148. How to assess ankle sprains & start rehab with Zoe Russell

You're listening to the Physio Edge Podcast, episode 148 with David Pope. Hey you and welcome to the Physio Edge Podcast. I'm your host David Pope and Australian sports and musculoskeletal physio. If you're a physiotherapist, physical therapist or health professional, when you've got a patient in front of you, there's a lot to know. You want to know exactly what's going on with them, what's causing their pain and how to treat it. And on the Physio Edge Podcast, we simplify that so you know exactly what to do and you can get great results with your patients. I talk to the leaders in musculoskeletal and sports injuries and get their experience, expertise and knowledge to give you the strategies, tactics and techniques that you can use with your patients to get those great results that you want. And on today's podcast, we're talking all about ankle sprains. When your patient comes in with an ankle sprain, how do you identify which structures are injured, which assessment tests that you need to perform and what's the best rehab for your patients? Do they need strapping? Do they need bracing? Do they need rehab? Or do they need imaging? We're going to dive into all out of today's podcast where we're talking with Zoe Russell. Zoe's a specialist sports physiotherapist based in Queensland, Australia. She's currently working with the Queensland Academy of Sport, QIS and she's also a senior educator and presenter here at Clinical Edge. And we've got a couple of great resources to go along with today's podcast and the first one is your Clinical Edge free trial membership. Zoe's a part of our Clinical Edge Education and Presentation team where we give you practical presentations that guide you through how to treat your patients. We give you video demonstrations of techniques, assessment and treatment techniques and we take you through how to help your patients make sense of their pain. If you've got a patient that comes in with acute pain or chronic pain, how do you help them understand and make sense of their pain without making it sound like it's all in their head? Well, we break it down, make those complex presentations really simple so you know exactly what to do. We've also got training that'll help you with your low back pain patients, with your neck pain, with your shoulder, elbow, whatever body part you're interested. We've got lots of great training on that. So grab your free trial Clinical Edge membership and now let's dive into this podcast with Zoe Russell. Welcome to the podcast Zoe. Hey Dave, thanks for having me today. And it's great to have you on here. You've got a lot of experience. You're currently working with Queensland Academy of Sport. You've treated lots of athletes in your time in private practice and all over the shop. So we're going to talk about ankle sprains and why ankle sprains are a problem and what are the sort of regular issues that therapists face when they're treating ankle sprains? I think a big problem with ankle sprains is that because most of us will have one at some stage in our lives, everyone thinks because they're so common that they're the type of injury that they don't actually need good assessment and management to get better. And I think this lack of awareness. I think the stats sort of tell us that 70% of people will say they've had an ankle sprain in their life, but less than about 44% of them will actually ever get treatment. And so because they think it's just a simple injury and they don't need management, I think there's a lot of people that lack the insight and awareness that first of all, this ankle injury can lead to other serious other injuries and issues, but also they're not aware of the sort of impairments that they might be lacking, whether that's a strength issue or a range of motion issue. And I think we're starting to see more and more coming out with the injuries that occur as a subsequent to that ankle injury, but we're also seeing a lot more research coming out on post-traumatic osteoarthritis of the ankle. And I think that stems back to that lack of awareness at the initial instance. So post-traumatic OAs have been a problem after injuries? Any other sort of sequelae that are common or that can result if they're not treated properly? Yeah, so obviously you can get recurrent ankle injuries. And then a progression from that is the people that develop a chronic ankle instability. So I think we consider ACL injuries as quite a serious instability, but we don't consider ankle instability in the same way. And certainly ankle instability has had well that chronic ankle instability where someone's repeatedly rolling their ankle and consistently loading the joint surfaces and not I guess rehabilitating those impairments. That leads to a you know that OAA, it can lead to obviously other injury risks, particularly around the lower limbs. So you know it can increase your ACL injury risk, an ankle injury and then obviously that extends up the kinetic chain. And I think that that's sort of of those things that are overlooked. I saw a friend of mine who was a professional basketballer and he's in his early 40s and he came in and said what can you do to help me with my ankle? And sort of said I look I'm actually going to get you some x-rays and I'm going to send you off to see a foot and ankle surgeon and he's just recently had a fusion at age 42 and that's the long-term sequelae of that repeated just "oh roll my ankle, all the ligaments are stretched, nothing I can do." And I think he's had a few arthroscopic debridements in that history as well but just that all it just is what it is and we're not going to restore those impairments has been a big problem for him. Yeah, that's not the sort of outcome that you're looking for especially anyone that's pretty active like a pro basketball player. I'm sure they're looking to stay pretty active even run around and play whether it's just having some fun basketball or any other stuff. Absolutely. Tell us a little bit about what's changed recently ago. We're looking at the latest evidence that's come out. What are some of the things that have changed recently with regas ankle sprains? Clinically we're seeing a lot more people who injure their ankle going and having a discussion with an orthopedic specialist. We're certainly seeing more lateral ankle sprains having reconstruction type procedures, particularly in professional sport and also that research coming out about the post-traumatic osteoarthritis and looking at some of those direct and indirect costs that are associated with having an ankle sprain. That research and that body of literature that we're starting to develop is actually starting to make us question how we're actually treating these now. It's going away from this, well she'll be right, mate, type of management to being a little bit more aggressive for lack of a better word in terms of making sure that if we are seeing someone with an ankle injury, we are addressing it rather than just that, let's strap it up a bit of ice and just keep playing. We're starting to see, like I said, a little bit more of that trend towards a repair particularly in more professional athletes, but I think just probably in my clinical practice, just in private practice, I'm just starting to see that trickle down a lot more now as well, a lot more people that are having orthopedic discussions. Yeah, okay. We might dive into that a little bit later about who you might think might be appropriate for those sort of procedures or to refer off for an assessment to see whether it is going to be something that the patient might need. So we'll dive into that a little bit, I want to talk through some of the key elements of rehab as well and what you might do pre-imposed. So I've got a lot of sort of dive into it, it sounds like there's some interesting stuff coming out. Talk to us a little bit