• LecturehallAnkle vs Subtalar Instability
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Marie Williams: Okay, so we're going to get started from the last of my lectures. I'm going to talk about ankle versus subtalar joint instability. It kind of goes hand-in-hand with all the things we were talking about with the tendons and ligaments, because the ankle and the subtalar joint people come in with "ankle pain", so we're going to talk about that.

    Some of the learning objectives. Just basically I'd love you to understand the pathomechanics and function of the ankle and subtalar joint. It is not a 30-minute lecture. So I'm not going to give you all of it. But you definitely should recognize an ankle joint instability versus the chronic and the acute, and understand how the subtalar joint ties in and develop a plan for both.

    You know, the typical ankle joint is more complex than you think because you have medial and lateral ligamentous structures which we'll go through. You have inversion and eversion, problems with the foot. You have plantar flexion and dorsiflexion problems, and sometimes you have a combination of an injury. We'll talk about it all.

    An ankle sprain accounts for 40% of all the athletic injuries and a recurrence can range from 56% to 74%. You see these injury whether you're walking and stepping off a curb, slipping on water, playing basketball or tennis. It's very common, more common than most injuries, so 40% of all athletic injuries for sure.

    10% to 30% of the ankle sprains results in a chronic instability, and often these injuries maybe non-sports related as I spoke about. I probably see more non-sports related ankle sprains for the people that are not paying attention, getting up from their desk or kind of falls asleep. They twist their ankle and they are doing nothing, and they have to come up with really good stories because they're so embarrassed by that injury.


    It's estimated that 50% of the patients don't even get treatment when they have an ankle sprain. I know, I'm in that category when I sprain my ankle. I just say, "Oh, okay. Let me just wrap it up and keep going." Or the guy that's playing basketball and comes off the court and goes to work, so you don't really get treatment.

    But down the road, you may have chronic pain or some type of instability and not know why. So as a clinician, you really need to probe these people and make sure, have you ever injured your ankle before? Have you ever had a problem before? Oh, I remember five years ago when I – and they'll tell you the whole story.

    Pathomechanics is important. You know, when you talk about the lower extremity, you talk about any injury in the lower extremity. You're always talking about pathomechanics. It's actually the mechanisms of injury that really guide us in how we are going to either evaluate and/or treat that patient. So the most common mechanism of the injury is due to a plantar flexion inversion injury. You've heard that over and over again.

    And you'll see that when you have these injuries, the proprioceptive reflexes are lost. I'll use Michael Jordan as a good example of someone who has incredible proprioception. You do remember Michael Jordan, right?

    Unidentified Male Speaker: Yeah. Yeah.

    Marie Williams: Okay. Maybe you want to say another player like…

    Unidentified Male Speaker: LeBron.

    Marie Williams: … you could say LeBron. I'm from Miami so I don't say that so often but he's a really good example. But you also see someone like, you know, it doesn't matter, one of these professional basketball players or someone I think of when I think about proprioception fibers because either up in the air, they're spinning, they're twisting, they're doing a 360. They're doing something in the air. And then they've got to come down and they have to make sure, A, they don't land on anyone else's foot. And they have to land in a right position or the foot being what I called righted.

    The guy that did that the best was Michael Jordan because he was always up in the air and always coming down, and you very rarely saw him twist or sprain his ankle. Because he had incredible proprioceptive abilities to know that that foot needed to be righted or put in a right position as he's landing. That's what that proprioception is all about.


    And you need to take a lot of time within repairing these. You're doing a lot of the physical therapy. These athletes are doing a lot of physical therapy to really get the proprioception back. It's when the proprioception is lost that it becomes a real problem. So it's really a positional thing. And when you lose proprioception, you lose the direct position of the joint, function and you can't put it in the right position.

    Some of the contributing factors of an ankle joint instability or ligamentous laxity. Once again, the proprioception defects in neuromuscular defects, weakness and postural control, which possibly an ankle equinus or someone who's in a genu recurvatum or some type of a hip flexion problem. They end up with ankle instability.

