Damien Gregory

Good evening, everyone, and welcome to the Benenden Hospitals webinar on foot, ankle, and lower limb injuries. If you haven't seen me before, my name is Damien, and I’ll be your host for this evening. So we've got two experts this evening. Our expert presenters are Mr Liam Stapleton, Sports Medicine Podiatrist, and Mr Mark Jones, Consultant Orthopaedic Surgeon. This presentation will be followed by a question-and-answer session. If you'd like to ask any questions during or after the presentation, please do so by using the Q&A icon, which you'll see at the bottom of your screen. This can be done with or without giving your name, so please note that the session is being recorded. If you do provide your name now, if you'd like to book your consultation, we'll be able to provide contact details at the end of this session.

Liam Stapleton

Hi there. Let’s make sure this works. Are you reading this? Sorry, we can start there. Okay, thank you for having me. Thank you for everyone signing in to listen to us talk about this. Hopefully, you can find some of this a bit interesting. So, as I said, I’m a specialist in paediatric sports medicine, or sports medicine podiatrist. My credentials are on the screen: fellow faculty of podiatric sports medicine, the Royal College of Physicians and Surgeons of Glasgow, and the Royal College of podiatry postgraduate certificates in podiatric sports medicine and podiatric surgery, as well as a special interest in foot and ankle diagnostics and injection therapy.

So we're going to talk over a few things in this session, and we each got a few common, mainly sports injuries that we found within our disciplines, which keep going backwards on themselves. So first thing we talk about the common thing we see foot ankle is lateral ligament injury commonly people rolling their ankle or an inversion injury classically we always we've always been told the rice is the way to treat this rest ice compression and elevation and that probably in in basic principles still stands one thing that has changed the British journal of sports medicine recommends now we use the peace and love which changes things slightly the main difference with this is avoiding anti-inflammatories in the acute stage as this is thought to slow down your healing process and maybe slightly different to what you guys might do in in orthopaedics early and obviously to remove ice from this and they've split this into two parts so you have your acute stage and then as you start to get better so you protect elevate avoid anti-inflammatories compression and education and some of that is communicating with healthcare professionals and then obviously as things start to improve you begin to reload the injury optimism not sure where that fits in I think they just need an o getting the getting your joint moving again to revascularize it and then begin to return to exercise ligament injuries can cause osteochondral lesions and this is potentially damage to the cartilage and bone within the joint and are a difficult problem in the ankle to treat so we usually use MRI scan to confirm this I think  MRI scan is really the gold standard for imaging for any ankle inversion injury both for assessing the ligaments and the damage to the underlying bones beneath ways of treating this if you have this and sometimes if your ligament Your ankle inversion injury is severe enough that, very often, this may be prophylactically advised before you actually have the injury confirmed on an MRI. Protecting the joint, or more often, walking boots, is recommended. Crutches are recommended to completely offload and rest compression elevation medication, so an analgesic Somehow this is a kind of injury that sometimes nooid anti-inflammatories are recommended for, and there are certain medications that can be injected that reduce the friction within the joint if you were confirmed with an osteo lesion. Obviously, surgery is difficult, and certainly surgeons prefer if we can treat these nonsurgical injuries because the primary bone, the square bone within the ankle, doesn't have a great blood supply, so it doesn't tend to work as well because there's not as much bone marrow in it. You have the micro-fracture that you might have in the knee. Obviously another common problem with the ankle, and depending on which sport you play, ankle impingement has three types. I usually see an anterior ankle impingement, a posterior ankle impingement, and a lateral ankle impingement. The anti-impingement is usually caused by degenerative changes in osteosis of the joint and is very often bony. Not always, but very often bony, where you have bone spurs begin to grow, and that can often be following a trauma, and that would damage the underlying bone. Posterior ankle impingement can be caused by various different problems. One of the most common is the prominent back of the tailor bone, the little square ankle bone that sits in the ankle socket, so you can have a very prominent posterior part of that bone.

