43. Chronic Ankle Instability (CAI) w/ Dr. Jay Hertel

Welcome back to episode 43 of the E3 Rehab podcast where we bring you the world's experts in rehabilitation, performance, and pain. Our mission is simple, empowerment through evidence-based education. I'm Mark Sertica and I'll be joined by my silent co-host Sam Spinelli. In this episode, we sat down with Dr. J. Hurtle to discuss chronic ankle instability. We hope you enjoy. Do you mind introducing yourself to the listeners? Sure. Hi, I'm J. Hurtle. I'm a faculty member in the department of kinesiology at the University of Virginia. So my clinical background is in athletic training and I also have a PhD in kinesiology and I do a lot of research, lower extremity injuries, especially ankle sprains and ankle instability. Perfect. And that's what we have you on today. You know, we really want to discuss a paper that you co-authored in 2019 titled an updated model of chronic ankle instability. Can you start by defining chronic ankle instability for us? Sure. So chronic ankle instability is really a condition that exists in patients after they've had an initial ankle sprain and they have ongoing instability, which can either be perceived instability. They feel like their ankle is going to give way oftentimes or it actually does. They actually have times where their ankle inverts too much. They have ongoing symptoms that oftentimes include pain, swelling. They have diminished function. And I think it's also important to put a definition on that the chronic side. So what we typically do is say that someone has chronic ankle instability when they have that instability symptoms and diminished function at least 12 months after their initial sprain so that people can certainly have that group of symptoms and reduced function as they're recovering from the initial sprain, but it's still going on more than a year after that first sprain. And especially if they're having recurrent ankle sprains, I think that's where we classify that as having chronic ankle instability. Gotcha. And I think in your paper and most of the papers that I've read, it's usually in reference to like after having a lateral ankle sprain. Can you fall underneath the umbrella of chronic ankle instability if you've had a high ankle sprain or like a medial ankle sprain or is it only a lateral ankle sprain? Yeah. That's a great question. I think we usually view it as having lateral involvement and there certainly are times when you have a lateral ankle sprain and can function with synismosis injury. The medial sprains and the isolated high sprains or maybe the combined medial high, those are usually kind of classified differently as kind of being their own thing. Fair. Okay. So in this updated model, you know it has eight primary components and we already touched on that first one. So the primary tissue injury that precedes the chronic ankle instability being that lateral ankle sprain. So why don't we talk about the next three components and these relate to the pathomechanical, the sensory perceptual and motor behavioral impairment. So can you tell us about the specific impairments that fall within these categories and how they present in individuals with CAI? Sure. Absolutely. And I think you know, one thing is, I use my point out is that, you know, when kind of putting this model together really was trying to look at the different impairments that have been reported in the literature and also through clinical practice and noting, you know, what are things that have, you know, kind of similar groupings to that. And, you know, you mentioned the three, the pathomechanical sensory perceptual and motor behavioral and kind of the groupings. And within each of those, we can see specific impairments. And I think it's important to recognize that, you know, this model doesn't, isn't meant to imply that every patient who incurs a lateral ankle sprain or every patient who has chronic ankle instability has all of these impairments. But when you look at it as collectively as a group, individuals either after ankle sprain or who have chronic ankle disability are more likely to have these impairments than people who haven't had ankle sprain or a history of ankle injuries. So I think that's just an important recognize. But, you know, when we look at the pathomechanical impairments first, you know, the one thing that everything's right away is laxity, right? That you injure those lateral ligaments and you've got structural damage to them. So now you've got laxity, especially in terms of anterior drawer and hyper inversion. But then you know, also making sure you're looking for potential laxity that might be like at the subtaler joint, you know, isolated to there as well. At the same time as we have, you know, the potential for too much motion in certain planes, we also have the potential for reduced motion in terms of like arthrokinematic restrictions. So, and we oftentimes will see, you know, for example, reduced dorsiflexion motion after ankle sprain. And that can be in conjunction with reduced post-heared tailor glide on the tibia. So at, you know, at the same time that we've got that laxity in certain planes, we can also get the joint capsule tightening up in other planes that we look at. And also looking at, you know, the motion at adjacent joints too in