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[Physio Discussed] All things ankle: assessment, imaging & evidence-based rehab with Dr Chris Bleakley and Andrew Wynd

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In this episode, we discuss assessment and treatment of common conditions that we may see within the ankle/foot region. We explore: 

  • Lateral ankle/foot pain
  • Cuboid Syndrome
  • Chronic ankle instability
  • Imaging to assess subtalar joint dysfunction
  • Lateral ankle sprain assessment and management
  • High ankle sprain assessment
  • Management of full thickness ATFL tears

Want to learn more about the ankle? Dr Chris Bleakley has done a brilliant Masterclass with us called “Ankle Sprain: Etiology, Diagnosis and Rehabilitation” where they go into further depth on this topic. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-bleakley

Dr Chris Bleakley is a physiotherapist and academic who earned his PhD in acute soft tissue injury management and now works full-time as a researcher and lecturer at Ulster University. He has authored over 100 scholarly works and plays key roles in postgraduate education, including directing the MSc in Sport and Exercise Medicine. His research focuses on soft tissue injury and ankle rehabilitation, and he has contributed to major clinical guidelines and international advisory boards in sports physiotherapy.

Andrew Wynd is an APA-Titled Sports Physiotherapist and is the founder and director of Balwyn Sports & Physiotherapy Centre in Melbourne. He also is the CEO of Freestyle Feet, an innovative company that aims to solve foot/ankle issues through education and products. Andrew is globally recognised for his foot and ankle clinical work and has been a casual academic teacher at La Trobe University. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

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SPEAKER_00:

Today we're diving into the complex world of foot and ankle injuries, exploring everything from subtalar instability and lateral foot pain to chronic ankle instability and the evolving evidence around acute ankle injury management. Professor Chris Bleakley is a physiotherapist and researcher at Ulster University, internationally recognised for his work on acute soft tissue injuries and ankle rehabilitation. He has published over 100 scholarly works and was one of the lead researchers of the price guidelines for acute soft tissue injury management. Andrew Wind is an APA titled sports physiotherapist with a master's in sports physiotherapy. He's regarded as one of Australia's foremost authorities in foot and ankle assessment. A former elite athlete, he now mentors clinicians and consults on complex cases at his clinic in Melbourne. Together, they bring a wealth of clinical and research expertise to today's discussion on evidence-based management of ankle injuries, subtalar instability and the future of foot and ankle care. I think you're going to love today's discussion. So let's dive in I'm Sarah Yule and this is Physio Discussed. Welcome to you both, Andrew and Chris. Thank you so much for your time today. Pleasure. We shall jump straight into it today. I think the first thing that I'd love to explore with you both is just touching on lateral foot pain, how it presents the common clinical culprits and what the literature says. Chris, perhaps you'd like to touch on that first.

SPEAKER_02:

I mean, I think that the key thing is when somebody is presenting with lateral foot pain is that you're really not the major significant traumas. And again, what that is might really depend on the demographic that you're dealing with. If it's an athletic population, I think that you want to obviously rule out any type of fifth met fracture. So whether or not that is a stress fracture or a traumatic fracture. And I guess if the pain is presenting a little bit higher up, it could be the remnants of a lateral ankle sprain, chronic instability, sinus tarsi problems or sinus tarsi syndrome, an anterolateral impingement, cerebral nerve there are I guess a range of different possibilities and potentially some type of problem with the calcaneal cuboid joint or cuboid syndrome.

SPEAKER_00:

I'm curious, Andrew, how do you see that present clinically?

SPEAKER_01:

Yeah, so all of Chris's points are spot on. I tend to always think anatomically first and just run through things, your bone, muscle, nerve, joint. As Chris has just mentioned, there's a lot of anatomy there. There's a lot of potential culprits in the lateral ankle and the lateral foot. So I think it's really important. And this is probably why I love the foot and ankle because it's so easy to palpate the exact spot. So if you ask your patient to point with one finger to exactly where they're sore, that'll really narrow it down for you. And yeah, it's quite a sensitive and specific test. And for most things, if you can get them to point to exactly where they're sore and whether that's around the ankle, or under the fibula or down around the foot, then that'll give you the first starting point to then apply whatever tests you've got in your toolkit to be able to start to narrow that down, whether it's muscle, nerve, bone, joint.

