From Sprains to Bunions: Making Sense of Common Foot & Ankle Issues

The human foot and ankle are astonishingly complex, and when they hurt, life shrinks fast. In this comprehensive episode of Aussie Med Ed, host and Orthopaedic surgeon Dr Gavin Nimon sits down with Dr Peter Stavrou, Adelaide-based foot and ankle specialist and past president of the Australian Orthopaedic Foot and Ankle Society, to unpack everything medical students, junior doctors, and GPs need to know about foot and ankle conditions.

From the emergency department to the operating theatre, this episode covers the full spectrum of foot and ankle care - with practical, evidence-based guidance you can use in clinical practice today.

We start with the realities of frontline care. Mechanism matters: inversion plantarflexion points to lateral ligament sprain, while dorsiflexion eversion sets off alarms for syndesmosis. You’ll learn how to use Ottawa rules wisely, why two to three weeks without improvement is the decision point, and when weight-bearing X-rays, MRI, or weight-bearing CT tip the balance toward referral. We demystify Achilles ruptures with simple bedside tests, compare nonoperative and surgical pathways, and outline honest timelines for walking, rehab, and return to sport.

From there, we pivot to the elective landscape. Think bunions, hallux rigidus, plantar fasciitis, metatarsalgia, neuromas, adult acquired flatfoot, and ankle arthritis. We share clear strategies that work in real life: rocker-soled shoes, arch supports, ultrasound-guided injections, and joint-sparing options like cheilectomy. When surgery is on the table, we contrast fusion and total ankle replacement, highlight who benefits most from each, and bring in up-to-date registry insights on survivorship and outcomes. We also tackle stress fractures, the underestimated role of vitamin D, and why chronic ankle instability often needs both soft tissue repair and bony realignment to succeed.

If you want practical, step-by-step thinking that helps patients move without fear and pain, this conversation delivers. Subscribe, share with a colleague who sees ankle pain every clinic, and leave a review to tell us the topic you want covered next.

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Chapters

• 0:23 Why Feet And Ankles Matter
• 1:26 Welcome And Acknowledgements
• 2:26 Guest Intro And Expertise
• 3:37 Common Ankle Trauma In Practice
• 5:28 Ottawa Rules And Red Flags
• 7:17 Not Improving At Two To Three Weeks
• 10:25 Boots, Bracing, And Early Rehab
• 12:43 Imaging Choices And Syndesmosis
• 17:38 Lisfranc Injuries And Subtle Signs
• 20:58 Fifth Metatarsal And Jones Fractures
• 24:10 How Common Are These Injuries
• 24:58 Achilles Rupture Diagnosis And Management
• 30:03 Recovery Timelines And Expectations
• 32:03 Elective Vs Trauma Practice Mix
• 33:14 Structured Assessment For OSCEs
• 37:20 Deformity, Pain, And Function Links
• 39:04 Adult Acquired Flatfoot And Tip Post
• 42:03 Nonoperative Care And Shoe Strategy
• 44:44 Fusion Vs Replacement: Key Differences
• 47:54 Who Suits Ankle Replacement Or Fusion
• 50:43 Longevity, Registry Data, And Outcomes
• 52:32 Imaging And Injections For Arthritis
• 54:57 Cheilectomy And Joint-Sparing Options
• 57:28 Heel Pain, Neuromas, And Metatarsalgia
• 1:01:03 Footwear, Orthotics, And Lesser Toes
• 1:04:16 Stress Fractures: Causes And Care
• 1:07:13 Chronic Ankle Instability And Realignment

Transcript

0:00

the cornerstone of the human body is the human foot and ankle. They're remarkable structures with 26 bones, 33 joints, and more than a hundred muscles, tendons, and ligaments working in perfect harmony to support our weight, balance, and movement. Yet they're often taken for granted until something goes wrong. Whether a simple sprain, a stubborn bunion, chronic heel pain, or even end stage arthritis, problems in the foot and ankle could profoundly affect mobility and quality of life. In today's episode, we'll explore this fascinating region. GPS and medical students should look out for in everyday presentations, how to assess and investigate common conditions when a referral to a specialist is appropriate, and what modern surgical options including total ankle replacement can offer. Joining me to unpack all of this is Dr. Peter Stavrou, an Orthopaedic surgeon who specializes exclusively in knee, foot, and ankle surgery. Together we'll discuss how advances in technology, implant design, and minimally invasive approaches are reshaping the way we treat these vital joints. And more importantly, how we can help our patients stay mobile active and pain free. Good day and welcome to Aussie Med Ed. The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture. I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you're practicing or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organizations such as Lifeline in Australia. well. Today I'm joined by Dr. Peter Stavrou, an Orthopaedic surgeon based in Adelaide, south Australia. He specializes exclusively in knee, foot, and ankle conditions and is past president of the Australian Orthopaedic Foot and Ankle Society, and he has over 20 years of experience in this subspecialty. Since 2003, Dr. Stavrou has dedicated his practice to the management of foot and ankle disorders, ranging from arthritis and deformity to sports injuries and complex reconstruction. He has a particular interest in minimally invasive keyhole bunion surgery, patient specific joint replacement, and the treatment of ankle arthritis, including total ankle replacement. He's actively involved in training the next generation of Orthopaedic Surgeons as a principal supervisor of a foot and ankle fellowship program, and he contributes to the National Joint Replacement and Audit through his role as clinical advisor on ankle replacements through the Australian Orthopaedic Association National Joint Replacement Registry. It's a real pleasure to welcome Peter Stavrou, to Aussie Med Ed To talk about foot and ankle conditions from everyday cases in the GP clinic to advanced procedures like total ankle replacement. Welcome Peter. Thank you very much for coming on board. Hi Gavin. Thanks for having me, mate. It's a real pleasure to be here and we'll cover lots of ground today, so hopefully be very informative for everyone. Excellent. Well, look, I thought we'd start off with this basic simple question. From your perspective, what are the more common ankle problems that medical students and junior doctors need to be aware of or they might encounter in primary care or in the emergency department? Well, trauma is common, so though for those in the ED that it might be a slightly different type. You can have high energy, trauma, car accidents, falls, that sort of stuff. So here making the diagnosis is the key, and then usually referral.'cause these sorts of things will often require surgery. But in other settings, in the ED or in general practice trauma can also be low energy. And that can be things like sprains, undisplaced fractures. So this isn't so clear cut. Sometimes the diagnosis may be a little bit tricky in terms of which investigation to use. And sometimes even something that appears to be a fairly trivial mechanism of injury or trivial injury can have significant pathology with it that you really need to be aware of and not miss. I like to try and think of trauma as a fractures, dislocations and infections, and obviously when the foot and ankle conditions might be tendons or nerve conditions too. When you see a patient with an acute ankle injury, what's a key history and examination aspects that you use to help divide up your specific traumatic conditions that you see? Yeah. Well, I think the mechanism of injury is important that will help you define, hopefully, where this is a high or low energy injury. Simple things like could they walk after the injury straight away, or if they're playing sport, could they play on, could they finish the game or did they have to come off the field? So things like that give you an indication of the sort of significance of the injury to some degree. Examination in the acute setting can be really quite difficult. People are sore, they're very swollen, so sometimes your landmarks may not be obvious due to the swelling. And it may be very hard to localize where exactly they're sore.'cause whole foot and ankle hurts. So that is really difficult. And even the pain may be difficult to put a finger on. It just hurts everywhere. So I think that's the tricky bit in acute trauma is trying to narrow it down to a particular injury. So the mechanism in the history can help you there where examination may not be so easy. Yeah, we always think about the Ottawa rules. Are they actually useful in practice and do you use them at all? Oh, look, I think they're very, they're a guide. Like everything, they're a guide. They're not set in stone, but they are, because the reason they exist is to avoid unnecessary x-rays and the radiation penalty that goes with that for patients. So really to explain the Ottawa rules, if you're unable to walk four steps either after injury or in the when you're seeing the doctor in the emergency room that's a significant, indicates some sort of significant injury. If you have pain around the malleoli, medial or lateral malleolus and also if you have pain up the posterior border of either the fibula or the medial tibia for six centimeters above the joint, that's an indication that there may be a significant injury and it's probably worth doing an x-ray. If you don't have those things, it's most likely a sprain and you probably don't need an acute x-ray. There are also some foot rules for Ottawa that have been expanded. So if you have pain at the base of the fifth metatarsal or over the navicular, or if, again, if you can't walk, four steps of the foot injury. That's another reason to do an x-ray. But if you don't have any of these things, the yield of finding a fracture on an x-ray is less than 1%, so it's probably not worth the effort. Excellent. What are the common red flags in ankle trauma then that signal the injury might be even more than just a simple sprain? Is it just purely the rules or are there other things too that you need to think about? Oh, look I think the history and the energy involved in the injury, so someone who's, in a car accident, high velocity, a fall from height and obviously the signs a lot of swelling that indicate there's a significant amount of trauma there. Other things you need to be wary of so that you don't think, oh, this is