Ortho on the go
Ortho on the go
Discussion regarding evaluation, treatment and return to sports after acute ankle sprains
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Hello, everybody, and welcome back to the podcast. Today I have the pleasure of discussing ankle sprains with Dagan Clutier. Dagan is a physician assistant that practices in the Northeast part of the United States. He is the editor-in-chief of the JBJS and JOPA or JOPA Journal. Dagan, can you tell us a little bit about that?
SPEAKER_00Yeah, so I think two since 2016 I've worked with uh JBJS and been the editor of Jopa. Um and so that has definitely definitely helped keep me motivated to read and stay on top of stay on top of all these topics.
SPEAKER_01And then you um also have your website, uh CME for PAC, right?
SPEAKER_00Yeah, so I've been writing self-assessment questions for CME for PAC for about 10 years now. And um that's another thing I love is just seeing case studies in the clinic and writing a discussion section. And and honestly, it really when you when you write a discussion section and or any type of case study and you take a deep dive into the literature, um uh it really helps you with patient care decisions, right?
SPEAKER_01Yeah, I would agree with you. I think that's definitely a great uh opportunity uh for you to educate yourself on a variety of different orthopedic and or general conditions. So when we're talking about ankle sprains, how would you kind of categorize, let's say, acute ankle sprains?
SPEAKER_00The big ones for me, in terms of the categories for acute ankle sprains, and that's kind of what that's a big enough topic to go over in one night, is acute ankle sprains as opposed to chronic, but acute ankle sprains, the the you know, they can be broken down into for me, your your simple lateral ankle sprain, and that has different severities. But then you have your avulsion fractures, your high ankle sprains, and then your your long-term pain, like when you start getting bone bruising and stuff like that. So those those are the four major categories I guess I think about when I see ankle sprains come in.
SPEAKER_01Yeah, I don't disagree with you at all. I I agree on that. And I think um, like from my perspective, I think the mechanism injury always plays a lot into it. Um, you know, if if they have an actual acute injury that's related to it, um, if they can weight bear on it, you know, that type of thing, and then you know, where their palpable tenderness is, make make sure not to miss, you know, synismotic injuries or masonive injuries. I just had one the other day that, you know, the urgent care treated her, put her in a boot, and she's like, Well, everything's great, but it hurts right here at the top of my boot, and sure enough, it's kind of her lateral fibular area, and I palpate and she jumps off the table and I get an x-ray and it shows that she has a fracture of her proximal fibula, and you know, they were just treating the ankle sprain. So I I think it's important, you know, joint above, joint below for the evaluation.
SPEAKER_00Yeah, you essentially when you diagnose a acute ankle sprain, you have to have an x-ray to rule out a fracture. So say we're assuming that the the x-ray has been done and it's been ruled out. And in terms of uh lateral ankle sprain, I I would key into that a lateral lateral ankle sprain diagnosis by pulpation, right? So uh my main palpation is lateral, anterior talofible ligament. So that you know, the most common ligaments it's sprained, palpate laterally, and that's usually where the significant swelling and tenderness is, and then I slide over and and pulpate the anterior synosis as well as the medial deltoid. And so if if I just have most of the swelling laterally and no tenderness over the deltoid and anterior synosmosis, I can assume that it's a lateral ankle sprain. And and again, though those can have different levels of severity. When I talk to patients, I try to be more visual with patients. And so I'll say, you know, when you sprain your ankle, it's like it's like a your ankle ligament's like a rope. And when the rope tears, and I'll interlock my fingers as if I'm forming a rope, I'll say, when the rope tears, it splits apart, and all the fibers tear. And then I'll I'll pull away my interlocked fingers and I'll visually show patients that it's like two mop heads when it's torn. And the healing process involves all those fibers coming back together and healing. And when you exercise too early and you don't allow or you don't boot the boot the ankle or protect the ankle from rolling again, then you don't allow those interlocking fibers to heal in. And if you sprain it while it's trying to heal, and I pull my fingers apart again to show that you're basically interrupting the healing, and as you interrupt the healing and you s and you don't treat it appropriately, then you end up with a s a loose ankle. Then the fibers heal loose, and you're you're more prone to ankle sprains in the future. So I think I feel like that visual of like the interlocking fingers and sh telling them the ligaments like a rope that tears that needs to heal in. It's sort of a simple visual for patients to understand the healing process and what the what was actually injured.