SPEAKER_00:

The use one finger test works every time, doesn't it? Narrows it right down.

SPEAKER_01:

Well, not so much around the low back, but the foot and ankle is so much easier to see and there's a lot covering it. I think it does work pretty well. But your question was more, how do they present? They'll typically be limping and they'll usually point to what sores, unless is an acute fracture, which has been probably non-white bear.

SPEAKER_00:

And I suppose just in the way of the literature on lateral foot pain, how well is that area of the foot represented in literature?

SPEAKER_02:

I think it really depends on the injury that you're dealing with. The literature is replete with data around managing the real acute fifth met fractures in terms of their incidence, their etiology and their management. So I think that's something that we do. We do that really well. We don't miss a lot of those. We get good management decisions early on and pretty good at rehabbing them. Around the lateral ankles, I think sprains and chronic instability were also good. And there's certainly plenty of prospective research to help us with our diagnostic decisions. As we go into the less common injuries, the literature gets a little bit more scattered. So for example, if we're dealing with sinus tarsi pain with some tail or joint instability, cuboid problems, we're very much limited to case series and anecdote. And I think that's where it probably gets it's a little bit trickier for the clinician that is faced with those types of injuries in the clinic.

SPEAKER_00:

A few questions sprung to mind from that, but just on the cuboid side of things, I'm curious as to both of your thoughts on cuboid syndrome, where it sits in terms of the literature, what it presents as clinically, do we call it cuboid syndrome?

SPEAKER_01:

Sure, sure. So I've changed my mind on this. I used to think that cuboid syndrome didn't exist. I worked in a post-op physio clinic here in Melbourne, doing all the post-op for a couple of Melbourne's prominent orthopedic foot and ankle surgeons and we also saw private patients but not a lot of them and we had this one person my boss who taught me a lot of at the time a lot of foot and ankle techniques wasn't there so I was on my own and a runner had come in and had been referred there not to see me to see my boss and she was unable to wait there and said something happened in my foot as I rounded a bend came off the bend she's a 400 bed track runner literally just come from the track from a meet and I can't walk on my foot. And I was thinking, oh, I'm in a bit of trouble here because I was only a few years out at this point. Maybe I was five years out. So I started Palpate and she had this lump underneath her lateral, fairly midline, under her midline to lateral plato aspect of her foot. And it was a palpable hard lump. I came actually out and asked the reception team, what do I do here? Because I don't think she's got fracture, but I think something's happened to her cuboid. And there was a podiatrist there working with us as well. He said, yeah, yeah, yeah. She'll have subluxed her cuboid. and just do that manipulation technique on it, it will all be okay. I looked up the textbook and couldn't find anything. And then I knocked on his door again. He said, you get it on her tummy, push on it hard, put it like it's the black snake technique or whatever you want to call it. And so I had to go and it went clunk and literally she walked out of there. And I have no idea what I've done. From that day forwards, it was really interesting. I now think that cuboid syndrome does exist. I don't believe it can dislocate fully unless they're a hypermobile person, which she was, interestingly. But I do think that the mechanisms around that joint do fail and it will cause all sorts of dysfunctions through the entire lateral column of the foot. I see it all the time in the clinic. So, I now believe in it and have great success treating a lot of people with it.

SPEAKER_00:

Just on that, Andrew, in terms of the treatment for it now, are you still using the whip technique and then presumably doing your sequelae of rehab after that?

SPEAKER_01:

Yeah, I am in a little more nuanced and structured and thought out fashion than that particular day. But yes, you can assess the cuboid position, I believe, clinically. I have healthy debates with surgeons on this. If you passively dorsiflex the fourth and fifth ray while stabilizing the ankle joint and the subtalar joint so you don't get any extra movement through there, if you've seen enough of them, practiced enough, nothing will convince me otherwise that you can feel a restriction in movement and you can palpate your cuboid and feel it's albeit small, articular movements, and then you can mobilize that and manipulate it. And then invariably, the muscles that act around the cuboid, there's always dysfunction in them with that same presentation. Then I'll go and have a look at the muscle functions around their perineus longness. FHB has a lateral attachment to the plantar aspect of the cuboid, and they'll often have first-rate dysfunction, toe dysfunction as well.

SPEAKER_00:

Fantastic.