just a sprain and send someone off. So, so Peter if an ankle injury or an ankle sprain just isn't improving after two to three weeks. what conditions should we be thinking about? For example, do you need to think about osteochondral lesions, Peroneal tendon lesions or even just stress fractures? What are the things that sort of go through your mind that are just more than just a simple basic injuries that the students might be aware of? Yeah, all those things are possible. And the realities, a really bad ankle sprain may take up to three months to fully recover in terms of someone being really comfortable and returning to sport with comfort. So, at two or three weeks a lot of people will still be quite sore. But I think the key is if they're not improving at two or three weeks, then you, your mind should be, you should be thinking there's something maybe more significant here than just a regular ankle sprain.'cause even if they're sore at two or three weeks, they should be getting better. So the things to really consider as you say, a chondral injury. So some sort of damage to the cartilage in the ankle joint. And that may not be obvious on an x-ray if you've taken one. Syndesmosis injuries and we'll talk about that later. They're a specific type of ligament injury. Peroneal tendon injuries, again, you, you said that, so that's very important. Fracture of the base of the fifth metatarsal. So that's one that is near the ankle and it may get caught up when you initially see someone and all that swelling and not be noticed. And it's often one that is right on the corner of an x-ray as well. So when you look at the ankle on the x-ray, you may look back and see there's a little fracture there that you haven't quite appreciated at the time. So that's always a tricky one. The anterior process of the calcaneus that's even closer to the ankle joint and it is really hard to see on an x-ray 'cause the 'cause of the shape of the bones and the overlying bone. So that's one that's again, commonly may not be appreciated immediately. And then obviously the Lis-Franc injury. So that's in the foot. But again, everything may be swollen, it may be hard to localize that and you have to consider that as well. So I think if you're not sure by two or three weeks, if the patient's coming back and they've still got a lot of pain and they're not really getting better. Take the opportunity to reexamine them at that point, hopefully by then their swelling subsided. They're not as painful everywhere. So you may be able to localize the area of pathology. And you'll be able to pick the landmarks up. So those are the sort of things that you can do at two or three weeks. And it's just not gonna be as uncomfortable for the patient at two or three weeks to examine them again. So don't be shy of examining the patient again if they come back after two or three weeks. And the other thing you can do is if you're concerned, you can re x-ray them and some of these injuries are ligamentous injuries, so they won't sharp on x-ray as a fracture, but the ligamentous instability will if you x-ray them weightbearing and sometimes you have to wait for a period of time, 10 days, maybe two weeks for the patient to be able to do that comfortably. So that's a tricky thing as well. So don't be shy and re reexamining the patient and talking to them again and seeing if you can get a different perspective than initially. So if it's not selling after two or three weeks, you're reexamining them. What would be your sort of protocol Would you do weight bearing x-rays first and then depending on where there's tender to further on investigate or how would you proceed at this? Oh, exactly right. Yeah. So I think if you can narrow it down to the ankle or the foot, then you get the appropriate x-rays and again, you may see a fracture then that you didn't see initially, or you may even see just a periosteal response. So the bone trying to heal rather than the actual injury. But if there are ligamentous injuries, then you may see widening either in the midfoot or around the ankle. And if you're at that point, then you need to further investigate. So we will talk later about different tests you can do. But yeah, I think it's always worth looking back at reexamining and reinvestigating if there are still concerns that someone is really struggling at two or three weeks where you think that shouldn't be given the injury they've had. So would you non-weight bear them in that time or would you put them in a special boot to protect them It really depends upon their symptoms. If someone's unable to walk, I think it's very sensible to put them in a boot. It will allow them to rest. It'll force them to elevate their foot, which will help with swelling.'cause obviously in the foot ankle, as long as your foot's below your heart, it will swell. So it'll allow 'em to swell. It'll also hopefully make them comfortable enough to weight bear rather than be stuck on crutches for a couple of weeks. But some people will still not be able to do that even with a boot. So I think it's quite reasonable and sensible to use a boot. If someone can walk but not very well, then they might get away with some crutches and just assisting them in weight bearing. But if they're really in trouble, then a boot I think is very sensible. If there is a fracture there, then you've already instituted the treatment for the fracture, even if you didn't know it was there yet, until you reexamine them in a couple of weeks. so Peter, if I just go think about this in a bit, the specifics, obviously someone comes in if a significant trauma. If they fulfill the criteria of Ottawa rules, you'd x-ray. But if they're normal, you still just protect them or at least re observe them two weeks later if they don't fill the, fulfill the rules of Ottawa and therefore they you're thinking it's more of a soft tissue injury. Again, you're gonna just treat it as a sprain. But two, three weeks later they come back. If you're still tender over the soft tissues and you're thinking it's still more of an ankle sprain and you've re x-rayed and it's still no fracture, would you proceed to an ultrasound to assess the ligaments at that stage? Or would you still continue down the ankle sprain pathway? Oh, look I think you, it would depend upon how sore they're, and I think they're both reasonable paths to take ultimately. If the ligaments are injured in most people, they're gonna go down the rehab pathway regardless. So it, it may not be necessary to know that the ligaments are injured 'cause you the treatment, certainly referring 'em off to physiotherapy for physio guided rehab. Maybe brace those things you would do regardless. The algorithm in terms of whether they need an operation or not really would depend upon if they failed that rehab treatment. So I think I treat them symptomatically. If they're really bad, they'd been a boot if they're not maybe a brace. And then once they're comfortable enough, and that's the tricky bit to institute physiotherapy, there's no point going to the physio if you're really sore. All you're gonna do is get tortured at that point and no one wins. So they need to wait long enough to be comfortable to start their physio rehab, is the key thing. And if they need a boot or crutches or a brace in that time, I think I treat them symptomatically. But the aim is that they should be getting better so that they need less and less of that and they can have their physio. Sort of a loaded question, I ask you that because sometimes you see junior doctors showing me a set of ultrasounds. showing complete tear of the anterior talo fibula and a complete tear of the calcaneo- fibula ligament. and they think it's something that needs urgent surgery . In that scenario, w hat do you say to the junior doctor who comes with an ultrasound showing them that you just, how do you reassure them? Oh, look I think ultimately you're treating the patient, not the x-ray, the ultrasound, and, this is an injury we've been doing for a long time, for many thousands of years, and we managed to get through most of that without people like me operating on them. So I would say, look, this is a significant ankle sprain, but that doesn't mean in most people, that doesn't mean you need an operation. So the ability of the ligament to heal and with good rehab to end up with a stable ankle is quite high from here. So, I think 90% plus of people with a really bad ankle sprain. Still won't need surgery. It's the ones who have recurrent instability after their rehab that will, so whilst that's concerning I would still go down the same path. I don't think there's a a place even in the elite athlete for an acute ankle sprain, a sprain like that to be operate on immediately. I think rehab would be the first goal and try and re rehab that and recover that as it is. And it's not just the junior doctors that do that. The patients often come with their ultrasound and they've read it and they're very stressed and saying, oh, what are we gonna do about this? And you just reassure 'em, say this is very common. It's a very bad ankle sprain, but in most people it doesn't require surgery. And they're actually quite relieved. They go from being very stressed about this finding on an ultrasound to realizing that they probably won't need an operation and they'll be fine just with some physio and a bit of time, which most of us aren't pretty patient. So Gotta reassure 'em. It will get better. Yeah. Reinforces what I tell, I told a medical student the other day that one of the best forms of pain relief is actually giving the patient education. And that can help reassure them and let them get through the acute episode. Exactly. I couldn't agree more. I think patients, you know that they, well they all go on the internet and look at Dr. Google and there's some great stuff on the internet and there's stuff that's not particularly accurate. So I think if you as an expert, if you say to 'em, look, I think you'll be fine here. It'll take a bit of time and you probably won't need an operation. Most of 'em are reassured by that. If we're going down that same pathway of thinking about how we investigate them, let's say at two to three weeks we do the x-ray 'cause they're still sore and there's nothing particular on that. But there actually either tender on a squeeze test between the tibia and fibula. And you're wondering maybe it's a syndesmosis the ligaments that join the tibia and fibula down by the ankle joint. or they're tender right down near the subtalar or