SPEAKER_01I think that's a great analogy. I think that works well as far as the patients trying to visualize exactly what the injury looks like from a ligamento dysjury perspective. So if a patient comes in and is having and or has an acute ankle injury, uh what is your, I guess, go-to initial treatment regarding this? Um, let's say from an immobilization perspective, what do you use to help protect that joint? What's your recommendation for that?
SPEAKER_00I I oftentimes start an issue with the walking boot and really feel patients out. And I can I can tell immediately almost what what their reaction is, you know, I'm not gonna wear this boot, throws off my hip, throws off my gait, it's uncomfortable. Um and of course I try to sell it, you know, this is the best option where you can just set it and forget it. You can wear it. And if you step on an uneven surface with this boot, your ankle's not gonna roll. Uh and if and if they still are not interested, uh then I talk about walking on even surfaces for three or four weeks and being very careful to go walk in the yard where there's an uneven surface or they're more prone to roll their ankle in certain in certain terrain.
SPEAKER_01I think I've learned that over the years that if if if you educate the patient upon you know on your thought process and they are a part of the decision-making process, a lot of the times um they'll feel more comfortable with the decision, feel like they have some control over that, and that leads to better outcomes for the patient. Yeah, so we've talked about how important it is to involve the patient in the decision-making process and how important it is to educate the patient regarding the specific uh injury. Let's discuss this scenario. Let's say a friend calls you up and says, hey, um, my buddy or my kid or myself, you know, sprained my ankle at a basketball game today, or maybe I missed the last step walking down the stairs and I twisted my ankle. Do I need to go in and get x-rays? Do I need to go in and get this checked out? What what do you tell them as far as when to seek treatment for ankle sprains and when it's amenable to just treat it at home?
SPEAKER_00I think any pain with weight bearing has to be seen, has to get an x-ray, has to be seen. Um, if they feel like they the ankle is significant significantly swollen, I believe that they should be seen just for an exam in terms of ruling out a synismotic injury. Um so it it comes down to severity. If if the ankle just feels unstable, they should be seen. If there's any significant swelling or swelling, they should be seen. If I guess they don't have any lateral swelling, and it, you know, you're just your typical slight role, but they were able to continue playing in their basketball game, you know, potentially they don't need to be seen. Those happen all the time. I I have the fortunate where I played a lot of sports and I've been through a lot of injuries, and I and I so I've sort of have a good feel of in sports-related injuries in general. I mean, if you you we people roll their ankle all the time in soccer and basketball, but don't they don't necessarily have a severe injury. So those are the things that I look for.
SPEAKER_01Yeah, I think I would agree with you on that one. I, you know, one of, like I said, uh for me, at least a lot of orthopedics is is based upon the mechanism of injury. You know, if if somebody you know misses a step coming down the stairs, I always ask them how many steps, because for me, if it's three steps versus one step, that could be a more significant injury. Like you said, if it's an athlete that twisted their ankle, let's say they came down from a rebound or you know, they stepped on somebody's foot, if they're able to finish that game, then I think, yeah, soft tissue injury, but maybe the severity of the injury is not as much. Yes, they're gonna have increased swelling that night and for the next few days, but it was stable enough for them to play on it at least for a short period of time. So maybe it could be more conservative with that treatment than somebody that injures it and can't weight bear right away. I I think more significant structural damage maybe needs to be seen, um, you know, and more significant mobilization and or weight bearing restrictions, if that makes sense.
SPEAKER_00Yeah.
SPEAKER_01No, right on, yep. Do you ever use the Ottawa anchor rules? Have you heard of those?
SPEAKER_00I have, but I I just think that instead of memorizing you know, four or five rules, it to me it's it's common sense. I mean, if they if they have pain to palpation, bony palpation over the lateral ankle, if they have pain with weight bearing, if they have significant swelling, uh you know, just get an x-ray.
