Ankle Surgeon explains BEST Ankle Sprain protocol

[00:00:00]Dr. Desai is an orthopedic surgeon and he specializes in uh foot and ankle surgery in Toronto. Um he is uh incredibly skilled at what he does. And um you know I had the pleasure of hanging out with him in Toronto, him taking me through his operating room and showing me some of the surgeries. And today we're going to be talking about sports injuries and how to recover quicker. Um I think some of the topics that we'll go over is ankle sprains. um some of the misconceptions of recovering from that and uh some of the other ankle and foot injuries that he sees.

[00:00:36]>> Thanks Jeeoff. Yeah. So um Jeff asked me to talk about you know I like exciting topics. I get to do some cool stuff and Jeff said, "Yeah, do you mind me like talking about ankle springs?" I like Jeff come on man.

[00:00:46]Like this is the most boring topic ever.

[00:00:49]But it's an interesting topic in that I I do have a high volume orthopedic practice and foot and ankle practice and I see a lot of ankle sprains obviously at various stages whether it's from you know the day of the injury the week of the injury month later 2 months later 6 months later I I see a ton of different patients at different levels at different times from injury and the one kind of key factor and I see in pretty much 90 say 95 to 99% of patients is the initial management in the first few days weeks months often is not ideal and not optimal. Um, and considering such a such a, you know, simple injury and such a common injury, which I'm sure you see a lot of, um, the fact that it's mis I wouldn't say mismanaged, but managed in a in a in a non ideal way is pretty surprising. Um, and that's why I think I'm just going to go through a very quick kind of discussion here with Jeeoff about, you know, what I would look for in terms of, you know, if you get an ankle sprain, what to do, you know, right away and and how not to delay. So, Jeeoff, if I can just um share my screen with you.

[00:01:51]>> What do you see? Yeah. Oh, yeah. Sure. I was going to ask, what are the things that frustrate you the most when uh you see people with ankle sprains that are eventually referred to you? You There must be some things that drive you absolutely nuts.

[00:02:01]>> I wouldn't say it drives me nuts, but it's it's frustrating in that um they don't start therapy. They don't one, they're way too conservative in terms of keeping the weight off the foot, not getting back to activities, not doing therapy. Um, so I think that's the biggest thing is just delaying the onset of um getting back to therapy, starting therapy, getting back to sport. There's there's always these major delays until I see them. Uh, and everyone wants me to see them first and then give them the clearance when, you know, the the the time for recovery and the the time to begin the process of recovery doesn't start with me. It starts with, you know, the day of the injury. Yeah. Yeah. So, we'll just kind of go through it's it's relatively small little talk here, but um and we can obviously have a chat as we go through, Jeff. So, I mean obviously it's the most ankle common ankle injury. I would guess Jeff is probably the most common ankle injury you see in the emergency department setting, uh family doctor setting, physiootherapy setting. Um and I see a lot and as I mentioned the initial management is I'd say 90 plus% of the time not done appropriately. Um very quick anatomy review. Everyone knows this already but you know the the major two ligaments on the outside of the ankle is the ATFL or anterior tailor fibbral ligament and the CFL or the calccano fibrillar ligament. The ATFL being the one that is most commonly sprained because as you can imagine if your toe is pointing downwards or planter flexed and you invert your ankle that specific ligament is more vertical.

[00:03:24]And just a simple thing um inversion versus eversion. Um I ask my patients this all the time like how what was your before I looked at the X-rays what position was your foot in um and inversion means your the lateral side of your foot goes inwards and ever means it goes outwards. This specific uh distinction in terms of the actual mechanism can kind of give me some clues on what to look for on clinical exam and X-ray. My clinical exam and X-ray assessment are the same each time. I don't kind of cheat. I do, but I don't I don't think about it too much. But it's just nice to kind of, you know, guess what the injury is before you actually see the X-ray. So, I always kind of ask, you know, was your foot in this position? And sometimes patients don't even realize what what happened, but it's almost usually it's an inversion injury. And it's kind of here's a classic couple examples, right? There's thousands of thousands of examples of this. So, these are classic inversion injuries.