    Someone with a – who has injured their knee. Have you ever seen someone with a knee ligament injury and all of a sudden they are walking in with ankle pain and heel pain, and foot pain, and you look, and they've had their ankle and their knee scope recently? Or they've had their ligaments repaired and the ankle is something that takes on a lot of stress so there's a lot of change in the way they walk.

    There's types of instability. The mechanical instability is determined by the physical exam when you evaluate the ankle joint. The anatomic variations, the varus or valgus, there's varus alignment. You'll see people with a rearfoot varus with ankle problems. Pathologically, you'll have an anterior impingement syndrome or a short gastroc, or some type of an equinus deformity.

    They can also lead to osteochondral defects in the ankle so you have this mechanical instability, because they have defects within the talus because of an old injury that they didn't actually even knew they had.


    Functional instability is usually a feeling of weakness or giving way. They're walking and their ankle just collapses on them and that's a functional instability. Peroneal retinaculum is really important. We talked about it with the peroneal tendon but also with the lateral ankle. The superficial peroneal retinaculum is something that you want to evaluate in ankle injuries because you get subluxations of the tendons in 54% of the patients. You might even see peroneal tears in 25% of the patients with ankle injury. You'll see lateral gutter lesions and you also can have osteochondral lesions in the talus.

    A great picture I think because it really does show how the ligamentous structures, calcaneofibular ligament, anterior talofibular ligament, posterior fibular ligament and the anterior tibial fibular ligament all are stabilizing structures of the ankle joint, and as well as how the retinaculum – you can see where the ligaments tie in with the peroneal tendons.

    Ankle joint anatomy, you're always looking at the anatomy. Why? Because everything is a pathoanatomy. When you get that patient in your office, now you have to know, you can't – I tell my residences when we were in surgery, "If you know your anatomy then you know your pathoanatomy. If you know where structures should be and they're not, then you're going to be better off when you're doing the repair of that pathoanatomy."

    So anterior talofibular ligament is the primary stabilizer of the lateral ankle. It's the shortest weakest of the lateral ligaments. It's stressed with ankle joint plantar flexion. Injured in 66% of the lateral ankle injuries, that's a high amount of percentage. The posterior tibiofibular ligament is stressed when the ankle is in dorsiflexion. So you might get a dorsiflex – someone in a dorsiflex inverted position and it's going to pull posteriorly.


    You might think it's actually a peroneal tendon problem but actually it could be a deeper ligamentous injury. The calcaneofibular ligament is the main stabilizer of the subtalar joint and it's stressed upon dorsiflexion and injured 20% of the time. So we're talking about ankle joint anatomy but remember that if the calcaneofibular ligament also stabilizes the subtalar joint that maybe something that you want to look at when you have subtalar joint pain.

    The subtalar joint instability is usually inversion forced applied to the foot while the foot is dorsiflexed. A little bit different than that plantar flexion inversion but you're going to get an inverted dorsiflexed problem. Also, the calcaneofibular ligament is the main stabilizer with the subtalar joint complex. So with the inversion dorsiflexion, it causes stress in the calcaneofibular ligament, a stretch or strain, which then leads to pain within the subtalar joint and you get a stretch on the interosseous talocalcaneal ligament, which is another stabilizer along with the cervical ligament.

    These are really common in volleyball, in basketball-type sports, rotational sports. Sometimes you'll see that in a tennis player who's actually running in and going for a high hit in the ball. It's the key here that you have the abrupt start and stop that creates a lot of these problems because in – one of the things that you missed too is that the talus is constantly moving and rotating in that mortise, and could put stress and strain on the ligaments as well.

    The extrinsic and intrinsic ligaments provide static stability for the subtalar joint. The extrinsic ligaments are the – primarily calcaneofibular ligament but also the deltoid ligament, which it gives you the extrinsic stability of the talocrural joint. And then you have the talocalcaneal, the interosseous and cervical ligaments which are the intrinsic ligaments. And the rupture of the intrinsic ligaments allow for increased movement of the subtalar joint which may result in instability.


