Flatfoot: post-operative pathway after endosinotarsal arthroereisis
Post-operative pathway after arthroereisis with the screw housed in the sinus tarsi, without a cast: limited weight bearing in the first 72 hours and active and passive mobilisation without resistance from day 1.
Active and passive mobilisation from post-op day 1 · Limited weight bearing for 72 hours, then 2 crutches · Crutches stopped at suture removal (~2 weeks) · Running from day 45 · Sport at 2 months
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical response.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
At a glance
- Weight bearing
- First 72 hours: only a few metres, a wheelchair or stroller is advised, foot elevated and iced. From day 3, walking with 2 crutches until suture removal (about 2 weeks), then free walking. Compared with the exosinotarsal technique, weight bearing in the first 72 hours is deliberately more cautious here, because the screw sits in the sinus tarsi without crossing bone.
- Active mobilisation
- From the first post-operative day: ankle dorsi-plantar flexion and circles in both directions, toe motion, foot alphabet — 20 seconds of continuous motion x 10 times a day, with no resistance.
- Passive mobilisation
- From the first post-operative day: parent-assisted mobilisation (one hand stabilises the heel, the other guides the foot into dorsiflexion, plantarflexion and gentle inversion/eversion) and belt stretching, 30 seconds x 10 repetitions a day. Always without resistance and pain free.
- Surgical wound
- Keep dry until suture removal (about 2 weeks). If the dressing peels off, replace it after cleaning with a povidone-iodine antiseptic.
- Running and jumping
- No running or jumping in the first 45 days; gradual resumption after day 45, with normal gait and no pain.
- Return to sport
- Sport at about 2 months, with symmetrical foot contact and restored dorsiflexion.
- Day 2Start of active and passive foot mobilisation
- Day 3Walking with 2 crutches (endosinotarsal)
- 2 weeksSutures out, wound washing, walking without crutches
- Days 15-30Cast removal in accessory-bone or Achilles-lengthening variants
- Weeks 3-4Foot strengthening, proprioception, elastic bands
- Day 45Return to running and jumping
- Month 2Return to sport
- Months 18-36Possible removal of the arthroereisis screw
Surgery for flexible paediatric flatfoot is based on subtalar arthroereisis: a screw (or a dedicated implant) placed in the sinus tarsi, between talus and calcaneus, limits hindfoot collapse into valgus-pronation and restores the medial arch. The implant does not mechanically straighten the foot: it acts as a proprioceptive block that redirects load while the foot learns to work in its new position.
Loading timeline
Step by step
Each phase lists the goals, what to do and the exercises for that exact moment: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
Before surgery — Preparation for surgery
Short phase in the weeks before elective surgery: it does not require a structured course of physiotherapy.
When it applies
- •Before elective arthroereisis (with or without associated procedures).
- •A standard course of preoperative physiotherapy has not been shown to improve the outcome of arthroereisis: preparation is mainly educational and organisational.
Goals before surgery
- •Understand the planned post-operative weight bearing and be able to use crutches.
- •Organise home and school for the first weeks.
- •Check baseline foot and ankle mobility and strength, where useful.
- •Know that active and passive foot mobilisation starts early after surgery.
Activities
- •Practical crutch training before surgery, on level ground and stairs.
- •Home and school organisation: pathways, bathroom, transport, accessible desk, temporary PE exemption.
- •Where useful, simple ankle and foot mobility exercises, without turning preparation into a mandatory programme.
Preoperative exercises
Crutch and weight-bearing training
- •Try the crutches before surgery, with correct height and the weight-bearing status set by the surgeon.
- •Practise on level ground, stairs and the entrance to your home, with someone assisting.
- •Also practise sitting, standing and moving in the bathroom while respecting the planned loading restrictions.
Dosage: At least one training session before admission; repeat until the technique is safe.
Active ankle mobility
- •Seated or lying, move the ankle into flexion, extension and slow circles, within the pain-free range.
- •Keep the movement smooth, without forcing the painful end range.
Dosage: Indicative: 10-15 movements per direction, 2-3 times a day.
Readiness criteria for surgery
- ☐Safe crutch use with the planned weight bearing.