[00:04:15]Obviously, you see, you know, swelling, bruising, tenderness over the fibula, potentially lateral ligament complex, really kind of standard findings with an ankle sprain. Um, patients may walk in, they may limp in, they may be wheelchaired in, various different levels of dis um, you know, disability based on multiple factors. Um in general it's a clinical diagnosis and I don't know Jeff how much you you use the auto ankle rules but you know this is you know may may be a controversial statement but if I have a patient comes in has a bad inverk injury and they come to see me they are getting an x-ray every single time now you may say this well the auto ankle rules the whole point is to avoid unnecessary x-rays the nature of our health care system now is I' and I've seen this you know when a lawyer has come to me and say hey this doctor missed this injury what do you think and it's often you know, an inversion injury and it's a little flex little little like avulsion fracture which is I don't want to say it's irrelevant but it's kind of irrelevant but the doctor missed a big fracture and that becomes a medical legal nightmare.

[00:05:16]So although I don't like practicing medical eagle medicine, this is a part of it and it's just a reality that if I quote unquote miss a small little avulsion fracture which is completely irrelevant in the eyes of a medical from a medical legal perspective, I missed a fracture period. And if someone claims, oh now I'm completely disabled [clears throat] because you missed it.

[00:05:37]Frankly, I'm not going down that path.

[00:05:39]So, if someone gets an ankle sprain, I mean, I I know auto it's I'm in Canada and the auto anchor rules I should be following it. I I personally don't because I've seen a number of times where it truly doesn't fit this criteria and they have a fracture and vice versa, right? So, I mean, it's it's a nice little template, but I mean, I frankly just don't use it. I'm not sure, Jeeoff, if you if you go through these points when you examine a patient. My guess is you don't, but uh >> Yeah. Yeah. Yeah. I I um so [clears throat] I'll preface this by saying that the person who created the Ottawa ankle rules was my medical school mentor. He was like my research supervisor from the first year of my medical school training all the way to my fourth. Uh but I actually >> don't show them this video.

[00:06:25]>> Yeah, I won't show them this video. I I actually do not follow the Ottawa ankle rules. And it's for the exact same reason. I have been in practice for now over 13 years and I've seen many patients that actually do not fit the strict criteria by the Ottawa ankle rules who end up having fractures. So for anyone who is not aware of the auto rules, what these rules say is if someone is able to weightbear both at the scene and in the emergency department and they um essentially do not have tenderness at four key points in the foot or the ankle, then they do not need an X-ray. But typically, you know, there's some deep part of me as an emergency physician that feels really uncomfortable having patients wait in our waiting room for like 4 6 8 hours to be seen and with an ankle injury or a foot injury and they're really concerned and they're limping around and for me to be like, "Oh, because of this piece of paper, I'm not going to send you for an X-ray." which really takes like all of like 5 minutes in the emergency department and it's such an easily accessible thing for me to do and it provides so much information for me to actually see what's actually happening in the ankle and foot. So, uh that's primarily the reason why I do not use it. I can definitely see like the utility of using this if you're in an underresourced area that if you don't have X-ray that's readily available, you're in a rural area. Um, but for, you know, an urban or academic center where it's super easy to get an X-ray just like that, I mean, I order X-rays for pretty much anyone that comes in with an uh an injury like that.

[00:08:02]>> Yeah. So, usually X-rays in these kids are obviously normal and I I present anybody. So, Jeeoff, here's a question for you. Although you're I know your job as an emergency physician is to rule out more sinister injuries and you get them on their way. I understand that. So the question becomes to those who see patients either in the office setting or even in the Mur setting. You know after an standard inversion ankle injury and you diagnose someone clinically with an ankle spring with normal X-rays, what's the next investigation? Um ultrasound, MRI, bone scan or none of the above? I'm not going to put you in the spot yet, but I mean what would you consider?