SPEAKER_02:

Yeah, no, I completely agree. I think it does exist. When you look at the anatomy of the cuboid, it's kind of wedged to the lateral arch as that really important keystone. And it's different than the medial side, because it's the direct link between the mid-tarsals and the forefoot, whereas the navicular will have the cuneiform sitting in there as well. So it's a really important keystone linking the mobility of subtalar and tarsal. And as Andrew alluded to, it's also the anchor point for peroneus longus. So when you look at the anatomy, peroneus longus takes this huge right angle dive medially and anteriorly. So it is prone to a lot of different glides and rotations. The rotations are mainly pronation and supination. So if there is an uncoupling between the subtalar joint and the mid-tarsal joint, then the cuboid will bear the brunt of that. I think when you look at it anatomically, there's also differences in thickness between the antramedial and posterolateral supporting structures. So again, it does create more of a rotation. So when you put your foot in extreme positions, whether or not it is a such as extreme plantar flexion, foot supination, or indeed if somebody just has an extreme foot type, then the loads and pressures that will go through that area are abnormal. It stands to reason that there will be potentially weakening or dysfunction of the supportive structures. We're talking about large loads going through there. So it is definitely going to move. Again, certainly clinically, I have seen patients present normally who have got unstable ankles or a dysfunctional medial arch where you can see a really subtle sulcus on the dorsum. The squeeze or whip will definitely relieve their symptoms. And I think obviously the caveat with any type of manipulation, and again, Andrew had mentioned it, that it's not just a kind of one and done, snap it in and stand back. I think it's also really important then to figure out what is overloading this structure, what is the underlying dysfunction and trying to stop that from happening. Case series is the ceiling at the minute for cuboid dysfunction. function. So I don't think it would take much to start to audit and publish those because there's really not a lot. There's not a lot out there. There's not a lot of imaging to try and quantify the direction and the magnitude of the movement of the cuboid. But for sure, I think everyone has, certainly colleagues anecdotally have those stories, you know, where they have that clunk and that manipulation and it does feel great straight away for the patient.

SPEAKER_01:

Well said, Chris. And the manipulation is quite effective and there's a planter to dorsal and dorsal a planted technique, a little different. And I think that is important depending on which way the cuboid is rotated in that axis. And that will increase your effectiveness with that. And it's hugely satisfying. Go jump up, walk around with immediate pain reduction if you're effective. It responds really well to mobilizing as well. I remember a patient got referred from a sports physician here who said, he rang up first and said, have you seen chronic perineal spasm before that we dry a needle and it relieves the pain for a day or two and it comes back again. It's in constant and spasm. I can feel it, but soft tissue work is ineffective. Do you know what to do with that? I said, yeah, more than likely. They'll have a cuboidal major foot issue that they go hand in hand. And there's often a very clear strength imbalance between tibialis posterior and peroneus longus as they work as a couple. And often peroneus longus is almost sort of locked short in a lot of spasm and tip post is almost weak and almost locked long, like sort of inhibited. Of course, that goes with the foot pattern again. And when you can unlock the cuboid and then restore that muscle to insecurity between the two usually go pretty well.

SPEAKER_00:

I've got many questions from that, but I'm curious what your rehab then looks like from there. So, let's say you've acutely provided them with some relief and knowing that that's your typical presentation, what does your couple of exercises look like knowing that it's of course nuanced, but presumably there's some consistencies there? Can

SPEAKER_01:

I preface the answer first that it's really important to treat what you find there and I think the really key thing in particular with the foot and ankle is that you really assess the whole foot and ankle together as one and check the muscle function as part of that assessment both up at the ankle you'll end up in the higher up the chain as well but at least at the ankle and in the foot itself before deciding what your course of action will be because There are certainly patterns that you'll recognize and that perineus longest to tibialis posterior. So just make sure you're strengthening the right one. And typically the default I'll go with more times than not will be tip post weakness. And if you give them perineus longest strength, their eversion strengthening usually makes them worse, even though they're testing weak in it if you're using dynamometry.

SPEAKER_00:

Presumably the weakness is driven by muscular inhibition and pain.

SPEAKER_01:

Correct.

