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Bill Klaproth (Host): UPMC West Shore Orthopedics is prepared to assess, diagnose, and treat an array of bone, joint, and spine conditions. On this podcast, we're going to talk about ankle instability, what it is and what you can do about it. So, let's find out what Dr. Michael Werner, an Orthopedic Surgeon at UPMC West Shore Orthopedics with locations in Carlisle and Enola.

This is Healthier You, the podcast from UPMC in Central Pennsylvania. I'mB ill Klaproth, Dr. Werner, thank you so much for your time. It is great to talk with you. So, let's talk about ankle instability. First off, what is it? So what characterizes ankle instability?

Michael Werner, MD (Guest): Well, thank you for having me. I really appreciate it. It's an honor to be here. And first and foremost, the ankle anatomy is such that the ankle goes up and down, and we call it dorsiflexion, plantarflexion, but the movement is up and down. Like you're waving bye-bye, I like to say, but the ankle does not, is not made to go side to side.

Of course, we have side to side motion in our foot, but that comes from the three joints of our hind foot and not our ankle. So, when we're talking about ankle instability, we mean that there's been an injury to the ankle that makes it unstable in a side to side plane. So, it doesn't just go up and down, there is some clunking or frank instability that could be quite severe or subtle that makes the ankle move in an abnormal way.

Host: So, if you feel clunking in the ankle that would characterize ankle instability?

Dr. Werner: It would, but the patient usually experiences an injury at some point in time. It could be an acute injury, meaning like you just sprained your ankle the other day, like we've seen numerous football players do on Sunday and it swells up and after the swelling goes down, it doesn't feel right. It may feel like it clunked at the time of injury, like felt really weird people say, but then after a while of treatment, it may feel chronically unstable, meaning you think it's better, but now it's still doesn't feel right. It's not swollen. It could be sore. Doesn't necessarily have to be tender. But what happens chronically in these ankles is you step on something small, like a pebble or a rock or something that doesn't seem like it should cause any problem and your ankle gives way. And so the patient really has a giving way sensation. It's not like they could grab their own ankle and see that it's grossly unstable. That's our job as, as surgeons to check that.

Host: That makes a lot of sense. So, I was going to ask you what causes this? So some type of an injury, and it may seem insignificant at the time, you said stepping on a pebble or a rock, or maybe you stepped on a curb or a sidewalk wrong. Right. You step off a sidewalk and your ankle kind of folds over. I mean, that kind of does happen to all of us. So, then when is it time to see the doctor?

Dr. Werner: Well, that's a great question. Most of us in our life have experienced an ankle sprain, right? On the other hand, it's one of the most common orthopedic reasons to go to the ER, because people are concerned that it could be broken and obviously, if you think it was severe enough injury and you can't bear weight on it, for instance, on your foot, it is a very good reason to go to the doctor, like our Walk In Urgie Center here at UPMC, West Shore Ortho, for instance. But, if you can't walk on it and it's an acute injury, that's certainly a time to see the doctor, but talking more subtly many times, it's an accumulation of trauma. So, maybe what happened for instance, what I mean by that is the patient may have had a severe injury as a youngster or playing sports or a weekend warrior thing, but it was a while ago and then they re-sprained it, but they don't think it's as severe more recently. And then they get over that. But now the ankle isn't quite right. And they're confused because they're like many times, like, I don't even remember doing all that much. I thought it was just sort of a small injury and here it was a cumulative thing. It was something that the ankle wasn't quite right for a long time. And it just sort of added up as a wear and tear thing and I call it the straw that breaks the camel's back. All of a sudden, a relatively minor injury, now you have your ankle feeling not right. And we all know that when you have a major injury of your ankle, you should go to the doctor.

But it's even prudent to go see the doctor what you think is a smaller injury, but the ankle isn't feeling right, it's feeling unstable or it wants to give away. So, it does not have to be some major injury. It could be sort of a chronic ailment that brings you to the doctor. And we're certainly happy to see those people too.

Host: I imagine it would be, could it be a chronic as well? My wife is a tennis player, so of course, hard on the ankles. Most of the time, she's fine. But then now, and then I'm like, why are you limping? I don't know, my ankle is just bothering me today or over a weekend. And then she seems to be fine. And it's like, why are you limping again? I don't know my ankle is just it's acting up today so there is a chronic ankle instability too.?

Dr. Werner: Absolutely. And some of those things are very obvious. Like the patient comes in and says, every time I step on a, anything bigger than a pebble my ankle gives way. Well that usually when you examine that patient, it's pretty obvious, but other people like your wife, that's a very, very common reason that people come to see me.