You can also have an extra bone there and a trigonum, and this actually gets physically compressed when your foot is pointed. The other way this commonly happens is if the posterior ankle irritates the tendon that moves your big toe. The tendon that moves the big toe can get runs very close in proximity to that part of the joint, and so this is common in ballet dancers and footballers, the two groups in the sporting world that you tend to see this most commonly, and so for some people, you get a combination of all three of those things. lateral ankle is probably less of a true impingement, and someone we see with an adult acquired a flat foot, so that's a foot that wasn't always flat and has become flat. We tend to see that in stage two of developing an adult's flat foot, patients come in with pain in that lateral ankle. How do we treat this part of that? It would depend on which of these varying types you have. Physical therapy is always part of the treatment of most muscular skeleton sports injuries. They usually have a part to play in almost all offloading, which can be ankle strapping and can help foot orthosis footwear activity modification al that's hard if we're looking at a footballer or a ballet dancer but sometimes if you have like a recreation or run changing the angle of drop on their shoe what makes a big difference in in in the mechanics through the ankle and takes a lot of stress off that that can be enough injections again work better if it's soft tissue rather than bone but you tend to have a lot of capsular swelling in that also and then obviously surgery to debride or remove what we whatever we think might be causing physical impingement and if it's now a required flat foot to reconstruct that foot which is no small surgery but needed in some people one of the most common things we see in clin is plantar fasciitis it's estimated that 10% of UK population will have it at some point in their life I prefer the term relative rest rather than complete rest so running within your load capacity within h within what's comfortable but not stopping completely rehabilitation we know that strengthening exercises for bl pressure is work better than stretching exercises although stretching exercises are still probably somewhat beneficial to most people but probably not optimal shock wave therapy orthotics and corticosteroid injections are all treatment options for that what I tried to do in clinic is work out which will I think will work best and if we see a very acutely inflamed but not very degenerative plantar fasciitis on ultrasound scan in clinic then probably corticosteroid injections probably the most likely then shock therapy more for those slightly chronic cases but there was also some variation within that and we tend to see quite a few people two weeks before the land m we with plantar fasciitis and steroid injection seem to be the only way to go as cut the master what we tend to know is that people who rehab their plantar fasciitis well don't come back and those that those that don't do their rehab exercises for quite some months after you got better I usually advise that you do at least three months of rehab then those that don't are more likely to come back the steroid injections themselves of a high recurrence rate anyway and probably the other most common thing I see in sporting population is probably Achilles tendinopathy so we're looking at painless swelling around the Achilles tent at the back of the ankle what I would say is rarely they're usually not that inflamed when we see them in clinic and there's normally an element of chronicity to them and sometimes we actually see an actually inflamed one we probably think it might not it might be something else so we normally separate these into midportion and insertional tendinopathies and then subcategorize within that mid substance tears calcification neovascularization tendonitis, haglin deformity involvement, and obviously other systemic problems that might be interplaying with that too. Modification of footwear: There are two main things we might do: Make sure your shoes don't press, rub, or compress the k tendon. We know the Achilles tendon has a low resistance to compression; it's estimated to be about 2% of its resistance. A tensile-force heel lift, especially in insertional auxopathy, helps a lot. Strengthening exercises: stretching exercises have been shown to be provocative to insertional pathy. There's a big no, at least until you're pain-free, and then analgesics over non-anti-inflammatory agents have been shown to reduce the activity of the cells that will repair your Achilles tendon. You don't want them acting any slower than they do already because Kist has a particularly poor blood supply and struggles to maintain any high level of metabolism for repair. The shock wave has estimated something like an 80% success rate over three sessions for treating Achillies tendinopathy. It's a pretty good hydrodissection injection primarily for large portion tendinopathy and is usually indicated if there's signs of neovascularization, which might be interpreted as inflammation in lay terms within the mid portion, again probably estimated at about an 80% success rate. I’d probably say it's higher if you picked the right patient. Prp injections have been shown to have long-term outcomes that are good, although the evidence base is weaker than the other two injections. Surgery has its risks, but certainly for calcific and insertional tendinopathies where a hind deformity is present, they're more in-depth, and they can be the ones that are really complicated to treat. Have we done time? Yes, front ankle fractures. So broadly speaking, I tend to see stress fractures in click rather than acute fractures. Sometimes you get the odd one that's not picked up in A&E, in which case we refer them to your good guys pretty quickly. stress fractures usually we would manage them with offloading and rest so whatever we think is the provocatory and which case for a lot of people running physical activity whatever it is that's over and above walking around physiotherapy orthosis certainly as you are returning back to your sport you know I think you're something like three times more likely to have a second stress fracture after you've had the first and if a woman it's something like 27 times the risk we look at trying to look at reducing the risk factors as much as possible, obviously with fractures. Surgery is often the case. Certainly, if the fracture is severe enough in the foot and ankle, there are certain bones that are prone to difficulty healing because they have poor blood supply. The one that comes to mind and is most routinely done in the sports world is a Jones fracture at the base of the 50-metre tassel in most high-level sports that is usually fixated. The recovery is about the same whether you fix it or not, and it guarantees recovery. I think it's about 10%. You might know, or maybe you know a bit better. I think it's about 10% of them going to non-union, which is quite high, and we can introduce Mark. I’ll let you introduce yourself.

