Are you constantly battling with annoying ankle instability? Join us as we delve deep into the subject of chronic lateral ankle instability with our special guest, the insightful physiotherapist Andrew Wynd from Balwyn Sports Physiotherapy. Andrew, with his wealth of knowledge, shares his experiences.
Diving deeper, we explore how a comprehensive patient history is crucial in dealing with ankle instability. Shedding light on the commonly overlooked symptoms like syndesmosis injuries and lateral ankle pain, we discuss how patients modify their movement patterns to compensate for instability. We also provide insights on how certain activities, such as multi-directional sports, can contribute to this condition. Laced with Andrew's insights, we discuss the use of braces, taping, lateral wedging strategies, and soft tissue therapy. Round out your knowledge on ankle instability and discover effective strategies to manage it effectively.
@balwynsportsphysiotherapy
andreww@balwynsportsphysiotherapy.com.au
@simplythebestpodiatry
@jasonagosta
jason@ja-podiatry.com
@officialfreestylefeet.com.au
Freestylefeet.com.au
Ottowa ankle rules
Definition chronic ankle instability international ankle consortium 2016
Cumberland ankle instability tool
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Are you constantly battling with annoying ankle instability? Join us as we delve deep into the subject of chronic lateral ankle instability with our special guest, the insightful physiotherapist Andrew Wynd from Balwyn Sports Physiotherapy. Andrew, with his wealth of knowledge, shares his experiences.
Diving deeper, we explore how a comprehensive patient history is crucial in dealing with ankle instability. Shedding light on the commonly overlooked symptoms like syndesmosis injuries and lateral ankle pain, we discuss how patients modify their movement patterns to compensate for instability. We also provide insights on how certain activities, such as multi-directional sports, can contribute to this condition. Laced with Andrew's insights, we discuss the use of braces, taping, lateral wedging strategies, and soft tissue therapy. Round out your knowledge on ankle instability and discover effective strategies to manage it effectively.
@balwynsportsphysiotherapy
andreww@balwynsportsphysiotherapy.com.au
@simplythebestpodiatry
@jasonagosta
jason@ja-podiatry.com
@officialfreestylefeet.com.au
Freestylefeet.com.au
Ottowa ankle rules
Definition chronic ankle instability international ankle consortium 2016
Cumberland ankle instability tool
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Welcome back to Simply the Best Pediatry, where we aim to pass on simple tips to enhance your best clinical practice. I'm Jason Agosta and today we are talking chronic lateral ankle instability. And we have our second physiotherapist on the show, andrew Wine from Bollin Sports Physiotherapy, joining me. Andrew has been a physiotherapist who has specialized in foot and ankle orthopedics and sports injuries for many years, been in practice for 22 years and continues to run a high level practice, which extends from his elite background being a cross country skier who represented Australia back in 2007 in Japan and again in 2009 in the Czech Republic. But he's one claim to fame is that he won the Rialto run in 2004 and it's my privilege to have you on today, andrew, and thanks for joining me. Thanks a million for coming on.
Speaker 2:Mate, you're most welcome. It's good to chat again after all these years. We obviously worked together some time ago and that was when I won the Rialto was. I was training in our old building in East Melbourne, going up the stairwell at lunchtime and then catching the lift back down.
Speaker 1:How many laps would you do in training? I'm doing that.
Speaker 2:Five or six reps was about five or six. Goes at it after work on a Friday or Thursday.
Speaker 1:No wonder you had bulging calves and quads Fantastic.
Speaker 2:The funny thing about it was the year I won it. I didn't do any stair training until the night before and I was just doing ski training out in the Dandenong's running the fire trails out there. And then the next year, when I had to defend my title and it was a big deal I trained on stairs and I came second.
Speaker 1:I've got to say I'd like to get more physio input into this show in the future, for sure, but we have had Nick Rison. For those who haven't heard, nick was our first physio on the show where we spoke about running technique, cracking round table show, if you haven't heard it, but it's such a pleasure to have you on and contribute to the podiatrists and their input to injuries, which we'll speak on shortly. And if you and I start throwing a sheet around, I can pull it out. But before we move on, I have to mention that you have a product developed called Freestyle Feet, which I've had in my rooms that can assist with the strengthening of toes and feet and over the last two weeks we've discussed in-depth strengthening of the lower limb and foot and strengthening for diabetics. Now you obviously saw that something was missing in assisting patients in developing foot strength, in developing this product.