    Most of the people that have instability of the subtalar joint always most of the people talk about the foot feeling like it's giving way or weak. They point to the ankle but they're also pointing in the subtalar joint region. They don't know that that's the subtalar joint but they call it the ankle joint.

    You know, it's funny because everything that hurts them around their tendon structures, around the ankle, is to them, the ankle joint. On clinical exam, you're going to ask for recurrent ankle sprains. You're going to ask them how they feel. What is the sensation that they have? It's usually a giving way. And when you inspect, you inspect you'll see edema, ecchymosis. Deformities, you'll see deformities when you palpate. You'll feel crepitus in the tendinous and ligamentous structures or the ankle joint itself.

    Sensory motor function, you'll test for muscle strength and you also – you'll find if there's any sensory defects. Sometimes you'll get a chronic ankle pain but don't forget there's tarsal tunnel syndrome.

    You want to always compare your ankles limb to limb, side to side, because sometimes that swollen, puffy ankle is normal and sometimes it's really not. Patient can describe the rolling on the ankle, likely a plantar flexion inversion, internal rotation, which can create that. Acute pain and edema, and ecchymosis. Individual ligaments, elicit pain on palpation, so you know your anatomy and know your ligamentous structure so you can palpate them.

    Put the foot through your motion while you're palpating them and you can elicit pain and inflammation. They'll have pain and then you'll find the inflammation. They all have sometimes an inability to weight bear. Interestingly enough, you'll see somebody come in with this foot looking like this after an ankle sprain, and it's very painful. They are limping. They could move the joint but the lateral – you know that the lateral ligaments are shot at this point.


    You have a lot of swelling and this doesn't look like a lot of swelling, but if it's a young person who has virtually a bony ankle, this is extreme. So on exam, I teach my residents, I do this myself every time I look at an ankle and inspect it. I always look. One of your best diagnostic tools is your eyes. Your ability to look and compare side to side, whether there's subtle swelling or subtle inflammation in one area to the next.

    Then, you look at the ankle systematically. I look at the anterior talofibular ligament. Anterior, inferior tibiofibular ligament, the high ankle sprain. You know, you actually put your finger there. These people will jump off the table. You compress the tibia to the fibula and they have exquisite pain. Know that the anterior inferior tibiofibular ligament is disrupted.

    Then the typical anterior tibiofibular ligament. I look at the calcaneal cuboid joint in the base of the fifth metatarsal and the inferior CC joint because what happens is sometimes when you have an inversion, injury to the foot or ankle, you get subluxation at the level of the CC joint.

    The cuboid can actually sublux. There's many articles now coming out. I can tell you that when I was a student, we had this sports medicine physician who tried to tell us that you should manipulate the foot and the head of the fibula needs to be adjusted, and everybody thought he was a little bit nutty.

    But if you actually listen to what he was saying, he was basically saying that tendons can pull these bones and these joints a bit out of place causing minor subluxations, which can cause chronic pain and commonly missed because it's not seen on X-ray. And it's not something that you're going to be able to say, "Oh, there's a fracture or dislocation."

    But if you start to palpate dorsally and plantarly over the CC joint, or the base of the fifth metatarsal, you'll know that you'll have some injury in those joints whether ligamentous or peroneal tendon longus or brevis.


    You'll also look at the inferior fibula and the calcaneofibular ligament both lateral and behind the peroneal grove area, and inspect your peroneal as well. So I look at both ankles and then I go, the one ankle is extremely swollen compared to the opposite ankle in a very young person, so be aware of that.

    It may not – you may not think it's swollen but it could be very edematous. Also, they come in sometimes during initial injury, something like this. They won't move their ankle. It's splinted. They are holding it still. When I look at an ankle like that and there's no fracture, I always consider that the talus is slightly subluxed out in the mortise of the ankle. Why? Because when you have a forced inversion injury with plantar flexion, the talus shifts and moves.

