CME OnDemand: Putting it into Practice: Ankle Instability (Part 1 - Lateral Ankle Instability)-Putting it into Practice: Ankle Instability (Part 1

Putting it into Practice: Ankle Instability (Part 1 - Lateral Ankle Instability)

Video Transcription

On behalf of AOFAS, I want to welcome you to tonight's Putting It Into Practice webinar on lateral ankle instability. Our moderators tonight are Drs.  Tracy Herrig and Richard Zell, and they are joined by our faculty, Drs. Megan Wolf, Kenneth DeFontis, and Stephen Short.  Disclosures for our faculty and program planners are listed here and posted in the AOFAS On-Demand Education Center.  The program is provided free of charge with funding from the Orthopedic Foot and Ankle Foundation.  To support education programs like this, make a donation to the foundation on our website or by texting GIVEAOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same  way you did the first time. Registered attendees may earn 1.5 hours of AMA-PRA Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to claim CME in the chat tab, and we will follow up in the email after the broadcast.  The webinar is being recorded and will be available to view in the On-Demand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentations. Send your question to the faculty, click on the Q&A tab on your navigation bar.  If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit the AOFAS website to register for upcoming events, including Part 2 of the Ankle Instability webinar series, which will focus on syndesmosis, and our on-person  sports injuries of the foot and ankle core is taking place this April in Boulder, Colorado. And lastly, to apply to become a member of the AOFAS.  Members receive access to a wealth of resources, including high-quality research journals,  in-person and online education, and a global network of orthopedic foot and ankle specialists. I will now turn the program over to Dr. Zell to begin. Thank you.  Good evening. Thanks for logging into our webinar. This is a continuation of our series, Putting It Into Practice, which goes through the basics of foot and ankle.  We initially geared our talks towards our allied health colleagues, but thankfully we've had a lot of other people on our webinars.  It's also been a great place to collaborate with our physical therapy colleagues. We have a great program tonight, and I'm going to pass you, I'm going to have Tracy  introduce our first speaker. Thanks, Dr. Zell. Dr. Wolf is a board-certified orthopedic surgeon who specializes in treating acute and chronic  multi-musculoskeletal injuries with a focus on sports injuries and foot and ankle issues. She is fellowship trained both in sports and foot and ankle.  She previously practiced at Atrium Health Wake Forest Baptist, where she took care of high school and collegiate athletes at Wake Forest University and Winston-Salem State  University. She is now in private practice in Central Connecticut. All right. Thank you very much. Let me share my screen.  All right. I was tasked to talk about acute ankle sprains, so I will talk about that. I have nothing to disclose. Acute lateral ankle instability. We all see this.  This is the thing that walks in. It's one of the most common things that we see in the U.S. Ankle sprains are the most common lower limb injury in physically active individuals.  About one ankle sprain in 10,000 persons in Western countries with over 2 million ankle sprains annually treated in the emergency department, both in the U.S. and the U.K.  It's about 16 to 40% of sport-related trauma cases, so again, one of the most common things that we're going to be seeing.  Some of the highest incidence sports sprain injuries occur in basketball, football, and soccer.  They tend to be more common in females and children and in athletes and indoor and court sports, again, with basketball being one of the more common ones.  Some other risks that could lead to ankle sprains include obesity, high-risk activities  like we talked about, connective tissue properties, foot morphology such as a cave of varus foot, strength, proprioception, range of motion and balance, and prior ankle injuries.  Some other reasons you could have ankle sprains is sport participation, level of competition,  the playing surface, different types of shoe wear, including cleats versus regular court shoes, and game versus practice.  So typically the history that you're going to have for an acute ankle sprain is a running, cutting, or landing from a jump or landing on another athlete's foot.  Typically the mechanism of injury is an inversion, so the foot coming underneath and plantar flexion or the toe going down.  Typically they present with swelling and pain, and some people will have difficulty with weight bearing.  And a lot of times they will have a history of previous sprains if you ask them. So why do ankle sprains happen in this position?  So the tailor dome, when you're looking down on it, actually is wider anteriorly. And so when the foot is in dorsiflexion or when you're standing, that tailor dome is more stable.  And so when you're in plantar flexion, you have that more narrow spot, and there's more room for that talus to move within the ankle mortis.  And that can lead to these ankle sprain injuries. And that's why we talk about athletes that are in plantar flexion that tend to have more common risks of sprains.  So dancers, gymnasts, soccer players, basketball players, and figure skaters. So when the foot is in plantar flexion, it puts the ATFL, which I'm going to talk about  on stretch, and there's less contact area in the ankle, like I showed you before with the talus.  So again, the mechanism of injury is typically for a lateral ankle sprain, plantar flexion and inversion.  So just some anatomy so we can kind of understand when we're talking about ankle sprains as well as the chronic ankle instability.  So when we talk about ankles, we talk about typically three joints. So we have the ankle joint, the subtalar joint, and the syndesmosis.  So first I'm going to talk about the ATFL, which is the primary restraint to inversion in plantar flexion.  It resists the anterior translation and internal rotation of the talus, where it sits in the mortis.  And it's the weakest ligament on the lateral aspects of the ankle, which is why it's the most common one torn with these inversion ankle injuries.  Next one is the CFL, or the calcaneofibular ligament. It's the primary restraint to inversion when the ankle is neutral or in dorsiflexion, and  it's the restraint to subtalar inversion. And it's typically injured in about 20 to 40% of ankle sprains. So how do we evaluate this?  So typically, I'm not able to do a great anterior drawer whenever we've just had an acute ankle sprain, but this is kind of how you would test the ATFL.  So we're taking that foot in plantar flexion, again where there's more space, and then you bring that talus forward.  And as you can see in the x-ray on the lower left, you can see that talus translating anteriorly, and that's due to that loss of the ATFL.  The Taylor tilt test typically will test for both the ATFL and the CFL. Again, the foot is in that more dorsiflexion, which is looking at the CFL, and then you're  inverting the ankle to try to see if you can strain that talus underneath the mortis. And if it opens like you're seeing on that lower left-hand corner, then that's going  to typically involve the CFL. So how do we treat acute ankle sprains? So typically, most can be treated non-operatively, especially whenever it's one of their first ankle sprains.  When we're thinking about operative treatment for this, we talk about open injuries, large avulsion fractures, not small flex, but large avulsion fractures that could potentially  lead to more instability later on, and associated pathology, which I'll talk about later on, such as peroneal tendon injuries, OCDs of the talus, and loose bodies.  But one of the questions, especially in sports medicine we talk about is, should we be treating severe acute injury in high-level athletes?  Can it get them back faster without the risk of them not being able to get back because they never were able to recover after non-operative treatment?  So when we talk about non-operative treatment, the first thing really is rice. So that rest, ice, compression, and elevation, that'll really help decrease the inflammation  and swelling. Initially, especially in the higher intensity sprains, you'll do immobilization. In the more severe ones, I'll make them non-weight-bearing in a boot.  Most of them don't want to be weight-bearing, so it's pretty easy to do that. And then the boot can really help with keeping both that foot in dorsiflexion so that we  can prevent it from getting stiff while it's in plantarflexion, as well as allowing them to start progressing their weight-bearing.  And then once they're able to tolerate weight-bearing in the boot, then I typically transition them into a rigid ankle brace.  I typically recommend, after having a pretty bad ankle injury such as this, to have the rigid ankle brace typically for about a year afterwards, whenever they're doing higher  level and sports that potentially are at high risk for reinjuring it. Edema management, again, that's that rice. And then mobility.  So really important to keep that ankle moving and preventing it from getting stiff so that they can get back to their activities.  Typically when I do have them in a boot, I have them come in and out, come out of the boot multiple times per day just to work on dorsiflexion and plantarflexion to make sure  that that ankle doesn't get stiff. So when we're thinking about treatment, we also think about how bad the sprain is.  So if a mild sprain, those are the ones that a lot of times aren't even coming to our clinic because they're able to walk on it afterwards, there's minimal swelling.  And typically they're ones that are walking in maybe with a slight limp into clinic. Moderate sprains typically are walking with a limp or they're not able to walk.  They have swelling mostly on that outside part of the ankle and they also have point tenderness, but they're unable to go onto their toes or hop or do higher levels of activity.  And then you have the severe sprain. Those are the ones that can't walk on it. They have crutches.  They really have a difficult time putting weight on it and a lot more swelling than you see in the mild and moderate sprains.  So within one week of injury, again, this all kind of depends on how severe the sprain is. You want to start working on active ankle dorsiflexion and plantarflexion, clockwise  and counterclockwise circumduction, and then also make sure that keep the strength in the  hip knee in order to help with recovery afterwards, especially if they haven't been weight bearing.  