Cast on Ankle After Surgery

How to Sleep After Ankle Surgery (Doctor’s 8 Tips)

by
Dr-Babar-Naeem.

This article was written by Dr. Babar Naeem (MBBS, MRCPCH) – a licensed and practicing medical doctor – to ensure maximum factual accuracy and unique content.

If you’ve just had ankle surgery, you’re likely feeling pretty exhausted and tired right now.

But there’s a good chance that the pain and reduced range of motion is stopping you from getting to sleep – so what can you do?

The most effective way to sleep better after ankle surgery is to take doctor-prescribed pain medications to reduce discomfort, and sleep on your back with your leg elevated to reduce swelling. Sleeping on an air mattress can also reduce painful pressure points.

The tips that I’ve provided below are based on the guidance that I give to my own patients after ankle surgery and may be of some help to you.

However, following the advice of your surgeon and medical team is paramount after any kind of operation.

Related: how to sleep better with a cast on your leg.

8 Ways to Sleep Better After Ankle Surgery

Ankle surgery is performed to relieve chronic ankle pain and improve mobility in patients with a fractured ankle, arthritis, and other related conditions.

There are different types of surgeries that are performed on the ankle, such as ankle arthroscopy, ankle replacement, fracture repair, and ankle fusion.

Good quality sleep is essential when recovering from any surgery because it promotes healing and reduces inflammation.

Ironically, after getting joint surgery, many factors contribute to sleep disturbance.

The things that make it difficult to sleep after ankle surgery include pain at the operation site, swelling of the ankle, fever, bruising, and limited mobility.

Recovery is usually slow after a foot or ankle surgery, depending upon the type of surgery. 

According to the Orthopaedic and Joint Replacement Clinic, Auckland, New Zealand, it takes about three to four months after ankle surgery for the pain, tenderness, and swelling to settle, while full recovery may take up to a year.

According to a study, about 86% of patients with foot and ankle conditions have difficulty sleeping [1].

Ankle surgery improves quality of sleep in the long term (after 6 months), but sleep problems can be prevalent in the first 6 months after surgery.

I have prepared a list of recommendations below that you can follow to improve the quality of your sleep after getting ankle surgery.

1: Sleep On Your Back to Avoid Abnormal Bone Fusion

The best position to sleep in after ankle surgery is sleeping on your back with your legs elevated because this posture keeps the ankle in a neutral position, and avoids abnormal fusion of the bones.

An ankle support, or a cast, is sometimes used to keep the ankle in a fixed position.

Bed rest, at least for the first few weeks, is essential to ensure optimum healing.

You should try your best to avoid putting weight directly on your foot.

An adjustable bed can help you to sleep in better posture with your leg elevated and help you get in and out of bed more easily.

Click here to see the best adjustable beds I’ve reviewed.

You Can Sleep On Your Unaffected Side a Few Days After Surgery

If you’re a side sleeper then you’ll likely want to get back to this position as soon as possible, and this may be possible a few days after surgery.

When sleeping on your side after ankle surgery, a pillow, or a foam block, should be placed between your legs to act as a support mechanism to avoid injuring the affected leg.

My recommendation is to use this position only if you are feeling comfortable.

Whenever you experience any pain or discomfort, you should switch back to the supine (back sleeping) position.

It is obvious that sleeping on the stomach is not practically possible after ankle surgery, and is not recommended.

Sleeping in a single position can get uncomfortable, and the position should be changed after a while, to avoid developing ulcers.

If you have stomach ulcers, try these 2 sleeping positions.

2: Elevate Your Leg to Reduce Swelling

How to Properly Elevate Your Foot and Ankle After a Surgery

Elevation of the ankle and leg can help drain fluid from the limb, and resolve swelling.

Fluid accumulation and edema can make the pain worse, and delay the healing process.

Body tissues are manipulated during surgery, and this results in the release of fluid from the tissues, resulting in edema.

Mild ankle swelling is normal after surgery.

However, as the limb is immobilized after the surgery, drainage of the lymphatics is also impaired, and worsening of the edema can be seen.

