Dr. Amol Saxena, DPM
Palo Alto Foundation
Medical Group
Dept. of Sports Medicine
3rd Floor, Clark Building
795 El Camino Real
Palo Alto, CA 94301
Office: 650-853-2943
Fax: 650-853-6094
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Dr. Amol Saxena, DPM

Return to Sports After Injury

Parameters to Assess Return to Sports after Foot & Ankle Injuries and Surgery:
Amol Saxena, DPM & Marc Guillet, PT, ATC

Basic guidelines to return an athlete to running sports, includes assessment of pain level, range-of-motion and strength. Simplistically, the patient must have no pain with daily activities. Some initial onset of activity stiffness or soreness may be present for long periods post-injury, and this is not uncommon to persist for up to a year according to our clinical experience. However, the soreness or stiffness should get better with activity. There can be mild pain with palpation to either the Achilles tendon or the insertion. Ankle range-of-motion should be within 5° of the contra-lateral (opposite) limb’s ankle but adequate to perform the necessary activities. The circumference of the affected limb should be within a ¼” or 5 mm of the non-injured side. Strength assessment includes pain-free hopping and 20 single leg heel raises. Generally, 45 seconds of consistent activity repeated five times, is a good guideline for allowing a patient to return to sport.

Our typical regimen is to have the patient progress to being able to perform five sets of single-leg heel raises of 25 repetitions each as a barometer. We have found this parameter, along with having the range-of-motion within 5°, and calf circumference within 5mm to be statistically significant in getting people back successfully, at least when we evaluated 200 Achilles surgeries. Patients should be able to walk briskly for 40 minutes before trying to run. Standard Vertical Leap Testing, Single Leg Three Hop Test and a 20 Yard Lateral Shuttle Test should be assessed in the athletic population, especially those involved in lateral motion sports (see Return to sport is not allowed unless all limitations are within 90% of the non-affected extremity.

A typical return to running program would be as follows: have the patient alternate walking and jogging for two minutes each, completing four cycles (16 minutes of total activity). Have them take a rest day and then re-assess two days later. If they felt challenged, have them repeat this every-other day for a week. If this was far too easy, then have the patient alternate three minutes jogging with one minute walking, again for four cycles. Again have the patient re-assess and repeat this every-other day for a week. Then the patient can begin with the following running schedule outlined in Table 1.

Table 1

  Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Wk 1 15 min Rest 15 min Rest 20 min Rest 20 min
Wk 2 20 min Rest 25 min Rest 25 min Rest 30 min
Wk 3 20 min Rest 30 min Rest 40 min Rest 40 min
Wk 4 20 min Rest 40 min Rest 50 min Rest 50 min
Wk 5 20 min Rest 50 min 30 min Rest 60 min 20 min

Anecdotally, we’ve found that patients with purely soft-tissue problems fare better with activity more often, versus those with bony involvement that may need to maintain an every-other day activity level for longer periods of time. We insist that the patients maintain their flexibility and strengthening regimen, along with any other therapy until they are up to their typical activity level, which again can take up to a year. We also encourage icing and compression (and even bracing with some injuries such as ankle sprains) up to a year post surgery/injury. Consistently patients say no matter which surgery or injury, that it takes a year to feel 100%, so be patient.

Sample Rehab: Warning- do not attempt without permission from your medical professional, coach etc
Grade II Ankle Sprain
Exercise %BW Time post injury Comment
Heel Raises/Balancing 60-70% Immediate Tape or Brace
Running 60-70% 2-14 days  
Grade III & High  Ankle Sprain
Exercise %BW Time post injury Comment
Heel Raises/Balancing 60-70% 2-3 wks Tape or Brace
Running 60-70% 4-8 wks  
Distal Lesser Metatarsal Stress Fracture 
Heel Raises 60-70% 1 wk Insert w cutout
Running 60-70% 1-3 wks  
Jones Fracture, Prox Met Str Frx, Sesamoiditis
Heel Raises 60-70% 3-4 wk Insert w cutout
Running 60-70% 4-6 wks  
Achilles Tendinosis, Plantar Fasciitis, Tibial Str Frx & Calf Strain 60-70% 1 wk Use insert or orthoses PRN
Heel Raises 60-70% Immediate  
Running 60-70% 1-3 wks  
Post Foot & Ankle Surgery
Heel Raises 60-70% Procedure dependent eg: bunion & Achilles surgery  6-10 wks
Running 60-70% When bone stable or tendon healing occurs
Note: Initiation & progression should be surpervised by a licensed medical professional
Initial experience with approximately 200 patients has shown that patients should adjust BW to be painfree, and that outdoor running is allowed once patients can achieve 85-90% BW on the G-trainer

