Ep 220: There's more to the ankle than the ATFL, with Liz Bayley

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. The anterior talofibular ligament gets a fair bit of attention in the ankle, but as JOSPT Insights listeners know,

[00:00:28] there's more to the ankle than the ATFL. Today, Liz Bayley joins me to share her approach to figuring out lateral ankle pain and diagnosing, managing and ideally preventing chronic ankle instability. Liz is a former professional dancer and she now works as a dance specialist physiotherapist. Her clinic is in London's West End in close proximity to the freelance professional and student dancers

[00:00:54] she works with at Trinity Laban Conservatoire of Dance and Music and on Matilda the Musical in Covent Garden. Liz also teaches on dance science, hypermobility and the foot and ankle. Today's interview is definitely a masterclass on ankle pain. Okay, over to Liz. Liz Bayley, welcome to JOSPT Insights. Thank you for having me. I'm excited to talk about ankles with you today.

[00:01:21] I'm really excited to have you talking about ankles too, Liz, because it's been a while since we talked about the ankle, particularly outside of the Achilles tendon on the JOSPT Insights podcast. So having you here to join us is wonderful. We're going to draw on your knowledge and expertise, extensive expertise of the foot and ankle today. Let's start with the very common lateral ankle problems. And you say that lateral ankle pain is so much more than the anterior talofibular

[00:01:48] ligament or ATFL. What is it that you want people to know about lateral ankle pain? Dr. Anne-Libert Atf-L injuries are incredibly prevalent in the population and there's a few reasons for that. But because of that, it feels like lateral ankle sprains, I always say they're massively over-diagnosed and they're also massively under-treated, which is a weird kind of dichotomy, I guess. The reason that they're very prevalent is what we know. I read a figure of around 30,000 lateral ankle sprains

[00:02:16] a day in the United States. So just, I mean, whenever I teach, I ask people who hasn't had a sprain rather than who has, you know, because they're so prevalent. But when you look at the lateral ankle ligaments, the ATFL is sprained in almost 100% of cases. So looking at ankle sprains, 85% of those will be lateral ankle ligaments. The other 15% are medial and syndesmosis. And the ATFL

[00:02:41] is pretty much all of those with 20% of them being the ATFL and the calcaneofibular ligament. So they are very common injuries. But I think for that reason, sometimes people diagnose a lateral ankle strain when actually they've got the location right, but it's not that tissue at all. And when you look at the mechanism of injury, for example, there might not even have been a spraining incidence, but the person has pain on the outside of the ankle and they've been

[00:03:08] diagnosed with a lateral or people seem to know it's not an acute sprain. So they just call it a chronic sprain. I had a patient like that who had lateral ankle pain and had a very clear ETTD, posterior tibialis tendon dysfunction, which was leading to a, what we would call now a progressive collapsing foot deformity, which causes compressive problems on the lateral ankle. And it was diagnosed as a lateral ankle sprain. Now they said it was chronic, but that isn't the driving

[00:03:35] factor behind the pain. What they had was compressive sinus tarsi pain. And it's an example of when I say lateral ankle pains are overdiagnosed. Another example is you can get bone stress injuries in the ankle, in the talus, which present right around where the ATFL is because obviously it's a ligament that inserts into the talus. And of course, the treatment for a bone stress injury of the talus is drastically different from something like an acute ankle sprain. But again,

[00:04:02] the mechanism of injury isn't really there for that. The mechanism of injury will tell you loads about what could be injured, which side of their ankle is going to have problems, hemisole forces, compressive forces. And then if you look at the energy behind the injury, so is it where someone just stepped off a curb or a path? Or did they fall off the roof of the house? Or is it someone in the army jumping out of a parachute and landing heavily onto their ankle? Because if it's a very high energy injury, you're going to be thinking about

[00:04:32] concurrent injuries. They might have a sprain, but they're likely to have a fracture as well, or an osteochondral defect or lots of, say, medial side bruising, bone marrow edema impingement, if it's a higher energy injury. So yeah, they could have a lateral ankle ligament issue, but there can be lots of concurrent issues as well, which you don't want to miss because those will change the prognosis. Even if it's a sprain, the prognosis can be between six to 12 weeks before

