Prakash Chandran (Host): When an ankle injury keeps you off the field, you might find yourself sitting there with a bag of ice and wondering, how did this happen and how long will it take before I can get back to competition? Luckily, we're joined by two experts today that can help answer all of the questions. Here with us is Dr. Evelyn Meisner and Dr. Sami Ahmed, both physical therapists for orthopedic Associates of Central Maryland, division of CAO. Coming to you from Westminister. This is a Bone to Fix Orthopedic podcast. My name is Prakash Chandran. So Evelyn and Sami, really appreciate you being here today. Thank you so much for your time.

Evelyn, I wanted to start with you, we're talking about ankle sprains today. How do they happen and what are some of the most common causes?

Evelyn Misener, DPT: So an ankle sprain can happen to anyone. Most often here in Westminster, we see patients coming in after a sprain that occurred maybe during a practice of some sort, a sports injury. But it really can happen to anyone who trips and they roll their foot inward. Usually that's the side of the ankle that is injured is when they roll inward. And we see people of all ages, but most commonly it is maybe a teenager or somebody that got hurt in a sports activity.

Host: Yeah, that makes a lot of sense. I remember, like I, I play pickup basketball, weekend warrior. I've definitely like rolled my ankle a number of different times and I just feel like, oh my gosh, like I'm out of the game. I want to get back to it. And that's only gotten worse as I've gotten older. Sami, are you seeing the same things, people coming in, weekend warrior or people just kind of slipping and falling and rolling their ankle inwards?

Sami Ahmed, DPT: It happens all the time. And I feel like it depends on the time of year and who's coming in to see us. Really when we kind of get into those winter months, we get a little bit more of some of our older population. As we get to our fifties, sixties, seventies, as we get a little bit older, our nervous system changes a little bit. You get a little bit less, what we call proprioception, balance, and you see a little more, a little bit more tripping kind of as the fall and winter season comes along with those type of people. But, throughout the year, yeah. As we're getting into March right now and end of March, beginning of April, we get our runners right, getting back in it, getting back into these weekend warriors, these 5Ks and 10Ks and Ultras and everything that you can think of from the Ninja Warrior Walls to whatnot. Everyone tries to get a bit more active this time of year. And here at the Orthopedic Associates, that's exactly what we see and we're lucky because for us we have this 360 approach, right?

In the state of Maryland, you do have direct access, so you can come right into PT and find a licensed physical therapist here who can come in, evaluate you, treat you, and if you need further evaluations, we'll send you back to our cohorts, our physicians that we work with, and we'll get an MRI, an x-ray, whatever you need, right on the spot.

And so it's a fun world that we live in cause we can see someone as, as early as day one who just sprained their ankle and they walk in the door and they need some help. Or someone who's had it for two weeks, three weeks, six months, a chronic injury that keeps on coming back.

Host: Yeah. That is so awesome. And let's actually unpack that a little bit, and Sami, I want to get your take on this and then we'll move over to Evelyn, but you know, just as a physical therapist, because people can come in and get assistance immediately, can you talk broadly about the role that you play in assisting them with the healing process?

Sami Ahmed, DPT: Absolutely. So initially we can be the primary caretaker. So in some cases we are the first point of contact for some of these people. So the evaluation and kind of diagnosis of kind of what is going on from a PT perspective, right? You know, where are you in terms of the acute versus chronic stage of the whole thing?

And a lot of times, based off of the rules and what's going on, sometimes we do need imaging and so we have to rely on our physician cohort to help us out with that to get the right diagnosis down for the patient. But sometimes they come in, we see them immediately and we can start treatment and rehab process right there on the spot.

And in some cases, ankle sprains are graded on a spectrum. One to three, being three being a bit more severe. Sometimes there's some ligamentous damage or tears. And so depending on where they are, sometimes we kind of have to hold back and it's more of a rest and recovery phase while we try to get additional support from our physician cohorts and other staff members. But, we kind of see it all.

Host: Yeah. And Evelyn, I'd, love to, get your. So when someone comes in and they have ankle pain or a sprain, talk to us a little bit about how you think about assisting them and also maybe a little bit about what that visit looks like, especially that initial one.

Sami Ahmed, DPT: Sure. So, like Sami was saying, there are grades of ankle sprains, so sometimes it's so bad that a person comes in, in a boot. So they've been unloading that ankle by being in a boot. So that person's going to look a little bit different than someone that maybe they're just like limping a little bit.