terms of the superior and inferior tibia-fibular joints and the subtaler joint as well. So certainly the motion aspect is there. And then I think you're also looking at the potential for secondary tissue injuries. And I think this especially comes in to those individuals who have recurrent sprains. And that, you know, after those lateral ligaments have kind of, you know, are torn and frayed. What's the secondary damage, you know, whether that be osteocontroletions on the tailors and the tibia, whether that be, you know, soft tissues like within the sinus tart side, they get irritated, synovial irritations and things like that. So I think all of those things kind of we've grouped its pathometanical as being, you know, changes, you know, directly within or around the joint. Then when you go on to the other two categories, the sensory perceptual and the motor behavioral, I think this is where you start to see, well, what else is going on, you know, beyond the structural? On the sensory perceptual side, you know, I think, you know, pain is obviously a big indicator there and I think the location of pain is really important that, you know, it obviously makes sense if you have a lateral ankle ligament injury that you're going to have pain on the lateral side and in the sinus tart side. But then, you know, what about those patients that also like, let's say, have medial joint line pain at the same time, or they have pain going up into this endosmosis that those have to be clues to the clinician that, okay, there's something more happening here. I think we also, then, you know, kind of group in the proprioception and the somatosensation that notion of the perceived instability, right, you know, the talk about people like who trip over the flowers and the rug, right, like there's a perfectly flat surface and they're, you know, rolling their ankle on that and that notion of, you know, sensory changes happening. And then, I think, you know, also getting into, you know, that that perception as well thinking about, you know, kinesiophobia or fear of avoidance, you know, not wanting to move or being reluctant to move or, you know, to walk on an even ground or something like that. And then also lower self-reported function and lower, you know, self-reported health-related quality of life. So kind of all those things that fall on the sensory side of the sensory motor, we've grouped together. And then the third component that we talk about in terms of impairments is, is that motor behavioral side. So what's actually happened on the movement, the movement output side of things. So, you know, obviously we think about things like muscle weakness, right, that we know that after ligaments get injured, that there's reflexive inhibition of the muscles around there. So it's common to see, you know, eversion weakness, torts of flexion weakness and things like that. And then, you know, also then getting into delayed or diminished reflex responses so that kind of stretch reflexes, the ankles turning really quickly into inversion. Do we have a delayed or diminished response of the evert or musculature balance deficits, obviously a big part there as well. And then I think you can get into the altered movement patterns. You know, one of the things that we've done a lot of work with in my lab is looking at movement mechanics and finding that people with chronic ankle instability tend to be more inverted and more planar flexed on the steps where they don't spray their ankle, right. So, but that ankle, especially in the swing phase, is kind of in that vulnerable position that if it hits the ground, inverted and planar flexed, it's got such a higher likelihood to roll over and cause an inversion instability event. And then I think the last thing on the motor behavioral side is kind of gets into the behavior is the notion that individuals who have chronic ankle instability are less physically active than people who don't. And Trisha Hubbard Turner down at University of North Carolina, Charlotte did a really nice study where she took college students who had chronic ankle instability and compared them to college students without a history of ankle spray and found that those with the chronic ankle instability were taking about 2,000 steps less per day, just in their regular activities at college. And you think about that happening to someone in their late teens or early 20s, what are the long-term consequences of that in terms of physical activity and other health-related factors that go with that? Yeah, I found that to be a really interesting study. I pulled it out from after reading your paper and I read through it and just seeing that difference and step counts and kind of their levels of moderate to vigorous physical activity was surprising and maybe shows just how impactful this condition can be. And I think you set the framework really nicely for later when we talk about some of the interventions that we can go through because there is this really big pool of impairments that we can choose from. And in the paper as well, you do a nice job of giving a few cases to demonstrate that not every person is going to be treated the same, we're going to try to use and individualize the approach. That's why I like this paper a lot is because it goes through all these things but it gives a