Ankle Surgery Recovery: Running and the Arthrex InternalBrace for Lateral Ankle Instability

On July 15, I underwent surgery to address years of unresolved ankle instability. After meeting two different surgeons, I opted for the generally well-regarded Internal Brace surgery from Arthrex. In this procedure, a surgeon shortens up and reattaches ligaments in the ankle (called a Brostrom repair) and then adds an additional brace that acts as a seatbelt for the ligaments. My surgeon was Dr. Kruelen of UC Davis, and I would recommend him to other runners. 

In this blog post, I’ll offer a detailed overview of my running before the surgery, the first few days after surgery, and my return to exercise. Hopefully it will be a helpful resource to other people considering this surgery. 

I am writing this 5 months post-surgery. Last weekend, I ran a 5K with a friend, and I did a 5 mile interval run on Monday and a 5 mile threshold run on Wednesday. I am not back to the mileage or the speed I was at pre-surgery, but every week I’m stronger. 

Feel free to jump to my detailed overview of exactly when I was allowed to return to various forms of exercise —I know that’s what I was searching for when I was considering this surgery.

Running before the surgery

I think of running as the most unadulterated good thing in my life. Before my running addiction, I suffered from choking depression, and years of therapy and medication hadn’t done much to make me want to live. I was a smoker. I drank, and I smoked weed. I had shallow friendships, and hated my life and my body. 

I picked up running in my mid-20s. I guess I thought running would help me lose weight, and instead it just made me far happier. Regular running was far more effective than a decade of therapy and a passel of medical interventions.

With the depression finally under control, everything else in my life was suddenly more manageable. I gave up weed, completely. My relationships started to change, to deepen and become more authentic. I didn’t feel as alone. I didn’t hate myself as much. I still didn’t love my body, but I loved that it could run.

After well over a decade of consistent running and four marathons, I think I’m just starting to be not terrible at it. In 2021, after years of telling myself I shouldn’t run more than every other day because it was “bad for my knees,” I changed my schedule to running five days a week. I was instantly, significantly happier. I spent the first half of 2021 working on my half marathon time, alternating Monday speed work with Tuesday steady days, Wednesday fartlek workouts and Friday easy runs. And of course, I lived for my Saturday long runs. Everything from the whole week worked its way out one step at a time in those long runs, until I was wrung-out, grateful, starving, sore, emotional, and more at peace.

Before the surgery, I was running 30-40 mile weeks. My biggest fear with getting surgery was having to take months away from running. And the possibility⁠—however slim⁠—that I might never run again.

Chronic Ankle Instability

My first bad ankle sprain happened in 2016. It was twilight, I was on a rocky trail in a park I’d never been to. I twisted my ankle badly. Miles from the car, I decided to just jog back to it. I think I finished the full 6 mile run. I went home and packed it with ice. 

I saw a doctor the next day, who assured me it was a “mild” sprain and urged me to stay off it for a few weeks. She didn’t give me crutches or refer me to physical therapy or do any imaging on the ankle.  She didn’t give me an ankle brace or recommend any particular type of ankle brace.  I wrapped it up and suffered a few weeks without running, but still walked on it often. I went back to running after 5 weeks.

Today, it’s hard for me to not feel resentment toward this doctor. I wonder, even now, if things might have been different if she had immediately sent me to a physical therapist who specialized in runners.

Within a month of returning to running, I sprained it again. More weeks with the ankle recovering, more bandages, still no physical therapy. 

After that, it was a cycle⁠—things would be fine, then a few months would go by and I’d tweak it again. The ankle felt loose, like it was never truly healed.

Years later, I saw a podiatrist who told me that my first ankle sprain probably hadn’t been mild at all, but apparently completely severed the ligament and fractured my leg bone. I went through physical therapy twice. I did ankle-strengthening exercises daily for a couple years. But the ankle just didn’t feel right.

In 2021, even as I was clocking 40-mile weeks and feeling so happy, I worried about my ankle. I would finish runs to find it swollen and achy. It felt wrong. It kept collapsing. On backpacking trips, I worried about it constantly.

