So they gave me the easy topic, so we'll make this make this quick. So here are my disclosures. So we're going to talk a little bit about the background just because I think it's really important to understand the underlying problem with high ankle sprains. We'll get into get into that clinical evaluation and the treatment a little further. The anatomy is the most important part. It's four main structures. The AITFL, which provides about 35% of the overall strength, and it's the one that is the main resistance to external rotation. Posteriorly, the ligament really consists of two main ligaments, the PITFL and the transverse ligament. It's the strongest. It makes up about 40 to 45% of the overall strength, and then of course the interosseous ligament. If you look at normal syndesmotic motion, if you have disruption of the AITFL only, the external rotation increases by about 25%. You include the interosseous membrane that goes up to about 35 to 40%, and you'll have posterior translation of the fibula up to about four millimeters. And this is very important to remember when it comes to trying to make decisions for treatment. You include the PITFL and we all of a sudden got a very unstable ankle. So how do we evaluate these? Well it's the mechanism of injury is a foot fixed in a stable position and an external rotation force to the ankle. As we rotate around the ankle, typically with a valgus force to the knee. The wide part of the talus comes into the mortis. You have increased stress across the joint, and that fibula will try to rotate out and spit out backwards. And the mechanism here is very typical. You can see this player's right ankle as he gets twisted around a foot that's planted, and you end up with a pretty severe high ankle sprain. It's important to examine the entire leg. Don't forget to look high. We want to look at ecchymosis and swelling extending well above the ankle joint. Do they have a positive squeeze test? And a positive squeeze test doesn't mean pain where you squeeze the leg. It means if you squeeze the leg in the mid portion of the leg, do they feel it at the ankle? Do they have painful fibula translation? Can you spit the fibula out the back of the ankle? And I think that's very important to understand sort of the shuck test to feel that posterior translation to the fibula. Can they do, do they have pain with external rotation? Can they stand? Can they rotate? Can they get up on a single limb? And then lastly, if there's any confusion, typically in the chronic setting, you can tape the ankle to try to give them a little external stability to see if their symptoms change. So we want to evaluate it with x-rays, apilateral and mortis, the typical ankle images. It certainly get comparison views. You know, orthopedists aren't the smart, so fortunately they gave us two sides. We can look from one side to the other. Don't forget to look up high. You want to look for the mason of fracture, so always evaluate the proximal fibula. Sometimes, you know, the surgical decision is pretty obvious, but other times not so much. So what are we looking for? We're really looking for rotational instability of the fibula. Is there decreased tib-fib overlap? Do we have medial clear space widening? I think one of the landmark papers was done by Ken Hunt. He's now at Colorado and he did this. He did his study when he was at Stanford and in the conclusion of his cutting study, which is an extremely well done study if you haven't looked at it, looked at the fact that you can have significant instability without syndesmotic widening. The classic teaching is, do you see widening? Does the medial clear space open? Well, there's instability of the syndesmosis that occurs well before you have widening of the medial clear space and I think that's an extremely important point to know. So, you know, it's a spectrum of injury. Grade one, it's a minor sprain all the way to grade three. It's that grade two, the more subtle instability is the one that gives us such trouble. So, what about the MRI? Certainly, that's a modality that we're all using to try to evaluate these and it's very sensitive to the injury. You know, there's a high inner observer agreement. We can all see if the AITFL is injured, if there's disruption posteriorly, if there's fluid coming out the back, what the interosseous membrane looks like. The problem is, it's not a dynamic test and this is a dynamic injury and certainly when we're looking at the grade twos to look for that subtle instability, the MRI doesn't, it provides a guidance but it doesn't tell us the answer because this is a dynamic problem and they're sitting there statically in the MRI tube and so it doesn't really point us to the exact mode of treatment that we may or may not need. So, it's those grade twos and those grade threes where the interosseous membrane is involved and how much of the PITFL is involved. There's a study done back in 2012 that looked at 36 players, grade 3 being the most common and as you can imagine, there's a positive correlation for the higher grade, the greater time lost. Earlier treatment is better. This is a study looking at football player, soccer players in Europe and they looked at how relative timeline to how they were treated and to how they did the acute or subacute chronic greater than six months injuries and certainly the chronic injuries did much worse than those looking at the FAOS quality of life. So, I look at high ankle sprains in really three silos and I once I get my evaluation of them, I look at them and try to put them in one of these three silos and so silo one's where there's an AITFL injury only, they have anterior pain on physical exam, they're typically tender anteriorly, they get mild swelling. They're able to do a double leg heel rise, sometimes even a single leg heel rise though they'll have some difficulty with effort. Often they were able to finish the game, the presentations either following the game or that next morning. So, modality treatment is important there. Corticosteroid injections, injection into the joint that will get the inflammation within the joint, the acuity of the injury in the joint and get up into the syndesmosis. Often you can do this ultrasound guided or fluoroguided if needed into the syndesmosis. Several of the physicians and athletic trainers involved in the NFL looked at corticosteroid injections and how do they, how do the players respond to these. So, in grade one injuries determined