nice framework for the clinician as well. So moving on to components 5 and 6. So these refer to the patient's personal and environmental factors. So what needs to be considered here? So this kind of comes from the ICF model, the International Classification of Functioning model, biopsychosocial theory where you have to also look beyond the individual in terms of their ankle and their organism and what else is happening there. So on the personal factors side of things, obviously demographics, teenagers are remarkable at their ability to heal from musculoskeletal injuries a lot quicker than people are aged kind. And so we have to be considering their demographics, their prior medical history as well, are there any comorbidities happening, things like that? Physical attributes that might come in, when we start to think about individuals, let's say with high body mass or they've got a real cave ovarus foot type or something like that. They're bringing it with them in a way that we have to consider that when we're looking at how they're going to respond to their ankle injury. And I think also thinking about what their psychological profile looks like in terms of how they deal with injury, whether that be self efficacy or tendency to resilience and things like that. So as rehabilitation clinician, we can't ignore that side of the equation and you say, oh, well, this ligament holds these bones together, we just need to figure out how we can hold those two bones together. We've got to put the whole person there. And also then realize that that person is interacting with an environment that's going to be individual and that can include things like, you know, what are their physical activity and sport demands, whether that be just the transportation, occupational types of things that cause them to be on their feet all day or, you know, the differences between dealing with, you know, a swimmer versus a terrestrial athlete who's, you know, doing a lot of weight bearing type of stuff. Also, you know, what's their support network, you know, in terms of how, what do they have around them, terms of being able to help them through this, you know, whether they're, you know, an 18 year old first semester at college, I don't have my family around anymore and I live out the fourth floor of a dorm or something like that versus, oh, you know, somebody who's got more, you know, support around them, you know, and then also thinking about what their access to healthcare clinicians is and, you know, from an athletic training perspective, you know, oftentimes thinking about, you know, high school or college or professional athletes and thinking, well, they've got athletic training in sports medicine clinicians that they can see on an almost daily basis, right? And that can be very different than somebody, you know, who might be, you know, accessing the health system, you know, through the emergency department for their initial injury and then, you know, what happens to them after that? So, so I think it's used to the personal factors and the environmental factors are just recognizing that we've got to take, you know, each individual's, you know, history, demographics and circumstances into the account. Absolutely. And I think that's important as well, just because we do see that this affects such a wide range of individuals and such a wide, like age range. So yeah, just not using the same shot going to approach for everybody. And so I guess that kind of ties in with the last two, which is the component interactions and the spectrum of clinical outcomes. So can you tell us about those? So the component interactions are really thinking about, like, how do the different groupings of impairments tie together? So when you look at the path of mechanical, the sensory perceptual and the motor behavioral impairments, you know, for the most part, the path of mechanical, I think we would agree, kind of drive the sensory motor impairments. But then within the sensory and the motor side of things, how is an individual patient's central nervous system self-organizing itself to deal with the impairments that are present? So you know, in this case, we go with the model, you know, towards the dynamical systems, theory, motor control, you know, kind of thinking about that. If you've got constraints on a physiological system, it's going to figure out some ways around that, right? You know, it's kind of like the three-legged dog, right? Like, how does it figure out? I'll walk. Well, in this case, it's not as severe as, you know, missing a limb. But it's like, okay, I've got a ankle that is lax, that maybe has reduced range of motion. That's, you know, that's a muscle weakness around it and maybe some sensory deficits around it. Say, well, how does the sensory motor system adapt to that? And, you know, one of the things that we look at is perception action cycles. So that, you know, we usually think about that in terms of like reflex responses. But there's so much more interaction that takes place in terms of, you know, how is the central nervous system dealing with the sensory information that's coming in, you know, not just from a, a fair and peripheral nervous system side, but vision and vestibular and all of those types of things as well. And how is that affecting the motor output that goes out