Mark Jones

So hello, everyone. I’m Mark Jones. I’m a consultant orthopaedic knee surgeon in east Kent hospitals, where I practice mainly with sports knee injuries, and this is through years of training. I went to Brisbane for my fellowship, where I trained a majority in sports knee medicine but also in my higher surgical training in Sussex.

I’m going to talk today about the common conditions in the knee that I see mainly in sports knee injuries, so we're not going to talk about arthritis today or anything like that, but mainly the sports knee injuries, and we're going to talk about meniscal tears, patella dislocations, tendinopathies, and ACL injuries. So, to start with, what is the meniscus? Well, a meniscus is a shock absorber of the knee; it basically takes the impact from the knee and takes it away from the cartilage and distributes the load. There's two meniscus within the knee: the inner, or medial, meniscus, and the outer, which is called the lateral meniscus. The idea is that this distribution of weight throughout the knee protects the cartilage and protects it from developing arthritis later on in life. So, you can imagine that having tears in this meniscus is not great; they tend to be broken down into two types of meniscal injuries. You can have an acute traumatic meniscal injury, which is mainly what we're talking about today with these sports knee injuries, and these usually occur with a twisting and loading of the knee that causes a sheer force of some kind onto the meniscus, which causes it to tear. These can then be isolated and just have an isolated meniscal tear, or you can have associated injuries, other ligament injuries, or conodal injuries within the knee, and most patients present with a sharp pain at the sight of the tear either on the inner aspect or the outer aspect of their knee, and then they get swelling of the knee over the next 24 hours—not an instant swelling but something that comes on gradually, and with the manis, you may have mechanical symptoms. The way I describe this is that it's like tearing a bit of carpet by your door; if you tear that carpet and it flaps up, then that carpet's going to catch on the door as you open your door, and it's going to cause the mechanical symptoms, and that's exactly what the meniscus does as you try and do your range of motion throughout that. And again, it's important to take a full history. Find out exactly what the mechanism was, make sure it was an acute traumatic meniscal tear, and examine the patient if you come to me with this history. I’ll examine you, and I’ll try and see if it is tender because you will be tender around your joint line and where that meniscus is torn because it irritates the capsule. You might also be able to feel a click within your knee, or it may be locked, and then I'll decide at that point whether I need to get an x-ray or the gold standard for these traumatic meniscal tears, usually an MRI scan to have a look at the soft tissue. This is compared to a traumatic meniscal tear, which is less of a part of the sports knee injury, and that it usually the mechanism is unknown, usually patients wake up with pain in their knee that they didn't have the day before their knee's a bit swollen, and they can maybe add a pinpoint it to one side or the other, but it's usually because they've overdone something the day before without really knowing about it again, though the symptoms are the same, so you get pain, you get swelling, and the mechanical symptoms of clicking, catching, locking, and the investigations are fairly similar except for the agrammatic meniscal tears I tend to build in an x-ray into my investigations because this will tell me whether it's associated with an arthritic type picture so the idea of this assessment is basically is a is a summary of the guidelines now the guidelines is the national association and they've basically looked at whether what happens with these meniscal tears and how we should manage them the main thing is it an acute sporting knee injury that is locked and if you've got a locked knee which basically means you’ve you cannot open your door because your piece of carpet is stuck in the way then the and an  MRI scan confirms it then these tend to need an urgent arthroscopic meniscal surgery usually to repair the meniscus if it's repairable this is in comparison to those patients with arthritis within the knee but have an a meniscal tear and again these ones don't tend to need any surgery at all apart from maybe later on needing a knee replacement we then have a group of patients in the middle those patients with a meniscal target with an acute injury these patients tend to do fairly well with an arthroscopic repair if it's repairable and then the two types of patients that have ongoing symptoms with  MRI scans confirming a meniscal tear clinical symptoms pointing to the meniscal tear that are then picked up on the clinical assessment as well and usually these patients can have a trial of non-operative treatment either with physio therapy offloading this knee for a period of time maybe a steroid injection and if this then fails then surgical treatment can then go ahead after this we repair depending on the type.