Speaker 2:Yes, absolutely. The biggest clinical challenge that I've had is patient compliance with doing their intrinsic strength work and I'm sure you can relate to that that I haven't been able to get patients to do their intrinsic strengthening past, say, two weeks. In all honesty, maybe in an athlete, a really motivated client, that then they'll do it for longer if they can relate that performance benefit to them. But it was just over the over years and years of seeing all sorts of different feet that the intrinsic function was was so compromised in so many of them. We know it's important, but coming up with some really good exercises that are easy to do was really hard. So what really made the difference was when we stabilized the forefoot. So if I go back a step, flamingo Feet's a product named after Flamingo standing on one feet. That's what Flamingo's do really well and they're nice and balanced.
Speaker 1:Oh sorry, I said freestyle, it's Flamingo.
Speaker 2:Wow, that's actually the overarching brand, but we've got a variety of products that solve simple clinical problems. Our hero product is easily the Flamingo Feet, which they're silicon toe spaces. They slip on between the toes and when patients walk around in them, they, their muscles, start working immediately more effectively. We're involved in a trial at the moment measuring MRIs. Using MRIs, I should say to to measure the, the cross-sectional area of their intrinsic musculature before and after wearing them, and just the support what we're seeing clinically, because we put these toe spaces on patients and say, just look, we'll give you exercises, but just wear them for a few weeks and they come back and they immediately do things with their toes they couldn't do before, right, and so it's been a bit of a game changer from from that point of view. That was the real reason that we started developing that product.
Speaker 1:So the idea is to stabilize your toes and just walk around with the spaces and the stabilizers so you can use your intrinsic more basically and you don't have to do any of the specific exercise regimes. Is that what you're saying? You can, but yeah, the day-to-day activities.
Speaker 2:Yeah, precisely If you do more activities with them on you're getting an immediate benefit, so that the patients don't need to think about they, just need to use them, just walk around and it's easy. But if they're motivated enough to do some exercises specifically with them on, you'll get a much more rapid effect. And they're leaning car phrases, leaning forwards, which already we know activates the intrinsic more. But the toe spaces prevent you from clawing, so the long flexes are turned off preferentially and then they can start discovering their short flexes.
Speaker 1:Yeah, okay. So obviously this fits in with what we're gonna talk about in a sec as far as chronic lateral ankle instability, as far as strengthening and, as I mentioned, we've done a couple of episodes recently talking about that with Matt Dillnott, which has been amazing and in-depth. So, moving on, if we talk about lateral ankle instability, obviously it's a huge part of physiotherapy. I mean the prevalence I don't know what the prevalence is in your rooms, but you must have significant numbers.
Speaker 2:Yeah, obviously we see a bias cohort through this clinic because it's got a bit of a reputation for foot and ankle issues going through here.
Speaker 2:So of course, with bias, but looking into the data, when we know that an inversion of lateral ankle sprains the most common lower limb injury of all the types. So, and we know that, depending on which literature you look at, 30 to 70% of them, and I usually draw an arbitrary line down the middle. So let's just say 50% of those lateral ankle sprains will go on to develop chronic ankle instability and that's just a staggering number, particularly and this is something I'm so passionate about because the sequelae of events for following chronic ankle instability. We know that if that cohort, that 50% of them report symptoms later on, up to 10 years, and that's more likely to lead to post-traumatic ankle arthritis. And, as you and I have seen all those post-ops, the really the replacements are getting better but the current standard of care is a fusion for that condition, for end stage arthritis and that's the end of running and skiing and so many activities that we love, and a huge amount of mechanical change, asymmetrically, obviously.
Speaker 1:So if we talk about that, though, I mean, people have a couple of injuries here and there, but if they're significant enough, that leads to the laxity, and then we have the chronic problem, don't we?