- ☐Family informed about weight bearing, crutch use and return to school.
- ☐Home and school organised for the return after surgery.
When surgery must not be delayed
- •Preparation is not a prerequisite: elective surgery should not be postponed to complete preoperative exercises.
What to prepare at home and school
- •Prepare clear pathways, a place to keep the foot elevated and comfortable wide shoes for the return home.
- •Check stairs, bathroom and school transport with crutches.
- •Inform the school: expected absence, accessible desk, temporary PE exemption.
Phase 1 — First 72 hours: swelling, pain and start of mobilisation
Indicative timing: Days 0-3
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Control swelling and pain
- •Protect the surgical wound and the implant
- •Start active and passive mobilisation on day 1, with no resistance
What to do
- •Limb elevated above heart level whenever sitting or lying, as much as possible in the first 72 hours
- •Ice pack (never directly on the skin) 15-20 minutes, 4-6 times a day
- •FROM THE FIRST POST-OPERATIVE DAY — active mobilisation: toe motion, ankle flexion-extension and slow circles in both directions within the pain-free range, with no resistance — few repetitions, many times a day
- •FROM THE FIRST POST-OPERATIVE DAY — passive mobilisation: the parent or physiotherapist stabilises the heel with one hand and gently guides the foot into dorsiflexion, plantarflexion and slight inversion/eversion, to the pain-free limit
- •Isometric calf contractions (venous pump) several times a day
- •First 72 hours: only a few metres, a wheelchair or stroller is advised, foot elevated and iced. From day 3, walking with 2 crutches until suture removal (about 2 weeks), then free walking. Compared with the exosinotarsal technique, weight bearing in the first 72 hours is deliberately more cautious here, because the screw sits in the sinus tarsi without crossing bone.
- •Analgesia as prescribed, anticipating pain before mobilisation sessions
Restrictions and precautions
- •No resisted exercise (no bands, weights or forced end-range pushes)
- •Keep the wound dry
- •No full weight bearing without crutches
Exercises for this phase
1. Static belt stretch (passive mobilisation)From day 2
- •Sit on the floor with a straight back and knees fully extended.
- •Loop a bathrobe belt around the base of the toes of the operated foot.
- •Pull gently towards you until you feel tension in the Achilles tendon, never pain.
- •The knee must stay straight: if it bends, the stretch does not reach the tendon.
Dosage: Hold 30 seconds, 10 repetitions every day
2. Active ankle mobilisationFrom day 2
- •Sitting or lying, move the ankle (not just the toes) pulling the foot up and then pointing it down.
- •Then draw wide circles with the foot, first clockwise then anticlockwise.
- •The movement must be gentle, wide and complete, up to the pain-free limit.
Dosage: 20 seconds of continuous motion, 10 times a day
3. Foot alphabetFrom day 2-3
- •With the leg supported and the foot free in the air, “write” the alphabet letters with the big toe.
- •Move only the ankle, keeping the knee still.
- •Make big letters: they are meant to explore the whole range of motion.
Dosage: 1-2 alphabets, 2-3 times a day
4. Toe mobilityFrom day 1-2, also inside the cast
- •Open and close the toes, then try to lift only the big toe and then only the others.
- •If a cast is in place, still move the toes that remain free.
- •It is the simplest way to activate the venous pump and reduce swelling.
Dosage: 20 repetitions, 5-6 times a day
Ready for the next phase when
- ☐Pain controlled with prescribed medication
- ☐Swelling decreasing with elevation and ice
- ☐Dry wound without discharge
Note for the physiotherapist
Early mobilisation is not optional: it is the actual therapeutic content of these first days. Very short, frequent sessions, always below the pain threshold.