Moving on to tendinopathy, it's usually tendinopathy of the pela tendon, a bit like what Liam was saying with the Achilles tendon. It tends to be an abnormal turnover of the tendon around either the patella tendon or the quadriceps, and it does have two distinct barriers. Patella tendinopathy tends to be in younger patients or quadriceps. tendinopathy tends to be in older patients, and they tend to overuse injuries again. I didn't realise that there was a new acronym, but I tend to use mice with movement. I quite like the need to continue moving, not to stiffen up or be braced, but icing helps. Compression bandaging can also help, as can elevation if it is a bit swollen. But the main thing is an eccentric exercise programme through your physiotherapy. This is the mainstay of treatment. We then get those patients who are a little bit resistant and don't, and they don't get better with this physiotherapy, and they may benefit from these what we're calling shoat straps, which are these braces that just shorten the patella length slightly and just take the pressure off the patella tendon. We've also talked about shock wave therapy in previous talks, and again, this has some benefit, but I don't think it's as good in the patella tendon as it is in the foot and ankle, and topical may also increase blood supply to this area, which may again help the healing process and healing phase of this injury. Injections are another last resort, and again, research doesn't show too much of a benefit, but it's sometimes better than the last result, which is surgical excision, which can be a big, painful operation with no guarantee of another sporting injury. I see quite a lot of these are usually non-contact injuries but obviously can be a big contact rugby injury or footballing injury, but usually with some kind of rotation of the leg that causes this kneecap to twist out of its normal place. Usually what happens is that it usually self-reduces as you straighten your leg in the quads contract that brings the kneecap back over and you hear a clunk, and sometimes this does need reducing either by ambulance crew, by yourself, or in the hospital. I always get x-rays and an MRI, and I always get x-rays just to make sure there's no fracture associated with this or an MRI scan. It depends on the patella, the history of the patient, and the examination to determine whether an MRI scan is warranted, but certainly in recurrent pella dislocations. I do, because this might help me plan surgery later on. So in simple acute injuries where this is the first time for a dislocation, the mainstay of treatment is physiotherapy, again bracing the knee initially for a bit of pain relief but actually trying to get this knee moving to try and get the quads to activate and try and get them to not weaken as much. Occasionally, these braces, which help the patella track, can be used. If there are complex knee injuries, such as cartilage damage or fractures within the knee, they may need urgent surgery. Again, physiotherapy is still the mainstay of treatment to try and really control the movement of this whole lower limb to control the tracking of the kneecap, but you may need to have activity modification, and then we may need to consider surgery about whether we stabilise this kneecap with ligament reconstruction bony procedures to change the alignment of the knee slightly or even to deepen grooves within the knee to try and let the kneecap track better.