Speaker 2:Yes, but we've got to dive a little deeper than that. There's even some confusion as to what the definition has been accepted in the literature of chronic ankle instability and there's been some great work in 2016 at the International Ankyl Concortium sort of agreed on a working definition for all the research going forwards and really there's kind of three key components there Recurrent spraying, so more than one, and where you keep spraying, the time frames can be debated, but generally six months, multiple sprayings within six months is pretty accepted. You need mechanical instability that you just referred to and then perceived instability, and some time ago, Claire Hiller, from is one of the key researchers in this space talked about these subgroups that exist with those three kind of key features. So recurrent sprayings, mechanical instability, perceived instability, and there's subgroups, so I'll have some of them, but not necessarily all. As long as we're thinking about those three things to meet that definition, we can identify that group and then start to subgroup down. So it's more than just mechanical instability is what I'm trying to get across.
Speaker 1:Yes. So our aims in attending a room from a physio point of view I'm assuming restore range of motion, restore strength.
Speaker 2:Yes.
Speaker 1:And then obviously increase our training to be specific for the activity.
Speaker 2:Yeah, at a high level, that's absolutely it. I think where it gets really fun is looking at the individual and making sure that your assessment is addressing the known risk factors and then the known identified factors that exist in these subgroups. So a patient reported outcome measures really important because the patient's confidence in their ankle and their perceived instability is a big part of it and that may or may not get better with rehab unless it's addressed as well. So the Cumberland ankle instability tool, the great outcome measure I'd recommend, or the practitioners use that if they get an ankle sprain or a recurrent ankle sprain patient in there, that's a good one. But yeah, there's range of motion deficits and strength deficits and balance deficits and it's so unique to the individual it's really interesting.
Speaker 1:So there's a bit more time to be taken, isn't there? When you're taking history with this, I'm just thinking when someone comes into your rooms, you're just spending a little extra time just working the patient out as to what they feel, what, as you said, their perception of instability.
Speaker 2:Yeah, yeah, yeah, episodes of giving way. You want to record that. Try to understand them. This takes a little bit of a relationship development with the patient, but try to understand their feelings around the ankle. Typically what comes through is that they don't trust it and so they feel like they need to brace it or modify their movement pattern to really make their ankle less vulnerable.
Speaker 1:Yeah Well, until you start discussing it they're not going to think about it. And then you've got somewhere to sort of lead from. I suppose in weeks down the track they can make judgment. And there's the confidence factor. Yeah, exactly. So what about activities? I mean, to me the multi-directional sports are obviously the ones that stand out, but what would be the most common activities that you would have as a history?
Speaker 2:Yeah, your spot on Jayce. The directional sports, or the lateral sports, are the ones that have that this happens to. So basketball is pretty big in Erie, melbourne and in terms of participation rates, so lots of basketballers. Of course AFL is unique to here, but in the literature soccer is pretty massive as well. So lots of soccer players, basketball players, tennis players, volleyball, tons of tennis, yeah, yeah, all those directional change courts.
Speaker 1:It's interesting. Just thinking about the tennis over the years You've known my involvement. But how many players do their ankle once or twice and then they're braced up? Oh, they're braced up every training session, every tournament. It's amazing, yeah, and clearly I mean maybe they do have these instability and very, very poor confidence. I don't know, but it seems that it's really common, and maybe too common, to see that brace.
Speaker 2:Yeah, yeah, couldn't agree more. I've been getting tennis lessons on a regular basis. It's never too late and every time my lesson finishes, quite a young, talented junior female player starts and she I can recognize her school uniform, I won't name it, but she starts straight after and I have a look at her warm-up technique. But it does my head and she's wearing a brace and I'm thinking which week will I turn up when she starts? And she hasn't got it on and it's been a year and so long.
Speaker 2:One brace on one side and I almost said something through the fence, but the coach looked a little intense. So yeah, I don't think I want to mess with their plan, but no, look, I'm really big on that. I think a brace is. I use a brace a lot. If anything, I've been using it more as a practice, more and more. It's really helpful for giving them confidence so you can move them through your rehab plan. But I'm very big on taking it off at some point because I do believe that it has impacts further up the mechanical chain For sure.