Phase 2 — Daily mobilisation and protected walking
Indicative timing: From day 4 to suture removal (about 2 weeks)
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Restore full ankle range and foot rotation
- •Prevent adhesions and subtalar stiffness
- •Maintain trophism of the intrinsic foot muscles
- •Walk safely with two crutches
What to do
- •Active mobilisation: ankle flexion-extension and clockwise/anticlockwise circles, wide and complete — 20 seconds of motion, 10 times a day
- •Foot alphabet: “write” the letters in the air with the big toe, 1-2 alphabets 2-3 times a day
- •Passive mobilisation with a bathrobe belt (sitting on the floor, knee extended): belt at the base of the toes, gentle pull until tension is felt, pain free — 30 seconds, 10 repetitions a day
- •Parent-assisted passive mobilisation, always within the pain limit
- •Mobility and grip: scrunch a towel with the toes, pick up and move small objects — 5 minutes a day, as play
- •Walking with 2 crutches, with heel strike and the most physiological roll-over possible
Restrictions and precautions
- •Still no resisted work
- •No painful manoeuvres: pain is the limit of mobilisation, not a target
- •No running, jumping or sport
Exercises for this phase
5. Dynamic band stretching (4 directions)From suture removal
- •Anchor an elastic band (TheraBand type) to a fixed support such as a table leg.
- •Move against the band’s pull: foot up, foot down, inwards, outwards.
- •Control the return: the slow part of the movement is what strengthens most.
- •Increase resistance (a stiffer band) once the exercise feels easy.
Dosage: 15 movements per direction, every day
6. Towel curlsFrom day 2
- •Sitting, place the foot on a towel spread on the floor.
- •Scrunch the towel towards you using only the toes, without lifting the heel.
- •Then try to grasp it and move it sideways.
Dosage: 5 minutes a day
7. Picking up small objectsFrom day 2
- •Scatter marbles, bottle caps or small bricks on the floor.
- •Grasp each object with the toes and drop it into a container.
- •It works best as a timed game: how many objects in 2 minutes?
Dosage: 5 minutes a day
Ready for the next phase when
- ☐Active and passive dorsiflexion improving day by day
- ☐Mobile toes able to grasp the towel
- ☐Walking with crutches without marked antalgic limp
- ☐Wound healing without signs of infection
Note for the physiotherapist
This is the window in which range of motion is gained (or lost). Ten short sessions a day beat one long one.
Phase 3 — Suture removal, crutch weaning and free walking
Indicative timing: From about 2 weeks
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Walk normally without aids
- •Complete recovery of range of motion
- •Reactivate calf and tibialis posterior
What to do
- •After suture removal the wound can be washed, crutches abandoned and normal walking resumed
- •Daily continuation of active and passive mobilisation and belt stretching
- •Gradual introduction of band work (TheraBand) anchored to a fixed support: dorsiflexion, plantarflexion, inversion and eversion — 15 movements per direction daily
- •Toe grip and mobility exercises maintained as daily play
- •Cycling and swimming (once the wound is healed) as low-impact aerobic activities
Restrictions and precautions
- •No running or jumping until day 45
- •Avoid very uneven ground and games with sharp direction changes
Exercises for this phase
8. Short foot exerciseFrom week 3-4
- •Sitting with the foot flat on the floor, heel and toes in contact.
- •Draw the forefoot towards the heel, “shortening” the foot and lifting the arch, without curling the toes.
- •The toes stay long and relaxed: if they curl, you are using the wrong muscles.
Dosage: 10 repetitions of 5 seconds, 3 times a day
9. Tibialis posterior strengthening with a bandFrom week 3-4
- •Band anchored to the side, looped around the forefoot.
- •Move the foot inwards and downwards against the resistance, keeping the knee still.
- •Return to the start position slowly, over 3 seconds.
Dosage: 3 sets of 15, daily
10. Calf raisesFrom week 4 (after cast removal in casted variants)
- •Standing, hands on a wall for balance.
- •Rise onto the toes keeping the heels aligned, then lower slowly over 3 seconds.
- •When it becomes easy, perform it on one leg only.
Dosage: 3 sets of 10-15, daily
Ready for the next phase when
- ☐Independent walking without crutches and without significant pain
- ☐Dorsiflexion similar to the non-operated side
- ☐No significant end-of-day swelling
Note for the physiotherapist
If dorsiflexion remains limited, intensify passive work before increasing load: early stiffness is far easier to prevent than to reverse.