the ankle joint themselves and you're thinking maybe it's one of these anterior process of the calcaneus, what's the next form of investigation? You're not going down the path of an ultrasound looking for a sprain. You're thinking of one of these other structures. How would you investigate then. Well, I'll start with the syndesmosis injury 'cause that is a significant injury and it's probably one that is more likely to need surgery than a regular ankle sprain. To start with in terms of considering that the history is slightly different, the mechanism is different. Your regular ankle sprain is inversion plant deflection. The foot is forced down. You roll your ankle with syndesmosis injuries it's the opposite. It's dorsiflexion aversion, so the foot's turned out or the foot is stuck on the ground and you are twisting away from it sort of thing. Which we often see in, we can see, I see that in footy players where they're in a pack and someone stomps on their foot and they get bumped on a trapped foot. So the mechanism is different in terms of investigating it. You need to know whether the injury is stable or unstable. So in terms of diagnosing the injury, an MRI is quite good. It'll show you whether the ligaments are intact or not. It'll also show you any other associated injuries 'cause that may not be an isolated injury. You may have a deltoid injury as well on the other side of the ankle. But ultimately to work out whether it's stable, you can do a weight-bearing x-ray. Now people's anatomy isn't identical and so, I think if you're concerned you would do an x-ray of the other side and see if there's, if they're the same, if there is widening of one compared to the other, then obviously that's an unstable injury and you should do something about it. The other tool we have available is a weight bearing CT scan, and that's a great instrument and what you do is you scan both feet as weight bearing as I said and what you're looking for is a difference between the weight bearing scan and the non-weight-bearing scan on the same foot to see if there's a difference in the distance between the bones or between the weightbearing one side and the other side. And again, there are some parameters, but if there is a significant difference, again that's indicative of a significant significant instability and that should probably be treated surgically. So even if the ligaments are intact, you can have that. And I guess the grey areas when there is on a, say an MRI or an ultrasound damage to the ligaments, usually it's the anterior syndesmotic ligament. But that doesn't necessarily mean that the joint is unstable. So if you've got x-rays or weightbearing CT that show no widening, I'd be happy to treat that non-operatively even if the liga, the anterior ligament is damaged. And also it's a similar situation for Lis Franc injuries in the midfoot. The weightbearing CT is very good there, as is a weightbearing X-ray. And again, you need to wait 10 days, maybe two weeks for the patient to be comfortable enough to do it with a fair amount of force through their foot to show that significant difference in widening. And same thing, if there is a big difference either between one side and the other or the same foot weightbearing and non-weightbearing, then you probably should be doing something about that. So that's how I treat it. In terms of the other injury, you talked about the anterior process fracture, the calcaneus. If you're suspecting it, probably an MRI is the best bet.'cause the great thing about MRI is it will show you the bones, the ligaments, the tendons, all the different things, the cartilage, all the different things that can cause pain in one image. Other imaging modalities have strengths, but they also have weaknesses. MRIs pretty good. So that, that's where I'd go with that if I was worried about that side of things. And I think just for the syndesmosis injury, the reason it occurs more when it's end dorsiflexion is 'cause the Talus wider when it goes into the dorsiflexion. Yeah. It's also the rotation. It's like a wedge and it, as it rotates around, it pushes the fibula, it opens it up, it opens it up like a door from, if you're looking at it, the ankle from the front, the fibula gets rotated out and it opens like a door from the front. And if it's significant, it'll tear the ligaments all the way from the front to the back. And that's obviously unstable. The tricky one is where you tear the front one or partially tear the front one. And the back is intact. And that's where that grey area where you need to work out, is this stable, is it not? If it's stable, then probably a boot and some non-weight bearing and they'll be fine. If it's unstable, I think you need to fix it because if those ligaments are unstable every time you walk, your tibia and your fibula are being pushed apart.'cause they're not the distance is not constant. That has a very high risk of damaging the ankle cartilage. So long-term problems can be significant in terms of people not being able to play sport or even leading onto arthritis. Yeah. And both Lis Francs and Syndesmosis are in dorsi-flexion as the most common. Cause Generally they are. I mean, the Lis Franc injury again, can be the same thing I was talking about in the football player. I've had a few who have been stomped on and then bumped. So their forefoot is stuck to the ground and the whole body pivots on it. So that sort of thing. Occasionally you get someone who falls, maybe misses a step going down some stairs and their foot gets folded under them. So this forced planter flexion with a whole body weight on top of it. those ligaments are very strong as are the syndesmotic ligaments. You require quite a bit of force to damage them, and sometimes it's because you're going at high speed, but sometimes it's just because your body weight, or if you're playing sport two times body weight, someone else tackles you and lands on top of you. and those ligaments are damaged by, two people's weight on top of the foot in a, in an odd position. Yeah, it's, I was smiling because both mechanisms will be classically. Cause when you're in the foot straps of a winds-surfer and thrown off a winds surfer for those who would know what a windsurfer is. I use this as, excuse as why I never got on the foot straps, but really it's because I'm a pretty average windsurfer. Yeah. Look, and again, classically, the Lis Franc injury was described in cavalry soldiers, who were thrown off their horse and their leg was stuck in the stirup. But the, I guess the windsurf is a modern form of that. And obviously the contact sport with people at close quarters getting bumped and is a similar sort of injury. It's the same mechanism. It's just the velocity's different, but ultimately if someone's got a bad injury, they, it'll it can be significant in terms of returning to sport or, long term in terms of just walking comfortably and Lis Franc injuries, are the injuries of the metatarsal joint second, third, and fourth predominantly? generally is, it's, and it can, again, there are, because of the number of bones there, there's a lot of different types, but it is through that joint. So sometimes you can have the first or between the first and second off, and it's usually around the second, the base of the second, the base of the first. Sometimes it can extend even more proximally, so it can come between the cuneiform bone, so it just sort of goes vertically through and splits the whole sort of first ray off. So you have to fix even a bit further back when you do surgery. But if you are suspicious of it I think, if they're really sore, the other thing you classically see which didn't appreciate till I was well into my training, is you can see some bruising. If you see bruising on the arch of someone's foot. Bleeding and bruising, that's almost pathognomonic of a Lis Franc injury. So if you see someone who turns up with an ankle sprain or they've twisted their foot and they have this bruising in the arch, you should be suspicious of it. And, probably investigate for it or at least think about it seriously. So that's, on the medial arch, I suppose, on the lateral ray at the base of the fifth metatarsal you'd be thinking more of a base of fifth metatarsal or a Jones fracture. I always got the two mixed up. And what are the different types of fifth metatarsal fractures you can get? Well, the Jones of, it's a lot, it's a term that everyone, people use to lump them all together, and you can get some that are just at the tubercle, which is the very base of the metatarsal right at the end of it. And further down the Jones fracture is notorious for non-union. That's the big thing that people worry about is, that it won't unite. Even then, probably 90% of them do. If you are seeing a young fit person. Having a 10% non-union rate is very high.'cause most of them will, almost all fractures will heal in a young fit person. So even 10% is still very high. And it's, it's a twisting injury. Often it can be, missed as a, as part of an ankle injury. Sometimes it can be a stress fracture that will then complete. So someone will do something and they hear a bit of a crack they can't play on, but when you look at it, this is not an acute injury. There's an old fracture that they've completed. In that case, it may actually heal the fracture 'cause you've stimulated a lot of healing for something that wasn't healing that well. If you've got certain types of foot shape, that can be more common. So if you've got a very high arch because you're putting more weight on your fifth metatarsal, that can lead to a fracture as well. But again, it's just being wary of it and knowing that it may not heal, but even as I said, even though it's notorious for non-union, 90% of them will still heal, and that's a pretty good outcome. But just, yeah, be aware of it and, if there's any concerns, refer it on for some to have a look at. And it may require surgery depending on the patient and their circumstance. Now, these are just a few other fractures, but how common do these syndesmosis injuries or the lisfranc injuries compared to a standard ankle sprain or an ankle fracture? Oh, look ankle sprains are incredibly common. I think it, it may well be the most sprained joint in the body. And in terms of ankle fractures, they're still the commonest lower limb fracture. So, so that even though these things are important, they are a small percentage compared to ankle fracture. So the commonest thing you'll see is an ankle sprain. The commonest fracture