Moreover, infection and inflammation can also increase the swelling of the tissues.

Elevation of the affected leg is a very good strategy to combat this problem.

The leg should be elevated above the level of the heart, so that fluid can drain easily under the effect of gravity.

Drainage of the fluids relieves pain and swelling, and the healing process can continue without any interruption.

The easiest method to elevate the leg is by placing a few pillows beneath the ankle and leg.

The leg can be placed on a table while sitting, to enjoy the same benefits.

The use of an adjustable bed can make this process of elevating the leg very easy.

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3: Use an Air Mattress to Reduce Pressure Points

The use of an air mattress decreases the risk of developing bedsores and pressure ulcers.

As patients who have had ankle surgery have to stay in bed for a long period of time, they are at increased risk of developing pressure wounds and bedsores.

A bedsore is a nightmare for a patient, as well as for a healthcare professional, because it is very difficult to treat.

Therefore, we put our maximum energy into preventing bed sores.

Air mattresses are specially designed to provide proper rest, without damaging the skin at pressure points.

They alternate pressure points, minimizing the chances of developing bedsores.

They also improve blood circulation in the dependent areas of the body.

The firmness of the air mattress can be adjusted according to comfort, by changing the amount of air in the mattress.

Researchers at the Manchester Academic Health Science Centre, Manchester, UK conducted a systemic review of 32 studies, comprising 9058 individuals, to compare the effectiveness of air mattresses and foam mattresses.

They concluded that air-filled mattresses reduced the incidence of pressure ulcers significantly, in comparison to foam and gel surfaces [2].

Click here for 11 ways to sleep better after a knee replacement.

4: Take Painkillers Before Going to Bed

Pain management after surgery is important in order to get a proper night’s rest.

Immobilization, cutting of tissues during surgery, and swelling are some of the factors that cause pain.

The pain can be worse at night, due to the absence of other distractions.

It becomes very difficult for a person to sleep, due to this continuous pain.

Below are some of the different types of painkillers that may be administered by your medical team during and after ankle surgery:

Nerve Blocks

A nerve block is usually given during surgery to block all the pain sensations.

That’s why the patient feels numbness in the foot and ankle after surgery.

A nerve block keeps a person pain free for 24 to 48 hours.

Once the effect of this local anesthesia (nerve block) wears off, the sensation of pain becomes worse after this.

The first few days are especially difficult, as it is very challenging to control this pain completely.

Analgesics (pain killers) are therefore prescribed for first use before the effect of the nerve block wears off.

There are different types of pain medications available, and your doctor can choose what’s best for you.

Opioid Analgesics

These include tramadol, codeine, methadone, fentanyl, and morphine.

Side effects of opioids include sedation, constipation, nausea, dizziness, and dependence.

Increasing fluid and fiber intake is advised to counteract constipation.

NSAIDs

Medicines like naproxen, diclofenac, etc., are also prescribed widely to treat post-operative pain.

Steroids

These also have a very potent pain relief effect, and are sometimes used as an adjuvant therapy to treat pain and swelling.

In my professional opinion, a long-acting painkiller should be taken at bedtime to have a night of good quality sleep.

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5: Use Cold Therapy

Cold therapy is routinely used after an injury to reduce inflammation and speed up functional recovery.

This is also a very effective option for patients after ankle surgery to reduce pain and swelling.

Cold therapy also reduces the dose of drugs required to control the symptoms of pain and swelling.

There are different ways to use cold therapy.

One simple solution is to wrap ice cubes in a towel, and apply it over the affected area.

Ice Gels

Ice gels can be applied to the ankle to get quick relief from pain associated with arthritis.

Cold Therapy Devices

Specialized cold therapy devices are also available, that can be used after discussion with a doctor.

Some of them have an ankle wrap that is about the size of a shoe, and fits perfectly to the ankle.

These devices provide uniform coldness to all areas of the ankle, and are more effective than the manual application of ice cubes.

Jon E Block published a narrative review of 33 randomized controlled trials, and demonstrated that cold compression therapy is more effective in controlling pain and swelling, and improving range of motion relief, than alternate interventions [3].

