Xenadrine. Herbal supplements: St John’s Wort, Metablife, Ephedrine compounds, Ginko Biloba, Echineachia, etc. If you are taking GLP-1 meds (Ozempic, Mounjaro, Wegovy, etc.) the oral meds must be stopped for one day and the injectable need to be stopped for one week prior to surgery.
   4. Depression: Brintellix and Trintellix (Generic: Vortioxetine) need to be stopped for 1-2 doses. Please talk to your primary doctor to confirm that is safe.
   5. Biologics: If you are on medications to suppress the immune system (common for RA patients) such as Actemra, Enbrel, Humira, Orencia, or Remicade, they need to be stopped two to four weeks ahead of surgery. Talk to your rheumatologist about this or ask Dr. Mitchell. If they have not been stopped ahead of time your surgery will be postponed. Talk to Dr. Mitchell about when restart them (Usually no sooner than initial postop appointment where wound healing is confirmed).
4. What to wear: Wear loose comfortable clothing that will not confine the surgical area. You can leave your underwear on. Please leave all jewelry and valuables at home the day of surgery. You may have toe nail polish on for surgery.
5. Contacts: If you wear contacts, please remove them prior to your surgery or bring your case with you to the surgery center.
6. Transportation: Please arrange for transportation to and from the hospital. You WILL NOT be permitted to drive yourself home under any circumstances. Make sure you have a responsible adult with you for 24 hours after surgery-unless you are being hospitalized after surgery.
7. CPAP: If you use a CPAP Machine and are staying overnight, you should bring your CPAP machine with you to surgery.
8. Diabetes: If you are diabetic, please check with your primary care physician regarding your insulin dosage. We will schedule you first thing in the morning if possible.
9. Anesthesia: An anesthesiologist will speak with you before your surgery. At this time, he/she will go over your medical history and answer any last minute questions you might have.
10. Insurance: Your insurance company will be contacted to check if authorization is needed and you will be notified if there are any problems.
11. Cancellations: Surgical scheduling requires a great deal of effort from our scheduling team. We coordinate the surgeon, assistant, anesthesiologist, operating room and surgical equipment for your operation. We ask you to be available for your operation at the scheduled date and allow cancellations only for emergencies. Should a medical condition or personal problem arise necessitating you canceling surgery, IT IS VERY IMPORTANT THAT YOU PERSONALLY speak to Sandra. Calling the surgical facility on short notice is not acceptable.
12. FMLA Forms: Please drop off all short-term disability and FMLA forms at the office. These will not be filled out on the day of surgery. FMLA forms will be completed within 2 weeks of the date of surgery.

FIRST POST-OPERATIVE APPOINTMENT:

Unless Dr. Mitchell tells you to return sooner, please note the date & time of your 1^st post-op appointment. Your 1^st post-op appointment will be with Jennifer Neil our physician’s assistant.

DATE: APPOINTMENT TIME:
LOCATION: Arizona Sports Medicine Center
8630 E Via de Ventura #201
Scottsdale, AZ 85258

Questions? please contact Sandra at (602)767-4555 or use the patient portal.