to kind of drive muscle contraction but also like muscle inhibition? And, you know, we've taken concept from, from Melzac, who's, you know, most famous for the gain control theory pain, but he actually later in his career kind of disavowed that and talked more about what he called neurosignature and this aspect of the neurosignature basically being like the real intricate ways in which the sensory motor system, you know, talks to each other if you will through neural signals. And I think what we realize with, you know, not just ankle instability, but I think any chronic joint pathology is that neurosignature looks a lot different after injury and especially after prolonged injury than it did in a healthy individual. So when we kind of look at, well, what are the goals of rehabilitation? Sure, we've got goals of like increasing strength and increasing range of motion and balance and things like that. And we've also really got to look at how do we affect that neural signature, you know, way that kind of gets those perception action cycles back, if not normal, at least towards more normal healthy organisms. Yeah, you know, and then, you know, the last thing that we did on the model, so this is down at the bottom of the model after you've got, you know, all that other stuff feeding into it kind of within the person or around the person. And it's like, well, what is their therapeutic or what is their clinical outcome? And recognizing that it's a spectrum, right? So, you know, I think the best thing we can hope for in somebody who incurs a lateral ankle screen is that they become what we consider a coper. That is that they recovered from that ankle sprain and they cope with it and it has not diminished their physical activity, their function, their health related quality of life. That's on the good end of the spectrum. On the bad end, right, is that notion of chronic ankle instability and recurrent ankle sprains. And, you know, they're having that increased symptoms, reduced function, reduced quality of life. And that there's a spectrum in between there and that, you know, I think ideally what we want to be able to do through our clinical interventions is to take somebody who maybe is having a poor outcome right now on the chronic ankle instability end of the spectrum and push them towards that coper side, you know, recognizing that we can improve their symptoms and their function and what goes along with that. So let's move toward that, actually. And so if somebody comes into you, you know, your clinic and has chronic ankle instability or you suspect that they have chronic ankle instability, what assessments are you prioritizing for that person? Sure. Absolutely. I think, obviously, you have to look at their amount of lactity and, you know, on some level figure out, like, you know, is this something that that is really a surgical case or not? I think that, you know, we need to acknowledge that. But then, you know, after that, it's really, you know, kind of targeting what impairments this person really have and tying that to like, you know, what are their goals as well. And I think, you know, on the impairment side, it's doing a thorough physical exam and, you know, making sure that, you know, you're looking beyond just the damaged ligaments. You know, is there anything happening at the adjacent joints? But, you know, then on the specific impairments, you know, obviously, strength, balance, what is their functional movement look like? You know, right? Proper reception, something that is really hard to actually measure clinically. So you kind of lean more towards, well, what does their motor system look like in terms of how they're able to do functional movements? But I do think, on the perceptual side, it is really important to assess things like kinesia phobia and health-related quality of life. And, you know, their self-reported function, I mean, I think using patient-reported outcomes really does help that. And, you know, you know, are you going to ask, you know, all 20-some questions on the foot and ankle ability measure of scales, you know, are you going to do that as part of your clinical exam? No, you're not. So I think that's the advantage of using some of the survey instruments. But then I think once you've done that, you can see, well, where do they have the largest deficits or the largest impairments? And that's what you can use to help develop your plan of care and figure out, well, what really needs to be emphasized here. And for some things like, you know, some research on diminished planar sensation, is that something that you think we should assess, even though, like, how much are we going to be changing that, whereas, you know, the perennial reaction time, you know, maybe we can't assess that clinically, but that is something that maybe we are addressing with some of these, like, you know, plyometric balance and proprioceptive type exercises. Sure. Yeah. I think the planar tutaneous function is a great example. I mean, that's really been shown in the research literature, but I certainly don't know many clinicians that are doing that on a regular basis. I mean, maybe that's something you do in patients of a certain demographic or medical history, you know, in terms of if they've got some history peripheral neuropathy or something like