From Sprains to Bunions: Making Sense of Common Foot & Ankle Issues

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the cornerstone of the human body is the human foot and ankle.

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They're remarkable structures with 26 bones, 33 joints, and more than a hundred muscles, tendons, and ligaments working in perfect harmony to support our weight, balance, and movement.

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Yet they're often taken for granted until something goes wrong.

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Whether a simple sprain, a stubborn bunion, chronic heel pain, or even end stage arthritis, problems in the foot and ankle could profoundly affect mobility and quality of life.

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In today's episode, we'll explore this fascinating region.

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GPS and medical students should look out for in everyday presentations, how to assess and investigate common conditions when a referral to a specialist is appropriate, and what modern surgical options including total ankle replacement can offer.

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Joining me to unpack all of this is Dr. Peter Stavrou, an Orthopaedic surgeon who specializes exclusively in knee, foot, and ankle surgery.

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Together we'll discuss how advances in technology, implant design, and minimally invasive approaches are reshaping the way we treat these vital joints.

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And more importantly, how we can help our patients stay mobile active and pain free.

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Good day and welcome to Aussie Med Ed.

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The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists.

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Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon.

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I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced.

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I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture.

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I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions.

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It's just general advice and may vary depending upon the region in which you're practicing or being treated.

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The information may not be appropriate for your situation or health condition.

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And you should always seek the advice from your health professionals in the area in which you live.

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Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organizations such as Lifeline in Australia.

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well.

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Today I'm joined by Dr. Peter Stavrou, an Orthopaedic surgeon based in Adelaide, south Australia.

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He specializes exclusively in knee, foot, and ankle conditions and is past president of the Australian Orthopaedic Foot and Ankle Society, and he has over 20 years of experience in this subspecialty.

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Since 2003, Dr. Stavrou has dedicated his practice to the management of foot and ankle disorders, ranging from arthritis and deformity to sports injuries and complex reconstruction.

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He has a particular interest in minimally invasive keyhole bunion surgery, patient specific joint replacement, and the treatment of ankle arthritis, including total ankle replacement.

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He's actively involved in training the next generation of Orthopaedic Surgeons as a principal supervisor of a foot and ankle fellowship program, and he contributes to the National Joint Replacement and Audit through his role as clinical advisor on ankle replacements through the Australian Orthopaedic Association National Joint Replacement Registry.

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It's a real pleasure to welcome Peter Stavrou, to Aussie Med Ed To talk about foot and ankle conditions from everyday cases in the GP clinic to advanced procedures like total ankle replacement.

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Welcome Peter.

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Thank you very much for coming on board.

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Hi Gavin.

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Thanks for having me, mate.

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It's a real pleasure to be here and we'll cover lots of ground today, so hopefully be very informative for everyone.

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Excellent.

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Well, look, I thought we'd start off with this basic simple question.

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From your perspective, what are the more common ankle problems that medical students and junior doctors need to be aware of or they might encounter in primary care or in the emergency department?

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Well, trauma is common, so though for those in the ED that it might be a slightly different type.

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You can have high energy, trauma, car accidents, falls, that sort of stuff.

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So here making the diagnosis is the key, and then usually referral.

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'cause these sorts of things will often require surgery.

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But in other settings, in the ED or in general practice trauma can also be low energy.

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And that can be things like sprains, undisplaced fractures.

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So this isn't so clear cut.

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Sometimes the diagnosis may be a little bit tricky in terms of which investigation to use.

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And sometimes even something that appears to be a fairly trivial mechanism of injury or trivial injury can have significant pathology with it that you really need to be aware of and not miss.

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I like to try and think of trauma as a fractures, dislocations and infections, and obviously when the foot and ankle conditions might be tendons or nerve conditions too.

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When you see a patient with an acute ankle injury, what's a key history and examination aspects that you use to help divide up your specific traumatic conditions that you see?

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Yeah.

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Well, I think the mechanism of injury is important that will help you define, hopefully, where this is a high or low energy injury.

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Simple things like could they walk after the injury straight away, or if they're playing sport, could they play on, could they finish the game or did they have to come off the field?

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So things like that give you an indication of the sort of significance of the injury to some degree.

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Examination in the acute setting can be really quite difficult.

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People are sore, they're very swollen, so sometimes your landmarks may not be obvious due to the swelling.

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And it may be very hard to localize where exactly they're sore.

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'cause whole foot and ankle hurts.

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So that is really difficult.

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And even the pain may be difficult to put a finger on.

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It just hurts everywhere.

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So I think that's the tricky bit in acute trauma is trying to narrow it down to a particular injury.

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So the mechanism in the history can help you there where examination may not be so easy.

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Yeah, we always think about the Ottawa rules.

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Are they actually useful in practice and do you use them at all?

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Oh, look, I think they're very, they're a guide.

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Like everything, they're a guide.

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They're not set in stone, but they are, because the reason they exist is to avoid unnecessary x-rays and the radiation penalty that goes with that for patients.

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So really to explain the Ottawa rules, if you're unable to walk four steps either after injury or in the when you're seeing the doctor in the emergency room that's a significant, indicates some sort of significant injury.

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If you have pain around the malleoli, medial or lateral malleolus and also if you have pain up the posterior border of either the fibula or the medial tibia for six centimeters above the joint, that's an indication that there may be a significant injury and it's probably worth doing an x-ray.

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If you don't have those things, it's most likely a sprain and you probably don't need an acute x-ray.

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There are also some foot rules for Ottawa that have been expanded.

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So if you have pain at the base of the fifth metatarsal or over the navicular, or if, again, if you can't walk, four steps of the foot injury.

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That's another reason to do an x-ray.

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But if you don't have any of these things, the yield of finding a fracture on an x-ray is less than 1%, so it's probably not worth the effort.

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Excellent.

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What are the common red flags in ankle trauma then that signal the injury might be even more than just a simple sprain?

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Is it just purely the rules or are there other things too that you need to think about?

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Oh, look I think the history and the energy involved in the injury, so someone who's, in a car accident, high velocity, a fall from height and obviously the signs a lot of swelling that indicate there's a significant amount of trauma there.

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Other things you need to be wary of so that you don't think, oh, this is just a sprain and send someone off.

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So, so Peter if an ankle injury or an ankle sprain just isn't improving after two to three weeks.

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what conditions should we be thinking about?

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For example, do you need to think about osteochondral lesions, Peroneal tendon lesions or even just stress fractures?

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What are the things that sort of go through your mind that are just more than just a simple basic injuries that the students might be aware of?

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Yeah, all those things are possible.

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And the realities, a really bad ankle sprain may take up to three months to fully recover in terms of someone being really comfortable and returning to sport with comfort.

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So, at two or three weeks a lot of people will still be quite sore.

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But I think the key is if they're not improving at two or three weeks, then you, your mind should be, you should be thinking there's something maybe more significant here than just a regular ankle sprain.

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'cause even if they're sore at two or three weeks, they should be getting better.

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So the things to really consider as you say, a chondral injury.

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So some sort of damage to the cartilage in the ankle joint.

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And that may not be obvious on an x-ray if you've taken one.

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Syndesmosis injuries and we'll talk about that later.

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They're a specific type of ligament injury.

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Peroneal tendon injuries, again, you, you said that, so that's very important.

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Fracture of the base of the fifth metatarsal.

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So that's one that is near the ankle and it may get caught up when you initially see someone and all that swelling and not be noticed.

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And it's often one that is right on the corner of an x-ray as well.

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So when you look at the ankle on the x-ray, you may look back and see there's a little fracture there that you haven't quite appreciated at the time.

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So that's always a tricky one.

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The anterior process of the calcaneus that's even closer to the ankle joint and it is really hard to see on an x-ray 'cause the 'cause of the shape of the bones and the overlying bone.

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So that's one that's again, commonly may not be appreciated immediately.

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And then obviously the Lis-Franc injury.

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So that's in the foot.

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But again, everything may be swollen, it may be hard to localize that and you have to consider that as well.

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So I think if you're not sure by two or three weeks, if the patient's coming back and they've still got a lot of pain and they're not really getting better.

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Take the opportunity to reexamine them at that point, hopefully by then their swelling subsided.

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They're not as painful everywhere.

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So you may be able to localize the area of pathology.

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And you'll be able to pick the landmarks up.

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So those are the sort of things that you can do at two or three weeks.

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And it's just not gonna be as uncomfortable for the patient at two or three weeks to examine them again.

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So don't be shy of examining the patient again if they come back after two or three weeks.

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And the other thing you can do is if you're concerned, you can re x-ray them and some of these injuries are ligamentous injuries, so they won't sharp on x-ray as a fracture, but the ligamentous instability will if you x-ray them weightbearing and sometimes you have to wait for a period of time, 10 days, maybe two weeks for the patient to be able to do that comfortably.

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So that's a tricky thing as well.

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So don't be shy and re reexamining the patient and talking to them again and seeing if you can get a different perspective than initially.

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So if it's not selling after two or three weeks, you're reexamining them.

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What would be your sort of protocol Would you do weight bearing x-rays first and then depending on where there's tender to further on investigate or how would you proceed at this?

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Oh, exactly right.

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Yeah.

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So I think if you can narrow it down to the ankle or the foot, then you get the appropriate x-rays and again, you may see a fracture then that you didn't see initially, or you may even see just a periosteal response.

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So the bone trying to heal rather than the actual injury.

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But if there are ligamentous injuries, then you may see widening either in the midfoot or around the ankle.

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And if you're at that point, then you need to further investigate.

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So we will talk later about different tests you can do.

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But yeah, I think it's always worth looking back at reexamining and reinvestigating if there are still concerns that someone is really struggling at two or three weeks where you think that shouldn't be given the injury they've had.

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So would you non-weight bear them in that time or would you put them in a special boot to protect them It really depends upon their symptoms.

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If someone's unable to walk, I think it's very sensible to put them in a boot.

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It will allow them to rest.

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It'll force them to elevate their foot, which will help with swelling.

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'cause obviously in the foot ankle, as long as your foot's below your heart, it will swell.

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So it'll allow 'em to swell.

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It'll also hopefully make them comfortable enough to weight bear rather than be stuck on crutches for a couple of weeks.

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But some people will still not be able to do that even with a boot.

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So I think it's quite reasonable and sensible to use a boot.

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If someone can walk but not very well, then they might get away with some crutches and just assisting them in weight bearing.

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But if they're really in trouble, then a boot I think is very sensible.

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If there is a fracture there, then you've already instituted the treatment for the fracture, even if you didn't know it was there yet, until you reexamine them in a couple of weeks.

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so Peter, if I just go think about this in a bit, the specifics, obviously someone comes in if a significant trauma.

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If they fulfill the criteria of Ottawa rules, you'd x-ray.

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But if they're normal, you still just protect them or at least re observe them two weeks later if they don't fill the, fulfill the rules of Ottawa and therefore they you're thinking it's more of a soft tissue injury.

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Again, you're gonna just treat it as a sprain.

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But two, three weeks later they come back.

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If you're still tender over the soft tissues and you're thinking it's still more of an ankle sprain and you've re x-rayed and it's still no fracture, would you proceed to an ultrasound to assess the ligaments at that stage?

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Or would you still continue down the ankle sprain pathway?

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Oh, look I think you, it would depend upon how sore they're, and I think they're both reasonable paths to take ultimately.

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If the ligaments are injured in most people, they're gonna go down the rehab pathway regardless.

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So it, it may not be necessary to know that the ligaments are injured 'cause you the treatment, certainly referring 'em off to physiotherapy for physio guided rehab.

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Maybe brace those things you would do regardless.

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The algorithm in terms of whether they need an operation or not really would depend upon if they failed that rehab treatment.

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So I think I treat them symptomatically.

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If they're really bad, they'd been a boot if they're not maybe a brace.

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And then once they're comfortable enough, and that's the tricky bit to institute physiotherapy, there's no point going to the physio if you're really sore.

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All you're gonna do is get tortured at that point and no one wins.

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So they need to wait long enough to be comfortable to start their physio rehab, is the key thing.

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And if they need a boot or crutches or a brace in that time, I think I treat them symptomatically.

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But the aim is that they should be getting better so that they need less and less of that and they can have their physio.

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Sort of a loaded question, I ask you that because sometimes you see junior doctors showing me a set of ultrasounds.

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showing complete tear of the anterior talo fibula and a complete tear of the calcaneo- fibula ligament.

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and they think it's something that needs urgent surgery . In that scenario, w hat do you say to the junior doctor who comes with an ultrasound showing them that you just, how do you reassure them?