And then progress to resisted dorsiflexion, plantarflexion, inversion, and eversion, and then standing gastroc ankle stretching.  So in order to return to sport, I know we'll probably be talking about this later on, there's specific tests that we can do in order to see if they're available, if they're ready  to return to sport. And especially for those severe ankle sprains, you might want to consider an MRI if they're unable to progress to four weeks after injury.  Again, just another test to look at postural control and strength. And then I'm just going to touch on, I know we're talking about lateral ankle injuries,  but I think it's important to always have in the back of your head the other types of injuries that could potentially be happening leading to this more severe acute injury.  So something to have in the back of your head whenever you're evaluating these patients. So the first one is syndesmosis injury or a high ankle sprain.  So the syndesmosis stabilizes rotational translation and axial forces, and it's more of an external rotation of the talus rather than that inversion injury.  You examine it with a squeeze test and an external rotation test, and typically they have a longer recovery.  So those, again, those ones that aren't able to really recover after an acute ankle injury, that this is what I'm concerned about.  The ligament injuries are on the medial aspects of the ankle. And these, again, typically will require more time to recover from. So why do sprains not get better?  We have to have other diagnosis in the back of our head. So syndesmosis injuries or a high ankle sprain, talus fractures, especially the lateral process,  which is on the upper screen, and the posterior process, which is in the lower. Calcaneus fractures, typically an anterior process fracture.  So whenever you're looking at the radiographs, you always have to make sure you're looking at these different areas to make sure you're not missing a fracture.  Osteochondral fractures on the talar dome, and sometimes you can't see them on x-ray. You might have to get an MRI in order to evaluate that.  Peroneal tendon tears, peroneal subluxations, such as superior peroneal retinacular abulsion fracture seen here, subtalar injuries, and again, deltoid ligament injuries.  So chronic ankle sprains occur up to 40 to 50% with persistent residual symptoms and injury recurrence.  And chronic typically means symptoms persist greater than six months from the index injury and failed nonoperative treatment.  And at that point, I'm going to pass this off to talk more about chronic ankle injuries.  Thank you, Dr. Wolfe. That was a great talk. Now it's my pleasure to introduce Dr. Kenneth DeFontis.  He went to medical school at Johns Hopkins and did his residency at Union Memorial Hospital in Baltimore.  He left Maryland to do his foot and ankle fellowship at Brigham and Women's Hospital in Boston, and now works for Towson Orthopedics in the greater Baltimore area.  So I hand it off to Dr. DeFontis. Thank you. Thanks, everybody. I'm going to share my screen in a second.  All right, can everybody see me?  Great. All right. So thanks, everybody, for having me. I got the easy part because Dr. Wolfe covered a lot of the really hard topics.  And so I'm happy to kind of extend into the chronic ankle instability realm. No disclosures on my end.  So today, we're just going to kind of review the definition and diagnosis of chronic ankle instability.  I'm going to discuss some surgical techniques and timing of surgical treatment, review some of the outcomes of the surgical treatment, and briefly delve into some newer techniques  that are on the horizon. So what really is instability? If you'll notice that this is not an ankle.  But when we talk about instability, there's obvious instability, then there's subtle instability.  And this is just an example of some things where I think it's pretty obvious that there's some obvious instability there of the knee.  So in chronic ankle instability, what does it really mean? I mean, simply put, from a basic standpoint, it means you're having frequent sprains or  your ankle is frequently giving out. Approximately 20% of acute injuries develop into a chronic ankle instability symptoms,  as Dr. Wolfe had said, it can be as high as 40% to 50% in some instances. And that's important to know. Those numbers are, I think, a lot higher than a lot of people realize.  So how do these patients present? So there's two kind of main ways that they present. They either have functional instability, and functional instability is where they feel  that their ankle is giving out, regardless necessarily of how loose the ankle feels on physical exam.  And then there's mechanical instability, which is where the ankle itself is very loose. And they present to the office and to us in various stages of treatment.  And so this is just an example of like the variety of things that I see in my office. We have an urgent care clinic, an after-hours clinic.  And I see patients everywhere from somebody that shows up, literally sprained their ankle on the field, and they come to me within half an hour of the injury.  Or similar, they come after a new second or third sprain. More commonly, we see a new ankle sprain in the office about a week out after they've been seen in an urgent care.  But I also see patients' first presentation, three months of frequent ankle sprains, the ankle's giving out. They've had no treatment.  I've had some patients that come to the office who've had six months of frequent ankle sprains, and they've already had multiple treatments.  And then we also see patients who come in who basically have had years of chronic ankle injuries, and they have pain with daily activities.  And so the challenge in the office is we see a wide range of presentation, and you're going to get these patients in various aspects of their treatment.  So physical exam's relatively straightforward. Oftentimes these patients have pain directly over the lateral ankle ligaments.  And again, this talk is just on lateral ankle ligament, chronic ankle instability with regard to lateral ankle ligaments with not associated other pathology.  They may have a positive intra-drawer test, and we saw a previous video of that. And then stress radiographs can also be obtained, although it seems in general I think that  they've definitely fallen out of favor for daily, for the average orthopedic surgeon diagnosed with chronic ankle instability.  And so as previously stated, I'm not going to rehash this too much, but traditionally it's done in gentle plantar flexion, and you basically pull the heel anteriorly as we saw  in the previous video with the tibia pulled posteriorly. You may hear a suction sound. The patient may have pain associated with the test.  And it's obviously really important to compare it to the contralateral side, because, you know, everybody's a little bit different.  But if obviously one ankle is much looser than the other, that can give you a good indication that they are having some mechanical instability.  So what are the indications for surgery? To be honest, it's relatively straightforward in terms of basically if someone presents  with persistent symptoms of instability, whether functional or mechanical, and they've already  undergone conservative management, in general, three to six months, it's very reasonable to consider surgery for those patients.  There's really no clear timeline in terms of, you know, guidance. Six months is a reasonable number, but some patients present much farther out and some  patients present earlier with multiple symptoms and have already undergone a course of conservative management and are still having difficulty.  From a nonoperative treatment standpoint, even if a patient presents to you with chronic ankle instability, it's very reasonable to offer them nonoperative treatment, even if  they have not, even if they've undergone previous treatment with focused bracing and physical  therapy, mostly focused on peroneal strengthening and stretching is going to be the mainstay.  Anti-inflammatories, steroids can be used, although that's obviously not going to address the main issue.  And so when it comes to surgical treatment of chronic ankle instability, the Brostrom Gould is basically the standard of care. It's basically an anatomic repair of  the anterior talofigure ligament and calcaneofigure ligament, which we went over earlier. Traditionally, the original technique was described as a direct repair of the ligaments,  just basically a soft tissue imbrication. Other modifications have been made either with bone tunnels and more commonly now, suture ankles are used to reattach the ligaments.  There's obviously other various modifications to the procedure. The gold modification incorporating the extensor retinaculum is pretty much also a standard of care.  A periosteal flap can be raised to help reinforce the repair. There are also non-biological augments such as super suture tape and other things that can be  added to reinforce the repair and other augments are also available out there. Just an example of the surgical technique for many of our allied health.  We basically make an incision over the fibula in line with the fourth ray. We identify the lateral ankle ligament layer. We transect the ligaments directly off of bone.  We mobilize the layer. If you're raising a periosteal flap, now would be the time. We place some suture anchors in a trough, we repair the ligaments,  and then we reinforce the repair, splint and neutral. This is just an example of here. Basically, I'm retracting the lateral ankle ligaments there.  You can see the fibula there with a trough in it. Once we've mobilized just prior to placing our suture anchors, and then afterwards, here's the fibula and  the rotated periosteal flap with the ligaments reattached. One of the things that we frequently do at the time of also repairing ligaments is we scope the ankle just prior to that.  The question is, should we scope the ankle and why do we scope the ankle? There's good data out there to suggest that it's not a bad idea to scope the ankle.  Many orthopedic surgeons routinely scope the ankle for every lateral ankle ligament reconstruction to look for additional pathology. For example, this was an older study in  1999 that looked at arthroscopic finding associated with the unstable ankle where they did scope every ankle that they did a lateral ankle ligament reconstruction on,  and 93 percent of them had some intra-articular finding. Now, it's unclear whether or not MRIs were performed on these patients. It's pretty common for all of us to have an MRI  by the time we get to surgery, and so we're able to see a lot of the pathology that we would expect. That being said, it's also not uncommon for someone to have  an MRI come to you and then have another injury as well to where that scoping the ankle can also help the pathology. That's something that I routinely do.  