So the last thing I’m going to talk about is ACL injuries, which are quite popular at the moment in terms of being on the news quite a lot. They were quite big around the time of the women's world cup in that so many female athletes missed the world cup this year because of ACL injuries; they're usually non-con pivoting injuries. You've seen the typical Michael Owen injury where he was standing alone with the ball and his knee just gave way on him, and most of the time patients will report that they have a pop within the knee; it has instant swelling and pain, and they usually have to hobble off or be stretched off the pitch because they can't continue. You need to assess these needs for early treatment because they can have associated injuries, such as meniscal injuries and other ligament injuries, which need to be managed. Again, early treatment might be a brace just to take away the pain and the swelling, but early motion is key as well as icing this need to take away the swelling. compressing and elevating, and an early MRI scan will give you the diagnosis and treatment that can be broken down into non-operative and operative. Early treatment is always with therapy and physiotherapy, whether we go down the operative route or not, because this will help build up range of motion. We have swelling control and swelling management, as well as building up the quadriceps as much as possible. ACL braces such as the one in this picture can be used to give control back to the knee long-term, and they can also be used later on to protect any reconstructions or repairs that have been done. Some ACLs can be repaired, but they're not as common as reconstructions, and reconstruction is usually the mainstay of surgical treatment.

I wanted to mention in this presentation a little bit about injury prevention because I think, given the fact that ACL injuries are becoming quite common and there's certainly been a huge increase in ACL injuries among the young, with a 29-fold increase in the last 20 years, we need to try and do something to protect our young population as well as our female population from having ACL injuries. The FIFA 11 Plus programme has been out for a few years now and is starting to become a bit more popular in this country. It aims to basically have a preventative warm-up programme, so if you introduce this to all sporting individuals from a young age in their PE classes in their training that they do, then they will reduce the chances of ACL injury in the future, reducing it to about 50% overall in all athletes and actually reducing it by 2/3 in biologically female athletes. This is a really worthwhile programme that we should all encourage our kids, our friends, and everyone in school to take up so that we can reduce the burden of ACL injuries. basically you can get this from the internet from anywhere and I’ll show you a good website where you can get it from but it basically goes through a 30 minute warm-up that you should do in introduces part of your training which goes through different steps and it shows you how to do the exercises and making sure that your knee is in the correct position or not and once you've done this you can introduce this into every training session you do again we need to worry about biologically female athletes because they are higher risk of having a high or they're more high risk of having an ACL injury and it's not just based on the anatomy in that their legs most there's a lot of female legs which are what we call knock kneed or valgus and their pelvis shapes but actually it can be hormonal it can be the fact that football boots are designed for male feet and not female feet and there's only a few brands out there which are designed for females and this can have an impact on ACL injuries the pitches that females tend to play on are not are usually not the ones that the males are playing on and usually are not as good quality and so can introduce increased risk of injury and also the lack of strength from condition that female athletes have there's a stigma behind it not to build up too big s their muscular but also in academy age groups if you're a male athlete going into an academy you will get strength and conditioning training from in under nine year olds whereas in females it's in the under 12s when you've probably missed that boat so they are more at risk of ACL injuries this is a website which you can go to after the presentation which is called power up to play which has been over the sky sports news recently and it's been set up by a group of knee surgeons around the region and it's a charity focusing on reducing the knee injuries in in the youth it gives This is where you can download the booklet FIFA 11 and also look for how to do these exercises and local centres that you can go to see how these exercises are done, so I do encourage you to go to this because I think it's extremely good to try and reduce our chances of ACL injuries in kids, and that brings me to the end of my talk, so I think we go to the questions and answer session now.

Damien Gregory

Lovely, yeah, thanks, Mark; interesting one both of you. It's quite interesting that you mentioned that last section on sort of ACL and prevention. It's just a simple warm-up. I was told at school to warm up, and I’m still being told to warm up now.

Mark Jones

Not warming up by actively warming up rather than stretching anything might slightly increase your risk of old-fashioned doing that we would have been taught when we were 12 years old isn't what would be done now, so it's kind of taken a slightly more modern scientific approach to it.

Damien Gregory

No, absolutely well, yeah, so if you've got any questions, please pop those in the Q&A icon box now, but we have got some coming through. So we've actually got a 40-year-old marathon runner who's had chronic pain in his ankle after an x-ray. It looks like he's got borderline osteoarthritis, a degenerative change to an accessory bone, and a borderline degenerative change affecting the first joint. I hope that makes a little bit more sense. No swelling, but pain and stiffness. So in the morning, the question actually seems to be more geared towards. Are there any supplements that he can take to help? But perhaps you can give us some insight into the condition in general.