[00:05:01] you get back to kind of sporting activities. And if it's a higher grade sprain, it can certainly be longer than that. But if you've got medial bruising or an osteochondral defect, the prognosis is stretched quite a bit further than that. I've had people not get back to sport for eight months following those kinds of injuries. So there's a significant difference. Other things that you don't want to miss. So yes, it's a lateral ankle strain, but is there anything else? So fractures are obviously a big one. Most physios are very aware of the Ottawa ankle rules, which are

[00:05:28] the gold standard, but Ottawa ankle rules will miss out certain fractures. And one of the key ones is the anterior process of the calcaneus. So that fits just next to the sinus tarsi. The mechanism of that injury is more of a plantar flexion injury with a bit more high energy behind it. Again, we're looking at like an avulsion fracture. So you're looking at the energy levels again. This isn't someone stepping off a curb, it's someone falling down the stairs with their foot

[00:05:54] in plantar flexion and inversion, or playing football and someone contacting them from the back with the foot falling heavily into plantar flexion and inversion. It's a bifurcate ligament injury. So either the bifurcate ligament will sprain or it will avulse the anterior process of the calcaneus. And that has significant effects down the line because it will affect foot posture and foot function. Because you're talking about the show part joint of the foot,

[00:06:19] so where the calcaneus meets the cuboid and navicular. Often you need like a medial arch support inside the boot so the foot doesn't deform as you put load through it to allow those ligaments to heal. And if you don't do that, you can end up with lateral column instability. So yeah, lots of other anatomy around the ATFL that can be affected. That's such a great summary, Liz. Thank you. It got me thinking, where in this process of diagnosing,

[00:06:47] if at all, does imaging come into it for you? It definitely depends on the presentation. If we're suspecting a fracture, of course, we have to rule that out. So if it's a high energy injury, or if the otter or ankle rules are positive at all, you're going to be sending x-rays. The higher the energy injury, the more I'm going to suspect some kind of talus or tailored dome injury. So that would raise my index of suspicion for a bigger injury, which might be picked up on an x-ray, but often osteochondral defects don't

[00:07:16] show on initial imaging anyway. It takes a bit of time for that to come out. So an MRI would be the imaging of choice if you want to be looking at those kinds of injuries, because it will show the bone marrow edema, the effusion in the joint. For the average person, if they're not an elite sports person, even if they do have like a low grade osteochondral defect, a high grade ankle sprain, that can still be managed conservatively without too many changes. You might want to offload them

[00:07:41] for a little bit longer or more carefully, but you can probably advise them. This might take longer than we think because it's a little bit more complicated of an ankle sprain, but you know, you'll probably be back in about four months or so back to the activities that you want to be at a good level. But if it's an elite sports person or a dancer like I work with, then they need a better idea of the prognosis and you need to know the level of damage as well. So those people are

[00:08:07] bringing the imaging forward if you can, but you don't always have access to that. And it's more about the prognosis. I'm not necessarily thinking, oh, they need to have surgery, but it's just to work out all the different concurrent injuries and then how much is this going to affect their ability to get back to doing what they need to do? Because if they're part of a company, they might need a good idea. Is this dancer out for six months or is it going to be a year? I've had people with high-grade ankle sprains, osteochondral defects out for nearly a year because they have to get back to such

[00:08:35] a high level and particularly dancers because you can't do anything with footwear for them. You know, your normal sporting person will do what they do in shoes or trainers or whatever it is, and you can use orthoses and heel lifts and certain types of bracing and strapping. But for dancers, they tend to work either in bare feet or point shoes, which are incredibly difficult to, they remove the stability completely from the foot because you rock on a point shoe.