Non-anatomic reconstruction, there's a lot of history behind this. There's various ways to basically use a peroneus brevis graft, the Watson-Jones procedure,  the Evans procedure, and Crispus Snook just to name a few. We won't go into the specifics about that, but basically these are other ways of stabilizing the ankle.  The Evans can also be used as an augment to an anatomic lateral ankle ligament reconstruction. Then there are allograft reconstructions that can be also anatomic,  either using like a semitendinosus or a gracilis. What's new in the lateral ankle ligament reconstruction world? The arthroscopic lateral ankle ligament reconstruction.  This is just a paper from 2018, looking at one example of the arthroscopic treatment of ankle instability. It's becoming more popular and definitely more widespread these days.  These are just some pictures. Myself, I do not perform the arthroscopic technique, but plan to incorporate in my practice in the future.  These are just some pictures from a colleague of mine. This is looking into the ankle. This is right after a drill hole has been made into the fibula,  and you can see down to the right, that's the lateral ankle ligament layer that's sitting there of all stuff, the fibula. Basically, you arthroscopically grab it.  This is just one technique. You thread some suture using a scorpion or a similar device, and then you basically, sorry about that.  I'm not sure why that picture is coming out that way. Basically, reattach it with an anchor to the fibula. You can also then also reattach it to the talus if you'd like.  Just briefly to go over some outcomes. The open Brostrom-Gould procedure, this is a great surgery. Patients do very well. Good to excellent outcomes in  approximately 90 percent in patients in multiple studies. Some are higher. More recent article that just came out looking at patient-reported outcomes.  In open Brostrom-Gould, basically, patient-reported outcomes and success stood up at five years. When we look at anatomic versus non-anatomic reconstructions,  anatomic in general seems to be better and have more favorable outcomes. That's obviously the ideal situation to perform an anatomic reconstruction if possible.  Then when we look at arthroscopic techniques, there's been a lot of data coming out recently looking at comparison of open versus arthroscopic techniques.  In general, just to summarize the literature up-to-date, they have roughly equivalent outcomes with  very similar complication rates. There's actually some newer studies that have actually had some slightly superior outcomes to open procedures,  but obviously, I think more data is needed. I think one thing to take into account is obviously, the learning curve takes a lot of, I think, extra technique to do these,  but when done properly, they can have great outcomes. I do think that this is definitely a big part of the future of the treatment of ankle instability.  Just an example of a treatment algorithm. When you see a patient, you assess their history and treatment, their prior treatment, you examine them.  You review their imaging, which frequently involves an MRI. If it's from just the lateral ankle ligament aspect of it, an ankle arthroscopy with the prostrum,  and again, many people use suture anchors. Sometimes we'll do augmentation for various situations. Again, that's surgeon-dependent.  Then for patients who have significant ligamentous laxity or for revision situations, an allograft anatomic reconstruction is a very reasonable option.  Just an example of post-operative protocol. I don't want to go too much into this because I think some of the rehabilitation will be covered shortly.  But in general, a period of non-weight bearing, bring them back into the office, stitches come out, they work on some gentle ankle range of motion.  Weight bearing is also surgeon-dependent. I weight bear my patients at four weeks post-operative in a boot and start some physical therapy.  At two months, we transition them to a brace, slowly begin sports-specific activities as early as three months. Again, in general, for most athletes, I find that they can return  somewhere around the four-month mark, but that's also patient and surgeon-dependent. Key points, it's important to note there's basically a non-inconsequential percentage  of patients with acute ankle sprains and instability develop chronic ankle instability. Atomic reconstruction is ideal, superior than non-atomic if possible.  Ankle arthroscopy is a valuable concomitant procedure which can help address additional pathology and the new data regarding arthroscopic techniques is very promising.  I'd like to end with just a quick review. This is a great review in FAI in 2020. If you'd like to just review some of the things that we've discussed  here for chronic lateral ankle instability, they just summarize things pretty much up-to-date. These are my references and thank you guys very much.  Right, thank you guys.  I'm excited to introduce Dr. Steve Short to you guys. Dr. Short is a board certified in both sports and orthopedic physical therapy. He's also a fellow of the American Academy  of Orthopedic Manual Physical Therapist. He is entering his 10th season with the Denver Nuggets and Steve, correct me if I'm saying anything incorrectly  and currently serves as the vice president of sports medicine for the Denver Nuggets. He's responsible for leading the development, collaboration and integration  of multidisciplinary evidence-based services for the Denver Nuggets. So I will turn the time over to Dr. Short to talk about return to play and return to sport.  Awesome, well, thank you so much for having me and putting up with my screen share here as we get into it. Thanks for all of the wonderful speakers  that set up this return to sport talk because that's what we all want to do, right? We wanna get past the injury and get back to the things that we love and are passionate about.  And for some folks that's sport and it sounds so simple, right? We're gonna just jump right in. You see it, lateral ankle sprain, sports center ticker, ESPN,  athletes gonna be out one to three weeks. We have our standard biology, our tissue healing timelines. We know if it's a grade one, grade two,  there's some swelling and it's that simple, right? Well, next thing you know, half the season has gone by. Joey's re-sprained his ankle seven times.  The media is throwing him under the bus. How could this ever happen? And as you can see down in the bottom right corner,  beyond the sprain, beyond the ligament, beyond just standard biology and physiology of tissue healing and what happens after the cascade of a lateral ankle sprain,  we have all these factors that influence an outcome. The athlete, the key stakeholders, the family, the coaches, how they respond, their engagement in the rehabilitation,  what level of impairments that they have lingering because of this sprain, the swelling, the fear, their credibility and livelihood that may be at stake for this large injury.  And so we have to navigate all of these factors beyond what seems to be just what is a straightforward lateral ankle sprain. So how do we navigate that web of chaos?  We try to have some criteria that can guide us along. When you're thinking about just return to play in general, the 2016 Sports Physio Congress, introduced the START Framework.  So you can see that in the top right corner. It's just generally grading everybody's risk tolerance. Now, what gives us indicators into risk tolerance  besides generalized understanding of outcomes, biology, tissue healing? Well, there's certain types of criteria and buckets that we wanna fill  within their rehabilitation progression to get us to the place that we wanna be. So you can see there are certain constructs and then there's certain tests and measures  that we wanna take to get us to the place that we wanna be. So there's some measures that we wanna check and then there's training modalities to train the test.  And we're gonna continually reinforce and check and retest and train within our rehabilitation. So standard mobility, we know that ankle dorsiflexion is a standard restriction  that we have and limitation that lingers well beyond return to play. We have great tests for that and we have training modalities to do that.  If you take anything away from my talk right now is that when we're strength testing, let's get beyond manual muscle testing. That's not gonna tell us anything.  The reliability between clinicians is challenging and let's find an objective way to assess strength power balance. That might be dynamometry, that might be a weight bearing test  depending on your clinical access and the resources that you have. But one of the best investments that you can do as a rehab clinician or if you're involved in owning clinics  is finding some form of dynamometry so we can get objective strength measures because strength underpins everything. Strength is gonna help us get our mobility back.  It's gonna help improve our power output. It's gonna underpin a lot of the dynamic qualities that we want in sport. So again, reinforcing that if we take anything away,  find the best way within your practice to objectively measure strength. Beyond that, we have hop tests, we have Y balance, we have reconditioning and agility tests.  And there's not one gold standard within all of these tests and constructs. We wanna fill as many buckets that we can to give us the confidence to assess risk  and make a decision between all the people that are involved, the physicians, the physios, most importantly, the athlete or the patient, the coaches, all the key stakeholders  to make that best return to play decision that we can.  When we're looking at, as we described before, just the different cascades of an injury and what a rehabilitation plan might look like,  we'll just work through a couple of the phases and talk about some of the impairments and the training interventions that we'll do to get there.  So obviously we know that there's gonna be swelling and pain and gait disturbances in that acute phase. One of the best things that we can do is provide patient education.  We're gonna utilize braces and boots diligently because we can protect and facilitate mobility, but we also want to reinforce that early motion. So being diligent and responsible  with how much we're bracing and booting and getting out of that as quickly as we safely can and as everybody agreed upon. How are we gonna gain pain?  