But the first thing we do, we look and see what their strength looks like. So the ankle generally moves in four different directions. So we check their strength there, unweighted, and then we're also going to look and see what they're looking like when they're standing. It's also really important to see what that stability looks like.

So we'll check their balance. We do a lot of work on being able to be stable on one leg. Because when you're doing something like running, it's like you're jumping and you're landing on one leg, so you have to have a very stable joint, stable ankle to be able to do that.

Host: Yeah, that makes a lot of sense. And you're talking about like the different grades of ankle sprains or injuries. I think one thing that everyone wants to know right when they come in is, how long is this going to take me to heal? So Sami, why don't you tell us a little bit about what you say to people that are really anxious to get back out there.

Sami Ahmed, DPT: What I tell them is that when they come to PT, they're going to have kind of two sides of every physical therapist. And for me, I tell them, there's, Dr. Sami, PT Sammy, that you'll get, and that rest and recovery. We got to hold you back a little bit.

And in some cases you get Coach Sami and that see we're going to, we're going to grind, we're going to push, we're going to get you through. But really what we do in PT, is obviously there are parameters in which we look at from a scientific method right. How many weeks is it going to take? You know, if you're on the younger end, we know that the younger you are, the quicker you tend to potentially heal.

Right? Could take four or five, six weeks. When you're a little bit older, I'm in my thirties right now and so even me, like my ankle sprains that I had when I was 12, it's a little bit different now. I don't spring back as quick as I used to. But we take all that into consideration, but we also look at, let's take a step back. What are your goals? Like, what are you trying to get back to? You know, if you've got someone who is, they're a high school kid looking for college scholarships and we've got to get them back onto the court cause scouts are coming within the next few weeks, we may have to play around with the frequency and duration and what we're able to do to try to promote their healing process as fast as we can.

Whereas if we've got unlimited time and you're kind of that weekend warrior and we just want to make sure you're as strong as possible, we may be able to elongate that recovery period and so, there's a lot of moving parts to answer that question, but initially I'd say, here at the Orthopedic Associates, we understand that what you need and what you want, is to get back and to be safe and to be stronger than you were before so this doesn't happen again. And that's our ultimate goal to achieve those two things.

Host: I love it, Evelyn, Sami was talking about goals and I think one thing that is oftentimes missed is that the healing process is a partnership, right, between the physical therapist and the patient that's coming in and they need to do their part as well. Talk a little bit about how you think about goals and how that partnership works.

Sami Ahmed, DPT: Yeah, so in, in physical therapy, like Sami was mentioning, you have to do the work too. Cause we're trying to get you back to full functioning. So part of PT is learning how to do these things on your own. So we'll give you a home exercise program. So we'll give you some exercises to work on at home.

So you'll have some homework to do. So we do some of the more challenging things while we're here in the clinic and we do some manual treatment. But then on your own, you're going to be doing some work as well to make sure you're getting back that strength and that stability so that you can go back and be even better than you were before.

Host: Yeah, and I imagine, I know that when I've been in physical therapy, sometimes the home exercises, maybe I've skipped a little bit and I only do the exercises in clinic. Evelyn, is this something that you see all the time?

Sami Ahmed, DPT: Yes, absolutely and we can tell when you haven't done your exercises. You know, if you're someone that we have to tell you every single little thing that you've got to do while you're in the clinic, then you're probably not doing the work at home. And it does make a really big difference, because just the repetition is going to make all the difference.

Host: Yeah.

Sami Ahmed, DPT: Yeah, I'd say that sometimes it even makes a difference at what you're looking at, right, Evelyn, like, in terms of if we need to get someone to be more flexible and they're not stretching at home; they're going to come back to us and we're just going to be fighting those things over and over and over again. Or if we need that one part of their leg to get stronger so that way they can get back to doing things. I feel like we see that all the time.

Host: Yeah. It's like, help us help you. Right? Sami, I'm wondering a little bit about braces and straps that you can use to support maybe the muscles around the ankle as people start to heal. Can you talk a little bit about devices or things that people wear to help them during their recovery?

Evelyn Misener, DPT: Sure. I mean, there are all different types of braces that are out there. They're stirrup strap braces, the ones that you've kind of seen in like Dick Sporting Good and stuff that you can lace up or they strap around the ankle to kind of lay it down. There're just come very gentle light compression braces that you potentially could see at some places.

I mean, there are a thousands of different models out there and all achieve something slightly, a little bit different. We do offer a wide array of different braces and bracing options that we use with our durable medical equipment group that we're associated with. But I'll say that the trick behind braces is it depends on what you're trying to accomplish.