SPEAKER_00:

Well, it sounds like Wind Bleakley and colleagues are going to be releasing a few articles on cuboid syndrome soon. Fantastic. Well, I think we've sort of touched on ankle instability in conversations earlier. So, I'm curious about perhaps, Andrew, your thoughts on how you approach rehab planning and progression in terms of the chronic ankle instability that might present in practice.

SPEAKER_01:

Yeah, for sure. So, I can talk to how we do it here in the clinic. We've got a five-stage ankle rehab plan and the entry point is usually, it can be first-time ankle sprains. Of course, a lot of people don't attend for that. And then the exit point is variable as well. So, to go right through, it's a bit like an ACL goal-oriented stage program that progressively takes them right through return to sport and that is then prevention of recurrence. So, some strategies on that sort of stage five in our plan. But a lot of people exit at stage three if they don't need to do the high-level directional change, limb symmetry index type things that they need to get back to directional change sports. But that's how we approach it here. And it really addresses both what you find clinically for testing in all the deficits, so range of motion, balance, directional change work, landing strategy, muscular imbalances, progressing down stable surfaces, and then creative force development and those sort of high-level things, depending on where they're at. It's largely informed from research as well, a lot of Chris's research as well. The Ankle Consortium, which I'm sure he'll mention, a lot of their great work is integrated into that process.

SPEAKER_00:

Amazing.

SPEAKER_02:

Andrew had mentioned about the consortium, and I think there are some really great resources that they have published over the past number of years. And one of the key things is to look at the various different impairments that will result and that are commonly associated with ankle sprain. And even before getting to that, I guess it's also key to figure out what you're dealing with, which ligaments are affected. Are you dealing with one joint, two joints or three? So is there disruption of the syndesmosis? Is it just ligaments that are crossing the talocrural joint or is the subtalar joint also involved? There's quite a broad spectrum of injury that you can get. They're commonly referred to as ankle sprains, but they're ultimately very different. I think just you look in a kind of helicopter view of it, that's a really important thing for a clinician, I think, to do is to look at that. Well, how many ligaments are involved and how many joints are involved? The more ligaments, the more impact, the bigger the ripple effect will be on mechanical instability and sensory motor control. And the more joints that are involved, then the bigger the impact impact there will be on the joint mechanics and the ability to have a functional foot and ankle complex. So I think that's really important as well. And that's when we talked about palpation to start, but again, that's the beauty of the ankle. The most sensitive test that you have for the vast majority of ligaments is palpation. So if your anatomy is good, you're pressing on the ligament and it's not sore, then there's a very low chance that it's involved in the injury. We also have some good stress tests as well that can help us. But I think once we're getting into the more subtle injuries involving, let's say, the subtalar joint, I think imaging can really help. I know that's not always available, but I think if you can get access to imaging, that can help certainly to rule in or out involvement of the subtalar joint. And then you're working from there.

SPEAKER_00:

Thanks. That's a great summary, Chris. I'm curious in terms of our clinical tests and how well they stand in terms of identifying issues across the talocrural joint, the subtalar joint and the syndesmosis. Clinically, what might make one suspicious of, I suppose, wanting to go down the imaging to investigate the subtalar joint component in that instance?

SPEAKER_02:

It could be just that it looks grossly unstable on supination. Even just something as basic as if the calcaneofibular joint ligament is involved in the sprain, then that automatically brings in the subtalar joint because that crosses both. So that's a very different scenario than an isolated injury to, let's say, the anterior telofibular ligament. So I think just first off, if you look at the epidemiological data, the vast majority of sprains are ATFL. Then the next most common are probably a combination of ATFL and CFL. So I think that's probably a good way to look at your first contact. Is the ATFL involved? probably is, particularly if it's been a supination type injury. It's very rarely going to be a CFL in isolation. They're probably two or three percent. So yeah, you're either looking at talocrural or combination of talocrural and subtalar. I think that's the first thing. I think you could get into the intricacies. There are obviously important ligaments within the sinus tarsi. The ligament of the neck of the talus or cervical ligament is a big, strong lateral stabilizer. But we don't really have clinical tests to look at their mechanical stability. So I think if you're suspicious, I think if the CFL is involved and they're not doing so well, then you should definitely look at ordering imaging and ask about potential involvement of ligaments around the subtalar joint.

SPEAKER_01:

Can I jump in there? I'd love to pick your brains. Are you seeing those subtalar ligaments being reported on MRI where you are? It's just rarely reported on. So CFL will or deltoid, absolutely. But yeah, I rarely see it in any of the reports here.