about, you've got a patient coming in, they've just had a lateral ankle ligament injury or any sort of ankle sprain. What are some of the key subjective questions that you want to ask or the help to guide what you're going to do with treatment or with your assessment? Probably the number one that we want to ask straight away is making sure we have an understanding of the mechanism of injury. So I think when people come in and they go, I rolled my ankle. Most of us assume that's a plan of flexion inversion type mechanism, but I think it's good to actually get the patient explaining what happened if they come in and just say, well, that's what they did. Getting them to show you with their uninsured leg about what sort of position it was in, was their foot on the ground and it rolled? Did they land and roll and sort of move forward over their ankle? Or did they have that dorsiflexion external rotation type mechanism? I think I don't know if anyone else is probably as a physio when you're watching the 40 on the weekend, you see it seems today in the NRL, anyone that goes off the field with an ankle injury, it's assumed that it must be a cinder's moses by the commentary team and you sort of sit there and I'm like, the mechanism wasn't right there, that you know. So I think having that really good understanding of the mechanism is key. Getting an understanding about their previous history of ankle sprains, other injuries as well, so I think probably every physio in Australia who works in private practice has seen someone who I rolled my ankle a few weeks back and I keep rolling it again and again. I think that's a common history and you know, we know if you roll your ankle once before, you're more likely to roll it again, but if someone's having these recurrent episodes, we need to get some clear questions about, okay, what's going on and why? Because this might be an individual that's progressing towards having a chronic ankle instability. I think understanding after when they had the injury, what happens? So the typical question says, okay, could you get up and walk off when you hurt this or did you struggle to weight bear? I think it's a good key question because it helps with some of our questioning around our auto ankle rules and I think getting an idea of when swelling comes in. So did it happen straight away or did it sort of come on delayed and that starts to help you think about will have I got to be more concerned about a fracture or a condral injury versus disease look like it's a lot more of the soft tissue components that I need to be considering and and sort of those questions as there was a consensus paper published 2019, what with what they call the roast guidelines and they actually outline some of the key clinical questions that we want to have an understanding of, but then also some of those key objective measures that we might be wanting to look at as well. Yeah, there's a lot in that I want to dive into. So you mentioned there about the mechanism of injury, so planiflection inversion, where is that guiding to if they describe or show you a planiflection inversion injury? Yeah, you're starting to think that we're looking at the lateral ligamentia structures say ATFL, CFL, PTFL depending on the position and the grade, having a bit of an understanding, did they land on sort of their toes and roll over the top, might start to make you think, okay, we might be looking more ATFL, CFL. If I sort of, I had a guy the other day who was basically slipped getting out of a truck and he was talking about the points of contact and he's like, well, I did have my three points of contact, but I just slipped because the ground gave way and his foot was sort of more neutral and then got that big inversion force. So just starting to think about then what that implications of that mean for how you might assess that. So if someone's highly irritable, you might want to assess those structures last. Someone's in the first couple of days after their injury, there's the O.S. and Research that says that clinical assessment on day four after an ankle injury is actually the most valid time to actually assess the ankle. As opposed to someone who sort of tells you this story where they're starting to get a lot of medial pain and that's not to say that someone who has that plan of flexioning version mechanism doesn't have medial side of ankle pain, they generally can do. It's just that person that, you know, they're running along and they got tackled from behind, their foot sort of got stuck, they got forced into that more externally rotated position. That's when you start to think, okay, well, I've got to have SINDAS Moses on my list of differentials here and how that might change what you do is if there's clinical evidence that suggests I want to x-ray this person, I'm going to make sure that I do get a weight bearing x-ray for that person if I'm sort of starting to think, well, we've got to be suspicious of SINDAS Moses as opposed to someone who's got very isolated, lateral ankle symptoms, just starting to think about what my next step is, what do I want to rule out with my clinical assessment and maybe some of my adjunct assessment like x-rays? Yeah. And so if they've got that plan of flexion inversion type injury and they do have a medial ankle pain, what are you sort of thinking there? They've got a medial and lateral what's, yeah. They could have a lot of things. So the capsule is obviously continuous. So that medial ankle pain could be part of their capsule pattern. It could be along the subtailer joint line. When you MRI people that have had a high grade lateral ankle sprain, you will see some fluid tracking through to part of that deltoid ligament. And that doesn't mean that they've injured their deltoid ligament as part of that. It's because the joint capsule communicates through to the subtailer joint and that's where all that fluid comes out. I think, you know, particularly posterior medially, we think, oh, everything's that they kill is in that region, but the posterior joint line, even if there's a small amount of swelling, we're jamming into those positions, we could be getting some medial symptoms as well. So it's just more being aware of all the anatomy in that area, I think. Yeah, okay. So it could be swelling, it could be that that's tracking around. It could be subtailer joint also causing that medial pain. And then it can cause that medial ankle pain when it comes to those inversion, planiflexion injuries. Yeah, you can obviously get some injury to the muscles and tendons. Obviously, we think, oh, yeah, literally everything gets stretched, but we also jam everything up medially as well. So you know, it's just being aware of that opposite effect on the other side. We could, because of swelling as a result of a lateral ankle injury, we could be increasing pronation. So we could be starting to load the tissues, you know, tip post, FHL, we could be sort of loading those tissues as well, having an understanding of what sort of how the person might be normally walking compared to how they're walking post injury could give you some insiders to whether that's potentially there as well. And you mentioned as well about whether they can weight bear it or walk off after they did it. What information does that give you when they tell you if they could weight bear or not? That sort of gives you a little bit of, that's starting to give you some thought process about consideration of your auto ankle rules. So obviously, they were designed for the emergency department setting, but for a lot of us that maybe work pitch side with sports or are seeing people as that first contact on a Monday or Tuesday morning after the weekend. I think that's a good question to understand is were you able to walk off? Were you able to weight bear initially? Because I think that's the time when you want to be considering their weight bearing status as part of that