The NHS recommends applying cold packs for 15 minutes every few hours.

Care should be taken to use a waterproof bag for ice, as a wet dressing can delay the healing process.

The NHS also advises that ice should not come in direct contact with the skin.

The Science Behind Cold Therapy

When we apply cold therapy to any part of the body, the metabolic rate decreases in the surrounding area.

This limits the tissue damage resulting from hypoxia, as the activity of the enzymes is decreased, blood vessels constrict in response to hypothermia, and the circulation of the blood decreases for about 30 minutes.

Extravasation of blood into the surrounding tissues decreases, resulting in decreased production of edema.

When blood flow is reduced, the lymphatic system can work more efficiently to clear up the edema.

Another function of cold therapy is to decrease conduction of sensory and motor signals from the cold area, which ameliorates the pain and discomfort [3].

So cold therapy relieves pain and swelling, and prevents tissue damage.

Here are 6 ways to sleep more comfortably after ACL surgery.

6: Take Medications as Prescribed

Antibiotics, anti-inflammatory drugs, steroids, and other prescribed medicines should be used exactly as directed by the surgeon.

Inflammation is one of the major issues that prolongs recovery, and results in disturbed sleep.

Mild inflammation is normal after any surgery, as various tissues have been handled.

But if inflammation is severe, or gets worse after 48 hours, it denotes an underlying infection.

There are five signs of inflammation that are commonly described by experts, and you should be aware of these.

They are dolor (pain), rubor (redness), calor (heat or increased temperature), tumor (swelling), and function laesa (loss of function of the affected area) [4].

Anti-inflammatories

These medicines are an essential part of the recovery plan, and are usually prescribed for every patient, especially in the early postoperative period. 

There are different types of anti-inflammatory drugs available on the market, and they are prescribed according to the needs of the individual patient.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most popular among patients and health professionals.

Examples of NSAIDs are naproxen, ibuprofen, diclofenac and mefenamic acid.

Possible side effects of NSAIDs include stomach ulcers, indigestion, headaches, drowsiness, dizziness, kidney disease, and liver damage [5].

Steroids

Steroids are used by some podiatric surgeons (surgeons with expertise in the bones and joints of the foot, and associated structures) after ankle surgery, to reduce pain and inflammation.

Examples of steroids include hydrocortisone, dexamethasone, prednisolone, and betamethasone.

Steroids should not be used without the advice of a doctor, due to the risk of delayed healing, fluid retention, mood swings, hypertension, blurred vision, and weight gain. 

Researchers at William M. Scholl College of Podiatric Medicine, Chicago extensively reviewed the literature available on the use of steroids after surgery, and concluded that steroids offer a safe and effective treatment option for reducing pain and edema.

No evidence of increased infection rate, delayed healing, or other side effects was found in postoperative patients [6].

Antibiotics

About $10 billion is spent on the management of surgical site infections each year in the United States.

Therefore, antibiotics are prescribed after surgery to prevent the risk of surgical site infection.

Antibiotic resistance and side effects are a concern for many experts, and therefore, antibiotics are used cautiously by health professionals.

The World Health Organization (WHO) issued a concrete list of 29 recommendations for stopping infection after a surgical procedure, and avoiding super-bugs.

These recommendations include 13 points for the pre-operative period, and 16 points for preventing infections during and after surgery.

These guidelines can be viewed here.

7: Gradually Start Physical Therapy

Strict bed rest is recommended after surgery, to ensure the proper healing of the wound.

However, sitting or lying in a single place for a long time carries the risk of causing a very serious condition called Deep Vein Thrombosis (DVT).

DVT is a condition in which a blood clot is formed in the deep vessels of the leg, or another area of the body.

A small piece of this clot (called an embolus) can become detached from the thrombosis, and travel to the lungs.

This is called a pulmonary embolus, and can be life-threatening, as it can compromise blood flow to the airways.

DVT prevention is strictly followed for any bed-ridden patient, especially if they are old, a smoker, a diabetic, or obese.