And to them, it's a mystery. And what really is going on there to sort of solve that mystery, to sort it out, to give you some clarification is it's subtle instability. It's not grossly unstable, but if you excessively stress the ankle or put a lot of impact on it or increased demands, I should say on it, then all of a sudden it has this little bit of instability.

And it doesn't happen on day to day things, but it would happen if you kind of had increased demands on your ankle, like playing tennis. And maybe not every time you played tennis, maybe you just had an exceptionally aggressive match where you did a lot of cutting and twisting and stopping all of a sudden. And then you get these subtle abnormal movements to the ankle and they add up and the next thing, you know, your ankle's inflamed and it hurts. And the patient's like, I don't understand it. It didn't happen the last time I did this. I tell patients, look, we don't follow you around with a video camera, but if we did, we would probably see that there was something or a number of somethings that sort of twisted the ankle abnormally and they could be subtle, like I said, but then they add up to ankle inflammation and then they come and see me and we sort it out with an x-ray to make sure there's not a chip and an exam to see if the ankle feels loose. And again, that's takes training to kind of check. That's what I do for a living. Or you could even get then an MRI or other tests to sort of figure out the next type of treatment needed.

Host: Sure. So let's talk about treatment then. And I would imagine it runs from, ah, you're okay. Put some ice on it or something, physical therapy to surgery, right. So can you kind of give us the cliff notes of the gamut of treatment for ankle instability?

Dr. Werner: Right and everything in between. So, we all know that if we have an acute injury, meaning a sudden recent injury to the ankle and it swells up; rest, ice ,compression, elevation the old RICE treatment and staying off of it. And certainly if you can't walk on it, going to get an x-ray is prudent. Other than that, the treatment can vary from depending again, on the severity an ankle corset, like a lace up figure eight thing that we give the athletes to a walking boot or cast, like one of those moon boots you see, or astronaut boots. And physical therapy, anti-inflammatories if the patient can take it and graduated rehab. Some of these, I call an ankle sprain plus, meaning they're really swollen. They're really sore. Or there could be secondary tendonitis involved and they may especially need one of those moon boots. And then try to rehab that over time, which could take two to four to six, even eight weeks.

But then there also is surgery for those times where the ligaments are just severely damaged or damaged repetitively over time and just not working like ligaments anymore. And they're not supporting the ankle. And that's the time where we proceed with ankle ligament reconstruction surgery, which is anatomically reconstructing, the ankle ligaments that make them act like ligaments again, not like the rubber bands that they seem to be acting like at the time where they're just kind of stretching and giving way, but not supporting the ankle any longer.

Host: Right. So a variety of treatment options. That's for sure. Generally, do most people recover from ankle instability?

Dr. Werner: Most people will heal from the acute injury and heal an ankle sprain, as we know it; 15% of people though will go on to some sort of ankle instability. And some of it, like I said, could be subtle, where most of the time, you're fine. But if you do something more aggressive, you're not fine. So, 85% of people after they acutely sprained their ankle, do fine on their own with the basic treatment that we talked about, the rest, ice, compression, elevation. And kind of staying off of it. But 15% of people do have either subtle or more severe instability. So it's not an insignificant number of people.

Host: Right. Are there things we can do to help strengthen our ankles to stave off ankle instability as we age?

Dr. Werner: That's a great question. And the answer is absolutely yes. So coordination exercises. So I have patients when they rehab many times from an ankle sprain, and physical therapy is intricate and imperative in helping us with this. But I was a physical therapist before I was an orthopedic surgeon back in the day. So, the exercises that I use are balancing on one foot. Balancing on one foot, will work on your proprioception or your joint sense and space. So, basically a fancy word of saying working on your balance. So, you could stand on one foot with your eyes open, hanging on to the countertop. Then when you get better at that, and that doesn't hurt or feel unstable, then you don't hang onto the countertop, but you keep your eyes open standing on one foot. And then if you really want a challenge, then you stand on one foot, don't hang on and close your eyes. And boy, you really have to balance yourself. It's harder than it seems. And I have people time themselves. And if you can do that 30 seconds, that's pretty good. I have an old ankle injury on one side, and I have a hard time doing that for 30 seconds. Other side, no problem.