auto ankle rules work up. As opposed to they might feel okay after a couple of days or 24 or 48 hours, I had a 50 year old woman who rolled her ankle, put in the bins out probably sort of last year sometime and you know, she walked in, she felt fine, obviously quite bruised and quite swollen, but she couldn't actually walk back into the house. And so we x-rayed her and we did find a small fracture in there and think probably in hindsight she was like, oh man, why did we get this x-ray? Because she sort of felt like having a little bit of immobilisation time really slowed her down, but if we had done her auto ankle rules based on how she felt when she walked into the clinic, you wouldn't have sent her for an x-ray. We might have missed that luchromaliola fracture that she had. So I think that's where it gives you a little bit of value clinically for your decision making. But I also think it starts to give you a bit of an idea about how irritability is and starting to get a bit of assessment, not only of how the patient is able to function, but also gives you start to give you some ideas about is this the type of person that's going to just get on with things a little bit or are they quite fear avoidant, which might become something that you do need to consider as part of their rehabilitation, particularly with ankles, you know, someone who is afraid to use their ankle after an injury or or displays those signs of that canesophobia. When you're looking at your dorsiflexion e-version injuries, what sort of things might you be thinking of that a year potential injured structures there? Yeah, so sort of we're looking there more at I think fractures one, that sort of way we'll tend to get a little bit of fractures. Obviously you've got your deltoid ligament, your medial ligament, but more commonly we're seeing with those hyper mechanisms, your fractures, or your cinders' mosa's injuries, the interosseous ligament and that AI-TFL and the PITFL and their ability to sort of give you that stability through the top of the ankle. So they're sort of your main ones with that mechanism. You mentioned before as well about the swelling and whether they've got the swelling happened immediately or it happened later and whether that helps to guide you about whether it's conural. So tell us a little bit about that. So if they've got swelling immediately, what sort of information does that give you? Yeah, so swelling immediately usually indicates we've sort of got some signs of a hematrosis in there. So they would be things like fractures being concerned about the conural surfaces. So those type of pathologies that you might want to refer on for imaging a bit sooner rather than later. In the same way that you would in a knee, someone swells up immediately, you might be a bit more suspicious of an anterior cruciate ligament or or a conural injury there as well versus to someone who presents and they go, "Oh, it got a little bit of swollen," but then when I woke up the next day, it was more swollen. That would sort of consistent with more like your lateral ligament complex and your tendons and soft tissues that are reacting as a result of the injury that they've sustained. Lots of great stuff there. All right. So if we sort of sum that up, you're looking at that mechanism of injury to help you identify some of the potential structures that might be involved. You're looking to identify whether they could walk straight away or whether they're going with weight bearing to identify if they're going to need x-rays or you're going to be fulfilling those auto-ankle rules, which we can go up into a bit as well. You're looking for then swelling when that happened, the irritability and so are there any other key things that you're looking for within that subjective? Then I would be looking at what's happened in the timeline since they got injured. So what's happened and also what they've done or haven't done. So what have you tried? Has that helped your pain? Whether that's things like icing, elevation, things like how they started moving it, those sort of things, compression is another one that commonly gets used and sort of exploring those a little bit. So I think everyone comes in and they go, "Oh, yeah, I elevated it, but if we're going to elevate, some it can need to be above our heart." So a lot of people sit on the couch and then just put their foot up on the recliner and so ultimately that is probably not high enough to give them a significant benefit and that's the same with all those things, things like ice. If someone's used over the counter, a panadol or your simple analgesia, what did you take? How much of it? What was the effect? Because the number of times people come and go, "I took panadol, it didn't work." They took two panadol and if you look at the reason you asked to take two tablets four times a day or three times a day, if it's panadolosteo, is because that's the minimum therapeutic dose that you need. So sort of getting into those little nitty-gritty details and then having understanding about what's its progress. Is it getting better? Is it getting worse? Does it feel like it's stayed the same? We might not see a lot of that in the first 72 hours, but if they go, "Oh, well, it's sort of got worse and it's still within those first 72 hours," well, that makes sense because we know the inflammatory process is going to peak at about that 72 hour mark and so we can explain that to the patient versus, "I saw a patient yesterday who's five months down the truck from his ankle injury and he wants surgery," and the surgeon's like, "There's nothing for me to operate on here. Let's go and get a different physio to have a look at it with a different set of eyes." And, you know, his role is ankle. He hasn't got any major significant structural pathology, but he's still got a persistent joint effusion and limited dorsiflexion range. And so that's leading to some of the things that are aches and impairments. So, you know, getting an idea of what that progress is is really key. You know, whether it's the first two days, whether it's within the first six weeks or whether it's even further down the truck. And what do you think with that patient was going on with that persistent ankle effusion? Was it because they just haven't rehabbed it properly? What was going on there? I guess that probably comes into some of our clinical things that we'll talk about Dave, but he had limited range of motion with his arthrokinematic lines. So we did some dorsiflexion mobs, got him up. He could walk a lot more comfortably. And so I think he's just had some residual impairments from the original sprain. The ankle, even though it's obviously got some nice congruent surfaces, it has, there's a lot of anatomy in there that needs to work together. to give you the foot function that you need. And so it's almost like if the joint swollen, you can't get good information about where the joint is in space, that then feeds into the muscles, which then helps control the joints and how they articulate with one another sort of becomes sort of this effective, oh, you know, where do we start? I think it was just more sort of, there was a little bit with him where he sort of said, he's like, I just felt like he had a story where he was sore, he sort of kept moving and it felt okay, then it got a little bit sore, then someone said, I'll go into a boot, saw someone else and said, oh, no, you need to go in crutches. And so he's sort of had this process where it's being very two and four, back and forward, back and forward, back and forward. So it's sort of gone from extreme to extreme and not sort of stepping between to do that. If you've gone from being a boot and then told, you know, hey, oh, no, you need to go get off his completely and then you have an MRI that shows that there's nothing there to warrant that advice. Oh, get off those crutches. Well, if he's been on crutches for three