Compression, cold, modalities, you name it. Manual therapy is an early motion like we talked about. So just a couple of drills. Here's some mobilizations, early exercises.  That's gonna be a little bit either weight bearing or non-weight bearing per their tolerance and a little bit more isolated.  As we transition onto the subacute phase, the impairments are gonna be pretty similar, except they're gonna be moving a little bit better.  That swelling's still likely gonna be there if we're floating around a grade two-ish or even a grade one. Obviously, of course, a grade three. And we're really gonna start hitting  that mobility strength and power loss, training that functional stability. And again, interventions remain the same. Our home runs are gonna be our exercise and our education,  maybe a little bit of stabilization, and we're gonna progress activity as tolerated. So what do those drills look like? We're gonna wean off some of the hands-on therapies,  wean off some of the modalities, and get back and keep up with some of that local inversion, eversion work, control that eccentric strength of inversion,  and then start getting into our compound lifts, both double leg and single leg. I think it's important for all of us to be very diligent in our exercise progressions  and not just throw whatever fancy exercise that we have, but having a very logical and solid and foundational strength conditioning program to back that up.  Once we get to that terminal phase, obviously our tasks are gonna get higher. Again, the interventions are still gonna be education,  symptom, we're getting away from the manual therapy and the modalities, just doing that as much as we can or making that independent for our patients.  And the exercise becomes more explosive, really working on those bottom buckets that we saw on that first chart. So the hop testing, the plyometrics,  the sprinting, the running, the stability, the coming down from a rebound, unplanned movements, changing direction. We're gonna talk about some of that sport,  reproducing movements on this next slide. So what does that look like? Now we're doing more power drills, maybe it's a kettlebell, maybe it's a clean, some medicine ball throws,  linear lateral plyometric drills, running, jumping, cutting, working within a team of multiple disciplinary clinicians, strength and conditioning coaches, athletic trainers  to get these drills done. It doesn't matter who does it, it matters that the athlete gets these things done and we fill those buckets. What- Oh, go ahead.  Are you able to switch to presenter mode? You betcha. This is good. Okay, thank you. Sorry to interrupt. No, not at all.  Can I go from that instead of presenter mode, is that okay? There we go, apologies. Perfect, thank you. So let's talk about some of the movements  that we might be training plyometrically and some of the tests that kind of coincide with that. So similar to a lot of the buckets that we wanna train,  there's not one thing that's gonna be predictive of a clinical outcome. So we can utilize and make up pretty much any shape, direction, type of test that we can.  We're gonna identify asymmetries or just performance to norms.  But again, these are just all little tiny clues that gauge athlete readiness. And not one of these is gonna be a gold standard. There's no evidence that supports that.  One single test is gonna be predictive of a positive or negative outcome. So we're gonna utilize all of these different things. Some of them might be more decelerations ability.  Some of them might be more reconditioning as you see those shuttle tests. The important thing is that we wanna fill all of these buckets and that just means good rehab,  good training and making it very, very comprehensive. Here's a couple of reactive drills that we can do within our rehab program. So you talk about unplanned movements  and the movements that may set up a further ankle sprain. So these are just a couple of drills that we might do with an athlete, just letting them react to a ball,  different types of starts and really getting their acceleration, stops and starts going. We can progress that to make that reactive in multiple planes.  Obviously we're gonna stress the lateral ligaments in these shuffle moves.  They're obviously sports specific before they're getting back out to practice and need to tolerate this with adequate stability and comfort and of course performance.  One more, a little bit of tag.  And again, just progressing these drills to have more unplanned movement, more reactive challenges as we go along.  Last but not least, we can do all the drills that we want within the clinic, but you can't replace playing the sport and reconditioning.  So we wanna recondition and play the sport as much as we safely can. We wanna monitor that. We're gonna collaborate and communicate with coaches. In the fancy setup shops,  we can match loads with accelerometers, optical tracking cameras, so we know that the exact stressors that they have. But on a more bare bones situation,  we might just be tracking some of the sport tolerance just by time of play. Is it contact, non-contact? How are they tolerating that? And the key thing there is communication,  tracking and getting athlete feedback with that. But you need to play the sport to be ready. You need to try that out before we're back to performing.  Because there's all types of contextual things that get an athlete back out onto the court. And we're able to delineate the fact  that an athlete might be participating in some practices as part of their rehab. They might be back to their sport, but they might not be performing at the level that they want  because we didn't resolve all of those impairments. And that's all within the cascade of risk acceptance that we're willing to take for our athlete. Is this the playoffs?  Is this the championship versus is this the first game of the season? And what level of performance are we expected to take?  And what is everybody's expectation for the athlete to be? So we can categorize these buckets and have healthy expectations within our education of where we want our athletes to be  when they're progressing, ideally to return to performance, not just the sport. Because we want to fill those buckets and then we know that those lingering impairments are there.  The goal is to be back performing.  Again, we talked a lot about criteria and I didn't just make up the criteria. There's not a lot of evidence of the criteria  that gets us to that performance-based outcome that we want. A group of 155 experts did a Delphi model to see what criteria meant the most to them.  So again, not high-level evidence, but took a lot of experts like we have in this room here today and talked about what types of criteria matter.  And it's the same, very similar to the chart that we saw in the beginning of this, right? So this is the past criteria. We're thinking about pain severity,  the lingering ankle impairments, the mobility or range of motion, the strength, endurance, and power. The perceived stability and confidence of the athlete is very, very important.  So the athlete's psychology and what they're feeling out there on the field or the pitch is super, super important.  Their stability, both dynamically and in static-based tests is super important. And like we talked about, you need to play the sport. So what is their sport-specific tolerance?  If you can check all that criteria, all of the experts in the room, we're feeling pretty confident that it's going to give you a good outcome.  The AnkleGo is another tool that we have clinically that combines a lot of that same criteria. So now the evidence is building in our return to sport framework.  So we're talking about patient-reported outcomes. What is their perceptual field of stability? Why balance or star excursion tests giving us that functional stability?  Hop testing and explosive and power movement. All things that we can quantify. And what we find out is when we reach that goals or people that achieve positive scores  or better scores than the comparable have a quicker return to play, have less recurrence and have better performance. So now we're seeing mounting outcomes  in multiple constructs of things that we want to fill in our rehab buckets that provide us with better outcomes.  And why do we want better outcomes? Well, because reoccurrence rates are through the roof. This is  from Herzog, I believe 2018-19, don't quote me on that, but in the National Basketball Association,  basically when you sprain an ankle in the NBA and younger athletes are more susceptible to that,  but reoccurrence is 1.5 times more likely within the next six months. And it's not just on the  affected limb, it's on the contralateral limb as well. So while we're spending all this time on  that injury, we want to treat the individual, we want to treat the patient, we want to treat those  impairments, and we want to treat them responsibly aggressive and fill all of those buckets so we  don't have this reoccurring problem. What evidence do we have for that prevention, for that risk  reduction? Well, before any injury happens, there's bracing. Before injuries, maybe there's  some not significant evidence that maybe some therapeutic exercise or prophylactic exercise  works, biometrics, balance, et cetera, et cetera. But then you're going to find that more after an  initial injury has occurred, right? And this comes from the JOSPT's clinical practice guidelines. So there's a lot of other things that we can do once an ankle sprain has occurred.  And that's why we want to fill those buckets during our rehab. And we can do early weight  bearing. A lot of this is going to sound familiar, our hands-on therapies, some of those modalities,  but most importantly, that exercise, that bracing, and that positive education is going to help us  hopefully prevent or reduce the risk of reoccurrence. What types of braces are most common? What I'm seeing in my practice is that a lot of the athletes don't want to wear braces.  So as much as we fight that battle, we know that braces have a little bit more evidence for  stability and risk reduction compared to taping. The taping efficacy is going to wear off, but  we'd like to tape just contextually. It's better than nothing and not having any stability.  But if we can get them in braces, the ASOs are really comfortable. They're more of a soft brace,  but they give you a nice figure eight. They loop up and they do a really nice job. You can get into  some of the semi-rigid. So the ZAMST semi-rigid brace with a little bit more rigid support  medially and laterally does a good job. And there's a plethora of braces, but I just wanted to share the ones that we're utilizing most often in practice. Last but not least,  referring back to those clinical practice guidelines, they provide a lot of those  cascades and pathways that we talked about and flew through. I know we covered a lot of ground.  