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Oh, look I think ultimately you're treating the patient, not the x-ray, the ultrasound, and, this is an injury we've been doing for a long time, for many thousands of years, and we managed to get through most of that without people like me operating on them.

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So I would say, look, this is a significant ankle sprain, but that doesn't mean in most people, that doesn't mean you need an operation.

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So the ability of the ligament to heal and with good rehab to end up with a stable ankle is quite high from here.

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So, I think 90% plus of people with a really bad ankle sprain.

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Still won't need surgery.

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It's the ones who have recurrent instability after their rehab that will, so whilst that's concerning I would still go down the same path.

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I don't think there's a a place even in the elite athlete for an acute ankle sprain, a sprain like that to be operate on immediately.

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I think rehab would be the first goal and try and re rehab that and recover that as it is.

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And it's not just the junior doctors that do that.

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The patients often come with their ultrasound and they've read it and they're very stressed and saying, oh, what are we gonna do about this?

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And you just reassure 'em, say this is very common.

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It's a very bad ankle sprain, but in most people it doesn't require surgery.

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And they're actually quite relieved.

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They go from being very stressed about this finding on an ultrasound to realizing that they probably won't need an operation and they'll be fine just with some physio and a bit of time, which most of us aren't pretty patient.

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So Gotta reassure 'em.

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It will get better.

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Yeah.

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Reinforces what I tell, I told a medical student the other day that one of the best forms of pain relief is actually giving the patient education.

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And that can help reassure them and let them get through the acute episode.

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Exactly.

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I couldn't agree more.

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I think patients, you know that they, well they all go on the internet and look at Dr.

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Google and there's some great stuff on the internet and there's stuff that's not particularly accurate.

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So I think if you as an expert, if you say to 'em, look, I think you'll be fine here.

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It'll take a bit of time and you probably won't need an operation.

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Most of 'em are reassured by that.

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If we're going down that same pathway of thinking about how we investigate them, let's say at two to three weeks we do the x-ray 'cause they're still sore and there's nothing particular on that.

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But there actually either tender on a squeeze test between the tibia and fibula.

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And you're wondering maybe it's a syndesmosis the ligaments that join the tibia and fibula down by the ankle joint.

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or they're tender right down near the subtalar or the ankle joint themselves and you're thinking maybe it's one of these anterior process of the calcaneus, what's the next form of investigation?

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You're not going down the path of an ultrasound looking for a sprain.

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You're thinking of one of these other structures.

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How would you investigate then.

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Well, I'll start with the syndesmosis injury 'cause that is a significant injury and it's probably one that is more likely to need surgery than a regular ankle sprain.

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To start with in terms of considering that the history is slightly different, the mechanism is different.

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Your regular ankle sprain is inversion plant deflection.

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The foot is forced down.

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You roll your ankle with syndesmosis injuries it's the opposite.

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It's dorsiflexion aversion, so the foot's turned out or the foot is stuck on the ground and you are twisting away from it sort of thing.

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Which we often see in, we can see, I see that in footy players where they're in a pack and someone stomps on their foot and they get bumped on a trapped foot.

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So the mechanism is different in terms of investigating it.

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You need to know whether the injury is stable or unstable.

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So in terms of diagnosing the injury, an MRI is quite good.

00:15:36.008 --> 00:15:38.018
It'll show you whether the ligaments are intact or not.

00:15:38.298 --> 00:15:42.107
It'll also show you any other associated injuries 'cause that may not be an isolated injury.

00:15:42.107 --> 00:15:44.447
You may have a deltoid injury as well on the other side of the ankle.

00:15:44.802 --> 00:15:48.613
But ultimately to work out whether it's stable, you can do a weight-bearing x-ray.

00:15:48.923 --> 00:16:02.822
Now people's anatomy isn't identical and so, I think if you're concerned you would do an x-ray of the other side and see if there's, if they're the same, if there is widening of one compared to the other, then obviously that's an unstable injury and you should do something about it.

00:16:03.072 --> 00:16:23.783
The other tool we have available is a weight bearing CT scan, and that's a great instrument and what you do is you scan both feet as weight bearing as I said and what you're looking for is a difference between the weight bearing scan and the non-weight-bearing scan on the same foot to see if there's a difference in the distance between the bones or between the weightbearing one side and the other side.

00:16:24.023 --> 00:16:32.732
And again, there are some parameters, but if there is a significant difference, again that's indicative of a significant significant instability and that should probably be treated surgically.

00:16:33.057 --> 00:16:35.457
So even if the ligaments are intact, you can have that.

00:16:35.847 --> 00:16:43.077
And I guess the grey areas when there is on a, say an MRI or an ultrasound damage to the ligaments, usually it's the anterior syndesmotic ligament.

00:16:43.437 --> 00:16:46.018
But that doesn't necessarily mean that the joint is unstable.

00:16:46.018 --> 00:16:54.557
So if you've got x-rays or weightbearing CT that show no widening, I'd be happy to treat that non-operatively even if the liga, the anterior ligament is damaged.

00:16:55.668 --> 00:16:58.817
And also it's a similar situation for Lis Franc injuries in the midfoot.

00:16:59.177 --> 00:17:02.972
The weightbearing CT is very good there, as is a weightbearing X-ray.

00:17:03.212 --> 00:17:11.923
And again, you need to wait 10 days, maybe two weeks for the patient to be comfortable enough to do it with a fair amount of force through their foot to show that significant difference in widening.

00:17:12.252 --> 00:17:20.623
And same thing, if there is a big difference either between one side and the other or the same foot weightbearing and non-weightbearing, then you probably should be doing something about that.

00:17:20.722 --> 00:17:22.032
So that's how I treat it.

00:17:22.083 --> 00:17:25.853
In terms of the other injury, you talked about the anterior process fracture, the calcaneus.

00:17:26.178 --> 00:17:29.208
If you're suspecting it, probably an MRI is the best bet.

00:17:29.387 --> 00:17:37.738
'cause the great thing about MRI is it will show you the bones, the ligaments, the tendons, all the different things, the cartilage, all the different things that can cause pain in one image.

00:17:37.867 --> 00:17:40.718
Other imaging modalities have strengths, but they also have weaknesses.

00:17:40.718 --> 00:17:42.038
MRIs pretty good.

00:17:42.258 --> 00:17:45.093
So that, that's where I'd go with that if I was worried about that side of things.

00:17:45.423 --> 00:17:52.353
And I think just for the syndesmosis injury, the reason it occurs more when it's end dorsiflexion is 'cause the Talus wider when it goes into the dorsiflexion.

00:17:52.423 --> 00:17:52.813
Yeah.

00:17:52.813 --> 00:17:54.012
It's also the rotation.

00:17:54.042 --> 00:18:04.182
It's like a wedge and it, as it rotates around, it pushes the fibula, it opens it up, it opens it up like a door from, if you're looking at it, the ankle from the front, the fibula gets rotated out and it opens like a door from the front.

00:18:04.182 --> 00:18:07.663
And if it's significant, it'll tear the ligaments all the way from the front to the back.

00:18:07.932 --> 00:18:09.403
And that's obviously unstable.

00:18:09.522 --> 00:18:13.123
The tricky one is where you tear the front one or partially tear the front one.

00:18:13.438 --> 00:18:14.548
And the back is intact.

00:18:14.548 --> 00:18:18.718
And that's where that grey area where you need to work out, is this stable, is it not?

00:18:18.807 --> 00:18:22.948
If it's stable, then probably a boot and some non-weight bearing and they'll be fine.

00:18:22.978 --> 00:18:31.077
If it's unstable, I think you need to fix it because if those ligaments are unstable every time you walk, your tibia and your fibula are being pushed apart.

00:18:31.107 --> 00:18:32.857
'cause they're not the distance is not constant.

00:18:33.157 --> 00:18:35.798
That has a very high risk of damaging the ankle cartilage.

00:18:35.978 --> 00:18:41.928
So long-term problems can be significant in terms of people not being able to play sport or even leading onto arthritis.

00:18:42.948 --> 00:18:43.008
Yeah.

00:18:43.008 --> 00:18:46.897
And both Lis Francs and Syndesmosis are in dorsi-flexion as the most common.

00:18:46.897 --> 00:18:47.768
Cause Generally they are.

00:18:47.768 --> 00:18:51.877
I mean, the Lis Franc injury again, can be the same thing I was talking about in the football player.

00:18:52.087 --> 00:18:54.807
I've had a few who have been stomped on and then bumped.

00:18:54.807 --> 00:18:57.478
So their forefoot is stuck to the ground and the whole body pivots on it.

00:18:57.817 --> 00:18:58.778
So that sort of thing.

00:18:58.958 --> 00:19:03.877
Occasionally you get someone who falls, maybe misses a step going down some stairs and their foot gets folded under them.

00:19:03.877 --> 00:19:06.577
So this forced planter flexion with a whole body weight on top of it.

00:19:06.917 --> 00:19:09.708
those ligaments are very strong as are the syndesmotic ligaments.

00:19:09.978 --> 00:19:21.567
You require quite a bit of force to damage them, and sometimes it's because you're going at high speed, but sometimes it's just because your body weight, or if you're playing sport two times body weight, someone else tackles you and lands on top of you.

00:19:21.817 --> 00:19:25.688
and those ligaments are damaged by, two people's weight on top of the foot in a, in an odd position.

00:19:26.768 --> 00:19:29.617
Yeah, it's, I was smiling because both mechanisms will be classically.

00:19:29.617 --> 00:19:34.807
Cause when you're in the foot straps of a winds-surfer and thrown off a winds surfer for those who would know what a windsurfer is.

00:19:35.137 --> 00:19:39.452
I use this as, excuse as why I never got on the foot straps, but really it's because I'm a pretty average windsurfer.

00:19:40.682 --> 00:19:40.803
Yeah.

00:19:40.803 --> 00:19:46.843
Look, and again, classically, the Lis Franc injury was described in cavalry soldiers, who were thrown off their horse and their leg was stuck in the stirup.

00:19:47.113 --> 00:19:49.813
But the, I guess the windsurf is a modern form of that.

00:19:50.032 --> 00:19:55.282
And obviously the contact sport with people at close quarters getting bumped and is a similar sort of injury.

00:19:55.282 --> 00:19:56.212
It's the same mechanism.

00:19:56.603 --> 00:20:12.923
It's just the velocity's different, but ultimately if someone's got a bad injury, they, it'll it can be significant in terms of returning to sport or, long term in terms of just walking comfortably and Lis Franc injuries, are the injuries of the metatarsal joint second, third, and fourth predominantly?

00:20:12.923 --> 00:20:19.387
generally is, it's, and it can, again, there are, because of the number of bones there, there's a lot of different types, but it is through that joint.

00:20:19.387 --> 00:20:25.387
So sometimes you can have the first or between the first and second off, and it's usually around the second, the base of the second, the base of the first.

00:20:25.657 --> 00:20:33.157
Sometimes it can extend even more proximally, so it can come between the cuneiform bone, so it just sort of goes vertically through and splits the whole sort of first ray off.

00:20:33.458 --> 00:20:36.127
So you have to fix even a bit further back when you do surgery.

00:20:36.428 --> 00:20:45.288
But if you are suspicious of it I think, if they're really sore, the other thing you classically see which didn't appreciate till I was well into my training, is you can see some bruising.

00:20:45.288 --> 00:20:47.508
If you see bruising on the arch of someone's foot.

00:20:47.928 --> 00:20:51.407
Bleeding and bruising, that's almost pathognomonic of a Lis Franc injury.

00:20:51.407 --> 00:20:57.617
So if you see someone who turns up with an ankle sprain or they've twisted their foot and they have this bruising in the arch, you should be suspicious of it.

00:20:57.807 --> 00:21:01.048
And, probably investigate for it or at least think about it seriously.

00:21:01.167 --> 00:21:08.278
So that's, on the medial arch, I suppose, on the lateral ray at the base of the fifth metatarsal you'd be thinking more of a base of fifth metatarsal or a Jones fracture.

00:21:08.278 --> 00:21:09.448
I always got the two mixed up.

00:21:09.448 --> 00:21:12.522
And what are the different types of fifth metatarsal fractures you can get?

00:21:13.002 --> 00:21:22.012
Well, the Jones of, it's a lot, it's a term that everyone, people use to lump them all together, and you can get some that are just at the tubercle, which is the very base of the metatarsal right at the end of it.

00:21:22.343 --> 00:21:26.282
And further down the Jones fracture is notorious for non-union.

00:21:26.282 --> 00:21:29.522
That's the big thing that people worry about is, that it won't unite.

00:21:29.792 --> 00:21:32.073
Even then, probably 90% of them do.

00:21:32.262 --> 00:21:34.153
If you are seeing a young fit person.