[00:08:34]>> No, no, totally. Yeah. I mean like typically none of the above. Uh, typically what I would do if I think that this is truly just like a typical ankle sprain from an inversion injury, what I get the patient to do is weightbear tolerated. That means that I'm getting them to mobilize as much as possible. Often times that means that they're kind of just toe touching on the ground with crutches. And as the swelling and the pain kind of subside over the next one or two weeks, they're putting more and more weight on it and trying to go through the full range of motion of the ankle to kind of lubricate the joint with with the synovium. and then you know in two to four weeks they're seeing a physiotherapist to regain that balance and the strength to actually tighten up those ligaments. But you can tell me if I'm wrong here.

[00:09:15]>> Yeah. Yeah. I mean I generally do none of the above. And here's the reason is again I would say 95% maybe even closer to 100% of my patients who come to me have had an ultrasound like almost every single patient. I don't think it's wrong, but I do think ultrasound personally is the most overutilized tool in the foot and ankle in foot and ankle imaging because the reality is if if you have an ankle sprain, the ultrasound is going to show some form of lateral ligament injury. It's super tech dependent as well as radiology dependent determine is this a grade one, a grade two, partial, full, this, that. So, I mean, I I I'll look at an ultrasound report because people bring it into me, but I I find almost zero utility. The only time I would order an ultrasound exam in the foot or ankle is if I have some clinical suspicion of like a paranal tendon injury, something something else. I can't like I see a lot of patients every week. I don't I can't remember the last time I ordered an ultrasound for anything. It's like pretty uncommon. But in a acute scenario I would say ultrasound for not for sprain but if they they have severe pain over their paranal tendons severe pain over their tibio tendon something else then I would get that even the Achilles tendon if it's a clinical exam if it's a clinical diagnosis of a full rupture to me there's really no role for an ultrasound and everyone kind of pushes back on that because like they want to see it but I have seen so many partial ruptures partial Achilles ruptures on ultrasound that are full ruptures and vice versa right we like possible full rupture again so tech dependent so operator dependent that it's really not an effective way unless I'm looking at something specific so to me ultrasound no MRI definitely no a lot of my professional athletes have an MRI within 2 hours of injury and you know it shows exactly what I expect right lateral ligament tears but only caveat here is that I I if I for my professional athletes who get MRIs within an hour and I see them most of them do have some bony bruising in their tailis or their ankle joint. Um, so I don't get a lot of MRIs on my ankle sprains, but if I am MRI everybody, I'm sure I'll see some bony contusions suggesting that, you know, the the bones struck each other as an ankle sprained doesn't really terribly change my management. So that's why I don't get it. Bone scan, I've seen some people with bone scans. To me, there's absolutely no role for bone scan in foot and ankle pathology at all. I think it's a massive amount of radiation and I don't think it's necessary. If I'm concerned about like a stress fracture for example, um I would actually just go straight to an MRI, um I don't really find bone scans terribly helpful.

[00:11:47]>> Yeah. And again, the reason why um is tech dependent, radial dependent, but the biggest reason is I I cannot even tell you how many people I've seen come to my clinic and they have not started their treatment because the ultrasound showed a tear of their tendon or their ligament and their doctor, their physio, their whoever told them unless daughter decided it's okay, you can't start doing something. I saw a professional soccer player I think I can't remember what it was now two days ago yesterday that was in a very high you know a very good institution had the best therapist and he said I I wasn't allowed to play until you told me to and sometimes it takes a bit of time to come see me so you know I've had people delay their start of initiation of therapy for weeks and months because of a quote unquote full tear of their ligament um and until I gave them the blessing to start therapy and these are people that should be starting therapy within 24 to 48 hours of injury. So that this ultrasound, these positive ultrasounds have delayed treatment in so many of my patients. I don't know that's necessary reason not to get an ultrasound, but we'll talk about later about treatment, but it does complicate the picture. Um, and I see it. I'm not exaggerating. I say every single day is these delays in treatment [clears throat] because they're worried. And I get that, right? You're not a physician. You're not in you're not in this world. My entire ligament's torn. I must need surgery. Well, no, you need physiootherapy. So this is a really kind of touchy topic for me uh in a way that you know it's I've seen so many patients mismanage because of a positive ultrasound.