SPEAKER_02:

Certainly in my experience, the radiologists are getting better at looking for it. I suppose sometimes if they're not looking for it, they won't report it, but just putting that idea in their head when you're ordering it to say that you feel as though that the subtalar joint is involved. Could you have a look? I mean, they will be there. They will light up on MRI. I think hopefully it's something that we'll continue to look at. But yes, it is one of those issues that if you're not looking for it you probably won't see it in there but it does change the game a little bit and as I said I think the more ligaments that you have involved the more problems that you can potentially have down the line the talus doesn't have really any direct muscle attachment it's just floating there and it's at the mercy of the passive structures the more of them that you cut the more it's going to start to spin and rotate and I think that we are starting to see a little bit of that in some of the research in the people with long-standing instability that they are more likely to present with a talus that will drop down in the internal rotation. or move anteriorly a bit more because you've taken away that seatbelt and that restraint. And if the interosseous ligaments in the sinus torsion are gone, again, they're like a check grain to stop that rotation, a little bit like the ACL works in your knee. So when they go, that rotatory instability can be particularly problematic. Again, anecdotally, they can cause foot dysfunction. We talked before about the overloading of the lateral column. I think that can be a massive factor in that. So something to look out for.

SPEAKER_00:

Andrew? Andrew, what's your clinical experience with that?

SPEAKER_01:

Yeah, what amazing insight there that we don't hear much about. And most of my patient load now is chronic. And the chronic instability, they're reporting functional instability, feelings of instability. So that's certainly there. That's objective feeling. But the instabilities seems to be more around the talus, exactly as you said, Chris, that it's rotating or coming forwards and rotating, commonly coming forwards and laterally with the ATFL sort of makes sense. sense, but then there's certainly some that are jammed up medially against the tibia there, the distal tibia. So I find the instability is more at the talus, but the subtalar joint for me doesn't move enough. It's usually gone the other way and is hypo mobile. Is that what you find, Chris? Sometimes. I

SPEAKER_02:

think something just depends on foot type, but one of the subgroups that I would see, and again, the more I look for it, the more I see it potentially. Let's say somebody has got a full thickness tear of their A ATFL and CFL. I do think that they get worse at supinating their foot. And I think there are a number of reasons for that. I think there can be a fear, number one, that drives it. But I also think there's a mechanical driver of that because their talus drops down and in. That creates all sorts of changes. Reading Kevin Kirby's theories around this, he talks about when the talus drops down and in, the axes of the subtalar joint It becomes more medial. The more medial that becomes, then you're really increasing the working moment arm of ground reaction force on the lateral foot. So again, it gets more and more difficult to create high quality supinated reef when you're pushing off. And I think that can potentially be a driver of post pain, FHL, dysfunction. Again, you're in not quite a collapsing foot, but certainly a dysfunctional foot. So I think they become more medial, more pronated. And I think that the loss of range is on supination. They lose that ability to come up. It does stop them spraining to a degree But it really limits their function and it creates a ripple effect on other areas. And they also lose efficiency in their gait and their running a little bit. So they have this kind of pronated, externally rotated foot. I think that's when you need to encourage inversion, strengthening and FHL and really try and build that

SPEAKER_01:

medial arch back up. Spot on. Yeah, it's exactly a description of a lot of the patients I have. And then there's proximal implications as well. That was all there all along or as a result of that. increased trunk lean to the same side, dysfunctions up through the hip and pelvis as well. We'll change the same thing and reinforce that subtalar joint access medialising.

SPEAKER_00:

Incredible insights from both of you. Thank you. Chris, you mentioned this sort of subtalar joint instability on imaging changes the game. What sort of conversations do you both have with your patients when something like that comes back? What conversations are you having around implications for management timeframes for recovery, of course, depending on goals. But yeah, I'm curious about that.