You know, with us as physical therapists, we want you to be as strong as possible, on your own. We don't want you to rely on anything for long-term use. Now we know that some, in some cases, if you have a history of ankle sprains, sometimes a brace is really good when you're doing some of that high-end impact stuff.

And so we'll promote and we'll tell you like, you know what? We're going to try to continue to get your ankle stronger, but we want you to use this brace at this point of your recovery. But the goal is long term. I see a lot of guys out in the basketball courts when I go play and I'm like, are you in PT?

And they're like, no. And I'm like, and you're still wearing that brace that you've had for 6, 7, 8 years. I think it's time. Here's my card. Let's chat a little bit. Let's go see some my podiatrists that I know. Can we get some better functioning footwear and something to help support you a little bit more? Because in general, we want you to be the best you can be without the support of something else.

Host: I love that statement of you want every single person to be as strong as possible on their own right. And Evelyn, when you think about that statement and also the body as an entire system and supporting muscles around the ankle, for example, how do you talk to patients about that? About the fact that, there are so many different factors and relying on crutches like braces, may not necessarily be the right answer for the long run?

Evelyn Misener, DPT: Yeah, sometimes it's necessary to wear a brace, especially if you're in that early stage of recovery. But it can be like a bit of a bandaid. So, you want to use the brace to, to help you initially, but we want to get you to strengthen enough so that you don't actually have to use that. And we do look up and down the chain as physical therapist.

So, even though you're just there for your ankle, we're even going to look at your toes. We're going to look at your knees and your hips to see how those are functioning, because it all works together. So you know, you may have injured your ankle because your knee's not strong enough to support you. So that's one of the great things about physical therapy, is we really try to look at everything, so it doesn't happen again in the future.

Host: Yeah, I really love that kind of holistic approach to physical therapy. Just that there's kind of a chain reaction to, for example, an unstable hip can actually cause an injury in the ankle. This kind of leads me to thinking around just prevention. As you help someone heal, Sami how do you talk to them or prepare them to go out back onto the field with prevention in mind, how do we make sure it doesn't happen again?

Sami Ahmed, DPT: It's a really good question. I got to say that. I think what it comes down to is first education. Like understanding what your body is saying and why it's saying it. When we talk about things like using ankle braces and whatnot, I often see some of my young gymnasts, they're taping their ankles constantly with this I mean, they're, wearing braces if they're football players, right?

Really tacking things down. And the next thing that you see is, you see an ACL tear or a hip tear or something labrum on the hip, something else going because that force that's supposed to be absorbed at the ankle just gets thrown up the chain, like we talked about. And so having them understand, what's going on. What am I feeling? I mean, the best example I can think of is one patient who shall go not named, who is an avid runner and who she goes through this cycle where every three or four months she's got some running, something that's going on from a calf to a hip to, to something else.

And I could thankfully say after us going through a couple of different injuries and talking about, what are prevention tips, what are ways that you can train to avoid certain injuries such as from calf tightness to knee sprains, to, to tons of other injuries over the time, I have not seen her in months.

And as sad as that sounds, I would love to see all my patients all the time. You're also a little bit proud cause you see the posts online later on and the shout outs for when she was able to achieve Boston and stuff like that. And I'm like, you know what? Good for you. Like the that's the one thing our biggest accomplishment is seeing the success of our patients.

And so I think education and having people understand that our bodies are machines and just like all machines, if you can listen to those weird sounds or understand what those weird things are early on, you probably could prevent the injuries that are happening later.

Host: Yeah, I absolutely love that. Evelyn, I wanted to just ask you about something that I'm sure you get all the time and maybe is something that's difficult to decide with your patient, and that is how do you know when a patient is ready to get back on the field? And I know you probably have people that are very anxious that want to get out there for whatever reason, whatever their goals may be. How do you think through that with your patients?

Evelyn Misener, DPT: Sure. So there are some sort of standardized tests that we look at when a patient is trying to get back on the field. And one of those things is a triple hop test. So you're looking at somebody doing three hops in a row and seeing how much distance they can get doing that. You're going to compare the injured side to the non-injured side and see what that difference is.

So if there's only like a 15 or 10% difference between sides, then that's telling us that they're probably ready to get back to running and back to actual sports activities. So that's one of the big things we look for. We're looking at your ability to jump and be pain free as well, and we're looking at single leg stability like I talked about before.