[00:08:59] So let's talk a little bit about ankle instability. We'll move from the ankle sprain, the acute ankle sprain to diagnosing ankle instability. What are the most important things to get right when diagnosing ankle instability? And perhaps what are your differential diagnoses here, Liz? If you have a patient that is, clearly has some kind of ankle instability. Again, I think physios are really good at picking that up. Often the patient will

[00:09:26] give you a lot of the information they'll talk about. These recurrence sprains, a feeling of not trusting the ankle, not liking uneven surfaces, loss of range of motion. Pain is part of the picture, but not usually the primary problem actually for those patients. That will give you a lot of information about whether or not this is an ankle instability issue. You need to try and work out, is the instability mechanical? I.e. do they actually have problems with their arthrokinematics? Do they

[00:09:53] have laxity in the ligaments? Is it functional? I.e. actually the ankle that is or isn't mechanically stable, but they can't control it. Often you get both together. We know that, we know I've seen myself patients that have mechanically unstable ankles, but you can train them and rehab them up to a really good level. So mechanical instability does not necessarily dictate their end stage function. And really good rehab is probably part of that. You want to try and work out which joints are

[00:10:20] affected. So it can be any of the joints. It could be a high ankle sprain that wasn't identified, and there's laxity and syndesmosis. Or it can be the talocrural joint or the subtalar joints, obviously. And then you also want to work out, is there any element of kinesiophobia or fear avoidance? Because these chronic ankle presentations can be really complex. And if you look at the famous diagram that's in the paper by Hertel, which was published or was republished in 2019,

[00:10:46] there's at least 20 different impairments on that diagram. It's complicated. They range from being mechanical, sensory, perceptual, or motor behavioural. There's environmental factors, there's personal factors. So it's very individual to the patient you see, and not everyone will have the same presentation, which is obviously the same for lots of NSK pathologies. But you want to try and work out what is the problem of the patient you have in front of you? Is it a fear avoidance

[00:11:14] and a real functional instability with loss of dorsiflexion? Or is it something else? You know, it'll be different from person to person, and you need to try and target your rehab to suit them. As far as differential diagnoses, so when you have someone that has chronic ankle instability, it's a chronic ankle pain problem, essentially, or a stability problem. What you don't want to miss is any other driving factors. So a bit like with the acute sprain. Okay, they've got a lateral ankle

[00:11:40] ligaments sprain, but what else could there be underlying that? And if you look at the research, it shows that for people with chronic ankle pain, up to 80% of those might have some kind of osteochondral defect. And some of those will be symptomatic and some won't, or some will get better with rehab because the ankle will just become more inherently stable. That will improve their symptoms and some won't, and they might be the ones that need referral onwards. You want to make sure you haven't missed

[00:12:07] fractures. So this is where if you get a patient six months or more down the line, you might want to think about an MRI scan if there's something that you're not sure about because it will show a missed avulsion fracture or a missed Taylor Dome fracture or something like that, which could be given in their ongoing symptoms. Nerve injury is the other one. So alongside ankle sprains, you've obviously got nerve traction injuries. For the lateral ankle, we're looking at the

[00:12:33] superficial perineal nerve. So you can have a neuropraxia which causes all kinds of burning symptoms down the front and over the dorsum of the foot. Those patients don't actually tend to report pins and needles or paresthesia. It tends to be the burning. That's the thing that should cue you to think about something neural. And not having pins and needles or numbness does not rule a nerve injury out. That's what I've learned over the years. And then you're looking at perineal tendon splits,

[00:13:00] for example. So if it's a tunosinovitis or a tendinopathy, it should improve with rehab. But if it was an acute split that happened at the time or something that's degenerative, then that might be something that needs surgical intervention going forward. So ultrasound would pick this up, but also an MRI would. I would always try to rehab a tendon, even if it had a longitudinal split in it, to see, because I think often they will respond well to rehab, but sometimes they don't and you do need to

[00:13:25] refer them on, but it's worth being aware of it. Then you've got your impingements. So a quarter of lateral ankle sprains will go on to have some kind of impingement problem. On top of that, there's the big systemic things that just because someone's had an ankle sprain seven months ago, it doesn't mean they can't have gout. So if you get someone with a sore ankle in front of you and it's red and hot and swollen, there's a chronic ankle instability that can still be on the background

[00:13:52] of something else or RA or one of the other red flag type pathologies. So don't miss potentially the other things that could be coming alongside it. Again, great summary, Liz, and lots of people to think about. How do you stop an acute ankle sprain turning into chronic ankle instability if we keep on the instability thread? That's a really big question because we know that 40% of people who have a first time ankle sprain will go on to get some kind of chronic ankle instability, which is a

[00:14:20] huge statistic. And that's why I talk about the overdiagnose and undertreat because I think when you look at the research, there's definitely evidence to show that probably the pathway to chronic ankle instability is made up of these abnormal movement patterns that develop in the first year after injury. And that's what turns people into what we call, quote, non-copers. So you have people that have ankle sprains and are okay, they get through them and they're not affected. Those are copers.