[00:13:16]>> Mhm.

[00:13:18]>> Again right kind of old school right so um this is what I was taught when I was in school rest ice compression elevation. Now obviously things have changed now a lot and the first most of this is correct the first one where is rest. there is some truth to that but you know we know now that you know resting and you know putting a cast on and and keeping non-weight bearing is not the right thing to do so um admittedly I don't follow these types of algorithm like these kind of like police and peace and love it's it's more of a kind of a academic thing um I >> I've never heard of this before >> yeah I I've heard of it so I kind of looked it up to see what it meant but um I I kind of naturally do this anyways but the whole point here is you know we want to get straight to you early initiation of of range of motion, early physiootherapy. It's been shown in, you know, every aspect of orthopedics um to be beneficial, not just foot and ankle, not just ankle sprains. So, um to go through this kind of relatively quickly, um initially kind of protection, uh versus, you know, old school casting.

[00:14:19]And I'll talk to you about my kind of general um approach here, whether it's bracing, c uh boot or or um stirrup initially. Early weight bearing obviously, right? So, you know, that's where the O comes in, I guess, is, you know, old school was cast, you know, even like nonweightbearing for weeks with a full rupture, a full full tendon tear. Now, we kind of recommend obviously, you know, early early vaping and the rest is kind of similar to before ice um for for swelling control.

[00:14:46]There's there's a lot of studies coming out now suggesting that ice might not be as effective as we think. I still think it's a good thing to do. I I mean I'm in my 40s and I do things I probably shouldn't be doing from a training perspective and I I get injured all the time and I use ice all the time and I still think it's very beneficial to me.

[00:15:03]I find it very helpful. Uh and I think that's the general nature of what most my patients find it quite helpful despite some of the evidence suggesting otherwise. Compression just to decrease swelling, I'll get to that later. And then elevation, you know, uh potentially helpful.

[00:15:20]So here's kind of my general algorithm.

[00:15:22]So, a minor injury. What does minor mean?

[00:15:26]Minor just means that the patient comes in, they might be limping a bit, but they're walking on it. They have some swelling and bruising, but it's not verely swollen, bruising. So, basically kind of the grade one ankle sprain. I don't even immobilize those. I let them walk immediately. So, from an immobilization perspective, no real immobilization and immediate weight bearing. The more severe ones, um, that's where kind of boots can come into play a little bit. If someone comes in, they're like, you know, in a wheelchair, they're getting pushed in or they can't put their foot down on the ground because there's so much pain. Um, that's where I think some level of immobilization is helpful. If you look at the boot pictures here, the classic thing for an ankle injury is a tall boot. For me, for something like an ankle spring, I think a shorter boot is completely fine. It still mobilizes the ankle. It's way more comfortable for the patient. So, I use short boots when I'm technically supposed to use long boots all the time. I just think it's way more comfortable for the patient. And you know these tall boots are kind of unnecessary for something like an ankle sprain. Whereas if I'm doing a massive tibia fracture or something, there's obviously benefit there. So to me, if someone's like lally can't walk and they have a lot of swelling, a lot of bruising, I would classify that more just clinically as a grade two or three.

[00:16:31]And that's where I would suggest boot brace of some sort and immediate still immediate weight bearing, but some protection just to get them through the first, you know, 5 to seven days.

[00:16:44]What is the So what is the risk of not using a boot? So if you tell someone to you know just like weightbear is tolerated without having that immobilization like the you're saying that it protects the ankle. So is it like the risk of actually re-rolling the ankle and injuring it further or >> No, it it's it protects the ankle to allow someone to wait bear to be comfortable.

[00:17:07]>> There's really to me there's no huge risk in terms of reinjury at that stage.

