Mandola there's a question about examination anesthesia for your Liz Frank injured athlete. How do you get patient buy-in first of all and then secondly how many times do you take them to the operating room do a stress test and they're actually negative and you just cast them or split them afterwards? I think you only buy in if it's a high-level athlete that needs to get back on the field quickly and it's it's not clear if they have a stable and stable injury and so I think you want to make that diagnosis early you don't want to wait two three four or five weeks waiting to see how they do. I think in the normal population I think you can certainly do that I don't think there's anything wrong with you know say this is a stable injury you know and we're going to immobilize it and let it let it settle down and re-examine you over over a few weeks. So I think I think in the very you know high-level athlete if a decision wants to be made you have to speak to the athlete the family the coach and then say okay this is what we're gonna do and it's not very often that they're not unstable but that was one one true case of an offensive line and he was a starting center yeah you know if you're the starting center you know that the offense can't run without it so you know I think you need to make a decision let him go back to back back quickly if you can but if they're gone they're gone and you take care of them. I've had maybe two or three my entire career too it's pretty pretty you have a pretty high suspicion going in with the plantar ecchymosis sign and the instability shock testing abduction stress you're pretty pretty much mostly we'll be fixing them and then for Dr. McCullough the other problem we have with ankle synismatic injuries is the chronic one so what do you do with an athlete he comes in six months four months it's you know comes in with chronic pain but now has widening and has calcification in the interosseous membrane what do you do with that athlete to try to get them back to play? Yeah so I think up until when you mentioned the calcification you know certainly with the chronic instability and bad bad injuries that they've had you know one of the important things is going to be what is that degree of calcification and are they having symptomatic heterotopic ossification from the bleeding that occurred along the interosseous membrane and that's the issue or is it instability or is it a combination of the two I think in that case if we were thinking about the calcified individual one I think the important thing to understand is is it instability is it FHL problems which which will frequently be in thinking about these kind of latent high ankle sprains it's the FHL that's the hardest one to get back they feel like they can't really push off or if they're backing up and they change in direction try to get up on their big toe they get pain but is that because of edema or is that because of instability so a differential if it's the heterotopic ossification can be an ultrasound guided injection even just with numbing medication not with steroid simply to that area to see okay if we inject the area that's calcified and they feel better well it's probably just that and it's a discussion of that if you do an ultrasound guided injection to the FHL tendon sheath and they get better well maybe it's just FHL tena sinovitis all they needed was a simple ability to kind of get past that and then they're okay I think the other consideration is what I showed which was that syndesmotic taping test that once again if that cures it certainly I think that will make a calcification more symptomatic and they won't like that but if it all of a sudden alleviates their pain that may be another key to where it's subtle functional instability. Ned what about your thoughts? I agree with everything you said I think the only thing I would add is an arthroscopic even the chronic situation I think arthroscopy would be helpful you know to help look at the status of the stability of the syndesmosis so you mentioned arthroscopy early but I think even you know like some of these that are are not treated early and they can function you know for you know at 80% then they show up at the end you know after four or five months I think those are the ones you're referring to I think that they they may have a an element of instability with the with the calcification. Yeah and I think also I mean the problem is is you get some of these folks that kind of limp along with these for a while it does not take very long to start to see instability related tibiotailor chondromalacia that will start to occur and obviously of the things that we can fix as surgeons the instability we can fix they start to they start to wear down that lateral tibiotailor joint that's a big problem so that's what we want to try to avoid because there are plenty of situations where Ned and Bob and some of these other folks have done it for a long time they get these as second opinions they see that and the cats already out of the bag it doesn't mean that you can't stabilize them but there's now an irreversible thing that that can't be changed and that's what we want to try to avoid with with early diagnostic you know criteria and something's going to prevent that from happening you know I think it depends upon you know is it simply just the syndesmosis is it also the syndesmosis and the deltoid you know because some of that drive-thru stuff and in all that you're seeing you may still see a drive-thru as far as it relates to the medial clear space but you not may not be able to drive around because things have scarred so you know trying to appreciate an anteromedial rotatory instability that is asymmetric from one side compared to the other can be one clue seeing that arthroscopically I think is another clue but it's also just system you know stage wise doing it stabilize that syndesmosis first I still think that we can we can do something to it and do tightropes but you know it just depends well thank you for an excellent morning to our speakers we have to shut it down but we're here for any questions you may have enjoy your trip home be safe see you next year thanks

examination anesthesia

Liz Frank injured athletes

patient buy-in

operating room

stress tests