Speaker 1:We'll get onto that in a second. We talked about conservative management, but if we go back a little bit to symptoms presented obviously lateral ankle pain, but we just see a myriad of different scenarios, don't we that coincide with the ligament sprain or rupture, and the most outstanding one for me is the perineal tendons get affected. But what else do you see?
Speaker 2:Yeah, and this is the thing, depending on what their strategy is to get over that initial sprain or even recurrent sprain. This is where the fun is, I think, clinically, is exploring what they did to get over it. So there's all sorts of common adaptions. So they'll move their force, their center of pressure, antrolateral, which is a little interesting. So as soon as you do that, you've got more pressure actually laterally so they can lock up their lateral column or their foot more. So you'll see cuboid saunas, as you said, perineals for sure.
Speaker 2:Typically lateral symptoms, sometimes forefoot, sometimes post-ear, post-rolateral, ankle not necessarily where the ligament was torn, and then sometimes medially as well. Sometimes they do do something a little unusual and they lock themselves up laterally and shift their weight medially or they pronate more, which then we get medial symptoms as well.
Speaker 1:To try and offload. So you can't, really can't be anywhere.
Speaker 2:Yeah, just shift the force away from that area.
Speaker 1:On that point, though, of medial pain, post-injury, if we invert so much, it's quite common to see that medial impingement isn't a rent subtaler region.
Speaker 2:Yeah, the deep fibers of the deltoid ligament get impacted and it seems to get bruised and they will look like they are even torn from the trauma, from the degree of inversion. Yeah, okay, and that absolutely will slow them down.
Speaker 1:something chronic Well sometimes that's worse than the actual lateral problem. Isn't it the actual chronic pain that like weeks and months later?
Speaker 2:Yeah, yeah, they get those, those pomylations, and then drag symptoms on for six months afterwards, so a high grade injury can really. I've got one on the go at the moment that's really complaining of lateral sorry, medial pain, but we also see it laterally, don't we?
Speaker 1:Sinus tarsii is the one that sort of gets dragged behind all this and months down the track that person still saw, you know, in that sort of that little joint cavity. So if someone comes in and we know they've gone over repeatedly, they have a chronic swelling, obviously we have to start thinking about things that may have injuries that may have been missed, and there's several that I think podiatrists and physios have to make sure they know of, One of them being the syndesmosis injuries, which I think you know. If you don't know what an ankle syndesmosis problem is, you need to look it up and learn about it for your practice. I think it's one of those most overlooked and misunderstood problems. So the syndesmosis one is my number one thing not to miss. What's outstanding for you.
Speaker 2:Yeah, it's certainly on my list Fractures. So subcontral fractures A bit tricky.
Speaker 2:So that's your acute fractures. Usually you'll pick up with your, your auto ankle rules of some of the best clinical guideline rules that still exist today, so you need to know them. You should be able to pick that up in the acute phase. But in terms of that, that more recurrent one where they can cope yet a low grade syndesmosis, a subcontral fracture, and that can be in anything that can be in the talus, in the calcaneus, the anterior aspect of the calcaneus, a cuboid. I've seen undisplaced subcontral fractures in the cuboid that present with that lingering lateral pain. They're still coping day to day pretty well. They're probably the big ones yeah.
Speaker 1:I think the osteocondral ones are the tailored dime. They're the common ones, aren't they? There's, sometimes there's not, a lot you can do. Sometimes people have scopes for them. But if they're really bad, but it doesn't lead to a great future, does it? If it's really bad because that surface is significantly affected Something you just mentioned, which I'll pass on here there's been plenty of studies on this about people feeling like they've lost the control of the foot, post lateral ankle injuries, and it's almost like this, like this loss of muscular control, and people sort of feel like their feet pronate or splay out and then practitioners say, oh well, yeah, you've lost all your control.
Speaker 1:It was interesting. There was a study published in the Journal of Clinical Medicine last year saying and it was a huge number of people this is out of China saying that there was and they're looking at navicular drop in all the lateral ankle problems and there was no more navicular drop in the people who had done their ankle consistently. There was a significant change. But do you think we sort of lose that? Maybe that muscular control as a? Maybe it's a protective mechanism in some way to maintain mobility? I'm not sure.