That's where the evidence is at. Stabilize, exercise, and fill all those buckets. So  with that, I'll turn it over to the crew. Thank you for that. Do you guys want to get into some  Q&A? Yeah, I think there were a few questions on the chat. So I don't know if Dr. DeFantis wants  to take on one of the questions. Sure. Yeah, I can take the first question, which was, any tricks in mobilizing the extensor retinaculum for the Gould modification?  It's a very interesting question. It's really challenging. It's not a simple thing.  In my experience, a lot of times I'm addressing perineal tendon pathology at the same time. And  if you're addressing perineal tendon pathology anywhere distal, on the way to the tubercle, you're going to be dissecting those perineal tendons out and disrupting that extensor  retinaculum. And in those situations, it's very challenging. You just basically have to take  whatever tissue you can after you've done the repair and suture it. I think the only advice I  could give there is just to try to minimize your dissection distally. If you're just doing a  lateral ligament reconstruction to try to maintain any integrity of that tissue. And then basically,  I just repair it with some vipral sutures right up to the lateral ligament repair as best I can.  But I'm not particularly always thrilled with the tissue quality there. So I agree. It's an interesting question. I think, just again, in my experience, just trying to minimize any  disruption of that layer when you're doing your dissection allows for a better repair.  We have quite a few questions about the internal brace. Does anyone want to take that one over? Wendy, use it.  So for me, I've actually used a few different devices, not just the internal brace and not just  suture augmentation. I typically reserve those. In my practice, I've reserved those for those  patients who are very ligamentously lax. I always am checking their biting scores. And so if they're  more, if I think that my repair is going to stretch out because they already have some underlying  ligamentous laxity, then I'll consider an internal brace or another form of augmentation. I do think,  there was another question earlier. I do think that you can overtighten it. You can cause stress  risers. They've developed some smaller implants because I have seen some implants that have ended  up in the sinus tarsae. And then people have issues with that. And that's just terrible to deal with. And so I think that there might be, I think there's, it's the field and the  augmentation is still evolving. But those are typically who I'm reserving it for. I'm not always doing it in my high-level athletes, especially those who have good tissue that I'm  repairing. I'm also pretty selective in use of it. Revision situations definitely is a great option  prior to going to Allograft. I put a handful in a year and it's a little bit just dealer's  choice if there's an athlete that I feel like, very high-level athlete that may benefit from it.  And it's more of just a decision, I guess, stall, but I definitely don't use it routinely.  I actually think the dissection to put it in, it definitely can do a lot more. It just disrupts a  lot more of the tissue. And as we spoke earlier, sometimes just good suture anchors or good bone tunnels with some good tissue, even in a high-level athlete is adequate.  Sure. Do you have any opinions on internal brace and patients that you've seen on your high-level athletes?  I unfortunately don't have an opinion. We've been fortunate enough not to have a lot of cases that required that. So no opinion on my end, unfortunately.  Yeah. And I know that some people are considering in high-level athletes, the use of internal brace to try to get people back faster. I do not change my  postoperative protocol when I use the internal brace. I know that's a question that some people  ask. I'm also not using the internal brace for any other augmentations. I don't use a CFL limb.  I don't do an internal brace or augmentation for the deltoid. I haven't found that it's been beneficial.  Agree 100%. If I'm going to do an internal brace, it's a single limb internal brace.  Yep. And again, I don't change the rehab at all.  Someone asked about the age-old question of to brace or not to brace.  City has multiple high school athletes that are being told by their ATC not to wear an ankle brace because it is making their ankle weak after an ankle sprain. After their initial  pain has resolved, they're being told that they will become dependent on the brace. How do you educate your patients after ankle sprain and stabilization in the future for best  outcomes? And I'd love to hear from the physical therapists because I get this a lot too in my  practice. Yeah, I would brace. Ankle sprains are the most common injury in our sport. And we have  very, very strong evidence that braces work to the arguments of maybe weakening some muscles or  proprioceptive or being a crutch. You can have some contextual awareness. There's other exercises  and programs that we can be doing to support that musculature and not create a reliance.  There's safe levels of practice and individual drills where you probably don't have to be wearing  braces compared to scrimmages and competition and more high-risk activities where you probably want  to be braced. I could hear maybe an argument for forces going up the chain and worrying about an  athlete with maybe chronic knee injuries or things like that. You could probably have a healthy  discussion there. But I would feel really confident and want my athletes to be stabilized to some  degree just from pure risk stratification and knowing that there's a lot of tools to negate some of the downsides that we can do outside of competition or higher-risk activities.  Yeah, I have that age-old saying of the highest risk of having an ankle sprain is having a previous ankle sprain. So if you've had an ankle sprain, you're at a higher risk  of having it again, especially when you're playing. And so I really coach my athletes that they should be wearing braces, especially in that first year after they've had an ankle  sprain. I usually recommend that they're wearing it even after that. But I do think that that first  year is really where there's a lot of changes that go on in that ankle ligament. It's never  normal again afterwards, and they're still going to have some sort of instability. And it's just  not worth it for them to then end up in that chronic ankle sprain category.  Do you have them wear it all the time for a set amount of time and then just wear it for practice  and play for that year? Yeah, for me, I have them wear it all the time until they're daily.  They're no longer limping, and they're able to walk without any support. And then I have them  wear the ankle brace just with the higher levels of activity, and I want them to do some of the  standard kind of flat line, straight line running, and then the exercises with their physical  therapist without the brace. Okay, here's another great question that I can relate to. Patients  present with pain or instability. Does instability cause pain? Many of my patients after stabilization  feel stable but still have pain with no OCD, normal MRIs. What? Maybe what's going on?  I mean, I see this too, right? They feel quite stable. They, you know, on all accounts should  be doing fine, but they're not. I definitely think instability does cause pain. There are  definitely patients, and I, you know, especially with, you know, when I'm, I can't, I can't say  there's any data on this, but when I'm examining some body and you're doing the anterior drawer  and it causes discomfort, and a lot of patients do get much better and they do feel better, but there's definitely a subset of patients that still have pain after lateral ligament  stabilization, and I'll be honest, I don't know what causes that. Some patients will still feel  very stable. They'll be able to participate in their sport to a high level, but they'll hurt  afterwards, and again, I don't have a great answer to that if anybody else has any more insight.  I do think that some component for some of those patients are that they've always been lax, and now we've made them stiff and stable, and so that can be, even though they're stable,  they're uncomfortable, and that can lead to pain, and so I've had those patients where they were so  ligamentously lax, I repaired their lateral ligaments, and then afterwards they're like,  I feel stable, this is great, I'm not spraining my ankles, but it's uncomfortable because I'm so stiff,  even though they're not necessarily stiff from our objective  exam, and so I do think that that's, that can be a component of some of it.  Any questions for Megan or Ken? Any thoughts on stress radiographs? That was something we did in  the past, but not all that common now. Do you ever use them? Do they ever give you any information,  and how do you handle the ligamentously lax patient? So, I don't use stress radiographs. It's definitely more, as I see in my talk, mostly a  clinical thing for me. I'm just not sure, for me, what additional information a stress radiograph  would imply, at least with regard to just, you know, tailored translation in terms of the decision  making process to do surgery or not do surgery, so just, again, we never even did it in  five, six years into practice, and we never even did stress radiographs at all with regard to that  in any of my training, so that would be my answer to that question. Yeah, I don't find, I, again,  I agree. I think when my patient is indicated for surgery, it's more of their subjective instability,  and then my physical exam findings, that's also confirming their instability. I'm not sure as  What was your second question, Dr. Zell? Yes, how you identify patients with ligamentous laxity  and what you would change if they were going to require surgery?  Yeah, so I think I always, because I think this is coming from some of my sports training, too,  is I always do a BITEN score, and I'm not sure if that's the right way to do it, but I think  some of my sports training, too, is I always do a BITEN score on patients, and I think that that  really helps. So a lot of these patients, you'll get into the OR, and then you go to lift up their  leg to prep them, and their knee is like 10 degrees of hyperextension. That's the patient  that I'm really concerned about, and that's, I feel like, is not an uncommon patient to see for these ankle, chronic ankle instabilities. And what would you do different for them,  if anything? Would you augment their brostrom? I do. I do. I augment them. I do. It's the same thing as I do with my knee ligaments. If they're that lax, then I'm augmenting it.  