That's because that ankles that are injured, chronically have problems with their joint position sense. So working on that balance, that simple balancing act is important. It could really help prevent further injuries if you had your ankle sprain and it more or less healed up, but you're trying to do prevention. And of course the other thing is to strengthen the muscles around the ankle, because again, our ankle is stabilized by our ligaments, but most of the day to day things like walking on uneven surfaces and even doing sports or working out the gym; it's the muscles around the ankle that prevent it from spraining first, not the ligaments. I said to patients many times that if we walked around counting completely on our ankle ligaments, we would walk, roll our ankle, walk roll our ankle, because it isn't until we roll our ankle that the the ankle ligaments really kick in and do something. We don't obviously walk like that. It would look silly. We walk around in a balanced fashion. And what happens is the muscles on the inside and outside of our ankle are always working during the gait cycle to balance us.

So, if you get those muscles stronger with exercise and physical therapy can certainly show patients how to do that. But things with the rubber bands and stuff, the strengthening that you see and just getting generally stronger in the lower extremity that and the balance exercises can go a long way to prevent further injury or any injury to begin with.

Host: Yeah. That is really good stuff. I have chronic low back problems, so I do yoga. And one of the things that I stand on one leg and you're right, when I do that, boy, the muscles are just firing all around that ankle when you try to stand. What about stretching before physical activity or is there a way to stretch the ankle tendons, ligaments to help prevent an injury?

Dr. Werner: Well, I like the balance, the joint reaction time, the strengthening. And then stretching is something that is important around the foot and ankle, most importantly to the Achilles. So, the Achilles, the calf muscle, the calf muscles are attached come down and form our Achilles tendon. We've all heard of the Achilles tendon. It is notoriously tight in elderly people, people that have diabetes, even athletes. I do a lot of running, even myself. I do a lot of running and I'm always stretching my calf muscle because a tight calf muscle is a culprit of many maladies around the ankle we think. So, things like adult acquire flat foot deformity that we're not talking about and Achilles insertional tendonitis. And other things can be prevented by really stretching the Achilles. That's the most important thing to do before aggressive working out is if you do stretch around the ankle, the one that's the easiest and the most important is to stretch the calf muscle. Then we do that by kind of leaning against the wall and having our foot behind we've we've all seen those type of exercises, so.

Host: And most of us has probably done those stretches as well. Those calf stretches leaning against the wall, keeping your feet flat on the floor. Absolutely. Well, that's good to know that, that does help ankle instability and that does help stretch the muscles around the ankle. So, that is good to know. And important to remember before any type of physical activity, especially like running. Right? So that, that makes a lot of sense.

Dr. Werner: Absolutely. And warming up and getting gently into this thing, especially as we get older, I notice it a lot. I feel kind of old when I used to go to the gym and just throw on a whole bunch of weight and start lifting immediately. And now I, like, I got to ease into this. Somebody who's going to get hurt.

Host: Right. Yeah me.

Dr. Werner: Somebody

Host: Yeah.

Dr. Werner: could get hurt here. So I have the ease into these things and, and that's really important, especially as we're older and I'm a big proponent of also cross training, as we get older, to not always doing the same exercise over and over and over and being a long time runner, that's a challenge for me, cause I like to run all the time. I still like it, but I find that if I do that activity, repetitively all the time and not mix it up with some biking or stair-step or glider, or just take a day and do some lifting or just some walking, I end up getting overuse injuries and that's where you can wear out the ligaments to your ankle too, and have some problems. So, I think all of that is solid advice. Warming up, not going from zero to a hundred, training appropriately, mixing the training up, stretching, strengthening, and also not forgetting about balance.

Host: Right now all really good points to remember and such good advice. Thank you so much for your time today. We really appreciate it.

Dr. Werner: I really appreciate you. And I do want to say one last thing that if anyone does have some unusual ankle pain and they're not sure what it is, I am very happy to see them. Most of these things can be worked out and figured out. It just takes a doctor willing to listen to you.

Host: And it's probably a good idea to get it checked out so it doesn't turn into something worse down the road, better to catch it early and take care of it, than to let it progress. Is that right as well?

Dr. Werner: Absolutely.

Host: 100% great Dr. Werner. Thank you again. This is really been fun talking with you. Thank you.

Dr. Werner: My pleasure Bill. Thank you.

Host: And once again, that's Dr. Michael Werner and for more information or to make an appointment, like he said, if you're feeling some ankle instability, give him a call and go see him. You can contact UPMC West Shore Orthopedics at 717-988-8135 that's 717-988-8135. Or you can visit upmc.com/centralpaortho.

And if you found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is Healthier You a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.