or four weeks with his foot in planiflexion, it limits your ability to get straight back in the dorsiflexion and get it walking. So I think it's just that gradual building of things really. Great stuff. And we'll explore that case a little bit as we go through it as well. So let's have a chat about some objective tests and how we're going to go through our assessment there. So we've got a patient walking and you can choose whether you're thinking whether a lateral ankle, ligament injury or lateral ankle complex or send us bones or something like that. It's not a fracture. So how might you go about assessing some of these patients? In that consensus paper, they talked about 10 elements that they recommended physios or I think it was anyone who treats ankle sprains assessed. So, you know, I think first thing, obviously, subjective history gives you a bit of an idea about irritability. And so you might have to abrid your clinical assessment depending on how irritable the person is. But, you know, I think having an understanding of their pain levels and before you do any of your clinical assessment, just going, what's your pain right now? Where is it? And before you move into some of your testing, you might go, I just want you to let me know if it changes. If it changes, that's okay. All I want to know is what you feel where you feel it and then whether that's your symptoms or is that something different that you haven't experienced before. And I think giving that advice very early, if you can get a VAS score, I agree, sometimes people just can't do that. That's okay. Just get them to give you the nature of the symptoms. If I'm not confident about doing sort of their functional assessment first, I'll get them on the bed and look at things like their swelling. So you can use your take measure in the clinic. You just basically you pick a point at the ankle and do a figure eight around the ankle and come back to your start point to get a measure. It has been validated for use in ankle injury and it does show even small amounts of swelling, sort of differences. And it gives you an objective outcome measure. You can use for your patient, you can use for your compensable bodies as well. And we all know they love those type of measures. You might also look at things like, I think need a wall, everyone sort of does that pretty standard. Now that weight bearing dorsiflexion to get your need a wall measure. Once again, it's very objective, but you also need to look at on the bed, you know, looking at planar flexion range, inversion E version range. I think also then looking at the strength. So I think we're pretty good around the ankle using our sort of zero to five manual muscle tests. But if you've got access to a handheld dynamometer, I think there's a lot of value in doing this with ankle patients because I think you can just get some really good, clear objective data to reassess. But I think you'll get a little bit more information than just your, or is that a grade four, is that a grade five? Sometimes you'll start in neutral with those tests and then you might having a look at, well, if I think someone's got some posterior traumatic sign of tenopathy in the perineals say, for example, I might put them into a little bit of planar flexion and slighty version and just sort of put that tendon in a little bit more of a compressive position and see if I can explore that. And I think there's a lot of research out there for the, you know, for strength in ankle injury. So I think we probably do need to be a little bit better than just a zero to five grading. Looking at those arthrokinematics. So I think looking at ankle joint, make sure you're looking at your sub-tailor, your inferior tip fib, but also don't forget your superior tip fib joint. So someone's had that sort of rotation effect, have a look up top. And I think that's probably something just be, you know, don't be afraid to palpate along with the fibula. Say someone's had an ankle injury and they're complaining about pain, sort of lateral fibula region up higher. You can get a mace nerve fracture. So just being aware of that, I think you have it in the back of your mind, but I think having a bit of an understanding of how those arthrokinematic blades feel and then you might get into more sort of your functional tests. So, you know, things like your static balance and whether you do that with a best or whether you just get the person standing still and repeating with eyes closed, foam surfaces and then progressing into your sort of dynamic balance. So whether that's a star excursion, now you might not be doing some of this stuff on day one and that's okay too, but just making sure that you've got these things on your list. And then you've got obviously you're walking. So it can be pretty powerful with someone with an ankle injury. If you can change their walking that it's pain free, that'll go a long way to helping them with their recovery. I think generally as physios, we're pretty good in quantifying their activity level of the person. So what's body applying? What level? How long have you been there? You can use a Tecno scale, which is that activity scale, but I just tend to sort of get a bit of a gauge of what the person's athletic sort of capability is. And there are some really good outcome measures as well. If you're that way inclined, you've got foot and disability index, you've got the foot and ankle measure. There's an ankle instability tool as well called the KATE. So you've got some pretty good outcome measures that you can have in your clinic for when you need them. And you might not use them every time. You might use them every time with someone who's compensable. And you can use these in sort of your full fee pain patients as well, your private patients. So in my experience, they're sometimes really happy to use those tools as well. It's probably a bit long-winded their day, but that would be sort of at least thinking about the domains that I want to be sort of having some understanding of. And then just adjusting how much of that I do on day one, depending on where the patient's at along their journey. Yeah, I think if some of that up nicely, you've talked through all the areas that you're interested in, but you're also gauging your preface with talking about your irritability and helping to understand how irritable the patient is now will help to guide how much of these tests that you're going to actually perform on day one. Like to say, for instance, how much are you very that with your strength tests, which ones might you focus on then if they're highly irritable? If they're highly irritable, I'd certainly look at their figure eight. I try and get an understanding of just what their active movement is and just give them a bit of guidance of soon as you start to feel an increasing pressure or any pain, just let me know. And then I'd measure that, I guess. I would still like to have a feel of their arthrokinematics, but I might not get them up to do dynamic balance or static balance. If there is some research out there in balance saying that, obviously, on our injured side, the centre of balance may change when we've got an ankle injury, but there is also some research that says that we'll see that change in the contractual limb. So those that might have forced plates in your clinic, you might want to try that on just the un-injured side and then compare that later on as you get them further along their progress. But if there's an opportunity, particularly if we've got a high level athlete, and we know that we're trying to get them back to some sort of specific activity, I would still try if I could to do a balanced test on the un-injured side, just similar to what we see with some of that research coming out now about ACLs, is if we get injured on our right ankle and we don't know what our baseline was on the other side, are we rehabilitating our athletes to the level