SPEAKER_01Yeah.
SPEAKER_00Just just to just to it keeps it simple in the decision making instead of having to try to hit every bullet point of the auto rules.
SPEAKER_01Yeah, and I agree with you too. I I I get a lot of students that come in with the Ottawa rules that they're taught in their in their schooling. And we don't have socialized medicine, at least in the United States. And so, you know, our ability to get x-rays on patients it usually is not significant. We usually, you know, most people can't walk in an orthopedic clinic without getting an x-ray. Now, some patients that don't have insurance and are self-pay, you could potentially use these rules to evaluate where you should x-ray, because that's part of the components of the rules is should I get ankle views or or foot views? But you know, most of our foot and ankle docs get five views, you know, um, three views of the ankle and two views of the foot on everybody, independent of what you come in for, just to kind of make sure we don't miss anything. So um, like you said, I think it's it's common sense um from an aspect of when radiology should be done.
SPEAKER_00Yeah, and I and I work in an urgent care setting as as you do, and um it I try to be a minimalist as well in terms of if you examine them and all the the tenderness is around their ankle, I I and you have no tenderness over their fifth med or over their over the dorso of their foot. I I tend to just get ankle x-rays. Um I I am sort sort of cognizant of costs and and you know just overording as well. So you know, I I try I try to keep it simple in that in that decision making as well.
SPEAKER_01You said something um which I agree with completely is individualizing their treatment based upon the patient's um kind of needs and the um severity of the injury. Um I think oftentimes patients will come in and they'll have a fairly large soft tissue presentation, you know, quite a bit of edema diffusely throughout the ankle, lateral and or medial, um, quite a bit of echimosis diffusely throughout the ankle area, and their x-rays will kind of end up being negative. What take us through like your thought process on these patients where, you know, maybe it is a significant soft tissue response, but radiologically the x-rays all look okay.
SPEAKER_00Yeah, no, if it's a significant ligament injury, you know, I tell patients that it's going to be a minimum four to six weeks on that lateral ankle sprain. And now now that's that doesn't include high ankle sprain. So let's just say that they don't have any anterior, anterior seismosis pain or medial deltoid pain, um, just lateral pain. You know, I would I will lock them in a boot and I'll tell them you only have to wear it when you're walking. Uh, and it's essentially to prevent your ankle from rolling as that ligament's trying to heal. Now they can get out of the boot and work on um some ankle pumps, simple exercises like that. I'll shut them down for three or four weeks just to get all the swelling down. Um and sometimes two or three is appropriate, depending if it's less swelling. Get the get all the swelling down, and then I would typically get them into physical therapy at that point, but I'd also transition them to an ASO. So you don't want to just get out of the boot and go back into a sneaker. You'd want to get them in an ASO. And I typically, the cheapest way to do it, if we don't have the the braces, the ASO type stabilizing brace in our office, I'll go on Amazon and I'll show them a picture of it. Uh that's the brand we use, ASO. It's a figure of eight stabilizing brace. And the they'll the cheapest way to do it, I think it's 40 bucks on Amazon. Get it ordered, and and you transition to that out from the boot. And now that you usually you're wearing a minimum of a couple months after the boot, you'd wear that stabilizing brace anytime you're walking. So if you catch an uneven surface or your ankle rolls, it gives you a little support. That combined with physical therapy, and in physical therapy is is another set of eyes that can help transition patients back to either sports or work, where they're seeing the patient a couple times a week and working on stabilizing exercises, single leg hops, things like that, and they can progress patients back into their activities. Whereas I don't typically get to see that patient twice a week. So I'll I'll have that initial evaluation and I'll spell out this treatment plan. And I may not even see them after the initial evaluation. I may just say this is the game plan, physical therapy, and they'll they'll work to clear you. And if you have any trouble beyond uh eight weeks, six to eight weeks, let me know.