I would agree, and the decision about what to do depends on how lax they are.  Some patients, I've just added an internal brace because I felt that they still had enough good  tissue, and other patients, I've gone right to an allograft in patients who are very ligamentously  lax, and somewhat just also has to do with just discussion with the patient, kind of getting a  sense of, you know, what would be the best surgery for them. Someone asked about, in the setting of  cabovirus, are you repairing lateral ligaments without really reconstructing foot deformity?  When would you push for a cabovirus foot reconstruction with lateral ligament reconstruction?  Cabovirus foot is a whole other ballgame, very challenging, complex, and there's a lot of other,  in terms of, you know, the decision-making process, I think, repairing lateral ankle ligaments in of itself, I think, in a cabovirus foot is really not going to obviously be very  effective. I think it is definitely a large component of the cabovirus foot reconstructions  that I do. I do repair the lateral ankle ligaments. It somewhat has to do with just the progression of  how you address the deformity, slowly correcting the foot, and then just kind of testing the  ligaments at the end and seeing, but I've never regretted repairing them on a cabovirus foot,  because I think most patients, they are lax, but I think it's kind of, you know, like the, for me,  the end of the cabovirus foot reconstruction. Yeah, I would agree. I think on all my cabo,  all my lateral ankle ligaments, I'm always looking for if there's cabovirus, and I think it depends  on how significant their cabovirus is, and is it symmetric to the contralateral side? And are  they having issues on their contralateral side? Because a lot of these patients are, what,  what are you trying to fix at that point? And so, so it is, I find that a lot of these, a lot of my  athletes will maybe have a subtle cabovirus, and I don't think it's worth doing a big reconstruction  on them. Someone asked about PRP. Do any of you guys use PRP? Not for this. Not for this.  There is, there is some data that you can get, that you can get thickening and scarring in the area, as well as you could potentially get calcification at the area of PRP.  So I'm very hesitant in the areas that I use PRP in. More commonly, I'll be, people are using it  in the athletes, but this is not an area I would do that. We have some other questions from the,  the chat. One about bone marrow edema seen on an MRI, and whether those patients have a higher risk  of prolonged pain as they return to function. Megan or Ken, any thoughts on that question?  I don't know if there's any, I haven't seen any data on bone marrow edema and  prolonged pain, but sometimes I have gone back to their MRIs if they're having prolonged pain, and I write it up to this bone marrow edema, but I'm not typically using that as my  indicator that they are, they are not going to have prolonged pain.  I agree. I think it's, I think it's a study that's helpful for those patients that are not getting  better. It gives a reason, and it's something that you can, you know, show the patients in  the office, but I also don't know of any studies that have correlated that edema with their, you know, return to the decreased pain.  Any thoughts on, on taping for, you know, the trainers would tape rather than bracing? Is that a, maybe Dr. Alban could handle that question?  Yeah, so taping versus bracing. What we know is that taping doesn't last as long, so as soon as  athletes start to sweat and run and jump, the tape starts to be less effective, and I think Steve  kind of alluded to this. This is why we prefer to have athletes in braces if possible. However,  there are some athletes that have shoes that, that's more challenging to accommodate,  and certainly taping is, is better, can be better than, than not. So those are some instances when  we would say, yes, you could, taping would be good, but certainly a brace would be better than tape.  I do have some, especially like in football players, it tends to be something you can't really fit a brace into their cleat. You can spat them, that can help. There also is now  a sport type external ankle brace that's available that I think is potentially an option for those  types of athletes that can't get a brace inside of their cleat, and so I think, I still do think  that a brace is a better option, and so I think that maybe for those who haven't seen it, it's  called Tayco brace. I think that could be an option for athletes that can't get a brace in their shoe.  There's a lot of questions about osteochondral injuries with ankle sprains. Me personally,  I scope every single one of my ankle instability. I do think that by the time I'm scoping them, they've had pretty chronic instability typically. And that constant kind of banging,  typically there is some sort of cartilage damage. And I do address anything that's unstable  during that time. If they're having symptomatic cartilage defects, then I'll consent them for  potentially a cartilage resolution procedure. And depending on the size of it, there's multiple  different options. But I typically do address it because I do think that while it may not be  causing them issues now, it might cause them issues later on down the road. But I think by  fixing their instability, that also will help with the healing of that osteochondral defect.  Someone asked about the adolescent patient population. Do you guys approach, I mean, obviously approach this population with a little bit more caution with rushing into surgery,  but an athlete's age 16 to 18 years.  And I'm gonna piggyback onto that question. Do you guys screen for or think about Ehlers-Danlos in this population?  Again, I screen for, I screen for a lateral, I screen for a ligament, any sort of ligamentus laxity for all of my ankle instability,  especially those who I'm thinking about operating on. I do think it's important if patients are, you know, in the adolescence and they're having significant instability,  that's only gonna harm their cartilage in the longterm. And so I think it is important to address it early on if they really are truly having symptomatic,  chronic instability of their ankles.  I agree as well. I do fix a lot of younger patients, you know, usually obviously when one's skeletally mature possible, but, you know, a lot of times people will come,  you know, 15, 16 years old, have recurrent sprains, their ankle is grossly loose and they wanna play. And if you get them out there and they have one major injury  it could do some significant damage to the ankle. So I don't think age alone is something that necessarily changes my algorithm. It's still kinda, you know, just, you know,  what are their symptoms? How does their ankle feel? And can they participate in the way that they'd like to?  I know that you mentioned that you don't typically order MRIs until around four weeks post-injury if they're still having problems.  How do you handle this with a patient or parents that are adamant about ordering an MRI at the initial ankle sprain visit?  So this is not an uncommon discussion, especially with my younger athletes. I go over with them that what the MRI is going to show, and I can tell them exactly, this  is what their MRI is going to show. It's going to show a torn ligament, which is scary to hear, but that's what a sprain is, is a torn ligament.  You may have some edema and fluid because that's what the sprain causes, is causes all this fluid and swelling, and it's not going to change anything that I'm going to do in  the acute phase. However, for patients who are really aggressive about it, I think there is some sort of patient  satisfaction of getting an MRI if their insurance will pay for it and or they want to pay for it.  I just let them know that it's not going to really change anything that I'm going to do. Yeah, I agree.  It happens very frequently in my practice, and I'm in a very foot and ankle heavy populated area in Baltimore, and I agree. I do the same thing.  I try to counsel them that it's not going to necessarily change what we do. I always use the term, look, we've got the MRI in our back pocket if we need it, if things  are progressing, try to be as cost conscious as I can. That being said, in my practice, if there's some family that's adamant about getting an  MRI, they can go across the street to somebody who will order it right away for them. There's definitely a threshold for me where I just say, look, it's maybe in the best interest  for the overall care of this patient to get the MRI, even though it's not necessarily going to direct my care for them in the immediate term, but it can help.  Again, there's a threshold we all have about that. I think with the way medicine is, and a lot of ways we're very patient centric, and if  the patient and family are really adamant about having an MRI and that's going to help them in some way, it's not unreasonable to order it, even if it's not necessarily going  to be a direct, it's going to change what you do. I see that multiple times a week where I practice.  Someone asked about subtalar joint instability. How would you assess for that? Do you assess for it?  I don't. I'll be honest.  Not really. At least not in the setting of just thinking about lateral ankle instability and the surgical treatment of it.  This might go along with the Ehlers-Danlos question, but with the spectrum of outcomes, any thoughts on what patient characteristics or physical exam findings to look out for  that tend to lead to more chronic instability outcome? Maybe looking for, I mean, like I look for hypermobility in other joints, but or other  patient characteristics that sort of clue you into this might become a problem down the road. Yeah.  Yeah. Again, it's more how many have they had, what type of ligament dyslexia do they have? What kind of activities are they involved in?  It's the same risk factors as it is for the acute ankle sprain that I think would be for that chronic ankle sprain.  And so I counsel patients who are at that high risk that there's a potential that down the road, this is going to be your reality that you're not going to be able to tolerate  this anymore.  Someone had a great question about post-op protocols. Following, I guess he's lumped in or he or she lumped in OCDs, you know, with or without  lateral ligament reconstruction, with or without OCDs. So what do your post-op protocols look like? Yeah, the OCD definitely throws a little wrench in it.  