00:21:34.248 --> 00:21:36.798
Having a 10% non-union rate is very high.

00:21:36.827 --> 00:21:40.788
'cause most of them will, almost all fractures will heal in a young fit person.

00:21:40.788 --> 00:21:43.488
So even 10% is still very high.

00:21:43.758 --> 00:21:44.897
And it's, it's a twisting injury.

00:21:44.897 --> 00:21:48.018
Often it can be, missed as a, as part of an ankle injury.

00:21:48.268 --> 00:21:51.278
Sometimes it can be a stress fracture that will then complete.

00:21:51.278 --> 00:21:56.708
So someone will do something and they hear a bit of a crack they can't play on, but when you look at it, this is not an acute injury.

00:21:56.708 --> 00:21:58.448
There's an old fracture that they've completed.

00:21:58.807 --> 00:22:04.657
In that case, it may actually heal the fracture 'cause you've stimulated a lot of healing for something that wasn't healing that well.

00:22:04.817 --> 00:22:08.307
If you've got certain types of foot shape, that can be more common.

00:22:08.307 --> 00:22:14.538
So if you've got a very high arch because you're putting more weight on your fifth metatarsal, that can lead to a fracture as well.

00:22:14.907 --> 00:22:24.438
But again, it's just being wary of it and knowing that it may not heal, but even as I said, even though it's notorious for non-union, 90% of them will still heal, and that's a pretty good outcome.

00:22:24.738 --> 00:22:29.458
But just, yeah, be aware of it and, if there's any concerns, refer it on for some to have a look at.

00:22:29.458 --> 00:22:32.458
And it may require surgery depending on the patient and their circumstance.

00:22:32.907 --> 00:22:40.778
Now, these are just a few other fractures, but how common do these syndesmosis injuries or the lisfranc injuries compared to a standard ankle sprain or an ankle fracture?

00:22:41.498 --> 00:22:44.423
Oh, look ankle sprains are incredibly common.

00:22:44.692 --> 00:22:47.633
I think it, it may well be the most sprained joint in the body.

00:22:47.913 --> 00:22:51.093
And in terms of ankle fractures, they're still the commonest lower limb fracture.

00:22:51.393 --> 00:22:56.813
So, so that even though these things are important, they are a small percentage compared to ankle fracture.

00:22:56.813 --> 00:22:58.762
So the commonest thing you'll see is an ankle sprain.

00:22:59.063 --> 00:23:03.117
The commonest fracture you'll see in this area is an ankle fracture a regular ankle fracture.

00:23:03.508 --> 00:23:13.498
Which will either be undisplaced and just require either a boot or a plaster or probably a boot more likely nowadays, or something that has some displacement that might require surgery.

00:23:13.498 --> 00:23:14.788
But that's the bread and butter.

00:23:15.028 --> 00:23:23.373
All these other things are much less common, but you just need to be wary of them because the missing them can be have quite significant outcomes for the patient long term.

00:23:23.623 --> 00:23:28.113
It's not just that it's dragged on for longer, that there may be damage to joints, which is hard to recover from.

00:23:28.323 --> 00:23:28.982
Excellent.

00:23:29.583 --> 00:23:32.292
Well, if we can move on to other injuries around the foot and ankle.

00:23:32.292 --> 00:23:34.542
One of the other ones that we hear about are the Achilles tendon ruptures.

00:23:35.077 --> 00:23:36.667
first of all, how do you diagnose them?

00:23:36.718 --> 00:23:45.387
You walk us through the squeeze test, the Thompson's test, and basically the pitfalls and diagnosis of them and how the management evolve from surgical to non-surgical to surgical.

00:23:45.387 --> 00:23:45.627
What?

00:23:45.657 --> 00:23:46.557
I get confused.

00:23:47.038 --> 00:23:47.367
Oh look.

00:23:47.367 --> 00:23:47.577
Yeah.

00:23:47.877 --> 00:23:49.498
And they are relatively common.

00:23:49.768 --> 00:23:53.387
The history again, is of an an acute injury.

00:23:53.548 --> 00:23:58.317
There's not often any precedent people, someone's just doing some sport and they hear a pop.

00:23:58.647 --> 00:24:01.738
They will often look around, see, they think someone's kicked them in the back of the heel.

00:24:01.738 --> 00:24:08.367
Or if they're playing something like basketball, someone's throwing a ball at them and hit 'em in the back of the heel and then they usually fall over'cause their Achilles isn't working.

00:24:08.577 --> 00:24:13.728
So that's the history most often the middle-aged male the weekend warrior sort of thing.

00:24:14.057 --> 00:24:17.337
And I see quite a few who, say, oh look, just playing social sport.

00:24:17.337 --> 00:24:19.528
They were short and they gave me a ring and I turned up and.

00:24:19.857 --> 00:24:20.788
Thing went pop.

00:24:21.057 --> 00:24:24.057
So that's often a common history, but it can happen in all age groups.

00:24:24.807 --> 00:24:29.887
So in terms of the diagnosis, once you've got the history the diagnosis is principally clinical.

00:24:30.067 --> 00:24:34.208
So the patient is placed face down on the bed with the feet hanging over the edge of it.

00:24:34.518 --> 00:24:38.718
And the calf squeeze test, or the Thompson test or the Simmons test depends on which side of the Atlantic you're on.

00:24:39.077 --> 00:24:40.337
I call it the calf squeeze test.

00:24:40.337 --> 00:24:41.718
And then there's no confusion at all.

00:24:41.928 --> 00:24:43.008
You squeeze in the calf.

00:24:43.008 --> 00:24:53.077
And what you should see is that the foot planter flexes other thing, obviously if you feel, if you run your finger down the back of the calf, you'll often feel a, a step or a, a gap in the tendon.

00:24:53.077 --> 00:24:54.607
So that, that's a giveaway as well.

00:24:54.907 --> 00:24:56.228
And I think that's the key.

00:24:56.448 --> 00:25:02.178
If you investigate them with ultrasounds or, generally with ultrasound, 'cause that's very easily inaccessible, easily accessible.

00:25:02.458 --> 00:25:06.508
The one to be wary of is the partial tear, where they report it as a partial tear.

00:25:06.928 --> 00:25:11.097
And that's really tricky because a partial tear may be 30% or 40%.

00:25:11.303 --> 00:25:12.897
It may also be 95%.

00:25:13.258 --> 00:25:15.278
So, they don't often quantify how much.

00:25:15.488 --> 00:25:20.087
So if a partial tear may be something that isn't such a big thing it, it may be a significant thing.

00:25:20.087 --> 00:25:29.238
So I will go on the clinical diagnosis if I'm convinced that's what it is, I may investigate 'em with an ultrasound or an MRI, if I'm concerned about something also, or where it is.

00:25:29.428 --> 00:25:31.647
'Cause sometimes it can be a lot higher than the usual spot.

00:25:31.647 --> 00:25:37.107
It's usually about five to seven centimeters above the back of the heel where the Achilles joins the calcaneus.

00:25:37.317 --> 00:25:42.768
But if they're higher up, they can be at the musculo tendons junction where the calf muscle becomes tendon, that's harder to repair.

00:25:42.798 --> 00:25:45.458
'cause you're not repairing two tendons if you're considering surgery.

00:25:45.847 --> 00:25:47.407
So that's the diagnosis.

00:25:47.407 --> 00:25:52.907
In terms of the treatment when we were young men you, the treatment was either surgery or not surgery.

00:25:52.907 --> 00:25:58.518
And non-surgical treatment was put 'em in a plaster for eight weeks and then say, oh, you'll be right off you go.

00:25:59.048 --> 00:26:01.607
And really now there are almost three different arms of treatment.

00:26:01.607 --> 00:26:02.387
There is non-operative.

00:26:02.732 --> 00:26:03.932
Which is usually in a boot.

00:26:04.212 --> 00:26:07.272
There is functional treatment and then there is surgery.

00:26:07.692 --> 00:26:14.512
And the functional side is very protocol driven where you put them in a splint almost immediately, within 24 hours of the injury.

00:26:14.813 --> 00:26:20.343
And then you can get them, start them going with very specified physio under observation.

00:26:20.653 --> 00:26:26.673
And whilst that has some good results it really requires almost like a bigger system where physios are integrated in the system.

00:26:26.673 --> 00:26:31.423
So, in places like Canada or the UK they'll often do that 'cause they're all working within a hospital.

00:26:31.722 --> 00:26:38.087
But in our system where, you, you may not have any contact with the physio at all, it's very hard to make sure we're all on the same page.

00:26:38.087 --> 00:26:39.587
So whilst that has some results.

00:26:39.917 --> 00:26:46.998
I'm not sure it's as effective in our system where, the physio may not be known to the doctor and you don't have a common protocol you're driving on.

00:26:46.998 --> 00:26:51.928
So for me, I would talk to the patient about the treatment and the pros and cons.

00:26:52.258 --> 00:26:53.998
And it depends on the patient.

00:26:54.218 --> 00:26:56.798
Non-operative treatment has still has good outcomes.

00:26:56.798 --> 00:27:00.008
You're talking about 85, 90% won't have any problem.

00:27:00.248 --> 00:27:02.377
And the big problem if you have one is rupturing the tendon.

00:27:02.377 --> 00:27:04.758
Again, where the tendon heals is a weak point.

00:27:04.978 --> 00:27:06.357
It's potentially a rupture point.

00:27:06.357 --> 00:27:10.278
Again, if that happens, it'll usually happen within the first year after the initial injury.

00:27:10.548 --> 00:27:14.288
So, if a non-operative treatment for me, you're in a boot for eight weeks.

00:27:14.778 --> 00:27:16.428
And I'll use some heel wedges in the boot.

00:27:16.428 --> 00:27:18.137
So they'll have three heel wedges in the boot.

00:27:18.468 --> 00:27:20.147
Every two weeks I take out a wedge.

00:27:20.357 --> 00:27:23.178
So they start with three wedges, two wedges, one wedge, no wedge.

00:27:23.327 --> 00:27:24.647
That's their eight weeks in the boot.

00:27:24.928 --> 00:27:28.772
At two weeks, they're usually comfortable enough to start walking, so I let them walk at two weeks in the boot.

00:27:29.458 --> 00:27:31.167
So that's my non-operative protocol.

00:27:31.167 --> 00:27:33.478
So you're not stuck on crutches for the whole eight weeks.

00:27:33.837 --> 00:27:36.077
You can walk but you just gotta stay in the boot.

00:27:36.337 --> 00:27:50.907
The other thing to be wary of if you, if someone is treated non-operatively is DVT even though we're not having an operation the calf muscle, all those calf veins in the muscle, it's not just that they're immobile because you're in a boot, you've actually damaged them as part of the injury.

00:27:51.087 --> 00:27:51.268
Yeah.

00:27:51.268 --> 00:27:53.657
You're actually damaging the calf muscle and that whole mechanism.

00:27:53.958 --> 00:27:55.577
So, I usually put people on aspirin.

00:27:55.877 --> 00:27:57.647
I'm not sure you need to do anything more than that.

00:27:57.897 --> 00:28:08.488
If there are risk factors, then you may need to use something else, whether clexane or one of the oral anticoagulants, but just be wary of DVT risk 'cause you're damaging the muscle where those calf veins are as well as immobilization.

00:28:08.847 --> 00:28:11.667
So that's something we don't often think about when we're treating someone non-operatively.

00:28:11.998 --> 00:28:18.298
And with an ankle fracture, I probably wouldn't think too hard about it, but with this one it's maybe something to consider in terms of the surgery.

00:28:19.357 --> 00:28:20.647
What are the pluses of surgery?

00:28:21.488 --> 00:28:23.438
Look the re-rupture rate is probably lower.

00:28:23.438 --> 00:28:25.057
It's probably three to 5%.

00:28:25.657 --> 00:28:26.678
So that's a lower rate.

00:28:26.678 --> 00:28:37.407
So you're talking about a risk of having no problems goes from 85 to 90% if you don't have an operation to maybe 95 to 97% if you if you do so, it's still not a massive difference.

00:28:37.587 --> 00:28:47.107
So lower re-rupture risk the amount of power and strength you lose after your injury might be a bit lower, but it's not that big a difference that you'd say you have to have surgery.

00:28:47.137 --> 00:28:48.127
And that's the tricky bit.

00:28:48.397 --> 00:28:49.597
There is a lot of grey here.

00:28:49.627 --> 00:28:51.278
There's not a right and a wrong way to do it.

00:28:51.548 --> 00:28:55.357
I talk to the patient given the pros and cons and then let them decide.

00:28:55.718 --> 00:28:56.468
That's the key thing.