SPEAKER_01Yeah, I feel like there's a lot, a lot to unpack, you know, regarding, you know, these ankle sprains, because there's, you know, we've all been burnt in the past by you know a lateral ankle sprain kind of healing and patient having pain eight weeks down the road and ends up showing, you know, you end up getting further imaging like an MRI, and it shows possible like perineal tendon tears that can happen with these lateral ankle sprains and kind of are hard to diagnose, at least acutely, you know, because the tenderness and the soft tissue response is similar uh for both of the injuries. Um so I think directing the patients on potentially when to come back and when maybe further imaging is necessary based upon the progression of their symptoms is important. Like you said, hey, at six to eight weeks, if if you're not noticeably improving, transitioning out of the boot, progressing with physical therapy, you know, getting into, you know, 70, 80 plus percent improvement, you know, I would consider coming back and following up. You know, we may need some further images to make sure we're not missing anything. Like I said, you know, I try to try to educate the patients on you know, when that potentially follow-up visit andor further imaging would be necessary.
SPEAKER_00Yeah, and I believe you can kind of tell a risk stratify that right off the bat. If they're just their ankle is just completely blown up, they're at a huge risk of having bone edema. And that's that's the kind of patient that it may be it may take them four months to get better. Whereas if if the patient ha has moderate, mild swelling, particularly laterally, then they they are probably gonna do better. Um I tell patients a personal story of me. When I when I was playing basketball um a few years ago, typical jump shot came down, landed on someone's foot, and and my ankle buckled, and um I had immediate pain, swelling, couldn't bear weight, and it it typical rehab, boot for a few weeks, then ASO ankle brace, and then I started running about the six to eight week mark, and my ankle blew up again, and I you know, I couldn't understand like that the it seemed like I had fully rehabbed from the ankle. Um, the sprain, the pain the pain and swelling had was gone with range of motion, but I was still getting pain with running. And so I jumped in the the uh we have an MRI at our practice, and um it my talus lit up like a Christmas tree. It was it was bone marrow edema at eight weeks throughout my talus, and it really kind of you know, a light bulb went off like these ankle sprains that this is why they can last so long is because of this bone marrow edema, and it and it took me four months uh to run pain-free. And so I from the significant ankle sprains, I I tell that story to my patients. I say, listen, that bone marrow edema takes four months. You know, and that's and that's you know, the the severe ankle sprains, that's why they can take forever to get better.
SPEAKER_01Yeah, and I tr I try to educate patients on that too. I had a similar scenario playing basketball, and you know, my ankle blew up, and I could have sworn that I broke my ankle. Um, but I went to see the doc, got x-rays, and the x-rays just showed kind of a you know normal x-rays, maybe a grade through ankle sprain. And I had to talk them into giving me a walking boot. And again, I used to very similar to you, it took me probably four to five months to get better. And I always try to educate them that the unpredictability of soft tissue injuries is probably more difficult than bony injuries. I mean, we know predictably a lot of bony injuries, if there's, let's say, a distal fibular fracture heals in a fairly predictable fashion, you know, six to eight weeks for bony healing, and we're able to keep them non-weight bearing for that time. For these soft tissue injuries are very unpredictable. They could, as you said, take two weeks to get better. They could take, you know, four to six months to get better. And so they have to be very patient with the healing process.
SPEAKER_00Yeah, and I would say, you know, nine times out of ten, you get an x-ray at eight weeks, and it just so shows persistent swelling in the lateral anterior tailor fibral ligament as opposed to an ostochondral defect or a perineal tear or bone marrow edema. But that's you know, it's at eight eight weeks to three months is when you start thinking the MRI, trying to rule those other injuries out.
SPEAKER_01Yeah, correct. Because I mean, even if they do have a perineal tendon tear or another injury, that potentially is not something they're gonna repair acutely. That's something that probably treat in that more prolonged fashion at that three-month point, even if it needs, you know, requires surgical treatment at that point. So um, again, I try to educate patients that, you know, if you do have a significant, let's say, syndromotic injury, a lot of the times the imaging like an MRI is not gonna change what we're gonna do. We're gonna immobilize you and make you non-weight bearing, and then see how your symptoms progress and discuss you know further imaging based upon that progression of symptoms.