you'll see in this area is an ankle fracture a regular ankle fracture. Which will either be undisplaced and just require either a boot or a plaster or probably a boot more likely nowadays, or something that has some displacement that might require surgery. But that's the bread and butter. All these other things are much less common, but you just need to be wary of them because the missing them can be have quite significant outcomes for the patient long term. It's not just that it's dragged on for longer, that there may be damage to joints, which is hard to recover from. Excellent. Well, if we can move on to other injuries around the foot and ankle. One of the other ones that we hear about are the Achilles tendon ruptures. first of all, how do you diagnose them? You walk us through the squeeze test, the Thompson's test, and basically the pitfalls and diagnosis of them and how the management evolve from surgical to non-surgical to surgical. What? I get confused. Oh look. Yeah. And they are relatively common. The history again, is of an an acute injury. There's not often any precedent people, someone's just doing some sport and they hear a pop. They will often look around, see, they think someone's kicked them in the back of the heel. Or if they're playing something like basketball, someone's throwing a ball at them and hit 'em in the back of the heel and then they usually fall over'cause their Achilles isn't working. So that's the history most often the middle-aged male the weekend warrior sort of thing. And I see quite a few who, say, oh look, just playing social sport. They were short and they gave me a ring and I turned up and. Thing went pop. So that's often a common history, but it can happen in all age groups. So in terms of the diagnosis, once you've got the history the diagnosis is principally clinical. So the patient is placed face down on the bed with the feet hanging over the edge of it. And the calf squeeze test, or the Thompson test or the Simmons test depends on which side of the Atlantic you're on. I call it the calf squeeze test. And then there's no confusion at all. You squeeze in the calf. And what you should see is that the foot planter flexes other thing, obviously if you feel, if you run your finger down the back of the calf, you'll often feel a, a step or a, a gap in the tendon. So that, that's a giveaway as well. And I think that's the key. If you investigate them with ultrasounds or, generally with ultrasound, 'cause that's very easily inaccessible, easily accessible. The one to be wary of is the partial tear, where they report it as a partial tear. And that's really tricky because a partial tear may be 30% or 40%. It may also be 95%. So, they don't often quantify how much. So if a partial tear may be something that isn't such a big thing it, it may be a significant thing. So I will go on the clinical diagnosis if I'm convinced that's what it is, I may investigate 'em with an ultrasound or an MRI, if I'm concerned about something also, or where it is.'Cause sometimes it can be a lot higher than the usual spot. It's usually about five to seven centimeters above the back of the heel where the Achilles joins the calcaneus. But if they're higher up, they can be at the musculo tendons junction where the calf muscle becomes tendon, that's harder to repair.'cause you're not repairing two tendons if you're considering surgery. So that's the diagnosis. In terms of the treatment when we were young men you, the treatment was either surgery or not surgery. And non-surgical treatment was put 'em in a plaster for eight weeks and then say, oh, you'll be right off you go. And really now there are almost three different arms of treatment. There is non-operative. Which is usually in a boot. There is functional treatment and then there is surgery. And the functional side is very protocol driven where you put them in a splint almost immediately, within 24 hours of the injury. And then you can get them, start them going with very specified physio under observation. And whilst that has some good results it really requires almost like a bigger system where physios are integrated in the system. So, in places like Canada or the UK they'll often do that 'cause they're all working within a hospital. But in our system where, you, you may not have any contact with the physio at all, it's very hard to make sure we're all on the same page. So whilst that has some results. I'm not sure it's as effective in our system where, the physio may not be known to the doctor and you don't have a common protocol you're driving on. So for me, I would talk to the patient about the treatment and the pros and cons. And it depends on the patient. Non-operative treatment has still has good outcomes. You're talking about 85, 90% won't have any problem. And the big problem if you have one is rupturing the tendon. Again, where the tendon heals is a weak point. It's potentially a rupture point. Again, if that happens, it'll usually happen within the first year after the initial injury. So, if a non-operative treatment for me, you're in a boot for eight weeks. And I'll use some heel wedges in the boot. So they'll have three heel wedges in the boot. Every two weeks I take out a wedge. So they start with three wedges, two wedges, one wedge, no wedge. That's their eight weeks in the boot. At two weeks, they're usually comfortable enough to start walking, so I let them walk at two weeks in the boot. So that's my non-operative protocol. So you're not stuck on crutches for the whole eight weeks. You can walk but you just gotta stay in the boot. The other thing to be wary of if you, if someone is treated non-operatively is DVT even though we're not having an operation the calf muscle, all those calf veins in the muscle, it's not just that they're immobile because you're in a boot, you've actually damaged them as part of the injury. Yeah. You're actually damaging the calf muscle and that whole mechanism. So, I usually put people on aspirin. I'm not sure you need to do anything more than that. If there are risk factors, then you may need to use something else, whether clexane or one of the oral anticoagulants, but just be wary of DVT risk 'cause you're damaging the muscle where those calf veins are as well as immobilization. So that's something we don't often think about when we're treating someone non-operatively. And with an ankle fracture, I probably wouldn't think too hard about it, but with this one it's maybe something to consider in terms of the surgery. What are the pluses of surgery? Look the re-rupture rate is probably lower. It's probably three to 5%. So that's a lower rate. So you're talking about a risk of having no problems goes from 85 to 90% if you don't have an operation to maybe 95 to 97% if you if you do so, it's still not a massive difference. So lower re-rupture risk the amount of power and strength you lose after your injury might be a bit lower, but it's not that big a difference that you'd say you have to have surgery. And that's the tricky bit. There is a lot of grey here. There's not a right and a wrong way to do it. I talk to the patient given the pros and cons and then let them decide. That's the key thing. And, but the treatment is much the same boot for eight weeks. Wedges take out wedge every two weeks. I let them walk after two weeks, once the wound is healed and then at eight weeks. Then when they come out the boot, then you start the physio. Right. And it's really just those basic things. Range of motion, some strength, and then some balance type stuff. With regards to return to sport or activities at six months, I'm happy for people to return to some sort of modified training if they're playing sport, but I'd want 'em to be in a position where they're not having to push themselves and push off and do things. At nine months, nine to 12 months is when you can return to full training and competition. And that timeline is the same for whether you have surgery or not really. That they're the, that's the sort of the goals I tell people after this, is that a slower recovery for an achilles tendon rupture than for say, someone with an ankle break or do ankle fractures also take a fairly bit of time to recover. And what about syndesmosis injuries as well? Again, some are quicker than others, but I think, if you are having a, if you're in a boot for six weeks. Things get very stiff and sore, even if it's a very small, minor injury. So I would think three months would be the absolute bare minimum for return to sport. But probably somewhere between three and six is reasonable. But yeah, some of the syndesmotic injuries, I've had people saying, you know what, it took me a year to fully feel really good about playing sport and not worry about it, and that sort of thing. So whilst you may be able to go back to sports sooner in terms of having that confidence to say, look, I'm fully recovered. Even if it's maybe just a mental thing of not being scared of reinjuring it, it probably is best part of a year. I think that's quite a reasonable assumption to make. Excellent. Well, we've touched a bit on the traumatic sort of scenarios. I presume all your work's not purely traumatic. what's your sort of mix between traumatic and elective conditions in your practice? And what would be the average foot and ankle surgeons? Most of my practice is elective. I don't do that much trauma nowadays. I think for others there may be a greater mix of trauma. But I, my mine is mainly elective. And I do all foot and ankle conditions, so I'll, do four foot, which is bunions and arthritis and morton's neuromas and things like that. And also some sports injuries. So again, the, ankle sprains, arthroscopy, ligament reconstruction, tendonitis or, these sort of overuse type injuries. And obviously arthritis and deformity. So I have a special interest in ankle arthritis and ankle joint replacement, but also the deformity, the flat foot and those sorts of things which can be combined with arthritis. So sometimes they're not separate things. They it's deformity with arthritis, which can complicate the picture. I also do some research and I'm actually with my interest in joint replacement. I'm the clinical advisor to the National Joint Registry on joint replacement. So, that fills a bit of extra time if I had any. Excellent. Well we did do a episode on the National Joint Replacement Registry with Richard Page from an upper limb perspective, but they covered most of the registry in general was actually a very interesting talks for those who