00:28:56.468 --> 00:28:59.048
And, but the treatment is much the same boot for eight weeks.

00:28:59.077 --> 00:29:00.758
Wedges take out wedge every two weeks.

00:29:00.998 --> 00:29:04.807
I let them walk after two weeks, once the wound is healed and then at eight weeks.

00:29:04.988 --> 00:29:07.057
Then when they come out the boot, then you start the physio.

00:29:07.417 --> 00:29:07.567
Right.

00:29:07.567 --> 00:29:09.367
And it's really just those basic things.

00:29:09.577 --> 00:29:12.248
Range of motion, some strength, and then some balance type stuff.

00:29:12.798 --> 00:29:25.018
With regards to return to sport or activities at six months, I'm happy for people to return to some sort of modified training if they're playing sport, but I'd want 'em to be in a position where they're not having to push themselves and push off and do things.

00:29:25.327 --> 00:29:29.407
At nine months, nine to 12 months is when you can return to full training and competition.

00:29:29.798 --> 00:29:32.857
And that timeline is the same for whether you have surgery or not really.

00:29:33.137 --> 00:29:44.178
That they're the, that's the sort of the goals I tell people after this, is that a slower recovery for an achilles tendon rupture than for say, someone with an ankle break or do ankle fractures also take a fairly bit of time to recover.

00:29:44.508 --> 00:29:46.458
And what about syndesmosis injuries as well?

00:29:46.508 --> 00:29:51.048
Again, some are quicker than others, but I think, if you are having a, if you're in a boot for six weeks.

00:29:51.542 --> 00:29:54.722
Things get very stiff and sore, even if it's a very small, minor injury.

00:29:54.903 --> 00:29:58.833
So I would think three months would be the absolute bare minimum for return to sport.

00:29:58.992 --> 00:30:02.242
But probably somewhere between three and six is reasonable.

00:30:02.423 --> 00:30:11.063
But yeah, some of the syndesmotic injuries, I've had people saying, you know what, it took me a year to fully feel really good about playing sport and not worry about it, and that sort of thing.

00:30:11.063 --> 00:30:17.482
So whilst you may be able to go back to sports sooner in terms of having that confidence to say, look, I'm fully recovered.

00:30:17.673 --> 00:30:22.678
Even if it's maybe just a mental thing of not being scared of reinjuring it, it probably is best part of a year.

00:30:22.678 --> 00:30:24.688
I think that's quite a reasonable assumption to make.

00:30:25.198 --> 00:30:25.887
Excellent.

00:30:26.307 --> 00:30:28.678
Well, we've touched a bit on the traumatic sort of scenarios.

00:30:28.758 --> 00:30:30.857
I presume all your work's not purely traumatic.

00:30:30.907 --> 00:30:34.448
what's your sort of mix between traumatic and elective conditions in your practice?

00:30:34.488 --> 00:30:36.738
And what would be the average foot and ankle surgeons?

00:30:36.748 --> 00:30:38.423
Most of my practice is elective.

00:30:38.423 --> 00:30:40.282
I don't do that much trauma nowadays.

00:30:40.472 --> 00:30:42.962
I think for others there may be a greater mix of trauma.

00:30:43.212 --> 00:30:45.282
But I, my mine is mainly elective.

00:30:45.502 --> 00:30:52.272
And I do all foot and ankle conditions, so I'll, do four foot, which is bunions and arthritis and morton's neuromas and things like that.

00:30:52.502 --> 00:30:54.522
And also some sports injuries.

00:30:54.522 --> 00:31:01.282
So again, the, ankle sprains, arthroscopy, ligament reconstruction, tendonitis or, these sort of overuse type injuries.

00:31:01.563 --> 00:31:03.182
And obviously arthritis and deformity.

00:31:03.182 --> 00:31:12.103
So I have a special interest in ankle arthritis and ankle joint replacement, but also the deformity, the flat foot and those sorts of things which can be combined with arthritis.

00:31:12.103 --> 00:31:13.803
So sometimes they're not separate things.

00:31:13.803 --> 00:31:16.923
They it's deformity with arthritis, which can complicate the picture.

00:31:17.563 --> 00:31:21.928
I also do some research and I'm actually with my interest in joint replacement.

00:31:22.258 --> 00:31:25.847
I'm the clinical advisor to the National Joint Registry on joint replacement.

00:31:25.847 --> 00:31:28.198
So, that fills a bit of extra time if I had any.

00:31:28.557 --> 00:31:29.067
Excellent.

00:31:29.097 --> 00:31:38.538
Well we did do a episode on the National Joint Replacement Registry with Richard Page from an upper limb perspective, but they covered most of the registry in general was actually a very interesting talks for those who are actually watching.

00:31:38.538 --> 00:31:39.557
They can listen to that as well.

00:31:39.958 --> 00:31:44.208
But moving on to basically assessment of a foot and ankle for an elective scenario.

00:31:44.508 --> 00:31:51.167
What's your approach does it vary depending on how they present with like pain or the neurological type scenario or with loss of function?

00:31:51.167 --> 00:31:56.117
How do you approach your assessment of a foot and ankle, particularly for a medical student coming up to the Osce exams as well?

00:31:56.647 --> 00:31:57.468
Oh look again.

00:31:57.512 --> 00:31:58.813
You go back to the basics.

00:31:58.843 --> 00:32:00.932
You look at the history, timelines.

00:32:01.053 --> 00:32:02.583
How long has it been going on for?

00:32:02.702 --> 00:32:04.182
Was there an obvious cause for it?

00:32:04.202 --> 00:32:08.462
Was there an injury of some sort or something in the history that, that would indicate an injury, an old fracture, or something like that?

00:32:08.462 --> 00:32:11.042
That may give you a hint as to what's going on here.

00:32:11.262 --> 00:32:14.923
And just simple questions of function because of, what we're treating is pain and function.

00:32:15.252 --> 00:32:17.143
So, you wanna know about the patient's pain.

00:32:17.452 --> 00:32:18.712
Is it activity related?

00:32:18.883 --> 00:32:19.932
Are they getting rest, pain?

00:32:19.932 --> 00:32:22.393
Are they getting woken up at night with pain at nighttime?

00:32:22.673 --> 00:32:23.962
What treatment have they had?

00:32:24.113 --> 00:32:25.222
Does pain relief work?

00:32:25.222 --> 00:32:26.272
Have they had physio?

00:32:26.423 --> 00:32:27.143
Anything else?

00:32:27.423 --> 00:32:30.423
If they had braces, injections, all those sorts of things.

00:32:30.673 --> 00:32:31.663
That's the main thing.

00:32:31.873 --> 00:32:33.343
Are there any aggravating factors?

00:32:33.522 --> 00:32:35.292
And then I said just functional things.

00:32:35.413 --> 00:32:36.492
How far can they walk?

00:32:36.803 --> 00:32:39.833
If they can walk, if they walk with others, this is a great question.

00:32:39.833 --> 00:32:41.663
If they walk with others, can they keep up?

00:32:41.962 --> 00:32:49.093
'cause they can say, I can walk a kilometer, but if they walk with their partner, the partner have to stop 10 times over that kilometer to make them catch, to allow them to catch up.

00:32:49.093 --> 00:32:55.163
So things like that, is it better, whether they're in shoes or out of shoes if they wear a brace, does that make it better?

00:32:55.403 --> 00:32:56.962
What are they like on uneven ground?

00:32:57.093 --> 00:33:00.502
That's a quite a good indicator of how good your function is if you can manage uneven ground.

00:33:01.087 --> 00:33:01.657
That's quite good.

00:33:01.657 --> 00:33:02.708
So those sorts of things.

00:33:02.708 --> 00:33:08.228
So questions about their pain and the character of their pain and aggravating factors, and also their function.

00:33:08.288 --> 00:33:11.738
So they're the main things in the history in terms of the examination.

00:33:11.958 --> 00:33:16.958
Stand them up, watch them walk, in, in my setting, I call someone from the waiting room.

00:33:16.958 --> 00:33:21.577
So I already get a hint of what's going on by how quickly they can get out of the chair and how well they walk into my office.

00:33:21.577 --> 00:33:23.798
I've already got an idea of how much they're suffering.

00:33:24.038 --> 00:33:26.587
For the medical student perspective, they're usually lying on a bed.

00:33:26.738 --> 00:33:29.317
So you've gotta remember to stand them up and watch them walk.

00:33:29.468 --> 00:33:31.208
Have a good look at their feet when they're standing.

00:33:31.387 --> 00:33:34.508
'cause obviously the shape of your foot changes between lying down and standing.

00:33:34.508 --> 00:33:37.347
So what may look like a fairly normal foot without too much trouble.

00:33:37.347 --> 00:33:40.448
When they stand up, they become quite obvious and have an issue.

00:33:40.657 --> 00:33:42.278
Get them to single heel raise.

00:33:42.278 --> 00:33:46.718
That's a very simple test of function if you can stand on one leg and then lift your heel off the ground.

00:33:47.093 --> 00:33:47.903
You're doing all right.

00:33:47.962 --> 00:33:49.133
and compare side to side.

00:33:49.133 --> 00:33:50.542
I always start with the good side.

00:33:50.752 --> 00:33:55.462
So I get an idea and I've got an idea of what I'm asking them to do, and then get them to do the symptomatic side.

00:33:55.712 --> 00:34:00.633
And then onto your examination palpation, feel for where their sore, look at their range of motion, assess their power.

00:34:00.932 --> 00:34:04.813
Neurology look for numbness or weakness instability of their ankle.

00:34:04.813 --> 00:34:07.363
So these are all the things you look for when you're examining a patient.

00:34:07.692 --> 00:34:12.682
Again, even though I know more than a lot of people about foot and ankle, the examination is still the same.

00:34:12.733 --> 00:34:14.172
That, that's still the basics.

00:34:14.172 --> 00:34:19.432
And making sure you're not missing something, try and be as thorough as you can with your history and examination would be the hint for medical students.

00:34:19.672 --> 00:34:20.092
Right.

00:34:20.572 --> 00:34:27.972
When they're presenting with more of a pain condition, is that usually gonna be more of a, like a missed fracture or an arthritis or a tendonitis?

00:34:28.313 --> 00:34:33.143
If they present with loss of function, will it be, could it be arthritis, but could it be deformity that's causing it?

00:34:33.443 --> 00:34:37.443
And is deformity always associated with pain, Not necessarily.

00:34:37.443 --> 00:34:47.887
I mean, sometimes someone will come along with a second or third toe that's problematic and they've got a, a large bunion and the big toe pushing across has caused the problem in the second and third toe.

00:34:48.188 --> 00:34:51.543
But the bunion itself doesn't hurt, and that's a conversation to have with the patient.

00:34:51.543 --> 00:34:56.913
We say, look, I need to operate on your bunion to straighten that, to give, to make room for the other toes to be where they should be.

00:34:57.213 --> 00:34:58.532
But they say, my bunion doesn't hurt.

00:34:58.682 --> 00:35:02.643
So those sorts of things, so the bunion deformity doesn't always equal pain.

00:35:02.822 --> 00:35:07.242
I guess, and especially, those sorts of problems with bunions and what have you, it really is a problem in shoes.

00:35:07.597 --> 00:35:10.777
If you are walking barefoot, it's probably not a problem.

00:35:10.838 --> 00:35:16.077
It's really the issue of trying to squeeze your foot into a shoe that's narrower than your foot that causes the forefoot pain.

00:35:16.077 --> 00:35:19.918
So deformity, it is a bit of a chicken and the egg thing sometimes too in the hind foot.

00:35:20.108 --> 00:35:29.347
Do they get arthritis and then develop deformity because of the arthritis or do they have a deformity 'cause of some weakness that then because of the abnormal forces on the joint causes arthritis?

00:35:29.617 --> 00:35:31.088
And sometimes it's hard to know the answer.

00:35:31.088 --> 00:35:31.958
You never work it out.

00:35:32.007 --> 00:35:37.947
Your job at that point is to say, well, I can only work with where we are now, what we can do forward, and give you options as to how to manage it.

00:35:38.248 --> 00:35:47.182
And as long as you appreciate that there is deformity and arthritis and that you need to deal with both of those things rather than just try and treat one and end up with a different problem later on.

00:35:47.452 --> 00:35:55.702
Well, the one that comes to mind is the acquired flat foot deformity where people get increasing flat foot deformity secondary to tib post dysfunction.

00:35:56.032 --> 00:35:57.052
Is that a common scenario?

00:35:57.052 --> 00:35:59.782
Is one I learned a lot about when I was studying for my fellowship exam.