SPEAKER_00Yeah, and you you bring up a good point about high ankle sprains. And now a lot of PAs, I think, get confused of what exactly a high ankle sprain is. And so I I think it's it's and even in uh the general sports medicine world, like what is a high ankle sprain? In my in my my my opinion, how I diagnose it is they have synismotic tenderness, right? So they have they have tenderness over the deltoid, they have tenderness over the anterior synosmosis, and they have lateral, lateral tenderness. And most of those patients with high ankle sprains come in with pain with weight bearing. So the typical lateral ankle sprain, they can walk pretty well. Even in a high ankle sprain, if you throw a high ankle sprain in a boot initially, most of the time they they still have to use crutches because they still feel that pain with weight bearing, they still feel that instability. So that's that's when I key on uh to talk to patients about a high ankle sprain and just say it's a much more severe injury. I mean, these instead of your typical three, four, four to six weeks for a lateral ankle sprain, you're talking at least two months for a high ankle sprain to get back and a period of non-weight bearing. So it's a much it's a much different injury.
SPEAKER_01Yeah, I agree with you. Um, like you said, and I I think you bring up some key factors there that I think are good teaching points for a lot of you know young practitioners is um you know, somebody that comes in with this kind of you know mechanism of injury consistent with a lateral ankle injury, but also has medial deltoid tenderness, um, you got to key on key in that this could be a more significant injury to cause this deltoid ligament uh pain. Um, you know, it's it's like we we're we're taught if somebody comes in and has a distal fibular fracture, whatever Weber classification may be, with this medial tenderness, you may consider that a functional bimallear fracture, or you may consider that more of an unstable fracture and probably more prone to make that patient non weight bearing because of that. Because that deltoid tenderness signifies possible, you know, syndismotic or instability within the ankle. Um and I think that's important to recognize is that anybody that comes in with deltoid ligament or medial ankle tenderness, you're probably going to be more prone to make them non-weight bearing and and immobilize more significantly.
SPEAKER_00Great point. Yeah. So that's where all my foot and ankle uh docs will say is you have, and we always ask you, all right, we have this distal fibular fracture. Do we keep them non-weight bearing or can we let them weight bearing? Can we let them weight bear, right? It's always medial tendinus, right? If they have tendanus over the medial deltoid, you gotta put them in a boot and non-weight bearing. It's an unstable injury. If if if it's a non-displaced distal fibular fracture and they have no deltoid tendonus, then then you can think of if they can, if they feel comfortable weight bearing, weight bear them.
SPEAKER_01Yeah, I agree with you completely. And that's the first question I ask when students present this to me. And that's the first question my doc asks me when I send them a picture of my you know distal fibular fracture that's maybe a Weber B or kind of right at that joint line, you know, concerning for surgery or not surgery, he'll say, Do they have medial tenderness? Um, and a lot of the times they'll get stress views, which we, you know, don't necessarily do in the urgent care setting, but um just to evaluate to see if there is a ligament or you know, syndizmotic injury that potentially would be more surgical than non-surgical. I think the other thing, you know, to talk about, like we discussed, is this proximal fibular tenderness as well. Um, I always start my ankle exams at that proximal fibular area because I can't count how many times you know I've seen or you know, I've had missed proximal fibular fractures, this mesonuve equivalent type injury to the ankle. And so for me, when I'm starting my foot and ankle exam, I always start first thing I palpate is that proximal fibular area and then I work my way down.
SPEAKER_00Yeah, no, yeah, no, I agree. Um of course x-rays you know for for for um for the bony injury too. Um you know, I in terms of cinismotic injuries and stress weight bearing stress views and stuff like that, I I guess I'm a more of a minimalist as well. Like if if I see medial clear space widening on initial x-ray, then then uh that's when I'll establish the diagnosis. If you know if there's no clear space widening I get on initial films, I guess I don't look for it. I guess I don't get weight bearing films or stress views. Even if they have medial medial deltoid tendanis, I I assume that it's stable enough where that they wouldn't need surgery. Um and I I don't know if you have a different point of view here, I'd be curious, but you know, I d I guess I don't chase it. If if the initial clear space is is equal, if there's no no significant clear space widening, then I I will just keep them diagnose them with a high ankle sprain and keep them non non-weight bearing and treat them like treat them like that for six weeks typically.