IMPORTANTPOST-OPERATIVE INSTRUCTIONS – PLEASE READ CAREFULLY

1. Symptoms to report to your doctor:
   1. Shortness of breath or chest pain when taking a breath.
   2. Increased calf or thigh pain accompanied by swelling.
   3. The feeling of pressure from your splint or cast that is painful and does not resolve with elevating the extremity.
   4. Pain that is worsening over time despite taking pain meds and elevating the extremity.
   5. Feelings of flu-like symptoms (i.e. nausea, general body aches, or temperature over 101 for longer than 24hrs).
2. Activity:
   1. DO NOT PUT WEIGHT ON YOUR OPERATIVE LEG, unless instructed by Dr. Mitchell that you may do so.
   2. Keep your foot/feet elevated at or above the level of your heart for the first 72 hours. This is important to reduce swelling & relieve pain. If your foot or ankle is throbbing when down it is telling you to elevate it. You may put ice on the bandages above the site, but do not get the bandages wet. Usually a bag of frozen vegetables works the best. If you have a bunion shoe and not a splint or boot, it is helpful to move your ankle frequently.
   3. You should limit being upright during the first 48-72 hours, although getting up for the bathroom and eating is permissible. Doing leg lifts and moving frequently decreases risk of blood clots.
3. Dressing care:
   1. Do not remove your dressing and do not apply any ointments or lotions to the wounds; it will be changed on your first return visit and you will be instructed on post-operative care.
   2. Keep the dressing dry. Take sponge baths or hang your leg outside of the bathtub while you bathe. You can get a Xerosox or waterproof cast protector or cover your lower extremity with a garbage or newspaper bag then tape or rubberband the top of the bag.
   3. The dressing on your foot/feet is applied with some compression to reduce swelling. However, if it feels too tight or if your pain is not relieved with the medication prescribed, you may loosen the dressing by splitting it along the front or side w/ scissors, allowing it to slightly open up or unwrapping it partially then rewrapping loosely with an ACE wrap if you are in a splint. If you are wrapped with an ACE wrap you may unwrap it and replace it more loosely. Leave the white cotton dressings in place.
4. Pain control:
   1. Nerve blocks: Many patients receive a popliteal block (shot behind the knee) or ankle block (shots around the ankle) for postoperative pain control. These can last overnight and occasionally two nights. With a popliteal block, patients are unable to move their toes until the block starts to wear off. Smaller procedures often receive local anesthetic into the operative site, which typically lasts 5 or 6 hours. It is a good idea to have some oral pain medication in your system before the block wears off as it can wear off suddenly and oral pain meds take 30-45 minutes to be effective.
   2. Narcotic pain medicine prescriptions are typically sent electronically to your pharmacy the day before surgery or on Friday if your surgery is on Monday. The prescription will be sent to the pharmacy you have given us. If you want it sent to a different pharmacy, please let us know ahead of time. We cannot change it on the day of surgery. We prescribe Percocet (Oxycodone and Tylenol) unless you tell us you have an allergy to it. The prescription says to take one every six hours as needed. For surgeries involving bone work such as bunionectomies, fracture repairs, and fusions, that is usually not enough. An adult size person can take two pills at a time (every 4-5 hours) but should not take more than 8-12 (8 for small or petite, 12 for large) in a 24 hour period as too much Tylenol can cause liver damage. Maximum daily dose of Tylenol is 3000-4000 mg a day depending on body size. Percocet has 325mg of Tylenol in each pill. Do not drink alcohol while taking the narcotics as they are central nervous system depressants and alcohol will make the liver less tolerant of Tylenol. The average patient with a bunionectomy or ankle fracture repair will take around 25 pills. For the first two days it is better to take the medication regularly than to tough it out. It is better to stay on top of the pain control or slightly ahead of it as playing “catch up” doesn’t work as well. By Post Op day 3 you should be cutting back significantly on the narcotics or stop taking all together. For bigger, more complex cases involving a lot of bone work we send in a prescription for MS Contin. This is a long acting (12 hour) narcotic that you take for the first two to three days and take the Percocet on top of it as needed. Narcotics commonly cause constipation so take stool softener (Colace) and make diet adjustments to help counteract that.
   3. We send in a prescription for nausea medication (Ondansetron/Zofran). If you don’t have problems with nausea you can leave the prescription at the pharmacy and only fill if needed.
   4. We typically send in a prescription for Vitamin D (50,000 IU/week) for patients that are having bone surgeries (bunionectomies, fusion, fracture repairs) as a lot of people are low and don’t know it. Low Vitamin D can impede bone healing. If you know your Vitamin D level is in a normal range you do not need to fill the prescription.
   5. If you are behind on pain control, it is permissible to take 2 Aleve or 3 or 4 Advil once or twice to catch up. These NSAIDs can lead to more bruising and swelling so minimize use when possible.
   6. Taking 1-2 81mg aspirin a day can be helpful in preventing blood clots while your leg is immobilized. It is not necessary if you are only in a post op shoe. Take aspirin only if you do not have a history of ulcers, take Coumadin (blood thinner), or have other contraindications.
   7. Try to anticipate in advance your pain medicine needs. Call the office with your refill requests Monday – Thursday between the hours of 8AM – 4PM and Friday from 8AM to Noon.

5. Durable Medical Equipment (DME):
   1. You may want to obtain a walker, crutches, or a roll-a-bout knee scooter prior to surgery to practice getting around. If you did not arrange for these items ahead of time, crutches will be provided to you upon discharge from the facility.
   2. If or when Dr. Mitchell places you into a Cam Walker, he suggests that you may want to get the Even-up shoe balancer which can be ordered online. This can decrease strain on your back and hips.
6. Dental work: Routine dental work is discouraged for the first 6 weeks post op. If there is a dental emergency, tooth abscess. Broken tooth, etc., get that taken care of right away.
7. Travel: Travel is not advised until after your 1^st post-op appointment. The risk of blood clots is higher with your leg being in a downward position for too long especially if immobilized in a splint or cast. Plane flights should be avoided if possible while in a cast. If you must fly while in a cast let us know so blood thinners can be provided if indicated.
8. Driving: You may drive once you are off narcotic pain medication, walking comfortably on operative extremity, and able to brake firmly, comfortably, and quickly. If your surgery was on the right side and you are in a non-weight bearing phase you should not attempt to drive. Your reaction time will be slower for a week or two after having been immobilized. Never drive or operative heavy machinery while taking prescription pain medications.
9. Other Medications: If you are on blood thinners such as Coumadin, Plavix, or Eliquis, talk to Dr. Mitchell regarding when to restart them.