[00:14:49] And then for chronic ankle instability, we call them non-copers. So it's something to do with their movement patterns. They start to compensate and they have deficits. And there was a prospective study done by Doherty et al., but it was back in 2016. But it was very interesting and it does show you a little bit what we need to target in people with ankle sprains to try to prevent them from having these ongoing problems. And what they did was they looked at people at two weeks, six months and 12

[00:15:16] months post their initial ankle sprain. It's a first time one. And they looked at different movement patterns. So balances, slight excursion balance test, single leg drop landings and double leg vertical jumps. So two of them were quite high level. And what they found was that at two weeks, most people were either unwilling or unable to do the bigger, the higher functional tests. Well, if you look at

[00:15:40] the data, the people that were unable or unwilling to do either single leg drop landing or a double leg vertical jump, so off a box onto the floor and a rebound on double leg, they would be two to three times more likely to get a chronic ankle instability going forward. What it does show is that probably the more severe the injury, the higher severity an injury is, adds to your risk of having a chronic

[00:16:06] ankle instability going forward. And then when they looked at the six months results, they found that there were deficits in these movement patterns, particularly in the posterior reach directions of the star excursion balance test. So that's posterior lateral and posterior medial. People that have those deficits would be two times, or they would have two times the risk of developing a chronic ankle instability. With the reach differences, there were deficits in hip control,

[00:16:32] there were deficits in dorsiflexion as well. But there wasn't a correlation between a static knee to wall measure, there was an anterior reach on the star excursion balance test. And what that shows you is that the deficits that were in the anterior reach direction were probably from spinal and supraspinal alterations in motor control mechanisms, rather than being a true structural block. It's the central nervous system, and it's the way the whole body processes information,

[00:17:01] feed-forward mechanisms and proprioception and motor control deficits, which go towards giving us these chronic ankle instability. People that had deficits on one side would also have deficits on the other side, so on the involved and the uninvolved side. And what that directly tells us about rehab is we have to make sure we rehab both legs. It also feeds into why people, when they've had an ankle sprain, they're more at risk of getting a sprain on the contralateral leg within the next year.

[00:17:28] I think that research is really useful. It shows us that we need to be rehabbing the entire movement spectrum and looking at the proximal chain, so hip and knee control as well. We need to do bilateral rehab and we need to do static and dynamic movements. Now, we're doing all of that in rehab, but it shows, it just gives you some evidence behind why that's more important in a chronic ankle issue.

[00:17:52] I think the other thing that this raises is to get us out of that real focus on the ankle joint itself. You said that when you talked about you need to look at the knee and the hip, and I think intuitively we kind of think about that, but it's very easy when you've got someone saying my ankle really hurts to get really focused in on the joint itself and forget maybe to look above. We always say look above and below. That works if you're talking about the knee and the hip, of course, but when

[00:18:21] you're talking about the ankle, you're looking above and maybe another joint above too, if I understand you correctly, Liz. Definitely. If you look at the ankle, the clinical guidance, the clinical recommendations that came out in 2019, if you look at the chronic ankle and disability section, they add in hip as part of the strength work. That isn't in the acute guidelines, it's in the chronic guidelines. We know the proximal chain is important, particularly in the chronic presentations. Now, Liz, you mentioned you work with professional dancers and theatre performers, and they've got

[00:18:50] really high demands and loads on their bodies. How do you think about managing load and ankle injury in these populations? It's a difficult population to work with because, like I said, you can't cheat with these guys. They have to be at a really good level by the time they go back, generally. But one thing, there's a bit of a stereotype about how the show must go on, and that's definitely true on some levels in

[00:19:15] theatre and dance. But certainly at very professional levels, we have structures in place where we don't have to do that. So if someone is injured, say someone sprains their ankle on stage, happened to me many, many times in the different shows I've worked on, and you're covering the show in the night someone comes off and they've sprained their ankle, you are pretty clear you don't want them to go back on. It's not a problem because they have things covered. They have swings, understudies, and standbys. And there's a different level of cover for the different people on the stage.