by physical exam and MRI, there was about a 40% decrease in time loss and up to 10 days and certainly in the football world, in collegiate and NFL world, 10 days can make a very big difference for some of these teams and for some of these athletes as they're trying to get back onto the field. So, there's definitely a role for corticosteroid use. So, what about when the interosseous membrane is involved? So, these are the grade twos and this is where it starts to get very gray in terms of how we're going to treat them. So, often these are the ones that have anterior pain extending two to four centimeters above the joint and that's a pretty key distinction that I'll talk about later. On physical exam, they have that tenderness anteriorly. Sometimes they'll complain of mild posterior soreness too. Oftentimes, they'll say it kind of hurts in the Achilles. They'll have swelling often located to the lateral side of the joint, difficulty with double leg heel rise, can't do a single leg heel rise, and oftentimes these are the players that couldn't finish competition. So, in these I consider a PRP injection. So, we'll boot, we'll do same modality treatment, boot immobilization, and PRP for these. Return to play after surgery. This is done out of the group, out of the Netherlands, and meantime in these grade twos for return to the soccer field was about 72 days. So, think about the time loss there if you're looking at nine to ten weeks of the grade two injuries. That's a significant time loss and is there a way we can improve that? Conservative management for high ankle sprains is done out of the group, out of Cleveland. It's an excellent, it's an excellent paper published in back in 2018, and we can expect return to play after conservative treatment, but you got to understand the extent of the injury based off the MRI findings, and that's what's so critical for understanding time loss. And everybody wants to know, is this the three-week injury? Is this the one-week injury? Is this the six-week injury? And that's where it gets difficult. So, silo three is the more significant injury where you start to involve the posterior ligaments. So, they have anterior and posterior pain. That anterior pain extends five centimeters above the joint, and there's two papers out there that are very clear that that five centimeter mark changes the ballgame. If you're getting five centimeters above the joint, the severity of the injury changes, and I think that's really important to understand when you're doing your physical exam, and that's not palpation from the ankle up, it's palpation from the knee down, and understanding where that cutoff is is pretty critical. So, for these, the ones that have poor effort with heel rise, can't do a single leg heel rise, this is the group that creeps into the surgery bucket. This is the one that gets the syndesmosis stabilization and possible deltoid repair if needed. And as we have evolved over the past 20, really 20 years, you know, we've changed from screw fixation to tightrope fixation or flexible fixation, in some cases even ligaments specific using the AITFL. So, in my case, why use an end-to-button type construct? Well, it's been shown to be stronger in cyclic loading. It avoids need for removal. I'm not a hardware removal guy, so if I can keep it in, that's important, and we don't want to go back ever if we don't have to and, very importantly, allows for micromotion, and that's been shown in all kinds of biologic literature that it's better for collagen healing. So, here's the problem. So, we have an MRI here that all look fairly similar. So, if you look on the left, the center, and the right, all play similar positions, play in the National Football League. One of these guys missed one week, one of these was treated non-operatively. One of them missed nine games, was treated non-operatively, and one of them was treated surgically and missed four weeks. That's why MRI can be a little bit unpredictable. So, if you look here on the bottom right, there's one little subtle thing that clues you out, and this is what I call the C-sign. So, when the interosseous membrane is disrupted and the fluid can get all the way around, I start thinking I might have a more significant injury. Well, this is the one that ended up getting surgery. I didn't base it off the MRI, it was very clear based off his stress exam that he needed surgery relative to the other two. The hard part is the one that was in the middle ended up missing nine weeks, and our trainers are looking at me going, why is he not back? And that's why it's so difficult, and that's where it gets difficult for all of us. I'm going to show a quick case study because we're going to get rolling into the rehabilitation process here, but this is our quarterback in the 2018 SEC Championship game. On the fourth play of the game, he injured his left ankle, and this should be in a textbook because this is the classic mechanism for a high ankle sprain. External rotation off a foot fixed on the ground as he spins around his ankle, which is stuck in the turf, and you can see his foot release, and you can see some of the instability there. Couldn't bear weight the following morning, pain 10 centimeters above the joint. Shockingly, had minimal medial set of deltoid pain. Well, this was not a gray area. This is very black and white. If you ever look at his MRI, his fibula is not even reduced. This wasn't, should I fix it or should I not? This is a pretty obvious, this thing needs to be fixed. My MRI series for high ankle sprains goes up higher than the normal ankle. I want to get, because of the five centimeters that I talked about, I make sure my MRIs go above eight, so I have my own series that our hospital does, because I want to see how high the fluid is getting and how high the disruption is. This is well up his leg, and you can see here he's got interruption of the interosseous membrane, and he's got that C-sign that I talked about with fluid going all the way around it. You can see the avulsion in the back. You can see the tear in the front. I can get the shaver between the tibia and the fibula, so there's obvious instability, and here's how he was fixed. I use a two-hole plate. The main purpose of the plate is to dissipate force, because my fear is certainly fracture of the fibula, and I talked to all the players about it. I have not had one yet. I know they are out there. It will happen to me at some point, but I think the plate