I went to a new doctor this year and asked for another referral to physical therapy. This time, I thought, I’ll get a better physical therapist and we’ll really get to the bottom of it.

The doctor told me what I probably should have heard years earlier: physical therapy hadn’t helped, and so the only option was surgery.

“Or,” he said, “You could just take up cycling.”

Ankle surgery

I spoke to two different ankle surgeons. One, an extremely nice doctor with Sutter, told me I would need to take at least 6 months off of running, and that I’d need to spend two weeks with absolutely no weight bearing whatsoever and 6 weeks without driving. I asked him whether I’d be running and hiking by the following spring (9 months away) and he said that he really believed in a conservative recovery program.

The second ankle surgeon I met with was Dr. Kreulen of UC Davis. A confident, rather brusque, excessively tall man, he told me he’d been trained in an Australian method of surgical recovery that pushed patients to activity and weight bearing faster. He explained that he would insert an InternalBrace and that I’d be able to bear weight immediately after surgery. When I asked how long it would take for me to return to running, he said 12 weeks. I asked him whether I’d be backpacking and running long distances by the following summer, and he said absolutely. He said not getting the surgery would be leaving me open to the ligaments tearing completely. 

Dr. Kreulen said he embraced “tough love.” He said recovery would hurt and I should expect it to hurt, but that he wanted me to work through the pain. He said early movement and putting some weight on the ankle would help prevent scar tissue from forming and limiting mobility. 

But really, he didn’t need to say any of that. I chose him as soon as he told me I’d be running in 3 months instead of 6 months.

Surgery day

I arrived at the surgery center early, and I wasn’t allowed to eat or drink anything. I got all checked in and changed into a surgical gown. They gave me these soft grey socks for my feet and a locker for my things, and the nurse came by and asked a bunch of questions. I declined the nerve block and then I was given anesthesia. 

I woke up groggy and everything was just a bit out of focus. My leg was bound up in a thick white bandage, and beneath it I could feel something rigid. It was apparently a bandage that would accommodate swelling. The nurse tried to interact with me, and a resident came by to talk to me but I can’t honestly say I remember that much of the conversation. I do remember that I was asked to rate my pain from 1 to 10, and I said 7 but then declined pain killers. 

The resident explained that, in addition to the Brostrom repair to fix my lateral ligament on the ankle, they’d had to repair two other loose ligaments and remove a rather large loose body⁠—which I think was sort of like a bone fragment⁠—that was rattling around in there. The repairs were a bit more extensive than had been expected based on the MRI, which made me feel like the decision to get the surgery was probably the right one.

They had me stand and walk (!) to the waiting wheelchair, and then they wheeled me out and got me in the car with my partner. I was overwhelmingly thirsty.

They didn’t issue me any crutches at the hospital (a mistake, it turned out later) but I had already bought some and so, with help from my partner, I was able to get into the house without trouble. I went straight to bed where I attempted to pack my foot with ice. 

As soon as I was home from the surgery, I was groggy, hungry, and emotional from the post-anesthesia effects. That first day, it was incredibly frustrating not to be able to go cook for myself in the kitchen. Having to individually ask for everything—and feeling hungry and in pain—was overwhelming. 

The recommendation is to keep the foot elevated and wrapped in ice packs for as much as possible during the first few weeks of recovery. The problem is that the bandages are so thick that the ice packs basically don’t penetrate down to the swollen ankle. So the ice always felt nearby but useless to actually soothe my foot.

I had read other reports of people recovering from Brostrom repairs who weren’t able to bear any weight at all for weeks post-surgery. But because of the Internal Brace, and possibly also because my surgeon had this whole “tough love” perspective, I was able to put weight on it right away. So it was easy to use crutches to get to and from the bathroom, and I didn’t need a knee scooter or anything. I couldn’t really cook, but within two days I could get to the kitchen, put coffee in a travel mug and tuck that in my apron, and then crutch outside to the backyard to lie in a low hammock.