Phase 4 — Strengthening, proprioception and gait retraining
Indicative timing: From week 3-4 to day 45
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Strengthen tibialis posterior, peroneals and intrinsic foot muscles
- •Restore single-leg balance
- •Normalise foot contact, reducing walking on the outer border
What to do
- •Short foot exercise: shorten the foot by drawing the forefoot towards the heel without curling the toes, 10 reps of 5 seconds, 3 times a day
- •Toe yoga: lift the big toe keeping the others down and vice versa, 10 reps each way
- •Tibialis posterior strengthening with a band in resisted inversion (first introduction of resistance), 3 sets of 15
- •Calf raises, double-leg then progressively single-leg, 3 sets of 10-15
- •Single-leg balance: 3 x 30 seconds, then on a cushion or wobble board, finally with eyes closed
- •Heel walking and toe walking alternated for 10-15 metres, as daily play
Restrictions and precautions
- •No running, jumping or team sport before the times given in phase 5
Exercises for this phase
11. Balance on an unstable surfaceFrom week 4-5
- •Stand on a cushion or wobble board on one leg.
- •Knee slightly bent, pelvis level, eyes forward.
- •Progression: eyes closed, then ball throwing, then light perturbations.
Dosage: 3 x 30 seconds per side, daily
12. Wall calf stretch (two positions)From return to free walking
- •Hands on the wall, operated leg behind, heel firmly on the floor.
- •First position: back knee straight (stretches gastrocnemius).
- •Second position: back knee slightly bent (stretches soleus).
- •The heel must never lift off the floor.
Dosage: 3 x 30 seconds per position, daily
Ready for the next phase when
- ☐Single-leg heel raise performed with the heel inverting
- ☐Single-leg balance ≥30 seconds
- ☐More symmetrical foot contact with less outer-border walking
Note for the physiotherapist
Walking on the outer border of the foot is an expected adaptation: it is corrected with proprioception and strengthening, not with forced passive eversion.
Phase 5 — Return to running, jumping and sport
Indicative timing: No running or jumping in the first 45 days; gradual resumption after day 45, with normal gait and no pain.
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Progressively resume running and jumping
- •Return to the chosen sport without pain or reactive swelling
What to do
- •Running progression: brisk walking, then walk/jog alternation, then continuous running on even ground
- •Introduction of jumping: double-leg hops, then single-leg, then jumps with direction changes
- •Return to team training before matches/competition
- •Daily maintenance of calf stretching and intrinsic foot exercises
Restrictions and precautions
- •Stop the progression if sinus tarsi pain or swelling persisting the next day appears
No new exercises are introduced in this phase: continue with the exercises of the previous phase, progressing load and difficulty as tolerated and as indicated by the physiotherapist.
Ready for the next phase when
- ☐Continuous running for 10-15 minutes without pain
- ☐Symmetrical single-leg hop compared with the healthy side
- ☐No swelling the morning after activity
Note for the physiotherapist
In children progression often happens spontaneously during play: the physiotherapist’s role is more to contain than to push.
Phase 6 — Follow-up and implant management
Indicative timing: From month 3 until screw removal
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Maintain the correction obtained and a mobile foot
- •Monitor implant tolerance
- •Plan screw removal when indicated
What to do
- •Scheduled clinical review assessing foot contact, dorsiflexion and sinus tarsi pain
- •Long-term maintenance of calf stretching and short-foot exercises, especially in high-impact sports
- •Comfortable shoes with a supportive heel counter; insoles only if specifically prescribed
- •The arthroereisis screw is not permanent: it is usually removed later (generally after 18-36 months, or once correction has stabilised), with a short procedure and rapid return to walking
No new exercises are introduced in this phase: continue with the exercises of the previous phase, progressing load and difficulty as tolerated and as indicated by the physiotherapist.
Ready for the next phase when
- ☐Pain-free foot with a maintained arch on weight bearing
- ☐Full and symmetrical ankle range of motion
- ☐Sport performed without limitations
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, temporarily reduce load and volume and have the situation reassessed by the surgeon or physiotherapist before progressing again. This document is informative for families and physiotherapists and does not replace individual clinical assessment.
Return to sport / full activity
Sport at about 2 months, with symmetrical foot contact and restored dorsiflexion.