SPEAKER_01Yeah, and I think those kind of further imaging sometimes and a lot of the times are more um when they follow up, you know, because I I think there's two different examinations, you know, when somebody comes in and they have an immediate uh ankle injury, I think, you know, it's important to palpate the bony prominences, it's important to palpate the soft tissue structures. But, you know, is a tailor tilt test, is an anterior drawer test, is a, you know, um dorsiflexion, external rotation, kind of synasmodic test going to change necessarily what you're gonna do, or are you gonna get a false positive with that test because of the severity of the soft tissue injury the patient has? And sometimes I won't necessarily do all those tests on patients that come in with these acute injuries because I'm gonna get a lot of false positives just because of the severity of their injury. I think those are things that they can reassess when they come back after a couple weeks of allowing that soft tissue to rest. Um, and then they can get those stress views or weight-bearing views, or maybe do those, you know, more ligamentous exams to make sure that there's not going to be a concern for chronic instability.
SPEAKER_00Yeah, I know. And I guess the that initial, you know, when there's their initial evaluation, when they're so swollen, so painful, to do stress views, to do weight-bearing fill views is kind of torture. Um so you bring up a great point as maybe seeing them back a couple weeks later and and potentially if there's if there's uh concern doing doing those, but initially for sure, just relying on your your initial cinismotic view and AP view of the ankle to view, to see if there's any clear space widening.
SPEAKER_01Yeah, I think when patients come in with these acute injuries, um, I have a lot of PA students and young PAs that um get so excited about you know going through all of the you know the tests that they learn um to kind of diagnose what's going on. And I think a lot of these tests are get false positives on them because somebody's coming in with such an acute injury that's um it's hard to really use those tests to delineate if there is a concern for that type of structural injury. So um I think for me, at least with these initial acute traumas or injuries, it's all about palpation and the mechanism of injury to try to diagnose potentially what's going on. And then, like you said, you know, immobilizing and giving the soft tissue time to rest and maybe reassessing in a couple weeks and then maybe doing more of those ligamentous exams. You know, when we put somebody into a walking booth, oftentimes um they ask, How long do I have to wear this? And you had mentioned only wear it when you're up and ambulating. Um, I'll sometimes have them wear it consistently for the first three to five days just to kind of allow the soft tissue to rest, because I think sometimes, you know, the the heaviness of the sheets, um dogs, cats, brothers, sisters, you know, whatever it may be, can sometimes bump the ankle and cause it to be painful. So I'll occasionally tell them to wear it kind of, you know, all the time except removing it for some passive pain-free motion and some icing activities, just to allow that soft tissue to rest for three to five days to get them out of that acute phase. I've even seen some of our docs, and I don't know if you've seen this before, put them in cast initially just to let things calm down. Have you seen that before?
SPEAKER_00No, honestly, I I have not not my practice, and I never I never use casts um really for any type of stable ankle fractures as well. I just think um, you know, the patient's ability to shower without a cast and ice it without a cast is it's just so much better for them. Um in terms of compliance too. It's like, you know, the lower extremity cast is pretty brutal.
SPEAKER_01Yeah, I think it's kind of a a bit of an old school mentality, but um I remember this distinct story. We were the team docs for a local kind of Division III college, and the athletic trainer was a good friend of mine, and she sent one of the athletes in that had an ankle sprain, and we had a a retired orthopedic surgeon who was just doing clinic-based stuff, and the athlete came in and saw him, and he put him in a cast, and and goes back to see the athletic trainer in a cast, and she calls me up and goes, What the heck's going on here? Like, I can't do any of my modalities with this cast on. And uh, and I thought it was funny, and I I've seen it since then, but I I think some of the old school mentality will come through occasionally just to allow that complete soft tissue rest, maybe not trust the athlete to give it another you know the rest that it needs, and they'll put them in a cast just to mobilize. But it's a controversial topic whether that will create increased stiffness within the area, you know, so that immobilization.