are actually watching. They can listen to that as well. But moving on to basically assessment of a foot and ankle for an elective scenario. What's your approach does it vary depending on how they present with like pain or the neurological type scenario or with loss of function? How do you approach your assessment of a foot and ankle, particularly for a medical student coming up to the Osce exams as well? Oh look again. You go back to the basics. You look at the history, timelines. How long has it been going on for? Was there an obvious cause for it? Was there an injury of some sort or something in the history that, that would indicate an injury, an old fracture, or something like that? That may give you a hint as to what's going on here. And just simple questions of function because of, what we're treating is pain and function. So, you wanna know about the patient's pain. Is it activity related? Are they getting rest, pain? Are they getting woken up at night with pain at nighttime? What treatment have they had? Does pain relief work? Have they had physio? Anything else? If they had braces, injections, all those sorts of things. That's the main thing. Are there any aggravating factors? And then I said just functional things. How far can they walk? If they can walk, if they walk with others, this is a great question. If they walk with others, can they keep up?'cause they can say, I can walk a kilometer, but if they walk with their partner, the partner have to stop 10 times over that kilometer to make them catch, to allow them to catch up. So things like that, is it better, whether they're in shoes or out of shoes if they wear a brace, does that make it better? What are they like on uneven ground? That's a quite a good indicator of how good your function is if you can manage uneven ground. That's quite good. So those sorts of things. So questions about their pain and the character of their pain and aggravating factors, and also their function. So they're the main things in the history in terms of the examination. Stand them up, watch them walk, in, in my setting, I call someone from the waiting room. So I already get a hint of what's going on by how quickly they can get out of the chair and how well they walk into my office. I've already got an idea of how much they're suffering. For the medical student perspective, they're usually lying on a bed. So you've gotta remember to stand them up and watch them walk. Have a good look at their feet when they're standing.'cause obviously the shape of your foot changes between lying down and standing. So what may look like a fairly normal foot without too much trouble. When they stand up, they become quite obvious and have an issue. Get them to single heel raise. That's a very simple test of function if you can stand on one leg and then lift your heel off the ground. You're doing all right. and compare side to side. I always start with the good side. So I get an idea and I've got an idea of what I'm asking them to do, and then get them to do the symptomatic side. And then onto your examination palpation, feel for where their sore, look at their range of motion, assess their power. Neurology look for numbness or weakness instability of their ankle. So these are all the things you look for when you're examining a patient. Again, even though I know more than a lot of people about foot and ankle, the examination is still the same. That, that's still the basics. And making sure you're not missing something, try and be as thorough as you can with your history and examination would be the hint for medical students. Right. When they're presenting with more of a pain condition, is that usually gonna be more of a, like a missed fracture or an arthritis or a tendonitis? If they present with loss of function, will it be, could it be arthritis, but could it be deformity that's causing it? And is deformity always associated with pain, Not necessarily. I mean, sometimes someone will come along with a second or third toe that's problematic and they've got a, a large bunion and the big toe pushing across has caused the problem in the second and third toe. But the bunion itself doesn't hurt, and that's a conversation to have with the patient. We say, look, I need to operate on your bunion to straighten that, to give, to make room for the other toes to be where they should be. But they say, my bunion doesn't hurt. So those sorts of things, so the bunion deformity doesn't always equal pain. I guess, and especially, those sorts of problems with bunions and what have you, it really is a problem in shoes. If you are walking barefoot, it's probably not a problem. It's really the issue of trying to squeeze your foot into a shoe that's narrower than your foot that causes the forefoot pain. So deformity, it is a bit of a chicken and the egg thing sometimes too in the hind foot. Do they get arthritis and then develop deformity because of the arthritis or do they have a deformity 'cause of some weakness that then because of the abnormal forces on the joint causes arthritis? And sometimes it's hard to know the answer. You never work it out. Your job at that point is to say, well, I can only work with where we are now, what we can do forward, and give you options as to how to manage it. And as long as you appreciate that there is deformity and arthritis and that you need to deal with both of those things rather than just try and treat one and end up with a different problem later on. Well, the one that comes to mind is the acquired flat foot deformity where people get increasing flat foot deformity secondary to tib post dysfunction. Is that a common scenario? Is one I learned a lot about when I was studying for my fellowship exam. But obviously as a upper limb stage, I don't see it anymore. How common is this? It is reasonably common. Yeah. You do see a lot of it, people talk about collapsing arches, and I guess as people get older, that does happen. The one to be aware of is when you see, one arch that's collapsed not a symmetrical flattening of the arches is that one is pretty flat and the other one's pretty normal. That's the one you think, well, something's going on here. and the other question I ask, what I often ask people is, have your feet always looked like this? Or has that changed over time?'cause someone may have flat feet from a young person, and so their feet may look no different, but now one hurts and one doesn't. But they haven't changed. the way they look. So you need to, get a feel for the baseline. But certainly the adult acquired flat foot. It is a, it is a problem and it, becomes a bigger problem as it progresses. it's often due to the failure of the tibialis posterior tendon, and that's the one that comes around the medial side of your ankle. So it's running just under the medial malleolus. It's the main one that helps hold up the arch of your foot. So when people have what's called a flexible flat foot, so kids with flat feet, it works. It just doesn't like working all the time. And when you ask someone to stand up on their tip toes, the arch will reconstitute, but in a resting position, it can't be bothered working. So in an adult, when that fails and it's an overuse condition, it's like in the shoulder, rotator cuff problems, as you get older, they become more common. The tendon starts to wear, it doesn't work as well, and the arch then collapses. So you end up with someone who had a normal arch. Is now got a resting position of a collapsed arch. And they will present with tenderness often over the tendon itself. So, you get referred with someone with ankle pain or thinking maybe they have ankle arthritis, and it's actually the tendon itself that sore. And the joints are all fine, but it's the tendon as it progresses because the change of shape in the foot, the joints will then develop arthritis. So that's one of those situations of deformity causing arthritis. And if you treat it while it's still in the position where you just have deformity without arthritis, there are simple things, inserts, good shoes, pain relief, all those things. If you're having surgery, you can reconstruct the tendon and do what's called a tendon transfer, and that will recreate the arch of the foot and give you a more normal shaped foot. But if you've got arthritis as a consequence of that. Then the only option really is to fuse the foot. So you're recreating the shape of the foot, but you can do that by stiffening the foot in a fusion rather than tightening up ligaments and transferring tendons, which will give you the same shape, but not losing any movement. So, that's, yeah it's a fairly common problem. And some people just say, look, I can live with it, that's fine. But in some people it's very problematic in terms of their quality of life. And that's really in foot and ankle surgery. We are dealing with quality of life issues. We're not life and death. We're not heart surgeons or brain surgeons. It really is about people being able to walk comfortably and do the things they enjoy doing without pain. And obviously with the force going through the body, you've got greater risk of getting arthritis in lots of areas from the great toe way up through the foot. The forefoot, the midfoot, the subtalar joint and the ankle joint. And I presume most of those areas have their own specific types of treatment. Is that correct? Yeah, look, I think that surgically they do in terms of the the initial treatment, it's non-operative surgery is always the last resort. So the initial non-operative treatment is obviously make the diagnosis try and support the arthritic area. So good comfortable shoes. Usually an orthotic, so an arch support orthotic. And that can just be an off the shelf one. It doesn't need to be often custom made unless your foot's, got quite an unusual shape. So, good shoes, good orthotics, pain relief, anti-inflammatories, panadol, osteo, these simple things. They're the main things, maybe modifying your activity. Having a sore foot doesn't mean you can't exercise or stay fit and well. It just means you, sometimes you need to be smarter about how you do it. And instead of walking a lot or trying or running, you might find that cycling or an exercise bike or pool work or gym or Pilates or yoga. These things can allow you to keep fit and well, but not have a sore foot. So there, and that's for all those arthritis conditions in the foot. In terms of specifics if we start at the forefoot, in the big toe Hallux, rigidus what you'll find is that the stiffer, the sole of your shoe