Speaker 2:Yeah, I'm not sure either, but without a doubt that muscular control is a huge factor, I think, in why they have that recurrent sprain. That's why you've got to identify that with really thorough. So, circling back to assessment, things go check range of motion and palpations, crucial in the whole foot and ankle, not just the lateral. I mean you're going to test the ligaments, the lateral ligaments, and test the medial ligaments to really pick up that mechanical instability and then look that perceived instability I think is driven largely from that loss of muscular control I think is what's driving that.
Speaker 1:Yeah, okay.
Speaker 2:And then your rehab is guided by that. So typically everybody gets eversion strengthening.
Speaker 1:That's a pretty classic ever we get taught it is useful, though, as part of your rehab the non-weight bearing eversion strengthening. Is that useful?
Speaker 2:Yeah, look, I reckon it is for about a couple of weeks, but it's no more than that. And I think the other thing is that they're usually doing it mid-range and it's not well controlled. So when I get these patients that have failed rehab and we dive into that, they haven't done any in a range but they're really strong mid-range.
Speaker 1:For example and that's a classic one with the TheraBand that they don't take it anywhere, they just tick the box, but in saying that, I think you know where I stand with the non-weight bearing strength. There is a time for it, though, isn't there? Just to at least start to turn on that muscular action. You may not get strong, but at least turn it on, and I think it gets back to starting to restore some motion. Am I correct in saying that?
Speaker 2:Yeah, I know where you sit with that, but it's got its place. It's got its place. It just can't be the only thing and yeah, I think it turns muscles on. It's a great activation. Like you want to be strong right through range in full plant-afflection inversion. That the position that you typically do a lateral ankle sprain. In that moment you're mechanically weak and your ligaments don't support you very well. All you've got is your perineal holding you desperately, trying to hold you back up. So I would want to train that once it's appropriate, right into that range, right through. And who knows, maybe the patient gets a little bit more confident when they're working their ankle right in and right out against this band and they feel good. I think that's helpful for when we get them up to weight bearing and then move them into functional positions.
Speaker 1:Okay, so what are we doing? Weight bearing, then, from a rehab point of view?
Speaker 2:All right. So you've done your basics. I assume you're doing calf raises with good control, making sure you're staying what we call stacked, keeping it. You're tailless over your second metatarsal and then we know that TIPP, post and perineals are working well together in that sling. I like exploring out to different positions so they get confident with that. And then what I reckon is not done well is jump land drills and a whole bunch of them Jumping to an object is so we call those feed forward mechanisms. So you put a bit of tape down on the floor or put even better, put two pieces of tape and get your patient to jump and land with good control between the two lines of tape. That's where I might start. And you want to go all planes of movement, fords, sideways, rotary, and add complexity and add fatigue to it. So do more, throw them a ball.
Speaker 1:Yeah, sure, but what you're getting at is that forefoot weight bearing, which we spoke about last couple of sessions. That that is crucial. That's crucial to activate everything in the chain. As soon as you do some sort of plyometric or whatever activity is on the forefoot, Just go back a step. What you did say which was important was doing the heel raise. You said you like to just vary it up. So stay centered but also start to move lateral, start to move medial, Sort of make sure it's like quite varied. So that is a big part of your rehab in making sure people can do that.
Speaker 2:Yes, in the chronic ankle instability subgroup. Yeah, absolutely Okay.
Speaker 1:We just spoke about bracing. Obviously, these people who wear bracing I'm not sure I'm not really up with the latest, greatest on all that, but are people actually turning off their protective mechanisms using a brace consistently?
Speaker 2:That's a million dollar question there.
Speaker 2:That's a tough one. 25 episodes in that one. There's 25 in that, I think, where the brace is really useful, again in this subgroup, and I want to specify in this chronic ankle instability subgroup. This subgroup is nervous. They've got altered movement patterns and they don't have normal pressures, they don't have normal muscular timing. We know that when you put them in a brace it makes them feel secure and it normalizes muscle function. So it's actually the inverse, I think, because they feel safe, their perineal activation and strength and timing is actually better with the brace. So it's that subjective feeling of support that makes them then go really well and that's why I love braces in the first one, two, three months of your rehab plan.