Host: Yeah, that seems like a really objective approach to just making sure that people are physically ready to get back out there doing it in a way that they can even see for themselves. Like, hey, maybe I'm not jumping as well on this foot as I am on my healthy one. Sami, do you approach it in the same way?

Sami Ahmed, DPT: Yeah, very similar. There are a bunch of different, just like Evelyn said, there are a bunch of different standardized tests that we can use. Lateral cuts, cutting back and forth, jumping. I mean, as we see our patients progressing, one of our offices, our Westminster office is Beautifulness. It's a beautiful large office. And so we're able to perform a lot of these single hop, double hop, triple hop tests, see how the body reacts to lateral motion, side to side. Once they show us that they have that strength that's there, and then to be honest, we get them running right? We'll get them on a treadmill.

We get them running in a safe, controlled environment before we introduce them to right, uneven surfaces. Things that are a little bit different, right? Because it's very different running closed controlled environment than it is when you're outside playing in a soccer match or a basketball match, or playing lacrosse with your friends.

And so, I'd say that all of our offices are a little bit different in terms of how they're set up and how they approach it. But at Westminster we have a beautiful new location that highlights just that, right? It's really built out for that big, explosive movements to check in, to make sure that people are able to get back in action as quick as possible.

Host: I love it. You know, I wanted to end with a question around physical therapy in general. I sometimes feel like people undervalue physical therapy and physical therapists. Sometimes they just feel like things will heal on their own. And I oftentimes think that things just take a lot longer to heal because of it, right?

Because they're not coming in sooner. They're not getting evaluated and they're not getting the programming, and the strength training in the way that they really should through a professional. So, Evelyn, just on that topic and as we close, do you have any thoughts around that and anything to share with our audience around the power of physical therapy?

Evelyn Misener, DPT: Yeah, I mean, the great thing is that we have direct access, so you don't even need to go to a doctor in most cases before you see a physical therapist. You can come right here and we can take a look at you. And it really it cuts down on the time that you have to be in physical therapy if you just get looked at right away.

I mean, even if you just come for one or two visits and we can give you an exercise program that you can work on, on your own, sometimes, that's all it takes to prevent an injury in the future. So I, do agree that we can be undervalued and I wish it could be something like every year everybody goes and has their physical therapy checkup.

Like you go see your physician once a year, your primary care doctor. Too bad we can't have people come to PT once a year just to get checked out and make sure everything's working properly to prevent some injuries in the future.

Host: Yeah, I, couldn't agree more. And Sami, I'll ask that same question of you as you think about physical therapy and leaving our audience with something just about the importance, of it. And, as they think about physical therapy and how it integrates into their lives?

Sami Ahmed, DPT: That's a good question. I'd say here in Westminster at the Orthopedic Associates of Central Maryland, we've had this conversation going back and forth between our PT cohort staff and kind of one of the things that a lot of the PTs have come to believe is that, for us, we are trying to build better bodies to shape better lives.

Right. So your body is something that you're born with. You're something that you can adapt, but there's tons of strengthening, stability work that you can do to get it stronger, faster, and better. But if you come see a specialist, come see someone who just knows a little something about how the body works and its mechanics, then you might be able to produce better outcomes in things that you're doing every day.

So, right, if you're going from reaching down to, to pick up a ball or to pick up your child or your grandchild, to doing things like whether it's playing a sport or just going to the grocery store. Cause sometimes going to a grocery store is someone's sport, right? That is the amount of activity that they need and that, that is what they do to get by.

And so, what we try to do is, just that, is to try our best, to use the knowledge and power that we have to give people an opportunity to just live a healthier, better life.

Host: I love that. I think that is the perfect place to end and something that I'm going to take away from this conversation is that you don't have to have an ankle injury to go see a physical therapist and that you can actually strengthen your whole self and live a better life. Pick up your kids pain free, fix those mobility issues that you've been experiencing with just by going to see an expert like both of you.

So thank you so much for both of your times.

Evelyn Misener, DPT: You're welcome..

Host: That was Dr. Evelyn Meisner and Dr. Sami Ahmed, both physical therapists for Orthopedic Associates of Central Maryland, division of CAO. Coming to you from Westminster. We have eight physical therapy locations for your convenience, so you can get the unique experience of doctors and physical therapists working together in one place towards your recovery.

For more information, you can head to mdbonedocs.com and I really just appreciate all of you for checking out this episode of a Bone To Fix. My name is Prakash Chandran. Be well.