The surgeon gave me 5 oxycodones to help with the first few days of recovering from surgery, but I found them too strong. I was already groggy and out of it; the painkillers made me feel even worse. So I only took two of those and then I opted for Tramadol, which I’d also gotten prescribed. The Tramadol I needed quite a bit over the first couple weeks, mainly to sleep at night. In general I tried to avoid taking anything unless the pain was quite bad.

I was thankful to have a lot of help my first 10 days post-surgery, including my partner (who normally is gone all summer working in Yosemite but took several days off to be with me immediately after the surgery) as well as close friends who helped out with cooking, cleaning and anything else I needed. 

Helpful Purchases

Honestly, I bought a bunch of junk on Amazon leading up to the surgery. Only some of it ended up being useful. Here are the things I bought that were super helpful for me:

    • A wedge pillow for elevating legs (I put additional pillows on top of this during the day, and jammed this under the mattress at night). I ended up getting two more (this kind and this kind) for different areas of the house. 

    • A chest freezer. Before the surgery, I cooked and divided up an entire lasagna, prepped freezer-bag crockpot meals, and stocked up on pretty much anything I could think of that would reasonably freeze: coffee, bread, soup stock, etc. I didn’t have to cook for two months. 

    • Some ice packs. I tried those fancy ice machines; they just broke. Simple ice packs with elastic straps saved me. 

    • This awesome apron, which helped me carry things around when I was using crutches. 

    • These well-reviewed arm crutches.

    • This Schwinn IC4 fitness bike, which seemed to be the best reviewed indoor bike that would sync with the Peloton app without actually making me get a Peloton, plus these biking shoes and cleats. (Though I didn’t get this bike until about a month post-surgery, and began exercising at the gym).

Nutrition Post-Surgery

All the guidance on post-surgical recovery seems to focus on eating enough food and specifically eating enough protein. For the first couple weeks of my surgical recovery, I aimed for eating my body weight in grams of protein every day, and I aimed for at least 1800 calories but often closer to 2,000. This was a little terrifying for me; I was not exercising and I was eating a ton of calories. It seemed inevitable that I’d put on weight (which I did; I gained 5 lbs over 3 months). But I did it anyway to try to support the ankle recovery.

I also incorporated Co-Q10, Glucosamine Chondroitin, a daily multivitamin for women that included Vitamin D, and iron supplements. I ate some sort of fish almost everyday, and I alternated between whey protein and my favorite plant-based protein. In my regular life, I do fasted runs first thing in the morning. In my post-surgery life, I ate protein and berries for breakfast every morning from a hammock.

Exercise Post-Surgery

Here’s a day-by-day guide to what exercise I did post-surgery until I was back to running. 

Day 0: Surgery day, no exercise. Foot elevated, dozing a lot. 

Day 1: No exercise, significant discomfort that often dipped into pain, keeping foot elevated all day.

Day 2: Floor Pilates for 12 minutes. Still in a lot of discomfort.

Day 3-7: 30 min of Pilates/day. Able to crutch to the end of the block by the end of the week.  A lot of difficulty sleeping with the cast on. 

Day 8: Able to take a crutch-assisted walk for 30 minutes outside. 

Day 9: Able to sleep through the night without painkillers for the first time. Still keeping foot elevated and packed in ice most of the day, still doing 30 minutes of Pilates daily.

Day 10-11: Pilates. Short walks around the block with the crutches. Lying on back with foot elevated most of the day. 

Day 12: Met with the surgeon to remove bandages and I was able to wash my foot, which felt amazing. Still mostly lying down all day. Moved into a new brace that fit into my sneakers, and then I could walk without the crutches.

Day 13-18: Allowed to drive. Able to do some weight lifting that didn’t tax my ankle. Started working again, but not full time.

Day 19: First day of physical therapy

Day 21: Back to work full time. 

Day 22: Started using an indoor bike while wearing the ankle brace. I started with about 30 minutes of indoor biking plus using the weight machines at the gym for another 30 minutes.