Speaker 1:Right, I was going to say it'd be early on, though, wouldn't it Not long term.
Speaker 2:Yeah, it might take them a little while, depending on how chronic it is, and then I absolutely wean them off where they don't.
Speaker 1:I think long term, I think it does shut down muscle function, yeah, and, as you said, it also obviously is going to have an effect on the more proximal chain as well.
Speaker 2:In my opinion. I think it absolutely does. The challenging part is when you some of the chronic ankle sprain research in terms of the author's recommendations that is now publicly available, as they recommend ankle brace or taping prophylactically because it'll probably it prevents.
Speaker 1:Yeah, sure Gio, I shouldn't you. That's the question. Yeah, so I was going to ask you about the taping. Is the taping similar? Do we restore normal perineal movement or do we turn it off? Is it a similar sort of range? Yeah, is it? Yeah, is one better than the other?
Speaker 2:You look at the research, no, they're both equally effective. My personal generally I get patients into braces because they can control it well, themselves, take it on and off, and particularly in this subgroup, if they're them controlling things and being in the driver's seat, it's an important part of the rehab. And it's just one other thing that positively feeds into that.
Speaker 1:If we're using the taping and the bracing and we're restoring a bit of normal function, but we take it off down the track, are we seeing less instability?
Speaker 2:No, we don't know. No one's done that. Okay, no one's done that.
Speaker 1:So it's almost like a restoration back to probably where they were previously.
Speaker 2:Look, I think with a good rehab plan, when you can identify known risk factors, if you address all those things, then I really think that we reduce the risk of any more sprains with a really good rehab program.
Speaker 1:Yeah, sure yeah, but the kickstart of that will be turning on muscular or normalising muscular control with the brace and the tape in the early stages. So what happens with us, compared to, say, your rooms, is that we will more than likely see the chronics. People are just laterally unstable and maybe they're just structurally inverted and what we see, that lateral weight bearing of the foot. Then they go and play basketball or tennis, which is like up to seven to nine times your body weight when you change direction. And there's a great photo on the Instagram page actually of a pro tennis player's foot. I think I put it up in the perineal section. So if you go back and look at that photo, there is a classic pick of a right foot overriding the shoe, which I'll get onto in a sec.
Speaker 1:But that person who is chronically laterally weight bearing and chronically unstable, what we see down the track is oh okay, you're laterally weight bearing, we better wed you laterally. So that's what comes into the podiatry rooms commonly and the way that I would deal with that is they would have foam adhered to the shoe insert laterally and even if we have to step it up a little bit, they would have a small two millimeter preform little blank laterally posted to give them some stability, and the height of that lateral posting would be anywhere from six to maybe nine mil. That's a common scenario. There's a few people, mainly the post-op ones, who would need to be much higher, which is a little less common. But is that something you're seeing or doing as well, like you have to? There comes a point where you've just got a laterally wedge.
Speaker 2:Yeah, and I do, and I refer to the podiatrists for that. Yeah, are you doing that rear foot or are you doing that forefoot?
Speaker 1:That's rear foot to the fifth MTP. Yeah, and you're right through the whole lateral column of the foot, yeah.
Speaker 2:Yeah, when the center of pressure has moved antero laterally in this subgroup, then we've got to somehow get it back centered again. Yeah, that's certainly a strategy that I'll try. The only time I reckon that comes unstuck is if they've got chronic spasm in their perineal, so they've had injury to that area, and they typically respond. A lot of them respond with sort of tightening and holding onto their perineals because they don't want to let that go Right, they don't want to get vulnerable, and if they do that then they lock up their lateral foot.
Speaker 1:So the fourth MTP the lateral column yeah.
Speaker 2:Yeah, the lateral column's all locked up, and then putting something under that to sort of push it back in sometimes locks that up even more. Yeah, I understand what you're saying. So the concept is certainly correct and it's all typical dual combos. So I'll mobilize them through their lateral column Muscle release, work through their perineals, release that spasm and then a lateral wedging strategy will be even more effective.