[00:17:11]They're usually pretty swollen and painful. It really just allows them to feel be comfortable and begin weightbearing. It's really just purely from a from a pain and function perspective. Doesn't actually necessarily quote protect the ligaments or anything like that >> cuz I [clears throat] would still in those situations which which I'll get to in a moment. I still recommend walking on it and I still recommend wearing the boot for a relatively short period of time until they feel comfortable getting out of it. [clears throat] >> So in terms of like this kind of police thing, right? So want to go back to it again minor no moization immediate weight bearing immediate physiootherapy ice compression ovation the only difference here with my more severe ones like I said the protocol is the exact same we just slow things down a little bit purely because I don't send my patients who have severe ankle sprains to a physiotherapist one day after injury I just think it's it's a waste of their time and money because they're so swollen and painful they're not going to be able to do anything. So this is where you know quote unquote rest although I just said we shouldn't rest ice we shouldn't use rice I I do recommend saying for the first few days at the very most one week is just take it easy ice it compress elevate but for some of these people who are so painful I just don't think it's realistic to start a functional treatment program so quickly um so for my more moderate and severe sprains I do place them in a boot or stirup brace and I'd say you know maximum 2 to 3 weeks in that in that boot or brace Uh, and I I give each of my patients a very specific protocol to to begin um their rehabilitation and to progress through their rehabilitation rehabilitation quickly with specific um instructions in terms of once the patient's feeling well without a boot and get rid of the boot. The boot is certainly not necessary. It's more really just for have them to get around, still be able to go to work and still be able to go to school and still be able to do their regular duty, regular life um responsibilities um a bit more comfortably.

[00:19:03]And then functional rehab is a is a is a staple, right? So strength, range of motion, balance, prop reception. The whole goal here is to strengthen the ankle up, maintain range of motion during the early phases so you eventually do do not get a stiff ankle.

[00:19:18]Work on balance and prop perception. So the ligaments as they're healing are healing strong and they're healing in a in a in a fashion that allows you to have good balance. And then it's an active program. So I'm very I'm very specific on my protocol saying active program meaning the patient is doing the work with an adjunct [clears throat] being the passive stuff. And the reality is in a lot of these in a lot of these you know um therapy settings the passive stuff is what kind of is easier for the for the clinician. Um it makes you know financially it's it's it's more lucrative financially if you stick someone to an ultrasound you charge them for attends red light. There's all kinds of stuff. I have no I I have I work in a place where I'm in a big Toronto center where most of my patients don't come from my area. I don't have a specific physio place for with my physio there for that reason cuz most of my patients don't live near me near near where I work. So I can't control where patients go. But ultimately the one thing that's that try to drive me crazy is like they come to me 6 weeks later like yeah I just been doing some ultrasound and some laser and some this and that. And to me again, 90% of your program should be active and 10% should be the adjunks. I have no problem with these adjunks. I'm not against red light, whatever. Put put your foot in whatever light you want. I don't really care. But just make sure that's only a small part of what you're doing, right? Um because it's not like I don't believe in that stuff. I just believe in the active stuff more because I know that's ultimately what's going to get them back. Whereas the passive stuff is good for kind of swelling management, maybe some pain, but ultimately we need the active program.

[00:20:52]So, how early are you actually getting people to start functional rehab after an ankle sprain?

[00:20:58]>> So, as soon as possible. So, let's say it's a minor ankle sprain. I don't see a lot of those to be honest, but let's say it's a minor ankle sprain. They're kind of limping in. Um, I would say start the next day, you know, start start right away. If it's a more severe ankle sprain, they're not able to weightbear.

[00:21:13]They're not they have a lot of swelling, I would say start in 5 to 7 days. So, it's still pretty quick. Um, but I still think like let's say someone comes and they're really, really swollen, they're really painful, they can't walk. Even 5 days later, they're still swollen, they can't walk. I still think starting some gentle range of motion at five days, even grabbing the bands and kind of working on some, you know, some passive motion. I still think that's helpful.