that we need to for them to get back to be successful at sport? Or do we just, are we detraining the un-injured side and rehabilitating the injured side when we really need to be up here on both? And that's sort of something that I'll probably do that a lot more now than I've done historically. All right, so if we just recap some of those, after you've identified their irritability and your varied your assessment, you're looking to identify with a measure using your figure eight, and we might put a link to some resources for that figure eight taping there. You're looking at their range of movement with a need of wall and their other active movements like flexion inversion, e-version, looking at their strength, looking at the other joints around it like the subtailer, inferior tip fib, and then your pelvis up along that fibula, then static balance, dynamic balance, walking, and then looking at their sport and activity and athletic capabilities, and then your outcome measures as well. So lots of great stuff there. If we come back to say your inferior tip fib joints, talk to us a little bit about how you might assess some of those. If we've got that, obviously we've got an appreciation of their ligamentus integrity with our manual tests, what we're looking for is we might see that the patient, when they're walking, they start to sort of rotate in. There's Mulligan sort of discusses that concept of the positional fold of the fibula. And so I think I use those tests a little bit sort of when we're working out with the patient what's going to give them the most meaningful change. So even down in your weight bearing door, see flexion, sometimes I might just stick my thumb there and say, "If I just change that position of the inferior tip fib joint, and you moved, does that change your pain response, or does that change the range of motion?" You can actually even do a little bit of an AP with that test as well. So just starting to get some of these little tests around those joint surfaces that might help working out which direction might I go first for that particular patient and they might go, "Oh, well, that actually feels quite comfortable in that feels that it's helping me." working on the inferior tip fib joint as opposed to the AP technique. Sometimes you can also get it indirect effect by doing that reverse up at the superior tip fib joint for someone that maybe just doesn't want to be touched locally. They might have a lot of bruising. You know, you sort of might find that all you can really do around there is a little bit of efflurage and a lot of that swelling and a deem emanagement stuff, but you might sort of say, oh, well, if I do the reverse at the superior tip fib joint, does that change what you feel as well for someone who's quite sensitive around that fibula? Yeah. So they've got a restricted range of even, for instance, they're often quite stiffened at dorsiflexion, aren't they? So you're talking about using your AP glides on that inferior tip fib joint to see if you can help make that more comfortable to give you something that you can do to help improve their range and get them walking more comfortably and moving more comfortably, or if they're quite sensitive going up to that superior tip fib and doing more of a PA through there. Is that right? Absolutely. Yeah. Yeah. Good stuff. And that's where you know, we get that blurring between your objective and your treatment, but it's giving you good treatment ideas about how you're going to progress them and how quickly you can help to settle their symptoms in improved range. So before we start to move into some of the treatment stuff, any other key areas in the objective that you want to cover? I think making sure that you do your clinical assessment of your ligamentar structures. My bias is I tend to do the uningured side. I think at least once a week someone says to me, oh, it's my other side, whether that's an ankle or knee and I'm like, yeah, I know, but how do we know what we expect? And sort of that goes back to having a bit of an understanding about your past history as well. So they might have had an ankle injury on each ankle for four or five years in a row. And so it starts to give you sort of some ideas about what are you actually expecting to feel on these clinical assessments? So I know if someone tested my left ankle, they'd get really nice end feel, a nice strong spring. Oh, great. But if they do my right ankle anterior draw, they'd be drawing a long way and they'd sort of go, oh, hang on, what's going on there. And you start to make you think about what you're expecting to see as well. And I think whenever you're doing any clinical assessment, I think you really need to be making sure that you've got a bit of an idea about what you're expecting there with those ligament structures. So that would be probably the other thing I'd make sure I have added in at all times. Yeah, great stuff. You say you've got that patient in, they've had lateral ankle ligament injury or something. You're looking at initial management and you mentioned there about potentially using some MWMs. But tell us a little bit about some of your early strategies when it comes to looking after what are we looking to achieve in these early phases of treatment? So I think if anyone that works sideline, I think if you get someone that has an ankle injury, I think you can get some really good management early on. You know, a good little technique that can be useful. If you've assessed them following that game, following that injury and you sort of go, look, we've injured some ligaments here. We want to give it some support. But let's also prevent the effect of some swelling. You can use your basket weave taping, which can be quite useful. And it's not always handy. I know sideline, but if you've got some access to some ortho foam, what you can actually do is cut that U shape and pat around the like meliolus and the medial meliolus so that you can really control that swelling. And then the basket weave technique, which is just that layering of the tape is really quite useful because it feels nice and supportive. Sort of holds a lot of people say to me, oh, it feels like it's like a little bit of a boot. So it holds them in a nice neutral position, helps to prevent swelling and will also give them some support as well. So I think if you get the opportunity to try that when you're working sideline with the team, I think that's a really good one because it means they'll come into the physio two days later and see you and they're already on top of some of that swelling management. So I think that's a little bit of a clinical pearl that I'd be giving to the people sports physios. I guess a little bit more who'd be working sideline, but for anyone, you know, you might be at kids sport on the weekend. And I think your education is really key like any other injury, but you know talking about what's expected and why we know the inflammatory process will peak at about 72 hours if we can maintain control of that at the moment, that'll help you. Some people go, well, what's the point? But ultimately, if you can manage the swelling, manage that early acute inflammatory response, what that actually will do then once you get out of that life a bit easier because you won't have as much swelling. There won't be as much sensitivity of the tissues in that area if we just let it go and let it manifest in its own way. So I think that education about what you want them to do, speaking to them about the role of medications can be very helpful. So, you know, we know that short course of any inflammatory is early may be useful, but if we can get you off that by day four or five, that would be really ideal. And also just making sure that we give them that education about why we want you to be moving it, but obviously not moving it into something that is quite painful. And, you know, simple strategies that you can