    And so now the talus is kind of pressing up on the lateral side of the ankle joint and they can't dorsiflex. And if you put a little traction on that ankle joint just as if you were going in to fix a fracture, the talus, you'll feel that talus slide right back in the mortise and their pain will significantly decrease. That's something I do on every single ankle injury.

    Sometimes you'll see somebody walking like this. I don't know, my foot doesn't hurt but I have this big bump on the side. So this is a Charcot joint with ankle joint instability. This is actually the talus slipping out of the ankle mortise medially.

    Eventually, this gentleman had the bone actually rupture right through in the skin even though we immobilized them and we did fixate him. He can't feel so he didn't know. But mechanically, you get weakness of the superficial posterior group, gastroc soleus complex, ankle joint equinus, which is uncompensated. You might get peroneal laxity or weakness, ligamentous laxity. Tibial varum is a really high cost for ankle sprains because you have already the varus rotation in the tibia.


    Forefoot valgus, fixed calcaneal varus, a plantar flex first ray that doesn't resupinate, ankle joint varus and a supinatus subtalar joint can all be part of your predisposing factors to one ankle joint and subtalar joint problem.

    When you look at radiographic images, you're going to do your standard radiographs and then the stress radiographs you see talar tilt is greater than five degrees, which you compare the injured to uninjured side. Anterior drawer three millimeters or greater, which indicates the anterior talofibular ligament and for the subtalar joint evaluation, you want the broader of use.

    Also what's really easy in imaging nowadays, we had to rely on all of these X-rays and now you can do MRI or CT-scan when you suspect the subtalar joint instability of the ankle. The best test is the MRI. This is a normal view of the ankle ligaments. As I told you earlier, you know, when I get these, I look at all these and then I suspect what I suspect. But to be certain, I take it over to my radiologist and have them read them with me because it's a learning tool. I constantly am learning. I don't see these every single day. I'm not looking at them all the time. But now, I can tell normals and abnormals, or what I suspect and it's a good thing. This actually should be prized instead of prince but okay, we'll use prince.

    Now, but in conservative treatment, you definitely want protection and prevention initially. But if you do have an injury, you want to use the physical therapy, the rest, the ice, the non-steroidal, anti-inflammatories, compression, elevation. All the typical things you would do in any type of a sprain or injury. You're really just stabilizing the soft tissues to get them to heal and you're going to get back range of motion.

    In physical therapy, one of the key things is to strengthen the peroneal musculature, improve the ankle joint proprioception. Ankle joint proprioception to me is one of the most important things you improve. I'll show you a couple of techniques that they do.


    You want to balance program. It may take over six weeks. What I do is put my patients on a balance program and make sure that they have good stability of the ankle, especially if they are starting their sport activities. Then there's functional mechanical treatments which require maybe surgical intervention.

    The orthotic taping-bracing things are important. There are literatures that state that there's no difference between taping and/or a brace. There's no difference in whether you actually have the ankle joint plantar flexed or dorsiflex. The key is that you want to bring back some normal bracing and strength to the area.

    I actually do this. There's the back board and there's the balance board, and then there's a TheraBand, and all of these are very, very important. In rehab, you know, you send your athletes to a sports rehab center, they're going to get all of these. The other thing that I like, and I don't promote it outside in your backyard although I have one, is the trampoline.

    The little trampolines are really good to get back your proprioception, your balance. You don't want to do that with your 75 or 80 year old adult but maybe the young athletes. It's a great way to get back to their proprioception and their ability to right the foot.

    I had a trampoline in my backyard, I still do. All the kids in the neighborhood would come and do flips and jumps, and I would look out my window and go, "Some parent, if they ever found out, they would probably arrest me." But it was amazing that these young kids at all did that. They're very strong athletes. I watched them over the years grow. Very few had ankle sprains or problems with their lower extremities and no one broke a bone, which is just my disclaimer on that, but it is a good technique, the small little trampolines.