00:36:00.097 --> 00:36:02.557
But obviously as a upper limb stage, I don't see it anymore.

00:36:02.557 --> 00:36:03.547
How common is this?

00:36:03.583 --> 00:36:04.972
It is reasonably common.

00:36:04.972 --> 00:36:05.182
Yeah.

00:36:05.182 --> 00:36:11.052
You do see a lot of it, people talk about collapsing arches, and I guess as people get older, that does happen.

00:36:11.322 --> 00:36:18.182
The one to be aware of is when you see, one arch that's collapsed not a symmetrical flattening of the arches is that one is pretty flat and the other one's pretty normal.

00:36:18.333 --> 00:36:20.432
That's the one you think, well, something's going on here.

00:36:20.682 --> 00:36:24.612
and the other question I ask, what I often ask people is, have your feet always looked like this?

00:36:24.612 --> 00:36:25.932
Or has that changed over time?

00:36:25.963 --> 00:36:32.233
'cause someone may have flat feet from a young person, and so their feet may look no different, but now one hurts and one doesn't.

00:36:32.532 --> 00:36:33.432
But they haven't changed.

00:36:33.483 --> 00:36:34.083
the way they look.

00:36:34.083 --> 00:36:36.373
So you need to, get a feel for the baseline.

00:36:36.563 --> 00:36:38.583
But certainly the adult acquired flat foot.

00:36:38.963 --> 00:36:44.503
It is a, it is a problem and it, becomes a bigger problem as it progresses.

00:36:44.503 --> 00:36:49.483
it's often due to the failure of the tibialis posterior tendon, and that's the one that comes around the medial side of your ankle.

00:36:49.483 --> 00:36:51.853
So it's running just under the medial malleolus.

00:36:52.182 --> 00:36:54.492
It's the main one that helps hold up the arch of your foot.

00:36:54.913 --> 00:37:00.103
So when people have what's called a flexible flat foot, so kids with flat feet, it works.

00:37:00.172 --> 00:37:01.552
It just doesn't like working all the time.

00:37:01.552 --> 00:37:08.603
And when you ask someone to stand up on their tip toes, the arch will reconstitute, but in a resting position, it can't be bothered working.

00:37:08.842 --> 00:37:16.922
So in an adult, when that fails and it's an overuse condition, it's like in the shoulder, rotator cuff problems, as you get older, they become more common.

00:37:17.132 --> 00:37:20.913
The tendon starts to wear, it doesn't work as well, and the arch then collapses.

00:37:20.913 --> 00:37:22.623
So you end up with someone who had a normal arch.

00:37:22.998 --> 00:37:25.157
Is now got a resting position of a collapsed arch.

00:37:25.438 --> 00:37:28.938
And they will present with tenderness often over the tendon itself.

00:37:29.208 --> 00:37:35.088
So, you get referred with someone with ankle pain or thinking maybe they have ankle arthritis, and it's actually the tendon itself that sore.

00:37:35.268 --> 00:37:42.527
And the joints are all fine, but it's the tendon as it progresses because the change of shape in the foot, the joints will then develop arthritis.

00:37:42.527 --> 00:37:46.038
So that's one of those situations of deformity causing arthritis.

00:37:46.038 --> 00:37:56.057
And if you treat it while it's still in the position where you just have deformity without arthritis, there are simple things, inserts, good shoes, pain relief, all those things.

00:37:56.518 --> 00:38:05.217
If you're having surgery, you can reconstruct the tendon and do what's called a tendon transfer, and that will recreate the arch of the foot and give you a more normal shaped foot.

00:38:05.498 --> 00:38:08.018
But if you've got arthritis as a consequence of that.

00:38:08.282 --> 00:38:10.293
Then the only option really is to fuse the foot.

00:38:10.293 --> 00:38:20.063
So you're recreating the shape of the foot, but you can do that by stiffening the foot in a fusion rather than tightening up ligaments and transferring tendons, which will give you the same shape, but not losing any movement.

00:38:20.063 --> 00:38:22.713
So, that's, yeah it's a fairly common problem.

00:38:22.963 --> 00:38:25.032
And some people just say, look, I can live with it, that's fine.

00:38:25.032 --> 00:38:28.672
But in some people it's very problematic in terms of their quality of life.

00:38:28.702 --> 00:38:30.472
And that's really in foot and ankle surgery.

00:38:30.873 --> 00:38:32.463
We are dealing with quality of life issues.

00:38:32.463 --> 00:38:33.302
We're not life and death.

00:38:33.302 --> 00:38:35.072
We're not heart surgeons or brain surgeons.

00:38:35.313 --> 00:38:40.773
It really is about people being able to walk comfortably and do the things they enjoy doing without pain.

00:38:41.313 --> 00:38:49.072
And obviously with the force going through the body, you've got greater risk of getting arthritis in lots of areas from the great toe way up through the foot.

00:38:49.222 --> 00:38:52.492
The forefoot, the midfoot, the subtalar joint and the ankle joint.

00:38:52.943 --> 00:38:56.873
And I presume most of those areas have their own specific types of treatment.

00:38:56.927 --> 00:38:57.527
Is that correct?

00:38:58.038 --> 00:39:04.608
Yeah, look, I think that surgically they do in terms of the the initial treatment, it's non-operative surgery is always the last resort.

00:39:04.608 --> 00:39:11.097
So the initial non-operative treatment is obviously make the diagnosis try and support the arthritic area.

00:39:11.257 --> 00:39:13.027
So good comfortable shoes.

00:39:13.217 --> 00:39:15.617
Usually an orthotic, so an arch support orthotic.

00:39:15.617 --> 00:39:17.088
And that can just be an off the shelf one.

00:39:17.088 --> 00:39:21.898
It doesn't need to be often custom made unless your foot's, got quite an unusual shape.

00:39:22.117 --> 00:39:27.208
So, good shoes, good orthotics, pain relief, anti-inflammatories, panadol, osteo, these simple things.

00:39:27.487 --> 00:39:29.827
They're the main things, maybe modifying your activity.

00:39:30.228 --> 00:39:33.827
Having a sore foot doesn't mean you can't exercise or stay fit and well.

00:39:34.172 --> 00:39:36.572
It just means you, sometimes you need to be smarter about how you do it.

00:39:36.813 --> 00:39:44.182
And instead of walking a lot or trying or running, you might find that cycling or an exercise bike or pool work or gym or Pilates or yoga.

00:39:44.182 --> 00:39:47.782
These things can allow you to keep fit and well, but not have a sore foot.

00:39:47.873 --> 00:39:51.322
So there, and that's for all those arthritis conditions in the foot.

00:39:51.693 --> 00:39:59.438
In terms of specifics if we start at the forefoot, in the big toe Hallux, rigidus what you'll find is that the stiffer, the sole of your shoe is the happier you are.

00:39:59.467 --> 00:40:04.458
'cause when you walk or when you walk barefoot the more movement that happens in the joint it becomes painful.

00:40:04.588 --> 00:40:09.358
For the ladies, obviously if they wear a heel, that can become problematic 'cause it puts a lot of stress through that joint.

00:40:09.637 --> 00:40:14.378
Same in the midfoot, that as the arch collapses, that puts a lot of pressure through those joints.

00:40:14.527 --> 00:40:19.427
So just something like a nice arch support will support the foot and relieve pain.

00:40:19.708 --> 00:40:23.387
And it's sometimes important to remember that you are supporting the foot.

00:40:23.733 --> 00:40:30.112
Sometimes patients will have an arch support where someone's trying to correct their foot shape and make a very flat foot into a normal looking foot.

00:40:30.413 --> 00:40:31.853
And that can be quite uncomfortable.

00:40:31.972 --> 00:40:40.422
So the, the support you're requiring is really supporting the foot to make it comfortable as opposed to trying to correct the shape of the foot to make it look like something you might put a photo in a book of sort of thing.

00:40:40.422 --> 00:40:47.952
So, so from that point of view and the midfoot, and then in the hind foot again good sensible shoes, often they'll have what's called a rocker sole.

00:40:47.952 --> 00:40:50.353
So that means the sole of the shoe is curved.

00:40:50.413 --> 00:40:52.603
So a good walking shoe, a running shoe will have a rocker in it.

00:40:52.722 --> 00:40:56.023
If you put it on a table, it, you can roll it back and forth 'cause of the curve.

00:40:56.302 --> 00:41:03.023
In some shoes you may need to build that up because obviously the more movement the sole of the shoe has, the less movement your ankle has to do.

00:41:03.023 --> 00:41:04.583
All those other joints have to undertake.

00:41:04.822 --> 00:41:07.972
So a rocker sold shoe and you can buy those commercially.

00:41:08.492 --> 00:41:12.242
It's a bit hit and miss because if you've got one foot, that's a problem.

00:41:12.242 --> 00:41:15.273
You don't need, usually need two rocker old shoes and sometimes.

00:41:15.527 --> 00:41:17.208
The curve can be quite a lot.

00:41:17.487 --> 00:41:21.717
And for an older patient, I've had a few say they felt that like they were on a boat the whole time.

00:41:21.717 --> 00:41:23.038
They were rocking back and forth.

00:41:23.277 --> 00:41:26.547
So some, and you can get them, you can get a rocker sole added to your shoe.

00:41:26.547 --> 00:41:32.637
So some of these people who do shoe repairs, they can add one to the sole of your shoe and if you only got one side, you just need one.

00:41:32.938 --> 00:41:34.407
And they may build the other one up flat.

00:41:34.407 --> 00:41:39.027
So you've got a rocker on one side, a flat on the other that you feel even, and your ankle's getting a bit of a rest.

00:41:39.237 --> 00:41:41.398
So, so that's sort of the simple things you can do.

00:41:41.677 --> 00:41:43.927
Correct deformity for the ankle or behind foot.

00:41:43.927 --> 00:41:46.717
You can use a brace as well as an orthotic for the arch.

00:41:46.958 --> 00:41:48.277
So these things will all help.

00:41:48.407 --> 00:41:51.137
The aim is to get, allow you to get around comfortably without pain.

00:41:51.418 --> 00:41:54.387
Once you go beyond that, then you're really talking about surgery.

00:41:54.697 --> 00:41:59.538
In terms of surgery for everything apart from the ankle joint, the treatment is fusion.

00:41:59.898 --> 00:42:01.807
So we're very simplistic in that way.

00:42:02.018 --> 00:42:04.507
You can't really replace other joints in the foot.

00:42:04.807 --> 00:42:08.797
There have been some attempts in the big toe, but none of have been particularly success.

00:42:09.338 --> 00:42:13.188
So fusing all the, all those other joints apart from the ankle joint is possible.

00:42:13.458 --> 00:42:15.407
And fusion's quite an emotive word.

00:42:15.407 --> 00:42:19.458
People hear fusion and they take a step back when I say that.

00:42:19.777 --> 00:42:25.338
And so you have to take some time to explain to people what does a fusion mean and what is the outcome of fusion.

00:42:25.617 --> 00:42:31.947
So, a fusion is basically an operation where you take away what's left of the damaged point joint and glue the two bones together.

00:42:32.318 --> 00:42:35.677
That means that there's no movement, but in arthritis movement equals pain.

00:42:35.858 --> 00:42:38.047
So you're gonna lose whatever movement you have in the joint.

00:42:38.168 --> 00:42:39.818
You'll also lose the pain that goes with it.

00:42:40.148 --> 00:42:43.657
And in some people they have very little movement to start with, so they're not really losing a lot of movement.

00:42:44.057 --> 00:42:45.498
So that's the fusion side of it.

00:42:45.737 --> 00:42:57.827
The aim of, say, an ankle fusion or a subtalar fusion or one of these things, or even all of them, is that someone walking on a flat surface in a reasonable shoe, someone looking at you, shouldn't know that you've had that operation.

00:42:58.307 --> 00:42:58.518
Right.

00:42:58.518 --> 00:43:02.148
Patients think they're gonna be like some sort of pirate with a peg leg when they're done with a fusion.

00:43:02.447 --> 00:43:05.748
And so, you need to say no, someone who doesn't know you shouldn't know you've had that operation.

00:43:05.748 --> 00:43:07.907
And then they go, oh, that's a lot better than I thought it would be.

00:43:07.907 --> 00:43:11.128
And then you can have a discussion on, whether they wanna go down that path or not.

00:43:11.367 --> 00:43:16.717
So, for all those arthritis conditions in the foot fusion is really the only option in the ankle.

00:43:16.807 --> 00:43:19.838
Ankle replacements are available, they do exist.

00:43:20.117 --> 00:43:23.728
They're much newer technology and we're still getting a handle on them.