that. But, but no, I think that you do, you know, choose to focus on those things that make the most sense, but like I can tell you on the, like, on the planar tutaneous side, you know, there is some research out there talking about like using planar massage before therapeutic exercise as a way of, you know, kind of almost priming the pump kind of thing of saying, like, okay, let's kind of activate these sensory receptors and now get them doing some weightbearing exercise after that. You know, I do think that that is something to consider. Okay. And then in terms of interventions, once again, our assessments are going to drive the intervention so that we're not just, once again, you know, using that shotgun approach. Right. And in the literature, you know, there's different things that we see, like, we see the proximal hip and knee strengthening, you know, maybe like the banded four way or the specific ankle strengthening as well as what I actually really like in this literature and maybe, you know, the athletic trainers do a better job of it is that that 2008, maybe it's, McKeein, McKeein, that you're an author on that paper, it's replicated over and over and over again, which is really nice because we can see, you know, how that compares to other interventions. So yeah, in your mind, are we just using those types of interventions based on, you know, what we find in the assessment? Yeah. You know, I absolutely despise, you know, the protocol that says, you know, here's your list of exercises and three sets of 10, three sets of 12, whatever, without any thought of, like, well, how does that actually relate to this specific patient? And thinking like, what's the starting point for that specific patient, right? Because you've got a limited number of visits with, with these patients and you've really got to think about the day that we start therapeutic exercise, we want to make sure that they're being challenged, right? So that I think it's really important to, you know, for example, let's say with balanced exercises is work them up through a progression to the point where, okay, they're starting to have difficulty with that. If they can stand on a flat firm surface with their eyes open and they can stand there for 30 seconds, why would we do three sets of 10 of that particular exercise when we know we could challenge them by either affecting their vision or putting them on an unstable surface or something like that. Make sure that you're starting them at a point that's challenging so that as you progress from there, they're going to continue better as opposed to, we'll start everybody at the same spot. And you get a patient that you might do two weeks beforehand before they really start to get challenged. So I think that's really important. And I think on the strength side, I'm really a big fan of manual resistance exercises when you've got the ability to work one-on-one with a patient. I mean, obviously when they've got home exercise programs, I think you need to go to the bands and the resistance bands and things like that. But I think doing manual resistance exercise really allows you to challenge the patient in a way that that's going to probably lead to better strength gains and just say, you know, you've got this band and, you know, we'll change the strength of the band in a couple weeks or something like that. Gotcha. And a question that, so we actually just had dusty grooms on. And we were talking to him about, you know, the balance training that he does and obviously he looks at a lot of it after, you know, ACL injury and reconstruction. Can you talk to us about the rationale for unstable surfaces as well as, you know, maybe eyes closed because I know that there's some pushback in terms of unstable surfaces for force production and power, but how do these things relate to, you know, the impairments that we see in chronic ankle instability or just the condition in general? Sure. You know, I think that if you think about, you know, balance is obviously having multiple sensory inputs that are necessary to control. So you've got your peripheral somatosensation, you know, in this case, thinking about what's happening around the ankle, you've got vision, you've got the vestibular system. And thinking about like, okay, well, if we take away vision, let's say do eyes closed, balance exercises, then makes sense that if you impose that constraint, it's going to put more reliance on the somatosensory information and on the vestibular system. So if we know that we've got this peripheral somatosensory problem, I think that kind of makes sense as a way to emphasize some things there. If you look at the unstable surfaces, I think what that really does is, you know, it's going to give the patient, you know, a lot of perturbations to deal with. More perturbations they do if you're just doing your balance exercises on a flat firm surface, you know, and if you think about it, I mean, use my little, right, tailless inside the mortise right here. And if you just think about that going back and forth, right, every time that's happening, you're getting reflex reactions to do that. So, you know, I do think there's some advantages there. You know, I see some things of, you know, people like doing jumping exercises onto unstable, you know, foam and stuff like that. I'm