Day 23-48 Indoor biking (30-60 min), weight lifting using the machines at the gym every other day, and slowly increasing time on feet in daily walks. All of this while still wearing the brace. Physical therapy exercises 2 times per day, plus in-person physical therapy twice a week. I often spent 3 hours a day on exercise and physical therapy.

Day 49: First day adding swimming (with a brace) to my routine.  Plus, I was now allowed in a hot tub. 

Day 84 (October 7): First day of running! After an extensive warmup, I was allowed to run 1 minute, then walk for 4 minutes, and repeat that three times—on a treadmill, while wearing my ankle brace.

Day 84-Day 112: Gradually following the return to run program, which let me run three times a week on a treadmill wearing the brace, slowly adding more time to my runs. The final run was 4 rounds of a 4 min run with 1 min walk in between. In addition to these runs, I was using the exercise bike for most of my cardio, building up time on feet through longer walks, and lifting weights. And of course, physical therapy two times per day. It was not unusual for various forms of physical therapy and exercise to take up to four hours in a day. I rearranged my work schedule to shift my hours back, but it was still a massive commitment.

In addition to running, I started doing weighted hikes. On Oct 16, I hiked for 3 hours with an 8 lb pack, then Oct 23 I moved that up to a 4 hour hike. I kept the 4 hour hikes while slowly adding in additional weight, until by the end of December I could hike for 4 hours with a 20 lb pack. 

I was still icing my foot a few times a day, and still some swelling and achiness after exercise. 

Day 113 (November 5): My first 20 minute non-stop outdoor run.

Now, finally, I was allowed to jog outside for 20 minutes with the brace.  I was surprised that running felt very difficult; I thought I had maintained my cardiovascular fitness with all the indoor biking. But, at least the first couple weeks back I really struggled. I didn’t record the exact date I was allowed to stop wearing my brace on my outdoor runs, but it was sometimes in the next week or two. 

Day 137 (November 29): 45 min runs 3 times per week, just starting to layer in some speed work. Continuing with long weekend hikes, weight lifting, and physical therapy. 

Day 150 (December 12): My first 5K race.

Big takeaways 

I’m glad I got this surgery. I can say that now because I am able to run again and my ankle feels more stable than it did prior to the surgery. I’m also very glad I got the Arthrex InternalBrace, and not a traditional Brostrom repair. If I’d gotten the traditional Brostrom repair, I would only now be starting to run again.

Here’s what surprised me: 

• I was overly concerned about being incapacitated the first couple weeks after the surgery. The first few weeks were hard and uncomfortable, but they were also very simple in many ways. There was a fair amount of pain management (what did I expect, choosing the “tough love” surgeon?) and there was uncertainty, but I could get around the house, heat things up in the kitchen, and even get to the end of the block.
•  I underestimated how much time and energy the physical rehab would take. Attempting to maintain my fitness levels on the bike while also rehabilitating my foot and building up strength in my ankle were all time-intensive. I was often awake before 6 AM, exercising before 7, and still rushing to finish the last of my physical therapy exercises by 10 AM. I was grateful that I could adjust my working hours, but it still sucked. By far the most difficult period of time of the recovery was the first two weeks back at work after the surgery.
• Sleep was really hard. Intellectually, I understood that sleep was one of the best things I could do for my ankle recovery. But looking through my journal, I struggled to sleep – first because I was so uncomfortable with the brace and trying to keep my foot propped up at night, and later because stress and not-running made me a bit of an insomniac.
• Returning to running was a lot slower than I expected. When I’d first heard that it would be “12 weeks before running,” I thought that meant 12 weeks before returning to my regular running plan. But the gradual return to run program has meant that even now, 6 months after the surgery, I’m really only running about 15 miles a week and then hiking on weekends. 
• Thank God for the Peloton app. 

If you’re thinking of getting this surgery or have specific questions about the recovery, please drop me a note and I’ll try to reply.