- ☐Normal gait, without limp and without predominant outer-border loading
- ☐Ankle dorsiflexion symmetrical to the other side (knee-to-wall test)
- ☐Single-leg heel raise x 10 repetitions without pain
- ☐Single-leg balance ≥30 seconds, including on an unstable surface
- ☐Continuous running for 10-15 minutes and symmetrical single-leg hop, without sinus tarsi pain
- ☐No swelling the day after sport-level loading
Without immobilisation range of motion returns quickly: the limiting factor is intrinsic and tibialis posterior strength, to be checked with the single-leg heel raise before jumping.
Red flags: stop and contact us
- •Fever, spreading redness, discharge or bad smell from the wound (suspected infection)
- •Pain that increases instead of decreasing after the first days, or is not controlled by prescribed analgesics
- •Marked swelling not settling with elevation and ice, or a hard, painful calf
- •Persistent pins and needles, numbness, or cold, pale or bluish toes (dressing or cast too tight: seek advice immediately)
- •Progressive inability to move the ankle, or stiffness worsening despite exercises
- •Persistent focal pain in the sinus tarsi (in front of and below the lateral malleolus) not improving after month 2: possible implant intolerance
Written and reviewed by Dott. Daniele Priano, Paediatric Orthopaedics. Last review: August 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the surgeon’s indications.
Frequent questions
Why is moving the foot from day 2 so important?
Because early motion does three things no drug does: it reactivates the muscle-venous pump and therefore reduces swelling, it prevents the deep scar around the sinus tarsi from forming adhesions, and it keeps the intrinsic foot muscles active. Subtalar stiffness is the most frequent functional complication after arthroereisis, and it is far easier to prevent than to treat.
What is the difference between active and passive mobilisation?
Active means the child moves the foot with their own muscles: flexion-extension, circles, alphabet, towel curls. Passive means the motion is produced externally, by the parent, the physiotherapist or a belt, with the muscle relaxed. Both are needed: passive work gains degrees of range, active work makes them usable during gait.
The child walks on the outer border of the foot: is that a problem?
No. It is the physiological adaptation to a hindfoot that no longer collapses inwards, and it can last a few months. It resolves on its own with walking and with proprioception and strengthening exercises. It should be reported to the surgeon only if accompanied by persistent pain on the outer side of the ankle.
When can crutches be discontinued?
Usually at suture removal, around 2 weeks, both with the endosinotarsal and the exosinotarsal technique. In casted variants they are discontinued at cast removal: about 15 days for accessory navicular excision, about 30 days for Achilles tendon lengthening.
Can the wound get wet?
No, not until suture removal (about 2 weeks). If the dressing peels off earlier, it can be replaced after cleaning the wound with a povidone-iodine antiseptic. After suture removal the wound can be washed normally.
Why is Achilles lengthening usually done one foot at a time?
Because that foot wears a below-knee cast for about a month and calf push-off is temporarily weakened: operating both sides together would make independent walking very difficult. Doing one foot at a time keeps a reliable support limb.
What is the night splint for?
It is used only after Achilles tendon lengthening, for a further 30 days after cast removal. It maintains overnight the length obtained surgically, because a healing tendon tends to shorten again if the foot stays pointed for many hours.
Does the screw need to be removed?
The arthroereisis implant is not intended to stay forever: it is usually removed later, generally after 18-36 months or once correction has stabilised, with a short procedure and rapid return to walking. The exact timing is decided by the surgeon based on growth and clinical review.
Are insoles needed after surgery?
As a rule no: correction is provided by the implant and the foot must learn to work in its new position. Comfortable shoes with a good heel counter are useful. Insoles are prescribed only in selected cases, on the surgeon’s indication.
When can the child return to school and PE?
School usually after suture removal, once walking is independent, avoiding stairs and frequent transfers in the first weeks. PE resumes for running and jumping after day 45, and fully at around 2 months (2-3 months if the Achilles tendon was lengthened).
In-depth content (full introduction, technique comparison, FAQ, references) at ortopediaevolutiva.com/en/rehabilitation/flatfoot-surgery-endosinotarsal-arthroereisis
Flatfoot: post-operative pathway after endosinotarsal arthroereisis — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
Other protocols
Any questions?
For information or questions, email me or view the locations and contact details.
Email: daniele.priano@ortopediaevolutiva.com