SPEAKER_02:

So let's say you've got a full thickness tear of ATFL and CFL. I think it changes the conversation a little bit for many patients in that probably won't heal. The chances of having a mechanically unstable angle moving forward are high. So I think it brings in the surgical intervention a possibility here. And again, there are a number of mitigating factors around that. Somebody's age, their levels of activity, what they want to get back to. But I think that, yeah, there are different considerations that we need to bear in mind. Surgical intervention, if they're a candidate for primary repair, I think the data from a lot of the cohort studies and actually even some randomized studies and have shown that early primary repair is a good option for certain groups. So again, those who are very unstable and those who are hoping to get back to higher level sport. So I think there's a conversation there that maybe wouldn't be there if this was, let's say, an isolated ATFL injury. I mean, that conversation can still occur with the single ligament sprain, I think. But again, it's very much dependent on the demographic. I'm not sure, Andrew, if that's similar to your experience or what you're currently doing.

SPEAKER_01:

Yeah, it's... really tricky. The conversations with the orthopods I've had late down here is not the same. If anything, they're probably not operating on even higher grade sprains with ATFL, CFL and deltoid and we might put them in a boot for a little while and the surgical threshold has almost gone up a little bit. I think that might be as a result of our rehabs and management is getting a little better, a little more comprehensive instead of put them in a brace or strap them up and let them play again in two weeks. Now we've got a little bit more I think, understanding of what happens with chronic ankle instability and the implications there. So, I think that might be the case. That's an interesting point. You've got me thinking a bit more now.

SPEAKER_00:

I'm curious, Andrew, on that, the ones that you do perhaps put in the boot that might end up in surgery, is it that subjective experience of continued instability that lands them in surgery in the end, as opposed to clinical mechanical instability on assessment? What do you find nudges them into the a surgical room.

SPEAKER_01:

It's different for every patient, that subjective feeling instability for some and others mechanical. Personally, in our patient cohort here, the mechanical instability is usually not that bad. So the tricky thing here is that the sequelae of those events with chronic instability, perhaps in the subtelogen and then that shift in the subtelogen axis and the compensation, as Chris said, that they tend to not sprain laterally again because they've shifted medially. So the problem is they will present then with medial overload. So they'll present with medial symptoms more so. And then if you send that one to a surgeon and they've got medial pain, then it's a surgeon that's got extra time, which is a rarity to think that through and then potentially want to operate and stabilize them laterally. Because some of those, if they get over-tightened, the consequence is even worse. So, they mechanically stabilize them, whether it's a Brostrom repair, a common one laterally. And often here, Chris, they're using a lot more Waldmentis implants on top of it as well, which is super Yeah. In my experience, most

SPEAKER_02:

of the surgeons, they're more likely to operate if there has been failed, what they call failed rehab. And that can vary depending on what surgeon that you speak to. It can be a tricky area to get into because what do the rehab entail? How intense was it? How adherent? But a lot of the cutoff points in the literature, certainly that I would see, They'll give them 12 weeks of some type of rehab. If they're still not working well, then that's at least the time to have a conversation around it and an honest conversation. First of all, did you do the rehab? Was the rehab adequate? And if the answer to both of those is yes, then potentially there's a surgical intervention there. I think it's very much patient dependent.

SPEAKER_00:

Again, some fantastic clinical insights. Going all the way from the chronic end over to acute ankle injury, sort of diagnosis and management. How do you think we as physios are faring in the way of what our ankle injury assessment looks like in the acute stages?

SPEAKER_02:

I think for some ligaments, we can do really good evidence-based assessment, accurate, high sensitivity, specificity. ATFL, we're good at ruling out fractures with the highly sensitive Ottawa. We can palpate ATFL well, and we've got a number of different ways to do a draw test. So if somebody's tender on palpation and they've got increased laxity on the draw, with a sulcus sign, then yeah, we're really good at ruling in ATFL injuries. I think CFL were pretty good as well, both in terms of diagnosing and maybe not just as good at grading. The reason CFL, I think, is a little bit more difficult is obviously its anatomy. It sits under the perineal, so palpation just isn't as sensitive. But various different iterations of tailored tilt, I think, in experienced hands, pretty good at ruling in. I think you do get some false negatives with those, but I think all in all, Looking at the clinical picture, we're good at those. High sprains, it's a little different because again, the tests that are available to us, not all of them are good. So I think if I was really going to put it in a nutshell for high sprains or distal syndesmotic involvement, I think we're good at really not both in and out. But one of the things that we will struggle with just using our hands is determining particularly those mid grades, the 2A, 2B, because the good tests that we have there are pain provocation. Rather than actually determining the mechanical instability. So there are, I think for new physios, high sprains can be difficult because there are probably several tests that I can think off the top of my head. And only about two or three of them are any good. But none of those tests will tell you much about how lax it is. If it's a really open book one, it's obvious. And the more minor ones are okay. But it's the ones in the middle that are always the tricky ones. So I think it's a mixed bag. It probably depends on what ligament we're assessing.