Again, I do non-weight bearing for four weeks for all of my lateral ligaments, that's just my protocol, how it was trained and seems to be a good amount of time for just a lateral  ankle ligament or a perineal tendon. But if there is an OCD, I do extend that two more weeks for the OCD to six weeks and again, that's my protocol.  So that's the only thing that can sometimes, you know, if we do find an OCD at the time of surgery, that's not identified on an MRI, you know, the patients get to wake up to two  extra weeks of non-weight bearing for me.  Yeah, I agree with the weight bearing status. I think for me, I get them out of the split pretty quickly.  I usually do it at one week, 10 to 14 days, so I can start with dorsiflexion, plantar flexion.  I don't have them doing any inversion, eversion, especially when there's an OCD, I think it's important to get that motion earlier because cartilage likes motions.  So whenever I do my cartilage restoration procedures, I tend to start moving them a little bit faster while I do limit the weight bearing for longer.  And we like to play it fast and loose here in Reno, Nevada, and we have the weight there on day one in a in a sport type race.  And the only time that changes is when there has been like a graph for the OCD, when we do something above like a micro cartilage repair, micro fracture repair.  And we've done that for the past 10 years.  I mean, I think the biggest thing is just not straining the repair. So as long as you're really protecting that inversion, eversion.  I think that's that's the most important part in the postoperative protocol.  Yeah, we have them start physical therapy at two weeks and that changes, of course, with peroneal tendon stuff.  So depending on how those peroneal tendons shook out, but just a lateral ligament, we let them work right on.  None of them are happy about it.  Yeah, whether they actually do it or not, there's some tears, you know, but we get them going right away.  Yeah.  How are we doing on time? OK, it looks like we got another 15 minutes. And Tracy, I have a case we can do. And we can find that.  Can everybody see it?  No, I don't see your screen.  OK, let's see.  How about now?  Yep. Okay.  So this is a 59 year old. He's a type two diabetic. As with many patients in my county, he smokes. He was referred over by his podiatrist  with ankle giving way, somewhat unsteady gait. He had surgery as a child for an ankle fracture. I'm unclear what that was. And he had a spine injury several years ago  where he had decreased sensation in both his right and left legs. But even though he has diabetes, doesn't have true neuropathy.  And so when I saw him in the office, it was initially a little bit difficult to figure out what his complaint was.  But because he didn't really complain of pain, but he felt something wasn't quite right about his ankle. His exam showed a neutral foot. So he wasn't a cave ovaries,  but he did have some apprehension with passive inversion. It was a little difficult to determine exactly how much inversion he had,  but it was increased compared to the opposite side. And because of his sensory deficits, he didn't really have any tenderness over the end of the fibula.  So I'll ask Megan or Ken what they think of these x-rays.  Yeah, so, go ahead. Go ahead Megan, go first. Oh, no, I was just gonna say, so, I mean, you see this old avulsion injury on the lateral, so on the AP view,  you can see that avulsion injury on the fibula.  While the joint space looks okay on the AP, there looks like there's some narrowing in the medial gutter. You also see some flattening of the tailor dome  with some osteophyte formation, exostoses on the anterior aspect of the ankle, concerning for probably some previous ankle injuries, ankle sprains or instability in the past.  And I don't think I see anything else,  but maybe something going on in the sub-tailor, the posterior facet of the sub-tailor joint, you kind of see maybe some changes there too.  Sure, so when I saw him, he also had an MRI. It was of poor quality, but a lot of fluid around his perineal tendons. It was unclear whether he had a tear.  And again, it wasn't the highest quality scan. And there was some edema around that fibular avulsion or this large fragment in the distal fibula here.  So I initially thought that, even though he wasn't complaining of pain, maybe he was having some issues with ankle arthritis. And I injected his ankle with steroid,  which helped a little bit. He did come back two or three other times to the office and it really became apparent that his ankle was unstable and that was his real issue.  He was a little bit of a difficult patient. So if you have this patient and he's unstable  and you're not bothered by his smoking, you're going to take him to the OR, what would you do for him, given that very large fragment at the end of the fibula?  I guess my question is, has he done a significant amount of conservative treatment? Because I think for me, when I'm looking at someone like that, a lot of ankle instability  is not just being unstable anatomically, it's also his inability to have that proprioceptive feedback that probably is making him unstable. So I'd probably really push for bracing,  AFO, things like that initially, and make him fail that before I'm thinking of starting something surgical. Yeah, all great points. And we always have to treat our patients  non-operatively first. And he had had use of an ankle brace, like an ankle LASA brace.  He had seen his podiatrist. He wasn't the physical therapy type of patient. I'm sure I've mentioned that to him.  But all good points. But if it became apparent that surgery was needed,  what would you do? And what would you tell him before surgery?  I mean, from a standpoint, I think I would just do a standard scope rostrum on him. I don't think I would augment it probably less or more with him.  I've done a fair amount of those large obstacles. You remove them. Yes, there's a little gap there, but you can usually mobilize the ligaments in a little bit,  as long as you don't dissect too much distally and get a little bit of the retinaculum to kind of add some imbrication there. And they usually do just fine.  I think I would counsel him as to just a little bit hesitant about expectations and outcomes given,  and not 100% clear that this is his only issue that he still may have some persistent discomfort, obviously from the arthritis of the ankle.  But again, as with everything, if he's been instructed on the risks and benefits and had a long discussion and we've done all the things conservative  and he still wants to proceed with surgery, it's not unreasonable to consider that.  Would this one be a good one for augmentation with the tape? Or would you try...  Also, would you remove that piece of bone that's there?  I would definitely take the bone out and I would use three all suture anchors. Again, less being more for him, trying to avoid any implants other than just suture itself,  just with the diabetes, a little increased risk of infection and the smoking with the wound complication risk. So I try to just do a very minimalistic approach to this.  I agree.  So I'm a big fan of the allograft reconstructions and I was concerned regarding the larger size of that ossicle. So I had that equipment ready to go  and I've done this surgery for a number of people. I've always been very happy with the outcome and it seems to be very strong right from leaving the OR.  So I removed that large fragment of bone and then I used a hamstring allograft tendon using tenodesis screws. I had to modify my tunnels because a lot of the footprint of the ATFL  and part of the CFL was gone when that piece of bone came out, but I was able to cheat my ATFL tunnel a little bit more proximal and was able to get a good result.  He was the kind of patient who was, no, I'm not going to say non-compliant, but he told me he was claustrophobic, he didn't want to be in his cast. I initially put him in a cast  because I didn't really trust him,  but we ended up taking that off and he transitioned to an air cast and he did nicely.  But I think it's a powerful procedure for either bone loss or the ligamentously lax population like we spoke about.  Ken or Megan, do you have experience using allografts and how do you think the patients do?  So funny enough, I don't think I've done a single allograft case at all  just because every time I've had someone like this, we've had enough tissue to be able to repair.  I've done maybe one a year, about probably five or six since practice. I did a few in fellowship and a few in residency and I do a very similar anatomic reconstruction  with a SEMI-T. They do very well. They can get really stiff, which is what you want, right? So it's very effective.  The only challenge is, this is kind of your last resort, right? So when you get to this point,  I try to avoid doing it unless it's my only option just because really after this, you're really running out of options for the patient.  And so, again, that's probably why I haven't done as many.  Sure.  Do you guys do the minimally invasive lateral ligament reconstruction? So you guys have tried that yet?  Like the arthroscopic? Mm-hmm, the arthroscopic lateral ligament reconstruction. So my concern, and I don't know, I don't have as much experience,  but just talking to people and seeing it performed is that you're only addressing the ATFL with the arthroscopic. And so that's my concern about it,  is that you're not addressing the CDFL. And I also use Vibrostrom to evaluate my perineal tendons because the MRI is terrible for evaluating perineal tendons.  And so I like to look at them directly. And I also use my scope to kind of do a perineal tendoscopy to take a look at them as well.  So I haven't jumped on that boat for those reasons yet.  I haven't as well. You know, I've worked with a few people who have done many labs and there's some people that are very slick with it. And I would say, again, in the right hands,  I think it's a great procedure, but I definitely think the learning curve is it takes a while to get very comfortable with it and do an adequate repair.  So that's the reason I have it done. And I will be open to it in the future for select patients.  If we don't have any other questions, I guess we can adjourn for the evening. I wanna thank our speakers and our panelists.  And we look forward to our continuation of the discussion for syndesmotic injuries,  which I believe is about a month from now. So. I think April 25th. Very good. A little longer than a month.  All right. Thank you very much. Thank you. Thank you everybody. Thanks everyone.