like, I'm not sure that, you know, is the safest thing in the world, but I do think in terms of, you know, initial, they're kind of medium intensity balance exercises that works well. Yeah. I'm interested because he was, you know, kind of walking us through his rationale as well. And he was interested to hear your thoughts, but he was also thinking, you know, that it might be helpful for addressing some of these prediction errors that athletes had. So, you know, he was talking about, well, how come these really elite athletes who are super coordinated can do a movement, you know, thousands and thousands of times. But then that one time, they have some kind of, you know, motor coordination prediction error and end up having this ACL injury. So he was kind of looking at it from that vantage point as well of, okay, can we change what they predict is going to happen? And we're just challenging that a little bit more. Yeah. I think that gets into, you know, probably movement variability quite a bit and, you know, kind of, you know, I think about it in terms of that, you kind of have an envelope of acceptable variability or functional variability, if you will, you know, every time that you take a step, the angles that all of your joints are at initial contact aren't exactly the same, right? There's a range that that someone can successfully, you know, navigate through a step or a landing or anything like that. And I think what we realize is that if we get too little variability, right, every step's exactly the same, then you probably can't respond to something that that's out of that, that range. And at the same point, if you get too much variability, right, it's really uncoordinated and that's going to have problems as well. And I think that, you know, through the rehabilitation process, one of the things we should be thinking about is getting the patient to function within that envelope of functional variability. So that they are able to respond to, you know, some of the usual circumstances and things like that. But, you know, at the ankle side, right, I mean, it's tough when you look at, you know, sports like basketball or whatever, you know, someone comes down from a rebound and lands on some of the dialysis foot, like, was that a preventable injury? I don't think they're all preventable, right? Some of them are just, you know, circumstances that that's what the physics dictates. That's the direction the ankles going if you land on that much of an uneven surface. Right. And I forgot what the author in the year, but a large proportion of ankle sprains are from contact injuries, right? So that makes it, makes it challenging. Yeah. Yeah, especially the first ones, you know, the recurrence range, I think we start to see happen more of it to be like the non-contact injuries and things like that, but, but, yeah, definitely into a lot of sports that contact injuries are frequent. And so if somebody, like, let's say I go out and I roll my ankle off the curb today, are there certain things that, you know, collision should be doing to reduce the likelihood of someone developing chronic ankle instability? Yeah. You know, so obviously the, you know, the initial injury care is important, you know, and, you know, dealing with the pain and the swelling and protecting the joint. But, you know, I think that the single biggest thing is how long does therapeutic exercise last? And, you know, one of the challenges with ankle sprains is that, you know, in, in relatively young and otherwise healthy people, the recovery time to get back to function is faster than the recovery time of the injured tissues, right? And I think that, you know, presents a parent exercise, like, oh, you know, I'm back to, you know, full-go within, let's say, seven to 14 days. But if you look at the studies of ankle sprain rehabilitation, they really point to four to eight weeks is where of therapeutic exercise is where you see the sustained benefit in terms of preventing recurrent ankle sprains. And that's a tough thing in crime, where you've got those athletes that are staying, hey, I'm back unrestricted to practice, but you want me to still come in and do these exercises for another several weeks. That takes a lot of convincing, and I think that's a role where the, you know, the clinician may become more of the motivator, and, you know, I think, you know, not to be giving it, making it actually paranoid about, oh, you're going to get chronic ankle spraility if you don't do this. But laying the facts out there, saying, like, here's what we know about reducing the risk of recurrence strain. And I think one of the big things that, that I take, that there's a study by effort for paying in that back in the early 2000, it was done with a large number of volleyball players. But if you can get athletes, athletes who suffered an ankle sprain through the first six months without a recurrent sprain, their risk of recurrence strain goes down substantially. And if you can get them through a year after that first ankle sprain without a recurrent sprain, they're actually back to the baseline injury risk in terms of their risk of suffering in ankle sprain. So that's where I used to look at that. Those prevention components, I think, are really important at first six months to 12 months after injury. That's really