SPEAKER_00:

If there's a half dozen tests, which are the two or three that you'd like people to keep in their toolkit?

SPEAKER_02:

I'll tell you the ones that I use and my approach to them. Maybe Andrew can see if he agrees or maybe he does something completely different. But the three tests that are useful, I would first of all do the squeeze test. So again, you're kind of starting proximally in the lower leg and you're squeezing tib and fib and it's pain provocation, essentially. I think the literature and certainly my experience, they're only really positive in the higher grades. You work down through there. If that's negative, then you kind of move on to the next stage where you put a little bit more stress through the syndesmosis. So Again, in a non-weight-bearing position, I would dorsiflex and externally rotate the foot. So again, you're looking to shunt the fibula laterally to try and widen the mortis to evoke pain. And then if that's still not positive, I would get them in the weight-bearing position. And again, almost looking at a combination of the tests whereby you're getting in the dorsiflex to widen the mortis. You can add in a little bit of a squeeze and even bringing in if they drop their knee in the medially to again create relative external rotation. of the foot and that's probably the most provocative if that's not positive and they don't have pain in their AITFL or that region then they probably don't have a high sprain but as I said that tells us nothing about the grade I think you need to look more Holistically, there'll be levels of swelling and bruising. And I think then that's when imaging can help as well to really nail down a grade because that's really key then in terms of how aggressively or conservatively you

SPEAKER_01:

manage those. All the same for me, pretty much the same sequence, squeeze test. The only one I throw in there as well is palpation, but you need to know how to find it in the right spot. And I used to know the exact numbers of sensitivity and specificity to these, but I can't recall them tonight. I know the cluster is pretty good. Yeah. Then into dorsiflexion, external rotation, exactly the same. And then finally, if they can, a hop test. And I completely agree, squeeze test. I find it's rarely positive unless it's a grade three. And you'll pretty much usually know that before they even come into the table from the degree of trauma and the exact mechanism and usually struggling with weight bearing, but not always. Yeah. But location of swelling, I think is super important. Take your time. I think finding the mechanism of injury will give you the major clues and Where are you going? really with the foot and ankle, just really take your time and really have a good hunter around everything and look where areas of swelling are. So those grade twos are the trickiest of course, as Chris said, and the 2A and 2B, you can't really tell clinically. Here in Melbourne, we're operating on those a fair bit still, any twos, and then they'll nose it at arthroscopy with putting a probe in between so they can spin it sideways to measure the degree of separation there. But usually they've already told the patient that if it's closer, because I'm already in there and you're prepped. And the ether ties, we're going to put a tightrope anchor across it anyway. And I think, yeah, so there's been a lot of work done here in Melbourne to try to figure out a better way of trying to imaging these, including a weight-bearing CT scan and the like. But generally speaking, we, even grade twos, we give them a go and see if they can get back to function within a reasonable time window around about that 12-week sort of period. And a lot of them do, but I guess if they're a professional athlete, then we don't want to take that risk that they fail that because they've lost so much time. Plus, we don't know the long-term consequence to that either. I'd love a 20-year follow-up study on what happens to those, but I don't think we've got that, have we? No, not to my knowledge.

SPEAKER_02:

And you mentioned palpation, Andre, and I think palpation can also help with prognosis. So again, one of the things we know from the data, if you have a patient who is not just tender around the distal part, so around AITFL, but if they have much more proximal tenderness as you move up the interosseous membrane then that's normally a worse sign. Also if they have posterior pain so if PITFL is involved or if the medial ligament is also tender or if any of those are showing up on MRI they seem to be associated with the worst prognosis. I completely agree as well about the longer term follow-ups because certainly a lot of the cadaveric data and even some of the the modeling studies that they show just how important it is to have stability around the distal syndesmosis. And even small levels of laxity, they completely change the force distribution, the force magnitude in and around the talocrural joint. Yeah, across the talus. Yeah. Yeah. So that does change the game and those kind of load spikes will really start to wear down the cartilage pretty soon. So again, need to be careful and I think just judicious. And that's definitely an area we need some more work on.