use is things like, you know, you might ask them what's an acceptable level of pain for you to have and you might give them a number. You might say to them, look, I'm happy for you to do things, but if you sit down and rest, I don't want it to ache and throb and you might give them more sort of description words like that as opposed to giving them a VA score, you know, I think having that really good education about that and empowering your patient to help themselves, you know, if they can, I guess, get away with particularly early, just some gentle even if it's only isometric work and it doesn't have to be into inversion and evotion, it could just be simply sitting on the ground just curling their toes into the ground or or doing some of your, whether you call it foot posture or or what have you even just doing some of those drills, you know, you can do that sitting, you can do it non-weight bearing. I think that can be quite useful really early on and so it gives them stuff that they can do safely that shouldn't provoke them and you've given them the education about, well, if this makes you feel sore, just stop it and just let me know sort of things. I think that really early on can be quite powerful for the patient. And so you're getting the moving within that comfortable what they are finding is an acceptable level of pain. Depending on your patient, I think sometimes having a bit of an understanding about their goals and that can be really key, you know, there'll be times where someone it always happens, I'll roll their ankle in the semi-final and I want to play the final the next week. And so obviously your timelines, I think, particularly with ankle injuries, really get affected by what's going on. There's this, she'll be right, attitude will just strap it up and play the final when you've got a short timeline, just as there is if it's the last game of the season, people go, oh well, I've got the whole off season to recover. So, you know, both those groups don't really want to interact with the physio because one doesn't see the need and one said, oh, I'll just deal with it after next week's game. So I think having a bit of an understanding of people's goals is really important. I can count on more than both my hands, the number of times you'll see a teenage female with an ankle injury coming on crutches. And I think that I've had their recovery sort of seems to be sort of much more aligned with the upcoming school formal or school dance than it has to what we're doing clinically. I think sort of expectation and goals becomes a key factor there as well as what we do management-wise. I think the idea is, is if you're quite comfortable that you haven't got a fracture or a serious pathology, what you should see is that it's a bit like a traffic cone, small gentle movements or strengthening exercises within comfortable range, that then they can expand upon and become bigger ranges or more resistance. You should see that sort of real just that progress should go. There shouldn't be as much swelling, there shouldn't be as much pain, when you keep progressing it on and that continues to progress in that fashion, I guess. I wouldn't say it's particularly linear, you know, but, you know, the general trend is on the way up. And I think that's what what you give someone to do and then what their response to that is will give you a big key about if you're heading in the right direction there, Dave. You mentioned there about setting expectations with your patient and looking at their goals and identifying stuff that you could help to educate them on. So when you're looking at prognosis and you're looking at identifying, when that patient there can ask you when can I get back to sport, when can I get back to when I can I get to the formal how am I going to go dancing, all that sort of stuff. What sort of factors are helping to guide what you tell them here and what do you tell patients? Depending on the person and what their understanding is, I think giving them some awareness about biological tissue healing times. And, you know, we know that we want to, if we've got a ligamentus injury there, we know we want that scar tissue to develop. And then it will continue to remodel over time. So I explain to them, we can't change that. But also too, we can manipulate the variables that we're working with. So, you know, I talked to them about, we're not going to change biological tissue healing time. But if you've got a swollen ankle, we're not going to be able to progress you on. So that's non-negotiable. So I talk about things in those kind of terms. I sort of look to rather than give them a time frame. If someone's really stuck on a time frame, I say, look, you know, we'd expect this to be where you want it to be in that sort of four to six week time frame. If you want a week time frame, but what I would actually rather you focus on is I think you can get rid of the swelling really quickly. So let's use that goal. Then I need you to be able to have a needle wall that's similar to your opposite side. Say someone's had a previous fracture that they've had an aura for. You might not expect that, but say, you know, we want to sort of get you to a range that would be considered functional for you in your sport. Then I would give them sort of goals, like strength goals. Now that might not be handheld dynamometry goals all the time. If it's someone who's a runner, we might give them a car phrase goal, give them a balance goal, those type of things and use those sort of objective criteria rather than getting caught up on a time frame because we all know we can and return someone back to sport much faster than six weeks. We might not necessarily have to have full resolution of tissue healing. We do it with hamstrings. Athletes go back to sport. They're playing. They have no symptoms. And we know that based on MRI studies, their hamstring still remodeling and getting rid of that scar tissue. So if they really desperate for a timeframe, I'll give it, but I just sort of explain to them that that's not our best outcome. They're a timeline. And if we've got a more pressing timeline in terms of something that they've got to be able to do by a certain time, we break it down into those smaller goals. OK, so to get to this big goal, you need to have no swelling. You need a wall, might need to be good. And I want you to be able to do a certain number of car phrases. Just depending on what information we've got from them, we might have some baseline screening data. We might have some strength data that we can use. So those kind of things I would focus on rather than eight weeks, four weeks, 10 weeks, we'll have you. Any other sort of criteria or goals you might have with them? So you mentioned there about balance. Are there any sort of dynamic or static balance tests that you might use or criteria? Yeah, so there's good research now that shows that the balance center changes. So I would always start someone on balance on that opposite limb very quickly, unless there was a reason not to. So they've rolled their right ankle. They'll start on at least static balance, but it'll probably be static balance with either a head perturbation or a skill that's related to their sport very early. And they just don't do it on their injured leg. Then what you would look at is looking at, you know, if you've got access to force rooms, you could look at force room data and have a look at where their center of pressure sits and the range of excursion. If you've got it, I look at some dynamic stuff with the star excursion, but also to looking at some of their landing strategies that they might use. So making sure that they're not landing with a really stiff leg that they've got the ability to absorb load. And then looking at more your agility tests. So if someone's in sort of a bit of a pivot or a change of direction sport, I think sometimes doing the footwork drills, whether