00:43:23.818 --> 00:43:27.737
But from, my work with the joint registry they are a niche market.

00:43:27.858 --> 00:43:37.047
So if you look in Australia at ankle replacement last year, the report just came out on the 1st of October And there were 729 ankle replacements done in Australia last year in 2024.

00:43:37.478 --> 00:43:39.728
There were about 80,000 knee replacements.

00:43:39.998 --> 00:43:42.518
So it's about a hundred to one ankle replacements to knee replacements.

00:43:42.518 --> 00:43:44.652
So it is a very small niche market.

00:43:45.318 --> 00:43:46.398
The numbers are small.

00:43:46.557 --> 00:43:49.708
From my perspective, I do about 25 probably a year.

00:43:49.987 --> 00:43:53.137
I do maybe a slightly less number of ankle fusions.

00:43:53.137 --> 00:43:56.077
So I'm about half and half in terms of my practice.

00:43:56.407 --> 00:43:59.797
Others will do more fusions or some people won't do ankle replacements at all.

00:43:59.797 --> 00:44:00.728
They'll just do fusions.

00:44:00.728 --> 00:44:03.438
So it's there, it's available.

00:44:03.597 --> 00:44:06.027
It's not an option for all people with ankle arthritis.

00:44:06.117 --> 00:44:17.027
So there are people who are more suitable than others, and that's part of the discussion as you have with any patient about any treatment, about what is the best treatment for them as opposed to what, the joint registry says is a good treatment.

00:44:17.367 --> 00:44:20.887
So in terms of that who's a good candidate for an ankle replacement?

00:44:21.498 --> 00:44:24.657
Ideally someone older a bit more sedentary.

00:44:25.288 --> 00:44:27.697
Often if they've got adjacent joint arthritis.

00:44:27.697 --> 00:44:33.967
So someone who's had a subtalar fusion or hind foot fusion if you fuse the ankle joint, that makes them quite stiff.

00:44:34.338 --> 00:44:39.657
So, if you keep movement in the ankle joint, then that makes a big difference in terms of their functionality.

00:44:39.907 --> 00:44:41.518
Also contralateral disease.

00:44:41.518 --> 00:44:45.688
So if someone's had a fusion on one side, you'd ideally like to replace the other side.

00:44:45.717 --> 00:44:48.628
'cause if you've got two ankle fusions, you can't propel yourself.

00:44:48.628 --> 00:44:50.518
You can't, it's hard to get up out of a chair.

00:44:50.518 --> 00:44:51.507
It's hard to push off.

00:44:51.958 --> 00:44:53.427
It's like walking on stilts sort of thing.

00:44:53.427 --> 00:44:56.788
So if you can keep movement in one ankle, then that's a really good thing.

00:44:56.788 --> 00:45:05.358
So, people like with rheumatoid arthritis, inflammatory arthritis, these sorts of things who have lots of joints involved, not just their ankle joint they're good candidates.

00:45:05.547 --> 00:45:07.708
In terms of fusion, who do I offer that to?

00:45:07.947 --> 00:45:09.297
If there's a lot of deformity?

00:45:09.297 --> 00:45:13.768
Sometimes there's things you just can't overcome with a joint replacement, if there's any sorts of weakness.

00:45:13.768 --> 00:45:16.197
'cause you need a stable joint to have a good ankle replacement.

00:45:16.538 --> 00:45:24.047
Young laborers, people who are doing heavy work they're gonna wear out their ankle replacement and they're probably better off with an ankle fusion.

00:45:24.268 --> 00:45:26.427
The arch enemy of the ankle replacement is the farmer.

00:45:27.402 --> 00:45:30.552
They are such hard workers, they can't help themselves.

00:45:30.612 --> 00:45:32.163
And so that's the one you worry about.

00:45:32.163 --> 00:45:36.693
If you've got a farmer with a bad ankle, you just worry that they're not gonna be able to help themselves and stop working.

00:45:36.742 --> 00:45:39.563
They keep going and going 'cause there's, they've got such a good work ethic.

00:45:39.902 --> 00:45:42.902
So in terms of fusion, what's the plus?

00:45:42.963 --> 00:45:44.402
The plus is that once it's done.

00:45:44.432 --> 00:45:45.663
You've had one operation.

00:45:45.932 --> 00:45:48.722
If it's few successfully, then your pain is gone.

00:45:48.972 --> 00:45:56.713
Potentially the adjacent joints may develop arthritis down the track because if you're stiffening up one joint, the others may work a bit harder.

00:45:57.163 --> 00:45:59.353
You don't see that often, but you certainly do see it.

00:45:59.623 --> 00:46:04.422
If you have an ankle replacement, like, like your native joint, it may also wear out.

00:46:04.452 --> 00:46:07.782
If you live long enough, you may wear it out, then you have to have that redone.

00:46:08.023 --> 00:46:11.652
And whether that's possible, whether you need to fuse it, that's a tricky thing.

00:46:11.652 --> 00:46:23.512
So that's why the younger heavier more active laboring type patient or someone on their feet a lot doing heavy work is probably best suited with a fusion because they know they won't have to come back and have a redo of their replacement.

00:46:24.182 --> 00:46:34.282
So that's where we're at In terms of the results, if you look at the results of ankle replacement at 10 years, about 13 point half percent of them will have come back to have their ankle replacement redone.

00:46:34.793 --> 00:46:35.032
Alright?

00:46:35.032 --> 00:46:38.643
So, if you compare that to knee replacements, it's about 4.5%.

00:46:39.063 --> 00:46:47.972
So, but, so it's not as good as knee replacements in terms of longevity yet, but when we look at the results, say from five years ago, it was 16% at 10 years.

00:46:48.213 --> 00:46:51.963
So in the short space of five years, we've come down 3% in terms of aboriginal rate.

00:46:52.277 --> 00:46:53.478
And it's getting better every year.

00:46:53.478 --> 00:47:00.478
So the aim would be that we're, that if you have an ankle replacement, hopefully it'll see you out and you won't need to come back and have it redone.

00:47:00.987 --> 00:47:01.467
Right.

00:47:01.978 --> 00:47:02.577
Excellent.

00:47:02.947 --> 00:47:10.927
Now I'm gonna probably ask a loaded question this way, but what's my, what's your favorite investigation when someone comes along to you and you're worried about arthritis?

00:47:11.827 --> 00:47:14.628
Oh, look, I think an x-ray, go with the basics.

00:47:14.818 --> 00:47:16.137
It's, it's a simple thing.

00:47:16.137 --> 00:47:18.458
A weight bearing x-ray you'll often see it.

00:47:18.572 --> 00:47:20.163
And that's all you need to do.

00:47:20.382 --> 00:47:27.413
Once you go beyond that I think an MRI scan, if you're not sure, or if you're worried about other pathologies as well, is very good.

00:47:27.443 --> 00:47:30.413
'cause you can see the state of the cartilage, you can see other things.

00:47:30.603 --> 00:47:33.452
If you're not sure where it is, if you want to localize it.

00:47:33.753 --> 00:47:36.463
Something like a bone scan is a very good test.

00:47:36.682 --> 00:47:43.132
It'll help you localize, especially in the midfoot if there's, 'cause there's lots of little joints there if you're not sure where it is.

00:47:43.163 --> 00:47:44.963
That's a quite a good test for doing that.

00:47:45.273 --> 00:47:48.663
And in terms of treatment, we talked about surgery for arthritis.

00:47:48.972 --> 00:47:53.773
I think a cortisone injection is a very good way of managing someone.

00:47:54.103 --> 00:47:56.922
It's not gonna solve their arthritis, but it will buy time.

00:47:57.222 --> 00:48:05.603
So somewhere in that, someone who's got midfoot arthritis who may not necessarily want an operation or a fusion then I think an, a cortisone injection is a very good way to go.

00:48:05.813 --> 00:48:07.822
But you need to make sure it's in the right spot.

00:48:08.123 --> 00:48:12.802
And if you're not sure which joint it's in, then something like a bone scan is a very good way to do that.

00:48:12.983 --> 00:48:17.572
Especially if the x-ray's not conclusive in terms of cortisone injections.

00:48:17.853 --> 00:48:19.922
I get them all done under ultrasound.

00:48:20.202 --> 00:48:23.172
That way you know that the injections in the right spot.

00:48:23.202 --> 00:48:26.833
'cause the worst thing is if you put an injection in and then someone comes back and says, I'm no better.

00:48:27.237 --> 00:48:28.498
Does that mean they're no better?

00:48:28.498 --> 00:48:30.358
Or does it mean that you didn't put it in the right spot?

00:48:30.628 --> 00:48:33.117
With ultrasound, you can be assured that it's in the right spot.

00:48:33.367 --> 00:48:35.318
And then the outcome is more obvious.

00:48:35.478 --> 00:48:41.538
I tell people that it'll take two or three weeks for the cortisone to work, so I talk to them about a month after their injection.

00:48:41.748 --> 00:48:43.668
By then, it's pretty clear whether it's made a difference.

00:48:43.938 --> 00:48:47.628
I also tell them to do their normal activities after the injection.

00:48:47.818 --> 00:48:50.728
If they take it easy for a month, they'll tell me they're better, but that's'cause they haven't done anything.

00:48:50.728 --> 00:48:55.737
So you gotta again get them to do their regular stuff and see if it's really made a difference in their quality of life.

00:48:56.108 --> 00:48:58.978
Is the key thing for for ultrasound guided injections.

00:48:59.427 --> 00:49:02.157
The other thing is there are other things that people are injecting as well.

00:49:02.157 --> 00:49:05.347
Now there are biologics, there is visco supplementation.

00:49:05.407 --> 00:49:07.538
So the biologics are things like PRP.

00:49:07.867 --> 00:49:16.282
Which is where you take someone's blood, you put it in a centrifuge, you spin it down, and you take some healing factors and inject it in around a painful area to see if it can cause some healing.

00:49:16.532 --> 00:49:22.447
The evidence here isn't conclusive, so there's certainly plenty of things available, but it's not conclusive.

00:49:22.538 --> 00:49:28.818
If there is evidence that's conclusive, it's probably more so to do with things like tendinopathies rather than with arthritis.

00:49:29.038 --> 00:49:33.237
And I guess in the upper limb things like tennis elbow and things like that, there's reasonably good evidence.

00:49:33.237 --> 00:49:43.557
So maybe with tendonitis or something, it's maybe better than arthritis, but so that's, again, something that's evolving and we're still getting the hang of it, but certainly it's something to think about in in, in patients.

00:49:43.777 --> 00:49:46.898
The other thing you can inject is what's called visco supplementation.

00:49:47.208 --> 00:49:50.867
And that's really synovial fluid effectively is what you're injecting into the joint.

00:49:51.228 --> 00:49:53.268
Again, most of the evidence here is in the knee.

00:49:53.327 --> 00:49:55.637
There's not very much in the foot ankle, in the knee.

00:49:55.637 --> 00:49:58.277
There is some good evidence that shows that you gain some time.

00:49:58.572 --> 00:50:01.873
In the foot and ankle, not so much just'cause the research hasn't been done.

00:50:02.052 --> 00:50:07.768
So again, it's something to consider, but ultimately you're probably gonna end up having to do something more than that in the long run.

00:50:08.367 --> 00:50:14.237
And what about one of my favorite foot and ankle arthritic operations is the Cheilectomy for Hallux Rigidus.

00:50:14.447 --> 00:50:16.668
Is that still a good operation in the early stages?

00:50:16.887 --> 00:50:17.577
I think it is.

00:50:17.577 --> 00:50:20.458
Ideally you need to work out what you are treating.

00:50:20.577 --> 00:50:25.237
So the Cheilectomy is really shaving the dorsal part of the metatarsal head.

00:50:25.237 --> 00:50:29.827
So just the top bit, often there's a spur there and that's where they tender when you push on top of the joint.

00:50:30.097 --> 00:50:37.588
And what happens is when you dorsi flex the toe the toe bumps into that and you get some some pain and it's really an impingement type problem.

00:50:37.807 --> 00:50:48.498
So if that's your problem, then shaving off that spur and some of the metatarsal head will allow the toe to dorsi flex, you might increase your range of motion as well, but not have the pain that goes with that.

00:50:48.797 --> 00:50:51.318
So, and in early disease, I think it's a good operation.

00:50:51.648 --> 00:50:56.628
The problem is that spur is there because there is some damage to the joint, so that damage may progress.

00:50:56.628 --> 00:51:02.128
So down the track they may present again with arthritis in the joint, in which case the treatment there is a fusion.

00:51:02.398 --> 00:51:10.503
If at the time of surgery there is a lot of joint damage, then you know, it's a bit of a dilemma because you suspect this isn't gonna last very long.