is the happier you are.'cause when you walk or when you walk barefoot the more movement that happens in the joint it becomes painful. For the ladies, obviously if they wear a heel, that can become problematic 'cause it puts a lot of stress through that joint. Same in the midfoot, that as the arch collapses, that puts a lot of pressure through those joints. So just something like a nice arch support will support the foot and relieve pain. And it's sometimes important to remember that you are supporting the foot. Sometimes patients will have an arch support where someone's trying to correct their foot shape and make a very flat foot into a normal looking foot. And that can be quite uncomfortable. So the, the support you're requiring is really supporting the foot to make it comfortable as opposed to trying to correct the shape of the foot to make it look like something you might put a photo in a book of sort of thing. So, so from that point of view and the midfoot, and then in the hind foot again good sensible shoes, often they'll have what's called a rocker sole. So that means the sole of the shoe is curved. So a good walking shoe, a running shoe will have a rocker in it. If you put it on a table, it, you can roll it back and forth 'cause of the curve. In some shoes you may need to build that up because obviously the more movement the sole of the shoe has, the less movement your ankle has to do. All those other joints have to undertake. So a rocker sold shoe and you can buy those commercially. It's a bit hit and miss because if you've got one foot, that's a problem. You don't need, usually need two rocker old shoes and sometimes. The curve can be quite a lot. And for an older patient, I've had a few say they felt that like they were on a boat the whole time. They were rocking back and forth. So some, and you can get them, you can get a rocker sole added to your shoe. So some of these people who do shoe repairs, they can add one to the sole of your shoe and if you only got one side, you just need one. And they may build the other one up flat. So you've got a rocker on one side, a flat on the other that you feel even, and your ankle's getting a bit of a rest. So, so that's sort of the simple things you can do. Correct deformity for the ankle or behind foot. You can use a brace as well as an orthotic for the arch. So these things will all help. The aim is to get, allow you to get around comfortably without pain. Once you go beyond that, then you're really talking about surgery. In terms of surgery for everything apart from the ankle joint, the treatment is fusion. So we're very simplistic in that way. You can't really replace other joints in the foot. There have been some attempts in the big toe, but none of have been particularly success. So fusing all the, all those other joints apart from the ankle joint is possible. And fusion's quite an emotive word. People hear fusion and they take a step back when I say that. And so you have to take some time to explain to people what does a fusion mean and what is the outcome of fusion. So, a fusion is basically an operation where you take away what's left of the damaged point joint and glue the two bones together. That means that there's no movement, but in arthritis movement equals pain. So you're gonna lose whatever movement you have in the joint. You'll also lose the pain that goes with it. And in some people they have very little movement to start with, so they're not really losing a lot of movement. So that's the fusion side of it. The aim of, say, an ankle fusion or a subtalar fusion or one of these things, or even all of them, is that someone walking on a flat surface in a reasonable shoe, someone looking at you, shouldn't know that you've had that operation. Right. Patients think they're gonna be like some sort of pirate with a peg leg when they're done with a fusion. And so, you need to say no, someone who doesn't know you shouldn't know you've had that operation. And then they go, oh, that's a lot better than I thought it would be. And then you can have a discussion on, whether they wanna go down that path or not. So, for all those arthritis conditions in the foot fusion is really the only option in the ankle. Ankle replacements are available, they do exist. They're much newer technology and we're still getting a handle on them. But from, my work with the joint registry they are a niche market. So if you look in Australia at ankle replacement last year, the report just came out on the 1st of October And there were 729 ankle replacements done in Australia last year in 2024. There were about 80,000 knee replacements. So it's about a hundred to one ankle replacements to knee replacements. So it is a very small niche market. The numbers are small. From my perspective, I do about 25 probably a year. I do maybe a slightly less number of ankle fusions. So I'm about half and half in terms of my practice. Others will do more fusions or some people won't do ankle replacements at all. They'll just do fusions. So it's there, it's available. It's not an option for all people with ankle arthritis. So there are people who are more suitable than others, and that's part of the discussion as you have with any patient about any treatment, about what is the best treatment for them as opposed to what, the joint registry says is a good treatment. So in terms of that who's a good candidate for an ankle replacement? Ideally someone older a bit more sedentary. Often if they've got adjacent joint arthritis. So someone who's had a subtalar fusion or hind foot fusion if you fuse the ankle joint, that makes them quite stiff. So, if you keep movement in the ankle joint, then that makes a big difference in terms of their functionality. Also contralateral disease. So if someone's had a fusion on one side, you'd ideally like to replace the other side.'cause if you've got two ankle fusions, you can't propel yourself. You can't, it's hard to get up out of a chair. It's hard to push off. It's like walking on stilts sort of thing. So if you can keep movement in one ankle, then that's a really good thing. So, people like with rheumatoid arthritis, inflammatory arthritis, these sorts of things who have lots of joints involved, not just their ankle joint they're good candidates. In terms of fusion, who do I offer that to? If there's a lot of deformity? Sometimes there's things you just can't overcome with a joint replacement, if there's any sorts of weakness.'cause you need a stable joint to have a good ankle replacement. Young laborers, people who are doing heavy work they're gonna wear out their ankle replacement and they're probably better off with an ankle fusion. The arch enemy of the ankle replacement is the farmer. They are such hard workers, they can't help themselves. And so that's the one you worry about. If you've got a farmer with a bad ankle, you just worry that they're not gonna be able to help themselves and stop working. They keep going and going 'cause there's, they've got such a good work ethic. So in terms of fusion, what's the plus? The plus is that once it's done. You've had one operation. If it's few successfully, then your pain is gone. Potentially the adjacent joints may develop arthritis down the track because if you're stiffening up one joint, the others may work a bit harder. You don't see that often, but you certainly do see it. If you have an ankle replacement, like, like your native joint, it may also wear out. If you live long enough, you may wear it out, then you have to have that redone. And whether that's possible, whether you need to fuse it, that's a tricky thing. So that's why the younger heavier more active laboring type patient or someone on their feet a lot doing heavy work is probably best suited with a fusion because they know they won't have to come back and have a redo of their replacement. So that's where we're at In terms of the results, if you look at the results of ankle replacement at 10 years, about 13 point half percent of them will have come back to have their ankle replacement redone. Alright? So, if you compare that to knee replacements, it's about 4.5%. So, but, so it's not as good as knee replacements in terms of longevity yet, but when we look at the results, say from five years ago, it was 16% at 10 years. So in the short space of five years, we've come down 3% in terms of aboriginal rate. And it's getting better every year. So the aim would be that we're, that if you have an ankle replacement, hopefully it'll see you out and you won't need to come back and have it redone. Right. Excellent. Now I'm gonna probably ask a loaded question this way, but what's my, what's your favorite investigation when someone comes along to you and you're worried about arthritis? Oh, look, I think an x-ray, go with the basics. It's, it's a simple thing. A weight bearing x-ray you'll often see it. And that's all you need to do. Once you go beyond that I think an MRI scan, if you're not sure, or if you're worried about other pathologies as well, is very good.'cause you can see the state of the cartilage, you can see other things. If you're not sure where it is, if you want to localize it. Something like a bone scan is a very good test. It'll help you localize, especially in the midfoot if there's, 'cause there's lots of little joints there if you're not sure where it is. That's a quite a good test for doing that. And in terms of treatment, we talked about surgery for arthritis. I think a cortisone injection is a very good way of managing someone. It's not gonna solve their arthritis, but it will buy time. So somewhere in that, someone who's got midfoot arthritis who may not necessarily want an operation or a fusion then I think an, a cortisone injection is a very good way to go. But you need to make sure it's in the right spot. And if you're not sure which joint it's in, then something like a bone scan is a very good way to do that. Especially if the x-ray's not conclusive in terms of cortisone injections. I get them all done under ultrasound. That way you know that the injections in the right spot.'cause the worst thing is if you put an injection in and then someone comes back and says, I'm no better. Does that mean they're no better? Or does it mean that you didn't put it in the right spot? With ultrasound, you can be assured that it's in the right spot. And then the outcome is more obvious. I tell people that it'll take two or three weeks for the cortisone to work, so I talk to them about a month after their injection. By then, it's pretty