interesting. And any benefit of tape, braces, things like that? Yeah. You know, both taping and bracing definitely reduced the risk of, especially recurrence strain. And I think that's really what we're talking about here. So I'm a big proponent of taping or bracing athletes for that first six months or 12 months after. Initially injury. Obviously, there's sports where that's easier to do than others. Sports like volleyball, that's almost like part of the game. But it's more like soccer trying to put a soccer player into an ankle brace is not an easy conversation, but maybe that's where taping something that is more low profile. It isn't going to take up as much space as you can. Right. And in terms of that primary injury, do you think that there are any exercises that more athlete should be including in their dynamic warmup that might reduce their risk of that first time ankle sprain? Yeah. And I think this goes a lot, you know, with similar like the ACL prevention programs that, you know, emphasizing balance, emphasizing landing strategies. I think those are important and I think that, you know, those types of dynamic warmup programs that address the whole lower extremity. I don't know that there's things that specifically need to be done just for ankle. So correct me if I'm wrong, the incidents of ankle sprains have they kind of decreased over time more recently or am I incorrect in saying that? Yeah. I'm not sure that that's true, but I'm also like, I'm not, I don't have a graph in my head right now that you can say it one way or the other. I do know that that the NCAA has just come out with a monster data dump from five years of data across 23 sports that just got published in the July issue, the general athletic training is going to be really interesting to go through and look at especially those sports that are most associated with ankle sprains, you're fielded in court sports and see what the ankle sprain numbers look like over time. Okay, and is there anything else that you want the listeners to know as it relates to, you know, either ankle sprains or chronic ankle instability? Yeah, you know, one thing I do need to acknowledge my co-author Reveigh Corbett on this paper so she was a PhD student of mine and I think it's important that we recognize it as her contributions to that. I think conversations with patients and parents and coaches about ankle sprains around that kind of analogy that, oh, it's just that ankle sprain is walking off kind of thing. I think it's important to use what we know about the percentage of patients who have recurrence brains or the percentage of patients that, you know, about 40% of first time ankle sprains will develop chronic ankle sleep. I think it's important to have those conversations to say, but here's what we can do to not only help you get back to sport and exercise in a quick and safe manner, but also what can we do that might take a little bit longer, but, you know, ultimately give you better functioning in the long run. And I think that it's important used to have that in your toolbox that there's probably some convincing that that needs to be done there at least presenting that information. I think, you know, a big emphasis about what we talked about that notion of that matching the patient's plan of care to what their impairments and deficits actually look like and, you know, to make sure that we're getting patient-centered care and not just saying, oh, you know, here's the protocol and it's going to be exactly the same for everybody. It was a great piece of advice. I know when I saw that 40% statistic, I was a little bit surprised because, like you said, you do hear it say, oh, it's just an ankle sprain, walk it off, but obviously you can have such, you know, big consequences on somebody's quality of life and function, even to the point where a college student is walking significantly less steps per day. So yeah, I think that's a really good point. Yeah, absolutely, and you know, also, you know, just thinking about, you know, and the business, I think, is true, but any musculoskeletal injury, and it's like, you know, there are teenagers and 20-somethings thinking about osteoarthritis, right? But, you know, just, you know, thinking about like that lifelong physical activity aspect and things like that is important. Great. So, Jay, if, you know, the listeners want to learn more about you or from you, where should they go? I'm on Twitter, I only do like academic Twitter, so you're not going to hear my thoughts on Aaron Rogers or Simone Biles or something like that right now, but you're getting here, you know, what I have to say about sports medicine research and things like that. So my Twitter handles @j_urtle, so jay_hbrtl, that's probably the best way to follow me. I do work at the University of Virginia, so I just need to be found on their website as well. Awesome. Jay, thank you so much for coming on today. Great. Well, thanks so much for, for this conversation, I really enjoyed it. Thank you so much for listening, please, if you enjoyed the episode, consider leaving us a five-star review, and thanks to Dr. Hurtle for joining us today. I'll be sure to link the paper discussed in the show notes. This episode was produced by Matt Hunter, also be sure to check out our website at e3rehab.com Peace.