plays a real role in helping dissipate those forces. So I admitted him to the hospital. Sometimes you can do this, sometimes we don't. That's really just so they can get IV tore at all. I no longer splint them. I put them immediately in a cold compression device, and I put them in a boot. We make them non-weight-bearing for three days. We begin motion exercises immediately, because avoiding stiffness is critical, and we begin weight-bearing it day three to day four. Swelling control is everything with the rehabilitation. I use every single modality I can think of, so we use GameReady, Normatec, whatever works for you, the HiVolt, Firefly, Massage, Elevation, because with swelling control becomes normal motion. With normal motion becomes normal gait. With normal gait, they can run straight forward without any compensation. When they can run straight forward without any compensation, they can learn to cut. They all fall in line. Swelling is the most critical part, and that's where the rehabilitation wins the day. So we use a lot of BFR. Whatever you choose to use, it doesn't matter. There's been a lot of scientific evidence over the past five to eight years that shows some of the benefits of BFR, so we certainly use it in this situation. And you can see here's the athlete. This is 12 days out, getting up on his toes, doing proprioceptive exercises, learning, trying to help retrain his muscles, both from the injury itself as well as from the surgical stimulation. So I do this on all my athletes. I have them video in the Alter-G because I won't let them off the Alter-G till I can see that they're not compensating. I don't want to see external rotation of the injured limb, and I don't want to see any increased weight bearing on the outside of the foot trying to compensate with the perineal tendons. When I can see that they can run straight forward, I'll let them get on the field. And then this is day 17. This is him throwing football. Our backup quarterback right there is not too bad either. So what are our goals? What are we looking for? Restore anatomic relationships. That's with any orthopedic issue, right? That's what we want to do. We want to... Many of the reasons, many procedures have fallen out of favor because they don't do that. We want to restore stability. We want to prevent long-term wear, and we want to preserve the normal biomechanics. And that applies to almost everything that we do in orthopedics, and that's no different here. So how do we achieve those goals? You know, ultimately we want to allow our patient to return to normal with full function without restrictions. So I use a lot of objective data in rehab. In particular, I use extensively our GPS, and we're collecting an extensive amount of data at Alabama using this stuff so I can better understand how these work. And ultimately when the athlete gets within 10% of the contralateral limb or within 15% of their pre-injury data, which is where the GPS is very helpful, I'll let them return to play. And this is that athlete's numbers. I'll go through it really quickly. This is what he looked like when we played Auburn when he was not hurt. And these are his normal numbers. I'm particularly looking at change of direction off the injured limb. So that was his left ankle. How well does he change direction to the right? And what was his velocity? What was his push-off? And could he withstand those loads? You can see this is what it looked like as he, after he got injured, and as he starts to return to play. He is not anywhere near where he was, but ultimately as we headed towards the Orange Bowl in this situation, you can see his ability to change direction and push off that, push off that limb returned to normal. And as that returned to normal, I felt very comfortable letting him play. You can see his velocity was getting back to where it was supposed to be. His push-off is getting back to where it's supposed to be. He could accelerate and decelerate. And that told me that he was safe to go back to play. Now the coaches have to make the decision whether he's going to play or not, but I was okay with it. So rehabilitation is the key, and I expedite the rehabilitation because I think it's good for the athlete, it's good for the ankle. There's been a little bit of misperception from people that it's for return to play. That's a secondary benefit and a secondary benefit only. We are not rehabbing him like this to get him back on the field. We're rehabbing him like this because it's good for the ankle, because it restores normal motion, it reduces chronic pain, and it reduces issues 9, 12, 18 months down the road. If they can go back early, that's awesome. So be it. So at Alabama, over the past 10 years, we're about to publish this. We've had 58 high ankle sprains. Unfortunately, the number is going up every year. 13 surgical repairs. So there's a little bit of misnomer that we operate on everyone. That's not true. My experience with the Saints has been 17 over the last two years. Only three have been fixed. So those numbers kind of fall in line with each other. And using that GPS data, hopefully we'll have, we think we have a valuable piece of information to add to the literature, which can help guide us in helping these athletes. So ultimately, we want to progress them back to play. You got to remember when we're returning them to play, you got to have a frank discussion with the player, the coach, his family, the medical staff, the athletic training staff. Can the athletes safely protect themselves? Subsequent injury risk is real, whether it's that limb or another body part. And that decreases with each week we return to play. So it's a multivariable decision. Communication is critical if you're going to put them back on the field. Safety's numero uno. So once an athlete can pass the return to play testing and demonstrate that they're back to the pre-injury levels of output, you know, you can let them play. If you have the data and you're comfortable with it, it's okay. Got to have the four C's. I refer to these all the time. Communication, consent, compassion, and competency. And if everybody's on board, you can do it. And then since I've been in the NFL, you got to add one more thing. You got to also understand what their contract is because that certainly plays a role in whether they're going to go back. So I appreciate it. Thank you guys.

high ankle sprains

clinical evaluation

treatment

rehabilitation

MRI diagnosis