Mark Jones

Well, what I probably say is first joint osteoarthritis, which I think is what we mean here process is the most common asymptomatic finding on plane-form radiographs, so plane x-rays are the most common thing people will find, so there would be no reason to stop running even if it was particularly sore. what I found so when you have an accessory in and there were three different types of that but almost all people have access tend to have very flat foot and I wonder whether the pain is more coming from a flatter foot type trying to run rather than the degenerative changes with the ankle if it's borderline so it' be very difficult for you to be able to tell which was hurting more because you can get this lateral ankle impingement as I speak about syndrome these things that are affected because the when you have this extra bone this access in angular puts your posterior tendon mechanical disadvantage so what it means is the tendon and muscle that hold the arch up in your foot and effectively shock absorb your foot when you hit the floor when you're running is at a disadvantage so it has to work harder than say the other foot if it doesn't have that that bone extra bone or your best friend that the same age and the same weight and runs the same as you then their tip post tender would have to work so see the force going through your foot when you're running being four times greater running than walking it might be that that muscle is just not strong enough to work that hard in that situation I it's an interesting one say the borderline osteophytosis again probably wouldn't probably that wouldn't be enough to stop you from running marathons like even if it was even it was that being the cause of symptoms certainly something should be fairly straightforward to managing clinic I think the feeling is probably that the accessory may be more of a problem than anything else. I'm not really a big supplement person. To be honest, try them if they're cheap and safe and see if they work, and then if they don't waste your money, that's probably what I would say.

Liam Stapleton

Yeah, okay, perhaps even there are some just diet changes instead of supplementation. Maybe diet changes have been shown to increase the symptoms of inflammation. It doesn't sound like it's particularly problematic; it's more of a worry that it's a bit stiff and sore after exercise than during, but yeah, I think probably if it's causing problems, yeah, maybe have an appointment and we can assess what exactly is causing any of those symptoms.

Damien Gregory

Okay, grand Yeah, we can look at some special offers actually to take up that offer, so we've got Kelly asking why she might suffer some sort of unusual sort of sensation in her knee and groyne after what looks like might be an ankle injury, particularly maybe, I’m guessing, maybe a broken ankle.

Mark Jones

I mean, ankle injuries can be quite nasty in terms of the soft tissue damage. You can get complex regional pain syndrome, or CRPS, which can cause electrical sensations, burning pain that can go up and down, and it may be associated with that, but I think you probably need it, and clicking noise. Again, the problem is with ankles; they scar up, and there's not a lot of soft tissue protection, so there's a lot of scarring around the ankle, which can bleed into the joint itself, which can cause stiffness with the soft tissues around it. The ligaments can also be damaged, and I think the clicking with pain is something you should probably know about. Yeah, it sounds like there's not a lot of diagnosis so far in what's been, you know. I guess if she's walking badly, she's irritating the sciatic nerve, and pain in the hip and knee can be coming from the top as well. Yeah, probably yeah, and further to your next question about whether you can get a tear in the knee material with a badly broken ankle, yeah, similar mechanisms You know that inversion injury that twisting can cause a twist in the knee, and because you're then so focused on your ankle because it's broken, you may then realise when you're rehabbing and you're recovering that actually your knee is also just as painful and the meniscal tear hasn't healed or is having problems, so I think you need to get to be seen about your knee as well because I think you can injure one and the other at the same time because they have a similar mechanism of injury.

Damien Gregory

Okay, we've got Ellena asking. I had my posterior repaired with groove deepening and had my perennial re-lens ACL reconstruction in July 2022. I'm still struggling with swelling and pain post-surgery. Any recommendations to improve this, I guess?