SPEAKER_00That's what I've found is if you lock them in too long, say you lock them in for three or four weeks, now their heel is completely tight, and and now they're they're fighting, you know, heel heel tightness, gastroc atrophy. Some of them develop plantar fasciitis rate off because their plantar fascia is so tight from from sedentary uh being sedentary in the boot and and not stretching their heel. So there it can snowball, it can it can make an an ankle sprain, you know, develop complications at four to six weeks that you have another four to six weeks to fight through, you know?
SPEAKER_01Yeah, I think it's walking a fine balance between kind of mobilizing them long enough and preventing the patient from being their own worst enemy, which some of us kind of always are, um, as far as allowing that soft tissue to rest and heal, but not too long to create that soft tissue stiffness. Just one more thing to touch base on. Um, uh what is your so most patients that come in, especially young athletes, their first question to me is can I play through this or when can I go back and play on this? You know, if they have a sport or activity coming up, or, you know, let's say somebody's out road running training for a marathon and they're like, I have a marathon in three weeks, you know, what do you educate patients as far as that's concerned? It's always when can I get back to sports? When can I play on this? You know, when can I be active again?
SPEAKER_00That's a great question. Some people will punt out to physical therapy and just say, oh, physical therapy will do some pyrometric exercises with you and clear you. But I try to take it a step further. When I educate patients, I say, you know, listen, if you can start doing some single leg hops independently, some dup double leg hops, some running, cutting, first you have to have pain-free range of motion. If you have pain-free range of motion, start to jog. If you have, if you don't have any pain after a week of jogging, you know, that's essentially to me rules out bone bruise or some of the other, um, some of the other more serious injuries, perineal tendon tears, osteochondrial lesions. So what if you have pain-free running after a week, start doing some running, cutting, single leg hops, double leg hops. And if you can, if you can do that pain-free, then I would say you're ready for starting to practice in game action. And you know, I think I think most therapists are on board with that. That's that would be my conversation.
SPEAKER_01Yeah, like you said, I think you know the therapists obviously have the benefit of maybe seeing them more often a couple times a week and watching the progression of their soft tissue swelling reduce and their ability to mobilize, improve. Um, but I agree with you. I, you know, I think you know, pain-free range of motion and then kind of near full strength back is is kind of my you know, components of when I can I start back to sports activities. And I think it's obviously all individualized based upon the patients, their expectations. You know, if it's a senior football lineman and he's like, hey, I really want to play in this game, and you know, he doesn't have that bad of an injury, you know, you can tape it up and let him go play and just deal with the soft tissue concerns afterwards. So there is definitely this individualization based upon the expectations for each patient.
SPEAKER_00And I tell patients they should, if you have a significant enough ankle sprain, you should wear the brace for a minimum of six months in sports. Because I I've you see it all the time. Patients come back three, four months and they re-roll it without any any type of stabilizing brace. You I feel like you you need that extra support, that extra confidence for a minimum four to six months after an ankle sprain.
SPEAKER_01Yeah. Yeah, I agree with you. Um, I agree with you. And uh, you know, I always have fun conversations with my physiotherapical therapist regarding this because they're always like, hey, let's get them out of the bracing so they're not relying on these external devices for stabilization. And uh, you know, I I I have a similar thought process to you, is you know, I think it's important to wear that to prevent reinjury. So there definitely is some back and forth for that, and and again, I think it's dependent upon the patient and the progression of symptoms.
SPEAKER_00Yeah, no, I uh the the figure of eight brace typically doesn't restrict motion, it doesn't restrict uh a f full you know, full strength, so it it's just an extra layer of protection, you know, so that they don't roll it again and they regain their confidence over that four to six month period.
SPEAKER_01Well, perfect. Well, I appreciate your time. Anything else yeah, you know, you can think about when we were kind of discussing this topic?