Speaker 1:So that's a good point to make, though, that the soft tissue therapy and the mobilizing is essential, which we have spoken a lot of in the last few weeks on that with perineal cuboid pain. But that's a great point to add in there that we can't deny that We've got to look at those soft tissue issues and the joint issues, don't we? I mean, the cuboid pain is so common and that's what comes in with these chronics.
Speaker 2:Yes.
Speaker 1:Exactly. It's so common I mean, you've got to learn how to manage that. And it is really simple too, which I think I presented.
Speaker 2:Yeah, yeah, really simple, really fun, like really satisfying when you can make a massive difference really quickly.
Speaker 1:Yes, With the patient. Yeah, we mentioned that, yeah.
Speaker 2:With mobilizing or manipulating it. I'd strongly encourage all your listeners to have a good look at the sub-tailor joint range of motion and the tailors position as well. We know that those two things are an issue in this cohort. They've got shifts or movements. The tailors shifts forwards typically and the sub-tailor joints typically hypo-mobile. And that's not just my bias is a really manual therapist bias, physio. The research shows that and you can't, you can't authorize that away. You've got to get your hands on and you go and free that up.
Speaker 1:Yeah, okay, yeah, so you're saying that you go over laterally, tailors moves anteriorly, so that whole sub-tailor joint just basically stiffens up. Yes, yeah, and we've got to mobilize it. Yes, so, as the mid-foot or cuboid, we've got to look at sub-tailor joint and as well as the soft tissue as you mentioned. Yeah, great point. Yeah, so that's the chronic sinus Tarsi. Well, the subtail of cavity pain and swelling. Yes, yes, is that? Is that why we get that?
Speaker 2:I think that's why that is taught physios and the masters course and they. It's always the same when we get to this topic. They say well hang on?
Speaker 2:I don't. Why would I want to increase the amount of range of motion in a joint by doing Manual therapy on it when they're too unstable? That doesn't make sense to me. Yes, like I know, on first principles, if you've, you're thinking correctly. But when you actually have a feel of these patients and dive into that literature, it shows you that they're actually hypomobile at certain joints. Yes, the ligament is buggered and you go laxity at the ligament, but the joint itself is lost its range of motion. And so when you, when you take a variability of say and I'm and I'm demonstrating, it's hard to have for me to, let's say, you got 30, some minutes available range and I suddenly shorten it to 10, if you step outside that, then you're gonna feel unstable Earlier on. So yes, storing normal joint kinematics is crucial.
Speaker 1:That goes back to the first thing I mentioned about the aims of this is restoring range of motion. That is so important for muscular control. So how do I do that clinically? Walk into my room someone turns up on Monday. Am I just Gliding or mobilizing sub-tailor joint and comparing it to the non-affected side and feeling, okay, this is really stiff. Is that how I'm doing it, or is there other things I need to be looking at Clinically?
Speaker 2:that's exactly how you're gonna do it because quick comparison, yep, because you've you've worked on your palpation skills glide that tailors backwards and forwards, and Not from a ligament testing point of view, but a joint range of motion quality point of view. And do the same on the calcaneus. So stabilize the tailors and and invert and either Calcaneus, yeah, and have a feel of how much movement there is, the quality of the movement compared to the other side.
Speaker 1:Okay, all righty. So just touching on with those is a second ago. There is no way I will Say that any more than a simple little device, just as a base to put lateral wedging on, is needed, because we know what it's going to do laterally it will throw you and change you in your pathway of direction. We are going to do several sessions on orthosis in the next few weeks, which I'll touch on, but I Hear today I'll reiterate that it I think it's got to be really conservative, if at all. There's a place for orthosis, depending on the individual, and most of the time they are used as a base for lateral posting.
Speaker 1:Now, the next thing from that is footwear. It never ceases to amaze me, and you may I mean, with this current trend of footwear being thicker and softer at the moment. Yeah, a few years ago in the tennis court, all the tennis shoes went like that as well. They went from being flatter and low profile and they started to stack them up and the foam densities changed. You know I haven't got the numbers, but the number of people in the tennis courts who would come in and say, oh my god, I'm going over that room overriding my shoes, changing shoes every two or three weeks because I overriding them. Some injured, some not. But the sloppy soft shoe, there is no place for it in the multi-directional sports and I Always say to patients you need to get something really firm yet has to be low profile but it has to be on a firm base.