that's figure eights. Sometimes I've set up foam rollers in a line through the clinic and getting them to run zigzags or diagonals. So just looking at making sure they're really getting that nice foot position and alignment when they're changing direction. And the foam roller doesn't matter if they hit it. A lot of people with low-level immunaries tend to sort of prop and prop a lot further away from where they need to change direction. And so that's where the foam roller can become quite handy. I can say, this is where I want you to land. Don't worry if you kick the roller over, it's not going to hurt you and you're not going to hurt it. So those type of activities and just modify how we would do it based upon their sport as well. When you say prop there, say change direction, can you just describe that to us a little bit? So what we will tend to see, we see it with knees as well, instead of flacing their foot, absorbing the load and then transferring their load off to change direction, I'll sort of just stick their leg out to get to the next step. So what you sort of tend to do is they tend to land with a heavy, like sort of a stiff leg strategy. And it's just they just push off it to get back onto their other leg. I think that's something to look for when people are running and changing direction with their low-level immunaries and ankle injuries specifically. Yeah, okay. And so we're looking to work them through to those stages and each of those, you know, achieve each of those goals before they're getting back into sport in return to play. Tell us a little bit about if we come back to those early stages as well. So you're walking people through these goals and what they rehab is going to involve and you mention there about getting some range of movement, you're going to get swelling under control, taping and bracing. Tell us a little bit about how that fits in if you use it when you use it, that sort of thing. I definitely use taping a lot. So basketball is probably my go-to for swelling management. Obviously, happy to use your stirrups and figure sixes. Heel locks, going depending on what the person's got going on. So, you know, I've certainly put heel locks on people to control subtailer joint motion to help them with their movement. I think obviously, I think there's space that you can use tape as a return to sport as well. So you might start with quite a heavy tape and then just relax it off as they get further away from their injury and towards the end of their rehabilitation program. Obviously, the research on tape is that it's really effective for the first 11 minutes and then after that, the effects questionable. I think the effects we see with tape are more proprioceptive, giving input and then hopefully limiting soft tissue damage if you do manage to roll your ankle. In terms of braces, you know, I use braces. I don't believe that I subscribe personally to wearing an ankle brace to prevent injury. I think I would rather be making sure we go out and give someone a really well-structured injury prevention program as part of their warm up. I'm probably biased there. I've played netball for a long time and wasn't someone that strapped my ankles. I think I'd probably be looking at giving them a really good injury prevention program. So depending on their sport, if it's a prep to play or a knee program or just making something specific for the athlete, braces really good for people that can't actually tolerate tapes. Not something that a lot of people tolerate here in Queensland. And I think probably what I see is we're using a little bit more of the ankle braces in people who are under allergic to tape or some of our sort of more older demographics. So people that are sort of in their early 40s to 50s and 60s that just risk of developing a chronic ankle instability or they're lacking with confidence as well. And so they might get to hold our get a brace. I probably see more braces put on people who are being supported by a compensable body, I think. I don't know if that's just the bias in the patients I see. The young Catholic ones that are less likely to be in that system or whether that's a general trend. But I do think it has its place that you've got to be able to weigh up the pros and cons. So if you're wearing a brace 24/7 and you're not doing anything outside of the brace, then I think that has a potential to become maladaptive too. And so we need to be making sure that the brace is useful when it is, when it's required, but also have them exercising outside of their brace and still trying to rehabilitate those impairments around their balance, their strength, then your muscular control and kinetic chain loading as well. And do you see many patients that have been strapping their ankles for a long time or that you might have seen them for a knee or a hip or something like some other sort of injury and they come in and they're like, oh, you know, just strap their ankles for every game. It's just one of the things that I do strapping or bracing. Is that something you see a fair bit of as well? - Absolutely. And I think, you know, with some sports, there's a general trend towards, it's just, you know, like netballers, like, you know, a lot of professional athletes will have their ankles strapped because there's very little risk with preventatively strapping your ankle versus the reward as such. So I think there's some professional sport certainly subscribes to that. And I think there's some sport. So certainly even at the recreational community level, netball is certainly told to do that that we don't see as much say in another sport. So I still think we're always going to have those stereotypes, you know, I know people that strapped their ankles so tight. I don't know how they move them, but they're the people that probably are bordering. They don't have any issues, but they just strap it so tight so they can prevent having an ankle injury. And I think that comes down to, I can't comment on what the status to their ankle is in terms of all those domains, but probably comes down to a little bit of culture within certain sports and certain past times. And what they were taught at a young level, you know, certainly my first rep netball team were told you have to strap your ankles for everything. And so the first thing my parents did was go and bought me ankle guards because tape was cost prohibitive back then. So we've got those cultural things, but I think also to some people really have confidence. They're gained confidence by having tape on and we know that tape has that proprioceptive effect and bracing to a lesser extent. I think we see bracing as more, it'll be certainly in younger athletes. I think it's certainly more apparent drives that bracing conversation a little bit more, rather than the athlete, there's not often too many athletes that will say, "I should have an ankle braided son." They'll laugh and ask about strapping first. And I think there's just a slight sort of perception of comfort there. - You've got a patient with a acute injury and they say, "You know, should I be just strapped from now on? Should I just be strapping my ankle, you know, going forward? What's your normally receivables?" - My advice would be look, as you get back into your sport, we will have you strapping your ankle, but then we'll gradually weep that down and our goal is that you can return to your sport long-term without having your ankle strapped. I think sort of a general guideline that can be useful with that is however long you were out with your ankle injury, strapped for twice as long, getting back into sport. So if it's four weeks, you might strapped it five to eight weeks, but that's sort of just a bit of a general guideline to sort of have in the back of your mind. My goal would be that you can deliver a rehabilitation program that addresses impairments, but also confidence of the athlete that hopefully they don't