Liam Stapleton

So that's quite it. It sounds like you had quite a bad injury, and it sounds like you had dislocation of the tendons. Just kind of reading in with what you've done. You know the look. It depends on exactly what is hurting. Obviously, if you had an ankle ligament reconstructed, they tend to be slightly stiffer after reconstruction than they were beforehand, so obviously, that can cause some symptoms. probably most likely is paranal still tendon apathic and obviously takes a long time for them to strengthen back up, making sure you're doing the rehab. probably would say surgery alone wouldn't be enough to get you back to 100% and the kind of the rehab is a really important part probably you say as important probably getting that right as anything you do in theatre and it's not easy to get it right it's hard work and takes ages and you know you've kind of make sure you've got someone good leading it also that's you know if you're sporting then then making sure someone has a background in sports physiotherapist who know have to rehab you back to whatever the sport activity that you play if someone's not experienced in doing that then you may well find you leave yourself a little bit short and you know underprepared for what returning to whatever activity you have again probably have a look and see what see what I think is driving some of that pain.

Damien Gregory

Okay, grand, so we've got Janet. I think basically the more information you can provide, maybe the better and more precise answers we can give, but Janet’s asking, having recovered from a severe ankle sprain, if it suddenly experienced pain in the ankle bone, would physio help?

Liam Stapleton

Then, as a general rule, most physio, yeah, look, seeing someone, yeah, define I think having someone assess it is a good idea, and probably you know once someone has seen it, then trying to judge whether physio would be you know, I’d say if it's broken anything, then physio there's a good chance physio will but help you know yeah, good, and if it you know if they worry that something more severe there's something more severe going on than they could deal with within their specialty, then hopefully they'd refer on and have you know some imaging and some diagnostics done to see what was actually going on.

Damien Gregory

Okay, grand, so we've got Anna. I had a partial tear in my right Achilles two years ago. I no longer limp but am aware of a lack of strength in my right foot that is causing me to walk and run unevenly. I now get pain in my left foot and Achilles after playing tennis twice a week and running a few times a week. Would a podiatrist be able to help with this?

Liam Stapleton

Yeah, so those are common. Certainly, as you get older, they're not necessarily reasons to stop. Obviously, it's going to take a long time for you to get over that injury. What we know is that you can. The likelihood is that the tear will stay. If it's the mid substance, the tear will stay there, and you strengthen all the tissue that's around the tear rather than filling in the gap. So really, we often still see the tear well after you know it, possibly for the rest of your life, but we know that you can lay down more collagen fibres around that, so long as the surrounding tissue is strong. Yeah, Achilles has a poor blood supply, so it takes a long time to get over, and the older you are, the more likely it is to take you a long time to get over. There are things that can certainly speed up that process. Mark Jones Make sure the rehab's right. You're obviously doing a lot more exercise than average for the average 64-year-old, so that obviously plays a part in trying to judge whether or not you’re doing more than you can recover from, especially if you're not as strong as that. That initial injury may still be underload if it's weaker, and pain on the other side certainly if that's where the majority of your propulsion is coming from. That's the foot you push off with as you begin to sprint or play tennis. Sometimes you just end up overloading your good side too. Absolutely. Yeah, one of the things we'll probably have a look at is an ultrasound scan in the clinic to see what's going on. Certainly, see what's going on to the left, which is the new side, and then see what's actually going on again. Good, yeah, thanks, Liam. and keep going with that exercise, actually yet again on Achilles. someone's ruptured their Achilles back in may maybe we can give them a little advice here I’m due to have an operation to rejoin it can I damage it while walking my walking speed is affected it can I damage further okay so he's not had the re hasn't had it repaired yet not yet not yet okay start a long time repair that's you can damage it further depends how complete it was then often not 100% are they I think there's often you know 90% of fibres but yeah say if it's not completely ruptured then then then you could we damage it further that that sounds a bit long to have that operation done you know I would say very often in those cases would you say that the normal would be to boot it and yeah we in this game we've got a protocol where we boot majority of Achilles as long as they're caught early in the acute phase you can treat them nonoperatively in a boot the ones that tend to be operated on the ones now that are missed or misdiagnosed or delay presentation and therefore they're lengthened there's nothing the gap hasn't closed up and then we need to do something surgically to bring it together but may is a very long time so I don't I don't quite know what's gone on all what's happened here so I think yeah definitely walking will be affected and I mean what simple walking by wouldn't do too much more than that until you know until you've seen the surgeon and ask them because I don't without knowing the further details we would want to give much more advice on that apart from just be careful.