[00:21:35]Um, so yeah, I say 5, seven days would be kind of the the latest I would recommend for the most severe ankle sprain. Gotcha.

[00:21:42]>> And again, it might be very limited to start, but at least get something started. And the reality is like physiootherapy is is it's it's expensive, right? So you I tell them go once a week, learn something for the week, do the rest on your own, go back the next week. And I think most people can handle handle that both from a pain from a time perspective and from a financial perspective, you know, once every week, once every two weeks. I think most physiootherapists understand that too. And it's mainly their job is being the education and and track tracking progress and progression.

[00:22:11][clears throat] >> Totally.

[00:22:14]>> Bracing. So, some people would say if it's like a minor sprain or a moderate sprain, instead of putting a boot on, you can do something like a brace. Um, that's certainly doable. Um, but mainly, um, for me, after you've done a therapy program and getting back to sport. So, I have a ton of ton of highle athletes and I and I recommend these all the time. I say, you know what, until you're 100% comfortable getting back, until you feel confident with your ankle, until your physiootherapist determines that both ankles are kind of equally strong, you know, use a brace of some sort. some people I had a a pro pro soccer player who um just didn't feel comfortable on the on the like he was strong he was doing great didn't feel comfortable on the field so even the mental part of things having a brace significantly helped his game without a brace just didn't feel confident with a brace he played like he did before his injury so I do think there is a role for bracing obviously what you don't want is to wear a brace 24/7 and I've seen that right I've seen people come in 6 months later they're wearing a brace full time I I don't think that's the right thing to Do I I my my instructions are very clear.

[00:23:13]Brace when playing sports or brace when doing something that would be considered high risk. Hiking, you know, running on uneven terrains. But for the most part, the brace should be off. And because I even think just basic walking on a flat surface is a form of physio is a form of therapy. With the brace on, you kind of lose that, you know, balance perception um aspect. So I say brace use very selectively.

[00:23:36]>> Yeah. True.

[00:23:38]Um, and then some people definitely, like I said, definitely use the brace.

[00:23:42]They use it, you know, for their entire career. I mean, look at Steph Curry, right? He's wears a brace to this day because he's had multiple injuries. And that's completely fine. Um, if he's wearing it, an hour and a half, two hours a day, um, you know, for twice, three times a week, that's not going to cause any long-term problems for him.

[00:23:58]Compression socks, I recommend starting quite quite early. Um, I see so many of these injuries. I have a standardized form that has everything already on it.

[00:24:06]And compression socks is a standard part of my protocol. Very good studies now showing actual not just people feeling better, but there's actually good literature showing quicker recovery. Um, it's evidence-based. And I generally recommend kind of medical quote unquote medical grade 20 to 30 millcury below knee daily use after an ankle injury. I think this is so again I do a lot of ankle surgery, foot surgery. This is a part of every single one of my post-operative packages. Every single one has a recommendation for a um compression sock. The only caveat being is when to start it. So, for example, if I'm doing like some major 4 foot reconstruction, um people aren't going to feel comfortable pulling a compression sock on at 2 weeks or or even 6 weeks. So, I just basically say for my big surgeries, 6 to 12 weeks in that range when you feel comfortable. for an ankle sprain.

[00:24:56]Again, it could be the next day, it could be one week, two weeks, but I definitely definitely recommend it. Um, and I recommend 20 to 30 as kind of the medical grade. Also, like just from an insurance perspective, the insurance starts covering these usually at 20 to 30. So, some people say, "Well, my ankle's too sore. I can't get the I can't get a such a tight brace uh compression sock on." Then, I tell them to instead of getting a lower grade that's not to be covered by their insurance policy, get the same grade um but just get the one that's too big. Uh and that way it kind of gives you some compression but it's you know the insurance will still cover it just a kind of way of getting around uh um insurance issues which is a huge huge factor for a lot of patients.

[00:25:35]>> Mhm.

[00:25:36]>> They went to refer to me right so I I mean technically speaking I shouldn't be seeing acute ankle sprains because they're not really a surgical problem.

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