SPEAKER_00Uh no, I think we caught a a lot of it. I guess one last thing I would mention is because this you see this a lot too, is the these avulsion type fractures. You see it on the lateral distal fibula, you see it on the uh dorsal talus and dorsal navicular, and patients will come back and they'll say, you know, I you know, they said I had an ankle fracture. And I and I talked to them about basically that's more of a soft tissue injury, right? So the the ligament complex attaches to the bone and it may pull a sleeve of bone off, but to me that represents more of an ankle injury. So that's a stable injury, something you can weight bear through, something we treat with the same timetable as an ankle sprain. You know, those distal fibulas, if it's just a slight little uh avulsion type fracture, it it to me it carries that four to six week um type of protocol with as an ankle sprain would. So that's I think that's another thing worth mentioning to your listeners, is uh, you know, how to treat those avulsion injuries.
SPEAKER_01Yeah, and I would agree with you completely on that. I I think how many times have we been sent, you know, patients that come in from an outpatient, you know, facility and they say, Hey, they told me I have a an ankle fracture, and you kind of look at their x-rays and it's one of these avulsion injuries, and you kind of have to educate the patient that it's more of a soft tissue ligamentous injury than it is truly an ankle fracture injury and and will still heal um in more of a predictable fashion, as you said. So I definitely think that's an important point uh point. Yeah. So regarding um, you know, if anybody's listening and they want to kind of access, let's say, the Joppa journal and or the um, you know, your website regarding um your CME, uh, how would they access that?
SPEAKER_00Yeah, so you could simply Google JOPA, Journal of Orthopedics for Physician Assistance. Um, you can go on our site, our contact information, um, our uh instructions for authors are on the website. We are always looking for PAs to write, uh whether it be case studies or literature reviews or even to review. Um peer review some of the articles that are submitted. And it's really kind of an easy process. I just send you maybe an article or two every six months. Um, and I think a lot of PAs find that rewarding and um and stimulating. Um so yeah, no, they can visit the website and definitely get involved. We're always looking for PAs to help out.
SPEAKER_01Awesome. And then I I think you know your website, um, CME4PACs, is a good resource to get some category one CMEs if necessary for you know a nice affordable price. And you know, if somebody's studying for you know the test, um, it does a good review as far as, like you said, those questions that you may see on the test um and kind of how to study and or practice those. So I think that's helpful as well.
SPEAKER_00Yeah, no, the the CME for PA sites uh PAC site is a great resource. It's uh we we have several hundred self-assessment questions broken down in different subspecialties, orthopedic subspecialties, um, all written by PAs, all case studies, most of them have images, real cases that we're seeing in clinic. Um, so it's just a great review, general orthopedic review for someone that you know, especially if you if you you work in spine and and you want to brush up on some foot and ankle cases or uh any any type of uh subspecialty if you if you get you know pinholed in in sort of uh you're just a you just work in arthroplasty, right? I think all PAs should have some sort of general orthopedic knowledge. Um, because we we do have the tendency to switch uh switch subspecialties throughout our career. Um, you know, you could you could be a joint PA, then you know, a great trauma job opens up. Uh so it's it's CME for PAC does a great job of keeping PAs uh familiar with all areas, all orthopedic subspecialties.
SPEAKER_01Excellent. Well, I appreciate your time today. Thanks for uh coming on and discussing ankle injuries. Um hopefully uh we can get you on in the future and maybe discuss another topic.
SPEAKER_00All right, thanks, Chuck, and thanks thanks for doing this. I mean, to to really uh educate PAs in our profession, I feel like it elevates our profession, gets PAs motivated to learn by listening to the podcast. So great work and looking forward to working with you again.
SPEAKER_01All right, sounds good. I appreciate it. Have a good night. Well, thank you again, everybody, for listening to the podcast. I hope you enjoyed the episode. I think this was a great discussion regarding ankle injuries um and how to treat them, both acute and chronic. Uh please again follow us on social media, both uh Instagram and Facebook. Uh please uh, you know, subscribe to the YouTube channel uh to watch if any x rays or videos are associated with these podcasts, and uh please uh feel free to comment regarding any extra episodes or discussions you would like to uh see covered. Thank you again.