The most important measure to take, in order to prevent the risk of DVT, is to avoid sitting still for long periods of time.

Smoking cessation and good diabetes control are also essential, and blood thinners are sometimes required.

Inappropriate exercise can adversely affect the healing joint, and delay recovery.

Therefore, the rehabilitation program should only be started after discussion with your surgeon, and under the supervision of an expert.

I have given a brief summary of rehabilitation for the sake of completion, in accordance with the recommendations from Congress Orthopedic associates [7].

For the first few days, leg elevation, and weight-bearing on the soles of the feet are enough to keep the blood flowing in the joint.

For the First Week

Tighten the small muscles of the feet for 20 seconds, and then release.

This type of exercise, in which muscles contract but don’t move, is called isometric exercise.

You should perform a set of 5 to 10 isometric contractions each time.

Crutches or a walker should be used for any type of ambulatory movement, as weight bearing is absolutely contraindicated.

Another option is to wiggle the toes of the affected foot for 15 seconds, and then rest for fifteen seconds.

Repeat this process 4 to 5 times a day.

In the Second Week

When the cast is removed, a gentle range of exercises can be started.

Examples include standing with the help of a rolling walker or crutches, and walking with crutches.

From the Third Week Onwards

Weight bearing is gradually started during this period, and is increased as stamina is built.

Daily activities, like getting in and out of the tub, getting up or downstairs on your buttocks, etc., can be started.

Click here for help sleeping better after meniscus surgery.

8: Look Out for Signs of Complications

You should be aware of the warning signs that indicate a severe underlying pathology.

I have prepared a list of warnings signs – immediately contact a health care provider if you develop any of these.

  • Severe ankle pain that is not responding to the usual medications.
  • Pain and tenderness in the legs.
  • Shortness of breath.
  • Chest pain.
  • Discoloration of the toes.
  • Foul-smelling discharge from the wound.

Summary

Sleep disturbance is a common complaint in patients who have undergone ankle surgery.

To solve this problem, the patient should sleep in the supine position with elevated legs, to minimize the pain and swelling.

All medicines should be taken exactly as directed by the doctor.

Application of cold therapy using ice cubes or ice gel provides quick relief.

If symptoms get worse, or any warning sign is experienced, immediate medical consultation is required.

References

[1] K. N. Kunze et al., “Patients With Chronic Foot and Ankle Conditions Experience Significant Improvements in Sleep Quality Following Surgical Intervention,” Foot Ankle Spec., p. 19386400211009364, Jun. 2021, DOI: 10.1177/19386400211009365.

[2] C. Shi, J. C. Dumville, N. Cullum, S. Rhodes, A. Jamali-Blasi, and E. McInnes, “Alternating pressure (active) air surfaces for preventing pressure ulcers,” Cochrane Database Syst. Rev., vol. 5, no. 5, pp. CD013620–CD013620, May 2021, DOI: 10.1002/14651858.CD013620.pub2.

[3] J. E. Block, “Cold and compression in the management of musculoskeletal injuries and orthopedic operative procedures: a narrative review,” Open access J. Sport. Med., vol. 1, pp. 105–113, Jul. 2010, DOI: 10.2147/oajsm.s11102.

[4] N. A. Punchard, C. J. Whelan, and I. Adcock, “The Journal of Inflammation,” J. Inflamm. (Lond)., vol. 1, no. 1, p. 1, Sep. 2004, DOI: 10.1186/1476-9255-1-1.

[5] “NSAIDs,” NHS, 2019. https://www.nhs.uk/conditions/nsaids/ (accessed Mar. 13, 2022).

[6] J. W. Fleischli and W. R. Adams, “Use of postoperative steroids to reduce pain and inflammation,” J. Foot Ankle Surg., vol. 38, no. 3, pp. 232–237, May 1999, DOI: 10.1016/S1067-2516(99)80059-3.

[7] “General postoperative guidelines for ankle surgery,” Congress Orthopedic associates. https://www.congressmedical.com/files/Post Op Instructions /Generalanklepostopguidelines.pdf (accessed Mar. 13, 2022).

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