00:51:10.742 --> 00:51:14.373
But again, if you're, again, you're buying time here for some people you'll cure them.

00:51:14.702 --> 00:51:17.282
If their problem is just that impingement, then you've solved it.

00:51:17.503 --> 00:51:20.353
In others that may progress, that they may be back to have a fusion.

00:51:20.603 --> 00:51:22.072
But I think it's still a good operation.

00:51:22.072 --> 00:51:22.943
It preserves movement.

00:51:22.943 --> 00:51:26.242
So we talk about joint sparing procedures and that's what we're talking about.

00:51:26.242 --> 00:51:29.753
Something that will allow movement for people who wanna run or do something like that.

00:51:29.992 --> 00:51:33.023
You can still run with a fusion, but it's probably not recommended.

00:51:33.532 --> 00:51:39.443
Yeah, I like it because it's one of the few operations where you actually are debriding an artery joint with actually reasonable results.

00:51:39.847 --> 00:51:40.568
In that setting.

00:51:40.838 --> 00:51:42.818
There's not many around the place that can do that.

00:51:42.818 --> 00:51:45.697
But it's has got short term reasonable results, I believe.

00:51:45.757 --> 00:51:46.478
Oh, exactly.

00:51:46.478 --> 00:51:50.378
And, and again the other one that I do a Cheilectomy sometimes is in the midfoot.

00:51:50.588 --> 00:51:51.938
So around the lis franc joints.

00:51:51.938 --> 00:51:56.978
So the tasa metatarsal joints, you'll often see people who have some arthritis here in Spurs on the dorsum.

00:51:57.288 --> 00:52:00.103
But their problem that their problem is pain when they're wearing shoes.

00:52:00.373 --> 00:52:03.672
And it's often related to the lump being rubbed on by the upper of the shoe.

00:52:03.972 --> 00:52:11.293
And if you can work out that the pain is coming from the lump being rubbed on rather than the joint, you can go in and shave that off and make them very happy.

00:52:11.322 --> 00:52:15.313
And again, same sort of thing, you're getting rid of that impingement that's happening by the shoe.

00:52:15.532 --> 00:52:20.032
But if the joint's not arthritic, they'll be very happy with that outcome, even though they've still got an arthritic joint on an x-ray.

00:52:20.813 --> 00:52:24.682
And what are some of the common elective conditions that GP should know apart from just arthritis?

00:52:24.682 --> 00:52:27.052
Are there other things you should be thinking about as well?

00:52:27.143 --> 00:52:28.652
Oh, there's a ton of things.

00:52:28.782 --> 00:52:31.753
I try and divide them up by sort of their location as a simple thing.

00:52:32.023 --> 00:52:37.413
'cause patient presents with, it says, I've got pain around my ankle, so you think, what is it around the ankle that might be giving me trouble?

00:52:37.592 --> 00:52:41.913
So things like Achilles tendonitis instability or sprains.

00:52:42.103 --> 00:52:49.648
The arthritis, obviously we talk about ankle arthritis and all the hind, foot joints deformity, so the flat foot or the high arch foot, which will have ankle deformity as well.

00:52:49.797 --> 00:52:52.797
The other thing you see fairly commonly is plantar fasciitis.

00:52:52.978 --> 00:52:54.478
So that's pain under the heel.

00:52:54.757 --> 00:52:59.498
And for that you don't often operate on it, I do occasionally, but you see it fairly commonly.

00:52:59.498 --> 00:53:05.768
And the treatment is fairly straightforward in terms of good, comfortable shoes, more padding under the foot, stretching exercises.

00:53:06.083 --> 00:53:13.463
Physiotherapy, pain relief, it will generally get better on its own, but it can take anywhere from say, six months to two years to fully get better.

00:53:13.793 --> 00:53:19.163
And so you just need to warn people again, it's about educating people and saying, look, this will take time to get better.

00:53:19.443 --> 00:53:22.983
And sometimes it does, or most times it does, but sometimes it doesn't.

00:53:23.193 --> 00:53:25.592
And if that's the case, then there is an operation you can do.

00:53:25.842 --> 00:53:33.648
And it's a little keyhole operation where you, divide part of the plant of fascia, that seems to take the tension off it and it helps settle things down.

00:53:33.648 --> 00:53:37.338
So you can treat it with surgery, but most often it's just time.

00:53:38.822 --> 00:53:52.193
So in terms of other areas in the midfoot, we talked about arthritis, we've talked about collapse, and the midfoot collapse can be due to arthritis, but often due to this adult acquired flat foot, we've talked about that, how to manage that shoes inserts, pain relief.

00:53:52.413 --> 00:53:56.463
And then beyond that, you can talk about surgery depending on whether there's arthritis or not.

00:53:56.733 --> 00:53:59.342
In the forefoot, bunions are very common.

00:53:59.652 --> 00:54:02.782
They don't always need surgery, but they, they are common.

00:54:03.052 --> 00:54:04.413
They tend to run in families.

00:54:04.432 --> 00:54:08.842
So there's often a story of my mom or my grandma, or my aunt, had these horrible feet.

00:54:09.152 --> 00:54:10.713
And it's important to reassure patients.

00:54:10.713 --> 00:54:13.322
They're not gonna suddenly wake up with grandma's feet tomorrow.

00:54:13.652 --> 00:54:17.583
The progression of bunions is very, is generally very slow and takes many years.

00:54:17.913 --> 00:54:21.963
And so, I tell patients the best predictor of what will happen is what has happened.

00:54:22.322 --> 00:54:26.253
If your foot was normal a year ago and now it's got a big bunion, it's probably moving quickly.

00:54:26.282 --> 00:54:27.422
It'll happen quickly from here.

00:54:27.632 --> 00:54:30.693
But generally, there's a story of many years of a bunion gradually getting worse.

00:54:31.233 --> 00:54:33.032
It'll gradually get worse over many years.

00:54:33.063 --> 00:54:37.413
At any point along that progression, if you wanna do something, there's an operation that can be done to fix it.

00:54:37.663 --> 00:54:39.943
But really the timing is entirely up to the patient.

00:54:39.992 --> 00:54:41.793
It's their call as to when they wanna do it.

00:54:42.163 --> 00:54:42.882
So that's bunions.

00:54:42.882 --> 00:54:44.322
Hallux Rigidis we've talked about.

00:54:44.543 --> 00:54:51.012
So the arthritis in the big toe joint Morton's, neuroma and metatarsalgia are two other things that are very common.

00:54:51.012 --> 00:54:52.333
So they're in the lesser toes.

00:54:52.583 --> 00:54:55.463
The metatarsalgia is pain under the metatarsal heads.

00:54:55.742 --> 00:54:59.222
and Morton's neuroma is the thickening of the nerve between the metatarsal heads.

00:54:59.492 --> 00:55:04.922
So we're talking about two conditions that are millimeters apart and sometimes are really hard to tell apart.

00:55:05.262 --> 00:55:07.452
So it can be very tricky working out what's what.

00:55:07.733 --> 00:55:10.163
For me, a lot of it comes down to the history.

00:55:10.402 --> 00:55:12.382
The history is opposite really for both of these.

00:55:12.742 --> 00:55:17.182
If you've got a Morton neuroma, the symptoms come on when your foot's being squeezed.

00:55:17.213 --> 00:55:18.472
'cause the nerve is being squeezed.

00:55:18.472 --> 00:55:19.523
So when you wear shoes.

00:55:20.063 --> 00:55:20.603
It's sore.

00:55:20.603 --> 00:55:25.342
People say, look, I put my shoes on and maybe after half an hour, I take my shoes off, I rub my foot, it gets better.

00:55:25.822 --> 00:55:27.472
And the pain is usually in the toes.

00:55:27.472 --> 00:55:31.213
They you can be described as electric shocks or numbness in the toes.

00:55:31.512 --> 00:55:36.672
For metatarsalgia, it's really a pressure point under the under the bone, the metatarsal head.

00:55:36.853 --> 00:55:39.432
So for those people walking barefoot is terrible.

00:55:39.672 --> 00:55:41.652
Walking in a good, comfortable shoe is really quite good.

00:55:41.652 --> 00:55:44.242
'cause there's lots of cushioning between the foot and the ground.

00:55:44.452 --> 00:55:48.023
For the ladies, again, when they wear a heel, that puts a lot of pressure on your metatarsal heads.

00:55:48.202 --> 00:55:53.253
So they'll often complain about that that, high heels or any sort of a heel will really give them trouble.

00:55:53.552 --> 00:55:56.853
And the pain is under the ball of your foot rather than in the toes.

00:55:56.913 --> 00:55:59.262
So the histories are generally quite different.

00:55:59.503 --> 00:56:01.722
Not always, but and the two things can coexist.

00:56:02.217 --> 00:56:07.717
So in terms of what to do again good, sensible shoes, lots of padding under there.

00:56:07.958 --> 00:56:12.487
In terms of an orthotic, this is somewhere where something a bit more customized will help.

00:56:12.708 --> 00:56:17.527
You can get what's called a metatarsal dome, and that's a an elevation in the metatarsal.

00:56:17.527 --> 00:56:19.927
And it sits under the shaft of the metatarsal.

00:56:19.927 --> 00:56:21.818
So it's not where you saw under the ball of your foot.

00:56:21.818 --> 00:56:27.487
It's further back and it uses the metatarsal as a lever really to elevate the far end of the metatarsal.

00:56:27.728 --> 00:56:31.547
It spreads the load more evenly across the front of the foot and that can often relieve symptoms.

00:56:31.547 --> 00:56:33.108
So that's a simple way to do things.

00:56:33.387 --> 00:56:35.307
Beyond that, there really is surgery.

00:56:35.487 --> 00:56:38.697
If it's a Morton's neuroma, the treatment is to excise the neuroma.

00:56:38.757 --> 00:56:47.568
So you take out the thickened nerve and then that will get rid of the pain, but you also end up with some numbness because you end up taking out the nerve that supplies a web space in the toe.

00:56:47.927 --> 00:56:51.378
But that's a lesser problem to have than the pain that people often experiencing.

00:56:51.422 --> 00:56:53.103
For metatarsalgia.

00:56:53.103 --> 00:57:01.313
If a dome doesn't work then you're really talking about surgery, which is to do an osteotomy, cut the bone and shorten it up so that you're spreading that load more evenly.

00:57:01.313 --> 00:57:03.833
So, so they're the sort of forefoot problems.

00:57:04.012 --> 00:57:09.202
And obviously you talked earlier about claw toes, lesser toe deformities, so claw toes, hammertoss, all those things.

00:57:09.472 --> 00:57:11.152
Again, simple things.

00:57:11.362 --> 00:57:12.893
A nice wide, deep shoe.

00:57:12.952 --> 00:57:15.443
If you've got a shoe with lots of room, they're not gonna rub.

00:57:15.472 --> 00:57:16.643
That'll solve the problem.

00:57:17.032 --> 00:57:20.123
You can solve these problems by the changing the shape of your shoe or the shape of your foot.

00:57:21.068 --> 00:57:23.378
And so if you want to get new shoes, that's fine.

00:57:23.588 --> 00:57:26.347
I often tell people, you can either look good or feel good.

00:57:26.378 --> 00:57:28.237
It's hard to do both at the same time.

00:57:28.237 --> 00:57:33.427
So, so if, yeah, but in terms of lesser toe deformities, surgery can be done.

00:57:33.588 --> 00:57:37.367
Usually involves fusing the joints in the toe so that you keep the toes stiff and straight.

00:57:37.527 --> 00:57:39.297
So that it just makes it more comfortable.

00:57:39.777 --> 00:57:42.717
So yeah there's lots of different things that, you need to know about.

00:57:42.958 --> 00:57:49.697
Most of them can be managed fairly simply with shoes maybe inserts pain relief, activity modification.

00:57:49.938 --> 00:57:54.248
Once it goes beyond that, then there are obviously more complicated things such as surgery.

00:57:54.918 --> 00:57:55.378
Excellent.

00:57:55.378 --> 00:58:01.333
is it still narrow shoes part of the factors in causation, or is it all genetic Oh look, I think it's a combination.

00:58:01.333 --> 00:58:06.012
I mean, if you've got a family history of bunions, I'm not sure what shoes you wear is gonna make a difference.

00:58:06.222 --> 00:58:10.882
The narrow shoe is probably in, in terms of the people I see is more an aggravating factor.

00:58:10.913 --> 00:58:16.413
Whether it caused it or not is hard to know, but it certainly irritates the foot when they're wearing narrow shoes.

00:58:16.682 --> 00:58:18.722
And and that's, that's why they come and see me.