SPEAKER_00:

That was probably going to be my next question. I think you mentioned skilled hands and assessment. And I think the wisdom that you both offer in this conversation, it's highlighting the skill set that we have with our hands and our objective assessment and our anatomical knowledge. Do you think we could be doing any better in the way of, for the clinicians listening, the dream Taylor tilt test and how it's actually done? What sort of errors do you notice clinicians making or rather opportunities for improving how we're actually mechanically performing the tests?

SPEAKER_02:

Well, there's a bit to go through there, isn't there? One bit of advice, make sure that the ankle, the foot and ankle, or the calf musculature, the triceps surae are relaxed. And also... I wouldn't go straight into the test. Just try and just do a little bit to get to know the foot and ankle. You know, what foot type are you dealing with? How does their big toe move? Just some gentle pronation, supination movements. Just do some passive work first. Don't go straight into a big, heavy thrust of a test. Get to know what you're dealing with. And yeah, Andrew had said it, just take your time. You're dealing with small ligaments and pretty subtle movements. Your hands need to be fairly soft. You mentioned the Taylor Tilton. I think that's probably done on average worse than let's say a draw test or the other test that we talked about for the high sprains I wouldn't just do one. I would probably make sure that you try it with the foot in various positions in the sagittal plane. Probably the common mistake I see students make when they're under pressure in an exam or an OSCE situation is that they're doing tailored tilt tests with the foot in complete plantar flexion. And again, if you respect the anatomy in that position, the CFL isn't really doing much. It's practically horizontal. So maybe starting in neutral and even repeating the test in a degree of small door I think the other thing I've seen in the literature, which again was done pre-surgery, they were just looking at the magnitude of movement. What they found was that they got more tail or tilt if they internally rotated the foot slightly before actually creating the virus strain. And their rationale was that you're less likely to miss if you're moving through a greater range. isolating the movement to the rolling the talus within the mortis.

SPEAKER_01:

I can add a few things in here. Firstly, I think it's really hard on physios because obviously we've got to learn all the anatomy and then we come out. And then if we don't see a lot of foot and ankles quickly, I mean, okay, we might get some ankles, but we rarely get feet unless we're in a pretty lucky environment. We don't get to practice that application of that anatomy fast enough. So I think it's pretty tough to start off with. That's the situation I was in. I was lucky enough to have some really good mentors and they could teach me a lot And then I had to go back and refresh all my anatomy. I'm still always needing to refresh my anatomy. So, I think it's tough to start off with. The shift away from manual therapy is making things a lot worse. And so, that's putting us even further behind as a profession, I think, because you need precision. As Chris said, the joints and the ligaments are really small. So, you need really precision with where you're directing your force. And once you've got really soft hands, as Chris said, and good handling and you're confident with where to stabilize what because so many parts move so if you just grab a foot by the end and move it around everything's moving so you've got to be able to really lock down one area and stress the other which requires to know where those bones are and then how to put your things on them and how to really stay it doesn't need much force as long as that force is directed to the right spot so you're really precise one thing that helps with that is putting the plinth up as high as possible and sitting on your treatment stool I don't do that all the time I sometimes do it when I'm struggling to get a patient to relax so the patient's sitting on the side of the bed with the feet dangling and you put your treatment table max height and then you've got the foot with the calf complex really relaxed and you can move things right in front of you and that's quite a nice way of help aiding and testing.

SPEAKER_02:

That's also why physios should never wear ties in the clinic because if you're wearing a tie it just dangles around and gets in

SPEAKER_01:

the way so no ties. Tie clips that's why my first boss we wore ties and we had tie clips. Yeah that's a more sensible suggestion.

SPEAKER_00:

So you don't have to get rid of the ties

SPEAKER_01:

yeah let's bring it back Chris no thanks

SPEAKER_00:

thank you both Andrew and Chris you've both brought a ton of nuance and evidence and wisdom to today's conversation and hopefully I think you've helped us be more critical and practice more purposefully with our anatomy in mind as well so thank you very much to both of you for your time

SPEAKER_02:

it's an absolute pleasure thanks it was really good really enjoyed the conversation

SPEAKER_00:

music