Speaker 1:There's two things with that one we don't want you to topple over off the height of it and we don't want the shoe to accentuate that lateral weight bearing. But the second thing is is sensory perception. You need to be on the court because, as you know, in a multi-directional activity you need to perceive the surface. You need to be up on your forefoot, utilizing all of your muscular control, which obviously is going to be the great preventer of, you know, the lateral ankle injury. But it's really interesting how shoes have gone down that pathway and then in the court sports have almost gone back again. I think it's a really important point for the podiatrist to to have a good hard look at, because we talk about running shoes all the time. But you know, in tennis and basketball and things like that, remember in the basketball courts, like the boots were stacked up, massive soft platforms. It was a disaster, disaster.
Speaker 2:Yeah, yeah, I've done it out of single thing there, mate. It's it. Yeah, completely great. That's the worst thing you can do it for a chronic ankle instability, especially latch on wants to build, I know yeah, yeah, on that note, talking about bracing and taping, there's always that argument about low profile.
Speaker 1:You know, shoes versus mid cut versus high cut. Which one do I use? As far as I know there's, it is that self-perception that you feel more stable in the higher shoe, higher cut shoe versus the low cut shoe, and that's about it. Mechanically, I don't think there's any benefit really.
Speaker 2:Try it might have been an MBA study some time ago that Might have talked about the high cuts, slightly reduced injury risk Maybe I don't get too fast about that Again with a really well, if you've got, if you've identified your unique findings with loss of range of motion and joints and muscle function through range and feed forward rehab, you've done that really well and and you've structured your rehab plan with good outcome measures Along the way, then it becomes a little redundant because it doesn't matter.
Speaker 1:So, just to finish off, we're talking about restoring range of motion, subtiler joint, ankle joint, all that is so important and then obviously the strengthening all the four foot weight bearing activities. We might have to start a little bit conservatively down the track. There may be a place for bracing and taping when people get back into activity, but the aim would be to discard that after a period of time, if that person can, and we just touch on lateral wedging Footwear. The things not to miss. You know, the osteocondrol stuff to send us most of sinjure is a perineal tendon injuries. Thank you so much for coming on. I love that direct information, andrew, as usual. Fantastic. I love to get you back on the show that we've got so much to discuss, as we have always. If anyone hurt us off air, the way we go at it with each other different problems, we should just do one of those episodes actually.
Speaker 2:Let's do that, and I'm sure it opened my but hey, I really appreciate you.
Speaker 1:It's a privilege to have you on because you're so experienced with foot and ankle and there's not too many physios are really honing on the muscus, skeletal, orthopedic side of things with foot and ankle and you have been one of those for the last 20 odd years and have a depth of understanding of knowledge and, as well as that, I love the fact that you've got that Elite background with your activities because that gives you more of that understanding. There is no doubt. So tons of thanks for coming on today and Hopefully we can have you on again sometime.
Speaker 2:Absolute pleasure. Thanks for having me on a good chat all day about foot. Thank you, no, I love it. I love working with the podiatrist and it's it's it's a myth that Physios and podiatrist don't work well together, because we've we've done it for For those two ever.
Speaker 1:Yeah, that's bullshit. We're all good. We were talking about this last few weeks. We were never taught I'm not sure what goes on these days anything about muscular or anything about strengthening. Never taught a thing, and you know how. I learned some from guys like you in a multi-disciplinary clinic and then obviously in the orthopedic setting as well. So there's so much to you know. Pass on and hope you listen into the show a little bit as well.
Speaker 2:Absolutely no, I'll be tuning you, mate. Thank you for having me on and thanks pleasure.
Speaker 1:Thanks, mate. We'll speak soon, excuse me. Thanks again for listening to simply the best podiatry, andrew Wines. Details will be in the show notes, where you can find other details and links, and you can also follow and support the show. Tune in again and we'll be with you shortly.