clear whether it's made a difference. I also tell them to do their normal activities after the injection. If they take it easy for a month, they'll tell me they're better, but that's'cause they haven't done anything. So you gotta again get them to do their regular stuff and see if it's really made a difference in their quality of life. Is the key thing for for ultrasound guided injections. The other thing is there are other things that people are injecting as well. Now there are biologics, there is visco supplementation. So the biologics are things like PRP. Which is where you take someone's blood, you put it in a centrifuge, you spin it down, and you take some healing factors and inject it in around a painful area to see if it can cause some healing. The evidence here isn't conclusive, so there's certainly plenty of things available, but it's not conclusive. If there is evidence that's conclusive, it's probably more so to do with things like tendinopathies rather than with arthritis. And I guess in the upper limb things like tennis elbow and things like that, there's reasonably good evidence. So maybe with tendonitis or something, it's maybe better than arthritis, but so that's, again, something that's evolving and we're still getting the hang of it, but certainly it's something to think about in in, in patients. The other thing you can inject is what's called visco supplementation. And that's really synovial fluid effectively is what you're injecting into the joint. Again, most of the evidence here is in the knee. There's not very much in the foot ankle, in the knee. There is some good evidence that shows that you gain some time. In the foot and ankle, not so much just'cause the research hasn't been done. So again, it's something to consider, but ultimately you're probably gonna end up having to do something more than that in the long run. And what about one of my favorite foot and ankle arthritic operations is the Cheilectomy for Hallux Rigidus. Is that still a good operation in the early stages? I think it is. Ideally you need to work out what you are treating. So the Cheilectomy is really shaving the dorsal part of the metatarsal head. So just the top bit, often there's a spur there and that's where they tender when you push on top of the joint. And what happens is when you dorsi flex the toe the toe bumps into that and you get some some pain and it's really an impingement type problem. So if that's your problem, then shaving off that spur and some of the metatarsal head will allow the toe to dorsi flex, you might increase your range of motion as well, but not have the pain that goes with that. So, and in early disease, I think it's a good operation. The problem is that spur is there because there is some damage to the joint, so that damage may progress. So down the track they may present again with arthritis in the joint, in which case the treatment there is a fusion. If at the time of surgery there is a lot of joint damage, then you know, it's a bit of a dilemma because you suspect this isn't gonna last very long. But again, if you're, again, you're buying time here for some people you'll cure them. If their problem is just that impingement, then you've solved it. In others that may progress, that they may be back to have a fusion. But I think it's still a good operation. It preserves movement. So we talk about joint sparing procedures and that's what we're talking about. Something that will allow movement for people who wanna run or do something like that. You can still run with a fusion, but it's probably not recommended. Yeah, I like it because it's one of the few operations where you actually are debriding an artery joint with actually reasonable results. In that setting. There's not many around the place that can do that. But it's has got short term reasonable results, I believe. Oh, exactly. And, and again the other one that I do a Cheilectomy sometimes is in the midfoot. So around the lis franc joints. So the tasa metatarsal joints, you'll often see people who have some arthritis here in Spurs on the dorsum. But their problem that their problem is pain when they're wearing shoes. And it's often related to the lump being rubbed on by the upper of the shoe. And if you can work out that the pain is coming from the lump being rubbed on rather than the joint, you can go in and shave that off and make them very happy. And again, same sort of thing, you're getting rid of that impingement that's happening by the shoe. But if the joint's not arthritic, they'll be very happy with that outcome, even though they've still got an arthritic joint on an x-ray. And what are some of the common elective conditions that GP should know apart from just arthritis? Are there other things you should be thinking about as well? Oh, there's a ton of things. I try and divide them up by sort of their location as a simple thing.'cause patient presents with, it says, I've got pain around my ankle, so you think, what is it around the ankle that might be giving me trouble? So things like Achilles tendonitis instability or sprains. The arthritis, obviously we talk about ankle arthritis and all the hind, foot joints deformity, so the flat foot or the high arch foot, which will have ankle deformity as well. The other thing you see fairly commonly is plantar fasciitis. So that's pain under the heel. And for that you don't often operate on it, I do occasionally, but you see it fairly commonly. And the treatment is fairly straightforward in terms of good, comfortable shoes, more padding under the foot, stretching exercises. Physiotherapy, pain relief, it will generally get better on its own, but it can take anywhere from say, six months to two years to fully get better. And so you just need to warn people again, it's about educating people and saying, look, this will take time to get better. And sometimes it does, or most times it does, but sometimes it doesn't. And if that's the case, then there is an operation you can do. And it's a little keyhole operation where you, divide part of the plant of fascia, that seems to take the tension off it and it helps settle things down. So you can treat it with surgery, but most often it's just time. So in terms of other areas in the midfoot, we talked about arthritis, we've talked about collapse, and the midfoot collapse can be due to arthritis, but often due to this adult acquired flat foot, we've talked about that, how to manage that shoes inserts, pain relief. And then beyond that, you can talk about surgery depending on whether there's arthritis or not. In the forefoot, bunions are very common. They don't always need surgery, but they, they are common. They tend to run in families. So there's often a story of my mom or my grandma, or my aunt, had these horrible feet. And it's important to reassure patients. They're not gonna suddenly wake up with grandma's feet tomorrow. The progression of bunions is very, is generally very slow and takes many years. And so, I tell patients the best predictor of what will happen is what has happened. If your foot was normal a year ago and now it's got a big bunion, it's probably moving quickly. It'll happen quickly from here. But generally, there's a story of many years of a bunion gradually getting worse. It'll gradually get worse over many years. At any point along that progression, if you wanna do something, there's an operation that can be done to fix it. But really the timing is entirely up to the patient. It's their call as to when they wanna do it. So that's bunions. Hallux Rigidis we've talked about. So the arthritis in the big toe joint Morton's, neuroma and metatarsalgia are two other things that are very common. So they're in the lesser toes. The metatarsalgia is pain under the metatarsal heads. and Morton's neuroma is the thickening of the nerve between the metatarsal heads. So we're talking about two conditions that are millimeters apart and sometimes are really hard to tell apart. So it can be very tricky working out what's what. For me, a lot of it comes down to the history. The history is opposite really for both of these. If you've got a Morton neuroma, the symptoms come on when your foot's being squeezed.'cause the nerve is being squeezed. So when you wear shoes. It's sore. People say, look, I put my shoes on and maybe after half an hour, I take my shoes off, I rub my foot, it gets better. And the pain is usually in the toes. They you can be described as electric shocks or numbness in the toes. For metatarsalgia, it's really a pressure point under the under the bone, the metatarsal head. So for those people walking barefoot is terrible. Walking in a good, comfortable shoe is really quite good.'cause there's lots of cushioning between the foot and the ground. For the ladies, again, when they wear a heel, that puts a lot of pressure on your metatarsal heads. So they'll often complain about that that, high heels or any sort of a heel will really give them trouble. And the pain is under the ball of your foot rather than in the toes. So the histories are generally quite different. Not always, but and the two things can coexist. So in terms of what to do again good, sensible shoes, lots of padding under there. In terms of an orthotic, this is somewhere where something a bit more customized will help. You can get what's called a metatarsal dome, and that's a an elevation in the metatarsal. And it sits under the shaft of the metatarsal. So it's not where you saw under the ball of your foot. It's further back and it uses the metatarsal as a lever really to elevate the far end of the metatarsal. It spreads the load more evenly across the front of the foot and that can often relieve symptoms. So that's a simple way to do things. Beyond that, there really is surgery. If it's a Morton's neuroma, the treatment is to excise the neuroma. So you take out the thickened nerve and then that will get rid of the pain, but you also end up with some numbness because you end up taking out the nerve that supplies a web space in the toe. But that's a lesser problem to have than the pain that people often experiencing. For metatarsalgia. If a dome doesn't work then you're really talking about surgery, which is to do an osteotomy, cut the bone and shorten it up so that you're spreading that load more evenly. So, so they're the sort of forefoot problems. And obviously you talked earlier about claw toes, lesser toe deformities, so claw toes, hammertoss, all those things. Again, simple things. A nice wide, deep shoe. If you've got a shoe with