00:58:18.722 --> 00:58:19.742
'cause I've got pain now.

00:58:19.742 --> 00:58:23.702
So it probably is partly environmental, partly genetics.

00:58:23.952 --> 00:58:28.393
But ultimately if you're wearing a nice wide shoe, it tends to be less of a problem.

00:58:28.682 --> 00:58:29.072
So, yeah.

00:58:29.072 --> 00:58:42.253
So I think it's a really, it's not, there's not a simple answer to that question, but certainly narrow shoes will make it more symptomatic for the patient who then if they wanna wear those shoes, will be possibly more likely to wanna have surgery to change the shape of their foot to fit into that shoe.

00:58:42.253 --> 00:58:46.663
But if you, if your shoes narrow than your foot, you're gonna have a bit of a problem regardless.

00:58:48.043 --> 00:58:52.152
So, we've covered a fair bit already Pete, but one of the ones I always struggle with when people ask me.

00:58:52.737 --> 00:58:54.358
About injuries are stress fractures.

00:58:54.358 --> 00:58:56.757
I believe you, it stress fractures in all parts of the lower limbs.

00:58:57.027 --> 00:58:59.458
What are the common ones that you see and can you tell me a bit about them?

00:59:00.117 --> 00:59:04.202
Yeah, look, stress fractures are overuse injuries like tendonitis, like those sorts of things.

00:59:04.413 --> 00:59:10.963
So often in the history when you're talking to patients there's often been a change in activity and, but that change may be six or 12 months ago.

00:59:10.963 --> 00:59:13.902
So it takes a long time for that to become symptomatic.

00:59:14.083 --> 00:59:21.862
So if someone is they may have commenced a new activity, they may have taken up running or gone going to the gym, or if they're doing it already, they may have changed their routine.

00:59:21.862 --> 00:59:27.862
They may train more often, they may increase the intensity of their training, they may have changed their shoes or the surface they're running on.

00:59:27.862 --> 00:59:33.083
So sometimes there's a change, and it may not be recent, that is a precipitant for the stress fracture.

00:59:33.083 --> 00:59:34.733
So that's the first thing you wanna see.

00:59:35.003 --> 00:59:36.932
You wanna work out initial management.

00:59:37.353 --> 00:59:39.273
Decreased activity truly become pain-free.

00:59:39.753 --> 00:59:48.242
So if if you're getting pain with sport, then stop that particular type of sport till you're pain free for a period of time, and then you can slowly increase what you're doing.

00:59:48.422 --> 01:00:00.163
If you're just getting pain say with walking, then it may will be that you need a boot or even a period of non-weightbearing to become pain free before you then go back to walking and then to training in terms of your recovery.

01:00:00.443 --> 01:00:02.873
You need to have a stepwise progression in your recovery.

01:00:02.873 --> 01:00:06.853
So if you can't just suddenly go back to running 10 kilometers, you've gotta build up to that after.

01:00:06.853 --> 01:00:12.193
So you need a period of being pain free, maybe even six or eight weeks, and then slowly increase what you're doing.

01:00:12.463 --> 01:00:14.382
Assistance from maybe one of the sports physicians.

01:00:14.938 --> 01:00:16.918
Or the physios is quite good.

01:00:17.047 --> 01:00:18.697
They can guide you through a program.

01:00:18.967 --> 01:00:20.827
They may they can measure things as well.

01:00:20.827 --> 01:00:25.358
So sometimes it's about, you may not feel like you're improving, but they could, 'cause they're measuring things.

01:00:25.628 --> 01:00:31.007
They can tell you that you are if there are particular biomechanical issues, sometimes podiatry may help with orthotics.

01:00:31.007 --> 01:00:34.387
If you've got a high arch or something like that may make you prone to stress fractures.

01:00:34.717 --> 01:00:35.677
That's the key thing.

01:00:35.677 --> 01:00:44.878
Sometimes when you're going back to activity you might find that if you get really sore, you need to drop down to a previous level for a bit, become more comfortable, and then slowly increase again from there.

01:00:45.208 --> 01:00:50.217
The other thing that is really underappreciated in stress fractures is vitamin D deficiency, right?

01:00:50.217 --> 01:00:55.222
I mean, even in, young athletes, you do see it and obviously in, in community it's very common if you test for it.

01:00:55.827 --> 01:00:56.818
It's very common.

01:00:57.007 --> 01:00:59.447
We think we live in Australia, how is that possible?

01:00:59.447 --> 01:01:01.398
But a lot of us live and work indoors a lot.

01:01:01.547 --> 01:01:02.807
We don't get a lot of sunlight.

01:01:03.108 --> 01:01:07.338
We're very conscious of skin cancer, so when we go out, we wear hats and long sleeves and sunscreen.

01:01:07.608 --> 01:01:10.887
So, if you see someone with a stress fracture, think of vitamin D deficiency.

01:01:11.128 --> 01:01:13.568
That's a simple thing to treat for that as well.

01:01:13.777 --> 01:01:15.818
What are the sites of stress fractures that you see?

01:01:15.907 --> 01:01:20.447
Yeah, I mean, the fifth, the base of fifth metatarsals, so that Jones fracture is one that you see.

01:01:20.688 --> 01:01:24.467
The second and third metatarsal is what's commonly called a march fracture.

01:01:24.467 --> 01:01:30.597
So that's someone who may have taken up running or a lot of walking the stress through that if you've got a high arch, that may be more common.

01:01:30.958 --> 01:01:35.338
Also the navicular has a stress fracture as well, and you see that often in jumping athletes.

01:01:35.338 --> 01:01:40.887
So I see a lot, a few footy players who get it, like ruckman and people like that who are doing jumping or basketballers the navicular.

01:01:40.887 --> 01:01:42.387
So that's further back in the foot.

01:01:42.668 --> 01:01:48.217
And every now and then I see someone with a an older person with a calcaneal / heel stress fracture, and that's due to osteoporosis.

01:01:48.512 --> 01:01:51.483
So they may present with something like plantar fasciitis with heel pain.

01:01:51.842 --> 01:01:55.532
And then, you do an MRI and you see they've got a calcaneal stress fracture.

01:01:55.682 --> 01:02:00.172
So, so they're the commoner type of stress fractures in the tibia and things like that.

01:02:00.172 --> 01:02:01.402
They're pretty uncommon.

01:02:01.402 --> 01:02:04.733
They do happen, but it's mainly, yeah, fifth metatarsal navicular.

01:02:04.952 --> 01:02:07.322
Second and third metatarsal are the common stress fractures.

01:02:07.373 --> 01:02:14.628
So the other thing I see a bit about, are people who recurrently sprain their ankles, have got lax ligaments or they've had a bad injury and they've got unstable ankles.

01:02:15.168 --> 01:02:15.797
Are they common?

01:02:15.797 --> 01:02:16.998
And how do you treat those?

01:02:17.907 --> 01:02:18.777
They are common.

01:02:19.018 --> 01:02:25.157
Again, most people with one ankle sprain or two ankle sprain with good rehab won't have recurrence.

01:02:25.338 --> 01:02:30.867
And it's the people who have that recurrent injury who they, whether you talk to 'em, they say, I just can't trust my ankle.

01:02:30.927 --> 01:02:32.398
That's the sort of common story you get.

01:02:32.668 --> 01:02:34.887
They're the ones who would you would consider surgery on.

01:02:35.188 --> 01:02:37.498
And again, it's working out what their problem is.

01:02:37.737 --> 01:02:38.458
It's the ligaments.

01:02:38.458 --> 01:02:42.447
If it's the ligament's, laxity, if they've got weakness, it may be peroneal tendon injuries.

01:02:42.447 --> 01:02:45.297
Every time you roll your ankle, you may cause injury to the peroneal tendons.

01:02:45.807 --> 01:02:50.518
The other thing is that usually their ankle is not painful in between sprains.

01:02:50.547 --> 01:02:52.588
So day to day they're not sore.

01:02:52.807 --> 01:02:54.518
But when they roll their ankle, obviously it hurts.

01:02:54.668 --> 01:03:03.197
If you've got someone who has pain day to day with an unstable ankle, you need to think about something going on in the joint, like cartilage damage or some chondral injury within the joint.

01:03:03.347 --> 01:03:04.697
So you need to investigate the joint.

01:03:04.697 --> 01:03:07.338
'cause they may require that dealt with as well as their instability.

01:03:07.498 --> 01:03:10.197
The other thing you need to look at is any deformity.

01:03:10.347 --> 01:03:12.318
So some people have a varus hind foot.

01:03:12.318 --> 01:03:15.648
So the heel is coming in the heel is come in towards each other when they stand.

01:03:15.648 --> 01:03:19.068
If you look at them from the back, that's gonna put a lot of stress on all the lateral structures.

01:03:19.068 --> 01:03:21.498
So the peroneal tendons, the lateral ligaments, all those things.

01:03:21.807 --> 01:03:28.407
If that's the case, then often if I'm gonna undertake surgery, I'll often do an osteotomy and realign the hind foot.

01:03:28.797 --> 01:03:34.972
So that you give the whatever operation you do to the Peroneal tendons or the ligaments has a much better chance biomechanically of succeeding.

01:03:35.242 --> 01:03:40.822
If you repair all the lateral structures and the foot still turns in, you're probably gonna be back where you started from after not too long.

01:03:40.822 --> 01:03:50.972
So, so, treating any deformity within the foot that may make them prone to rolling their ankle, treating any weakness such as peroneal tendon injuries, and then obviously treating the ligaments and any other cause of pain.

01:03:51.333 --> 01:03:57.672
So that, and in terms of that, it's probably 5% or maybe 10% of ankle sprains that'll ever get to that point.

01:03:57.853 --> 01:04:05.802
But if they've had a good trial of proper management with physio and all those things, and they're still not able to trust their ankle, I think it's a very reasonable and sensible thing to do.

01:04:06.112 --> 01:04:08.422
And, timelines to return to sport.

01:04:08.902 --> 01:04:13.012
In my case, they're in a boot for six weeks, so at three months they'll be getting there.

01:04:13.063 --> 01:04:14.532
They'll have had six weeks of rehab.

01:04:14.713 --> 01:04:22.592
But yeah, to really get back and say they're fully into it, it's probably best part of six months for them to be comfortable back at sport and confident that they can trust their ankle.

01:04:23.583 --> 01:04:25.652
Well, Pete, that's, we've covered a lot of ground today.

01:04:25.682 --> 01:04:30.483
We've covered everything from fractures and dislocation, sprains through to arthritic conditions.

01:04:30.693 --> 01:04:38.853
I think you've really appreciated you coming on Aussie Med Ed and going through what are very common foot and ankle conditions and you've said yourself are the most common fractures in the lower limbs.

01:04:38.853 --> 01:04:41.012
So look, thank you very much for coming on Aussie Med Ed.

01:04:41.012 --> 01:04:42.123
It's great to have you here.

01:04:42.782 --> 01:04:43.353
Thank you, Gavin.

01:04:43.353 --> 01:04:45.983
It's been a real pleasure and great to talk about some of these things.

01:04:45.983 --> 01:04:49.072
Hopefully someone's gained some value from it and some useful knowledge.

01:04:49.072 --> 01:04:49.552
Thanks, mate.

01:04:49.853 --> 01:04:50.722
Thank you very much.

01:04:50.782 --> 01:04:51.413
Thanks a lot.

01:04:51.413 --> 01:04:51.802
Cheers.

01:04:52.092 --> 01:04:53.862
well, that's been a fascinating discussion with Dr.

01:04:53.862 --> 01:04:59.202
Peter Stavrou giving us a valuable insight into one of the most intricate and essential parts of the body, the foot and ankle.

01:04:59.771 --> 01:05:05.981
We've explored how GPS can recognize early warning signs, manage common presentations, and understand when is appropriate.

01:05:06.431 --> 01:05:11.516
We've also learned how surgical advances, including total ankle, ankle replacement, are improving patient outcomes and quality of life.

01:05:12.972 --> 01:05:21.581
As always, the key takeaway is collaboration between gps, physiotherapists, podiatrists, and Orthopaedic surgeons to ensure patients get the best possible care.

01:05:22.121 --> 01:05:30.822
If you'd like to find out more or catch previous episodes, visit medicalpodcast.au and don't forget to follow us or subscribe to Aussie Med Ed wherever you get your podcasts.

01:05:31.211 --> 01:05:32.052
Thanks for listening.

01:05:32.202 --> 01:05:35.172
I'm Gavin Nimon, and I look forward to joining you again next time.

01:05:35.231 --> 01:05:36.791
Until then, please stay safe.