  Outside running   Alter-G time Alter-G body weight    
week 1     30-->40min 70-->85%    
week 2     30-->60min 75-->90%    
week 3 20 min qod 3days   40-60min 75-90%   1 day off
week 4 30-40min qod 3 days   60-75min 75-90%   1 day off
week 5 40-50 min qod 3-4 days   60-90min 75-90%   1 day off
week 6 50-60min 4 days strides on grass 60-90min 75-90%   1 day off
week 7  60+min 4 days strides on grass 60-90min 75-90% tempo/speed
on alter-g
1 day off
week 8 60+min 4 days strides on grass 60-90min 75-90% tempo/speed
on alter-g
1 day off
week 9 Gradual ->Full Training          


Check list Return to Run Program

Commence running upon successful completion of the following;

  • Steps 1-9 should be carried out IN ORDER (steps are progressive)
  • Ideally there should be NO pain. If pain is felt record the movement and inform your medical professional
  • Steps/levels may be progressed with caution under advice of medical professional with minimal discomfort (<3/10 pain-scale)
  1. Walk
    • Flat ground
    • Up stairs
    • Down stairs
  2. Air Squats x10
  3. Alternating lunge x10
  4. Double Leg Heel Raise x20
  5. Single Leg Heel Raise x10
  6. Run on spot 10 seconds (knee to hip height)
  7. Double Leg Hop
    • X20 up and down
    • X20 swivel
    • X20 side to side
  8. Single Leg Hop
    • X10 up and down
    • X10 swivel
    • X10 side to side
  9. Run drills
    • Ankling x20m x2
    • A Skip x20m x2
    • B Skip x20m x2
    • Straight Leg x20m x
    • Stride 40m x3

Return to Run Program

  • If no pain progress
  • If pain stop and speak to a medical professional
  • Pace should be comfortable “conversation pace”
  • May progress with minimal pain (<3/10) if cleared/advised by a medical professional
  • Patience is key to facilitate physiological adaptation
  • RTR should incorporate strengthening/technical drill program (RTR programs are specifically designed to allow time for corrective exercises to address deficits and asymmetries) “Window of Opportunity”
  • Each run should be proceeded by muscle activations for maximum effectiveness
  • After successful completion of level 8 the athlete has “earned the right” to commence a running program

Level 1

  • 2x2mins (1min)
  • Rest

Level 2

  • 3x2mins (1min)
  • 4x 2mins (1min)
  • Rest

Level 3

  • 3x3mins (1min)
  • 5x2mins (1min)
  • 4x3mins (1min)
  • Rest

Level 4

  • 3x4mins (1min)
  • 5x3mins(1min)
  • 4x4mins(1min)
  • 3x6mins(1min)
  • Rest

Level 5

  • 2x9mins(1min)
  • 2x10mins(1min)
  • 3x7mins(1min)
  • 5x5mins(1min)
  • 4x6mins(1min)
  • Rest

Level 6

  • 20mins
  • 3x9mins(1min)
  • 25mins
  • 3x10mins(1min)
  • 25mins
  • 3x11mins(1min)
  • Rest

Level 7

  • 30mins
  • 3x12mins(1min)
  • 35mins
  • 3x9mins(1min)
  • 35 mins
  • 3x10mins
  • Rest

Level 8

  • 40mins
  • 25mins
  • 40mins
  • 30mins
  • 25min
  • 45mins
  • Rest

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