need that or don't feel the desire to require tape. So that's for someone who's got an acute first-time lateral ankle injury. If you've got someone who's got an instability, so you've got that ligamentus laxity and then they've got neuromuscular impairments, it means they do roll their ankle. I would encourage them to strapped because the reason for that is is if you've got those ligament laxity and those neuromuscular impairments and they keep rolling their ankle, what you're generally going to do is keep a butting those bony surfaces to one another and that's where the difficulty and the progression of that post-traumatic osteoarthritis lies is that I just run my ankle on Missalweek, I'll do it again and again and again and again and that might be someone that I might go, you know what, you might benefit from weren't using an ankle guard. If you are really keen to continue to play your activity or continue taping in those circumstances. I think it's a bit of a horses for courses in that situation. That makes sense. I've heard other therapists talking about immobilising it after a Lachlanca ligament injury. Tell us a little bit about your thoughts on that. It's a good question, because I think Moonbeek is so accessible these days. If you're pretty confident that there's no fracture and you've got a Lachlanca ligament injury, if the person is able to wait there and they can walk with a good gate pattern, my preference would be to keep them using that rather than putting them in a boot. Maybe even giving them a crutch on the opposite side just to offload the area a little bit. I think we should be sort of reserving Moonbeek for our syndesmodic injuries and fractures as such. But I think practically that doesn't really happen. I think it's pretty easy to stick someone in a Moonbeek because it helps them get moving pretty quickly and you don't have pesky crutches and all of that sort of stuff. I think there is some value, but I think with really good judicious use, if someone has a Lachlanca injury and they're quite sore, then you could get away with using it. But my preference would be is that you hopefully you shouldn't need to for most Lachlanca injuries. If you're suspicious of a syndesmodicist, though I think you do have to have them in a Moonbeek and crutches to obviously offload that area. But yeah, that sort of the indication for using the boot is more that syndesmodicist fracture type stuff. The other indication would be if there's a significant osteocondral injury. So the person you might see with that is someone who comes in, thought they had a relatively innocuous injury, but they talk about massive swelling really quickly and that might be the person you go, or a might just be on the side of caution and put you in a Moonbeek here. If you can get someone's walking with reasonable walking patterns, so I'm not saying that every person with ankle injury we're going to be able to get them to walk in, limping and walk out with a fantastic gate, but just thinking, going back to, you know, you might talk to them about a step two gate versus that step through gate that can help them, you know, things like good go to heaven, bad go to hell when you're walking up and downstairs. Some of that stuff can get people pretty mobile fairly easily without using a Moonbeek. I'm not opposed to them, but I think we sometimes forget our clinical reasoning, we just go out to see just stick you in a Moonbeek. That'll do. We've got to remember that if we over-emobilise people as well, we might be contributing to some of these arthro-communomatic strength and proprioceptive impairments. So there is some value in the calf pump working for people that helps flush swelling out. So I think we forget about that element of the immobilisation and that's just something to sort of have a, I think a good respect for when we're considering putting someone in a boot. Perfect. And I think that's a great place to wrap up this podcast. We've dive into heaps of details there. We've really talked through some of the key subjective questions that you're looking for. Just looking to ask when a patient comes in, you're looking at how that will guide your objective assessment. We've talked through the key objective tests. And then we've started, we've discussed some of your early management and your bracing, taping. And giving people a lot of really good ideas about how to describe the recovery process to their patient and why it's important to get involved in their rehab at every stage. So tons of great stuff. And I think there's a lot more we go into and we might do that on future podcasts as soon as most as there's treatment progressions. There's lots of great stuff that we can talk about. So I think that's an awesome place to wrap this up. So it's been really great to get on and share your experience and your knowledge and the recent research and how we can apply it with our patients. So thanks. No, thank you for having me, Dave. It's good to talk about someone who can enjoy treating. Yeah, for sure. It's been awesome. And also I'm looking forward to filming some neuromachines sensitivity with you soon. We're doing a, it's part of our low back pain module. We're diving into neuro-mechanosensitivity and some of those tests that you might do. So that's going to be a lot of fun to record. Yeah, we'll be. We'll absolutely. Yeah. And finding out how that relates to your low back pain patients, identifying when that's an issue and should be addressed. So yeah, we've got to have some practical videos coming out on that soon. So looking forward to that and your other presentations on, you've done for us as well, conquering conflict, red flags in low back pain and lots of other great ones. So it's really great to have you as part of the team and be able to share your knowledge and experience with everybody. I've learned from my mistakes for the viewers, I think. Awesome. Well, thanks. So we can tell us where can people find it more about yourself and what you're going on? I work at the QAS. So I think if you follow the QAS on social media channels, you'll see what we're up to there and also on Twitter at physiozo. Physiozo. Good stuff. And we've got your profile on the Conglades website as well. But give Zoe a follow and a like and let them know what you enjoyed about the podcast. And thanks again, Zoe. No, thank you. Thank you so much for having me, Dave. That was awesome. Hope you enjoyed that podcast and you got lots of really great ideas about how to approach your ankle sprain patients and what sort of questions to ask them, what sort of assessment tests to perform and then how to start your treatment. We look forward to having Zoe on future podcasts. We will talk about ankle sprains and lots of other sports injuries. So he's got tons of experience. So we're going to look forward to having Zoe back on the podcast in the future and having a chat about all sorts of stuff. If you'd like access to other presentations by Zoe, you can head on over and grab your free trial clinical edged membership where you can improve your clinical skills, your clinical reasoning, your knowledge and then really improve your treatment results. Because that's what it's all about. So you can get help with your low back pain patients, your neck pain. If you'd like to help your persistent pain patients make sense of their pain. Or if you'd like to improve your communication with patients or your clinical reasoning. We've got heaps of great stuff over there that'll take you through exactly how to do it. So if you'd like to help out, grab your free trial clinical edged membership over at clinicaledge.co/freetrial. And say hi to me on Twitter. I'm @DavidKape Pope. Zoe's at PhysioZoe. And we're on Facebook as well over at facebook.com/clinicaledge where you can get access to heaps of other great resources. So thanks for joining us and I look forward to catching you on the next Physio Edge podcast.