Damien Gregory

Okay, interesting, and maybe a little bit worrying as well, do get missed. Yeah, okay, what's the chance this is from Judy? What's the chance of getting back to full recovery following a meniscus tear?

Mark Jones

I think it depends on the type of meniscal tear you've got whether it's an acute injury a chronic degenerative issue and then the management and how quickly you present so I would say for those patients who have an acute sporting need meniscal injury where I get to have an early  MRI scan an early operation where I can repair the meniscus I think the majority of these patients get back to full recovery fairly well I think by about three months they'll probably be starting sport again avoiding deep squatting but actually getting back to their exercise and hopefully will be pretty symptom free if it all heals by about the six month stage if this then becomes a degenerative meniscal tear that someone's being where n is being debrided then again the chances of full recovery are probably not as good because there probably associated degeneration with that knee so it all depends on the situation of that meniscal tear.

Damien Gregory

Okay, we've actually got an anonymous attendee who almost asked exactly the same question, but this time with an ACL injury. A little ACL injury: can people return to full activity after completing the surgery?

Liam Stapleton

Yes, you can, so look at all the professional athletes out there who are getting back. It's not just professional athletes; it's amateurs as well. I think the only difference between a professional athlete and an amateur is the physio and rehab and the free conditioning that you've got. So a professional athlete has a lot better condition than an amateur, and so getting back that range of motion, getting back the strength, and then the physio in terms of the training is a little bit quicker, so most athletes will be looking to get back to sports around the 9-month stage after an ACL injury. I would tend to suggest that if you're not doing this for a living, I would aim for around a 12- to 18-month stage, but you know some people are getting back at nine months if their physio goes well and they're good and committed, but certainly people. The reason I do ACL surgery is to get them back to full activity and to complete, but the issue mainly comes with psychological reasons, so a lot of people don't want to get into themselves again and actually find getting back to surgery or getting back to sport is actually quite a psychological impact on them because they don't want to injure them. They don't want to have that 18-month recovery again, so they avoid the stuff they know may rupture.

Damien Gregory

Okay, interesting, so we've got Janice asking that she just had her left ankle open reduction and internal fixation ankle broken on both sides after fainting and still painful with slight swelling. How soon after the surgery can metal work be removed?

Mark Jones

Yeah, so what do I mean? I put a lot of metal work in the ankles, and my advice to everyone is that I will only remove that metal work if there's a problem with the metal work for some reason. You know, a lot of patients in America and Australia will have routine removal of metal work, but in this country we don't remove it, and actually, the research shows you don't need to have metal removed unless there's an issue. However, if you are to remove it, then the reasons you're removing it are usually infection, skin irritation, or further surgery. It needs something else done, but you need the fracture to be healed before you can remove it.

Damien Gregory

Sorry, I think our system is still there, but all the questions have now gone, so I’m sorry we can't answer anymore.

Okay, all right, thank you now. If we hadn't managed to answer any of those questions, I think they may have been captured somewhere during the recording or somewhere via the Zoom platform, so what we will do if you've provided your name is answer your questions via email. So I’d like to thank you all for attending. If we can just move over to our last slide, okay, never mind. Well, if we can't move on to our last session, here we are. As a thank you for joining this session, what we are offering is 50% off the value of any consultation related to Liam and Mark. Here is a call back from our dedicated private patient advisor. Now for all of you, an email will go out tomorrow with a recording of this session and further information and updates on news and future events. So, if you'd like to discuss or book your consultation, our private patient team can take your call up until 8:00 p.m. this evening, or between 8 a.m. and 6 p.m. Monday through Friday, using the number on the screen. We'd be grateful if you could complete the survey when this session closes to improve future events. Our next webinar is on cataract surgery, which you can sign up for via the website. On behalf of our presenters and expert team at Benenden Hospital, I’d like to say thank you for joining us today, and we hope to hear from you very soon.