Video Summary

The video transcript explores the topic of managing lateral ankle instability and guiding athletes back to play after ankle injuries. It stresses the importance of a comprehensive approach to rehabilitation, encompassing factors beyond just tissue healing. The speakers discuss criteria and tests used to assess an athlete's readiness for return, focusing on mobility, strength, stability, agility, and power. Objective measures like dynamometry are highlighted. Different phases of rehabilitation and associated impairments and interventions are outlined, emphasizing early motion, education, and exercises targeting mobility, strength, and power. Plyometric and reactive drills are suggested for sport-specific training. The importance of gradual reconditioning and communication with coaches is also underlined. Additionally, the transcript emphasizes evaluating an athlete's capability to participate in their sport effectively post-injury, utilizing tools like AnkleGo, patient-reported outcomes, and balance tests. The discussion touches on risk reduction strategies like bracing and addressing lingering impairments to prevent future injuries. The use of evidence-based methods, considerations for special foot conditions, and the importance of a thorough rehabilitation process are key points stressed throughout the video's content.

Asset Subtitle

Putting It Into Practice is a series of virtual courses providing the basics of foot and ankle care. In this installment, multidisciplinary faculty will discuss the management of lateral ankle instability. Topics include Acute Ankle Sprains, Chronic Ankle Sprains, and Return to Sport. This webinar is ideal for physical therapists, physician assistants, nurses, nurse practitioners, athletic trainers, orthopaedic residents, and primary care physicians.

Moderators: Tracy K. Harig, DNP, APRN, FNP-C and Richard A. Zell, MD
Faculty: Megan R. Wolf, MD; Kenneth W. DeFontes, MD; Steve Short, PT, DPT, SCS, OCS, FAAOMPT, CSCS

Educational Objectives
At the conclusion of this webinar, you will be able to:

Describe the evaluation, treatment, and outcomes of an acute lateral ankle sprain
Describe the long-term outcomes/morbidity of chronic ankle sprains
Identify goals of physical therapy for patients with acute lateral ankle sprains, including return to sports protocols
Identify when to refer for surgical evaluation of a chronic lateral ankle sprain

Keywords

lateral ankle instability

ankle injuries

rehabilitation approach

athlete readiness assessment

mobility

strength

stability

agility

power

dynamometry

plyometric training

risk reduction strategies