lots of room, they're not gonna rub. That'll solve the problem. You can solve these problems by the changing the shape of your shoe or the shape of your foot. And so if you want to get new shoes, that's fine. I often tell people, you can either look good or feel good. It's hard to do both at the same time. So, so if, yeah, but in terms of lesser toe deformities, surgery can be done. Usually involves fusing the joints in the toe so that you keep the toes stiff and straight. So that it just makes it more comfortable. So yeah there's lots of different things that, you need to know about. Most of them can be managed fairly simply with shoes maybe inserts pain relief, activity modification. Once it goes beyond that, then there are obviously more complicated things such as surgery. Excellent. is it still narrow shoes part of the factors in causation, or is it all genetic Oh look, I think it's a combination. I mean, if you've got a family history of bunions, I'm not sure what shoes you wear is gonna make a difference. The narrow shoe is probably in, in terms of the people I see is more an aggravating factor. Whether it caused it or not is hard to know, but it certainly irritates the foot when they're wearing narrow shoes. And and that's, that's why they come and see me.'cause I've got pain now. So it probably is partly environmental, partly genetics. But ultimately if you're wearing a nice wide shoe, it tends to be less of a problem. So, yeah. So I think it's a really, it's not, there's not a simple answer to that question, but certainly narrow shoes will make it more symptomatic for the patient who then if they wanna wear those shoes, will be possibly more likely to wanna have surgery to change the shape of their foot to fit into that shoe. But if you, if your shoes narrow than your foot, you're gonna have a bit of a problem regardless. So, we've covered a fair bit already Pete, but one of the ones I always struggle with when people ask me. About injuries are stress fractures. I believe you, it stress fractures in all parts of the lower limbs. What are the common ones that you see and can you tell me a bit about them? Yeah, look, stress fractures are overuse injuries like tendonitis, like those sorts of things. So often in the history when you're talking to patients there's often been a change in activity and, but that change may be six or 12 months ago. So it takes a long time for that to become symptomatic. So if someone is they may have commenced a new activity, they may have taken up running or gone going to the gym, or if they're doing it already, they may have changed their routine. They may train more often, they may increase the intensity of their training, they may have changed their shoes or the surface they're running on. So sometimes there's a change, and it may not be recent, that is a precipitant for the stress fracture. So that's the first thing you wanna see. You wanna work out initial management. Decreased activity truly become pain-free. So if if you're getting pain with sport, then stop that particular type of sport till you're pain free for a period of time, and then you can slowly increase what you're doing. If you're just getting pain say with walking, then it may will be that you need a boot or even a period of non-weightbearing to become pain free before you then go back to walking and then to training in terms of your recovery. You need to have a stepwise progression in your recovery. So if you can't just suddenly go back to running 10 kilometers, you've gotta build up to that after. So you need a period of being pain free, maybe even six or eight weeks, and then slowly increase what you're doing. Assistance from maybe one of the sports physicians. Or the physios is quite good. They can guide you through a program. They may they can measure things as well. So sometimes it's about, you may not feel like you're improving, but they could, 'cause they're measuring things. They can tell you that you are if there are particular biomechanical issues, sometimes podiatry may help with orthotics. If you've got a high arch or something like that may make you prone to stress fractures. That's the key thing. Sometimes when you're going back to activity you might find that if you get really sore, you need to drop down to a previous level for a bit, become more comfortable, and then slowly increase again from there. The other thing that is really underappreciated in stress fractures is vitamin D deficiency, right? I mean, even in, young athletes, you do see it and obviously in, in community it's very common if you test for it. It's very common. We think we live in Australia, how is that possible? But a lot of us live and work indoors a lot. We don't get a lot of sunlight. We're very conscious of skin cancer, so when we go out, we wear hats and long sleeves and sunscreen. So, if you see someone with a stress fracture, think of vitamin D deficiency. That's a simple thing to treat for that as well. What are the sites of stress fractures that you see? Yeah, I mean, the fifth, the base of fifth metatarsals, so that Jones fracture is one that you see. The second and third metatarsal is what's commonly called a march fracture. So that's someone who may have taken up running or a lot of walking the stress through that if you've got a high arch, that may be more common. Also the navicular has a stress fracture as well, and you see that often in jumping athletes. So I see a lot, a few footy players who get it, like ruckman and people like that who are doing jumping or basketballers the navicular. So that's further back in the foot. And every now and then I see someone with a an older person with a calcaneal / heel stress fracture, and that's due to osteoporosis. So they may present with something like plantar fasciitis with heel pain. And then, you do an MRI and you see they've got a calcaneal stress fracture. So, so they're the commoner type of stress fractures in the tibia and things like that. They're pretty uncommon. They do happen, but it's mainly, yeah, fifth metatarsal navicular. Second and third metatarsal are the common stress fractures. So the other thing I see a bit about, are people who recurrently sprain their ankles, have got lax ligaments or they've had a bad injury and they've got unstable ankles. Are they common? And how do you treat those? They are common. Again, most people with one ankle sprain or two ankle sprain with good rehab won't have recurrence. And it's the people who have that recurrent injury who they, whether you talk to 'em, they say, I just can't trust my ankle. That's the sort of common story you get. They're the ones who would you would consider surgery on. And again, it's working out what their problem is. It's the ligaments. If it's the ligament's, laxity, if they've got weakness, it may be peroneal tendon injuries. Every time you roll your ankle, you may cause injury to the peroneal tendons. The other thing is that usually their ankle is not painful in between sprains. So day to day they're not sore. But when they roll their ankle, obviously it hurts. If you've got someone who has pain day to day with an unstable ankle, you need to think about something going on in the joint, like cartilage damage or some chondral injury within the joint. So you need to investigate the joint.'cause they may require that dealt with as well as their instability. The other thing you need to look at is any deformity. So some people have a varus hind foot. So the heel is coming in the heel is come in towards each other when they stand. If you look at them from the back, that's gonna put a lot of stress on all the lateral structures. So the peroneal tendons, the lateral ligaments, all those things. If that's the case, then often if I'm gonna undertake surgery, I'll often do an osteotomy and realign the hind foot. So that you give the whatever operation you do to the Peroneal tendons or the ligaments has a much better chance biomechanically of succeeding. If you repair all the lateral structures and the foot still turns in, you're probably gonna be back where you started from after not too long. So, so, treating any deformity within the foot that may make them prone to rolling their ankle, treating any weakness such as peroneal tendon injuries, and then obviously treating the ligaments and any other cause of pain. So that, and in terms of that, it's probably 5% or maybe 10% of ankle sprains that'll ever get to that point. But if they've had a good trial of proper management with physio and all those things, and they're still not able to trust their ankle, I think it's a very reasonable and sensible thing to do. And, timelines to return to sport. In my case, they're in a boot for six weeks, so at three months they'll be getting there. They'll have had six weeks of rehab. But yeah, to really get back and say they're fully into it, it's probably best part of six months for them to be comfortable back at sport and confident that they can trust their ankle. Well, Pete, that's, we've covered a lot of ground today. We've covered everything from fractures and dislocation, sprains through to arthritic conditions. I think you've really appreciated you coming on Aussie Med Ed and going through what are very common foot and ankle conditions and you've said yourself are the most common fractures in the lower limbs. So look, thank you very much for coming on Aussie Med Ed. It's great to have you here. Thank you, Gavin. It's been a real pleasure and great to talk about some of these things. Hopefully someone's gained some value from it and some useful knowledge. Thanks, mate. Thank you very much. Thanks a lot. Cheers. well, that's been a fascinating discussion with Dr. Peter Stavrou giving us a valuable insight into one of the most intricate and essential parts of the body, the foot and ankle. We've explored how GPS can recognize early warning signs, manage common presentations, and understand when is appropriate. We've also learned how surgical advances, including total ankle, ankle replacement, are improving patient outcomes and quality of life. As always, the key takeaway is collaboration between gps, physiotherapists, podiatrists, and Orthopaedic surgeons to ensure patients get the best possible care. If you'd like to find out more or catch previous episodes, visit medicalpodcast.au and don't forget to follow us or subscribe to Aussie Med Ed wherever you get your podcasts. Thanks for listening. I'm Gavin Nimon, and I look forward to joining you again next time. Until then, please stay safe.