[00:19:45] And if not, they can cut the show so people can cover other people's parts and things. So we have mechanisms in place that we, if we need to use them, so you don't have to send people back on when it's really not safe for them. So that's a good thing. Of course, there's always pressure to go back on and that's usually from the person themselves because they've worked hard to get to that position and they don't want to be replaced. But it's a whole other conversation. When they are fit to come back. So often keeping them back can be tricky, but this is where the

[00:20:14] education is important. And I think if we can, just as a culture, and I'd say this to the experienced ankle physios who work maybe with the higher level people or have an influence over maybe younger younger physios or, you know, more influential patients who have like social media presences, if we can change that, the saying of it's just a sprain and try to get people to take ankle sprains a bit more seriously, because everyone knows how serious an ACL injury is. I'm not saying

[00:20:43] an ankle sprain is the same as an ACL, but they're in the same spectrum. We brush off ankle sprains so easily and we really shouldn't do. And if that wasn't done as a culture, it would be easier to manage on a patient by patient basis. So the first thing I do when I think it's a significant sprain, if it's a grade one sprain, I have definitely taped those people up and allowed them to go back on stage. But it's always, I say I've allowed them, it's not me. I say to them, it's their body,

[00:21:08] they can do whatever they want, but I'm going to give them the advice and recommendations and then they can make the decision. It's important that that's their part of the process. I never want them to feel like they haven't got a choice and that's to go on or go off, keeping them back as long as you can, so they've got reasonable range of motion and better control and their confidence is there. It's the confidence that's always the last thing to come. It will be for every patient, but often they'll be pretty good in the room testing it with you. But if you ask them to do

[00:21:36] something more complex or the thought of putting that particular leap move from a choreography on stage with people around them, with flashing lights in their eyes, that's a whole different kettle of fish. So this is where the neurocognitive rehab is so important. You have to take into consideration that they're dancing on the injury with lots of other stimulation and just because they can do and move well in a quiet rehab room, it doesn't mean they can do it well on a stage in costume with other

[00:22:03] people around them where someone might accidentally turn the wrong way and that there's lots of things that happen on stage which are unpredictable as well, even in choreographed shows and that's often how injuries happen. And that will often happen because a show has been changed because someone else has been injured. The spaces change and then someone goes to run off into the wing but they're not where they thought they were. That can happen quite often. So that's the extra mental challenge, which is what then adds to the risk of things like non-contact injuries, like cancer

[00:22:32] sprains. And you definitely see that happening in real time. When we get them back on stage, sometimes it will be a little bit earlier than you would want, but the other thing is it's their job. So when they're off, it comes out of their sick pay and they don't get a lot of sick pay. And they still have to pay rent, you know, so we get them back as quickly as we can within reason. Use lots and lots of K-tape. So you don't tend to use rigid tape on dancers because they need their

[00:22:59] own devotion. But if you use lots of K-tape in the right way, you can give your uncle a pretty decent amount of stability and it certainly improves someone's confidence in using it. So, and then I pay a lot of attention, lots of education and lots of information around warming up, lots of neuromuscular control, postural control exercises. And really importantly is foot intrinsics. And this is something we should be doing more probably anyway with our lateral ankle sprain population. So there's definitely evidence to show that firing up the intrinsics of

[00:23:28] the foot will improve dynamic postural control outcomes. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.

[00:24:14] Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.

[00:24:55] Dr. Dr. Dr.

[00:25:25] Dr. Dr.

[00:25:56] Dr. Dr. Dr. Dr. Dr. Dr. Dr. we'll be right now. Number, Dr.