    Kinesio tape, I've used a lot. I'm telling you that I have evolutionized my practice with this silly tape. I have techniques for the Achilles tendonitis and tendonosis but for ankle sprains, especially the young athlete, instead of putting them in big braces, I would use the K-tape. And it's actually based on the body's own natural healing process.

    It exhibits its efficiency through activation of the neurologic and circulatory system. It has an incredible lymphatic drain which reduces swelling and causes increased stability of the muscles, and it's constantly working as you have them on. I don't know if everyone has ever used it.

    As in the side, I use it on my hammertoe surgery to reduce edema because it helps lymphatic drainage, so I use it on bunions and hammertoes, and plantar fasciitis and tendonitises and I'm getting very good relief. I give that patient their own box of tape. They go home, they learn their own techniques and their recovery is quick.

    Just couple of examples on how you would put it on. I put it on according to the anatomic structure of the problem along the ligaments and tendons. I have my own plantar facial strapping and my ankle sprain strapping that I do. Also, I stabilize the subtalar joint. You can use it for shin splints, although this, I could do a whole lecture just on this topic, I'm not. But just know that it's part of your plan for treatment.

    Surgical intervention is indicated on that failed conservative treatment after rehab orthotics and taping haven't helped. Maybe in the high end athlete who has a chronic recurrence and you want to get them back to their season quick, you might need to do surgical repair.

    You have continued mechanical instability. That's very symptomatic and they have compromised their daily living activities, they can't walk, they can't run, they can't play. They can't go to golf. They can't – they tell you their list of things they can't do. Well, it's time to look at the surgical intervention because there are good techniques of stabilizing these joints.


    In the primary anatomic repair, there are articles that show that there is improvement of up to 90% overall with primary repair versus a secondary reconstruction. So sometimes in these young athletes who have the primary repair, you get a really good success rate. If you have subtalar joint instability and it's long-term, and maybe primary repair is not the best option, but if it's long-term, they found that if you had a long-term injury or chronic injury over the years with an increased talar tilt or greater than 15 degrees in an anterior drawer sign. [Zwip] [00:22:35] did an article in 2012 that said tenosuspension for that joint was a good alternative.

    The actual stabilizing and reconstruction of the joints are usually done with tenodesing. You can use the peroneus brevis, the plantaris. Some use the Achilles. I don't use any of those. With the advent of acellular dermal matrices, I use acellular dermal grafting for all my tendon and ligament repair, and I get a really incredible result without compromising any of the natural tendons of the body.

    Surgical treatment is indicated of course when you have that failed conservative treatment when the bracing isn't working anymore and you can consider repair versus reconstruction. There's a lot. This is more for you from a board standpoint. They'll ask you what procedure is what. When you repair in the anterior talofibular ligament, calcaneofibular ligament extensor, retinaculum, you can do it open and/or through arthroscopy.

    I am not an arthroscopist. I don't do it through the arthroscope. I'll open it and do it the modified Brostrom-Gould. And then there's this single tenodesis Watson, Jones and Evans have where they actually reroute the peroneus brevis tendon and strengthened the ankle joint and/or subtalar joint.


    The subtalar joint instability is really treated with a tenodesis and ligament reconstruction with attending graft. Once again, I don't use the – I make my own tendon graft and I'll show you that. And then there's Chrisman and Snook who did a tenodesis, the disadvantages overtightening. I don't know if you ever had that happen or have seen that in clinic where people who have had the subtalar joint reconstruction and/or the ankle joint reconstruction, sometimes it's so tight that they can't move and it restricts their motion and they complain that it's too tight. So just remember that that can happen.

    Arthroscopy is a good alternative if you're actually well-trained in that area. You can actually repair ligaments with these new little anchors. The very simple techniques where you can repair ligaments through the scope. I'm not an arthroscopist, as I said. I can scope and ankle but to repair ligaments, I just rather see it and then repair it open.

    Primary anatomic repair, again, it's very simple to do when you open it up and you can see the anterior talofibular ligament and you can suture. You can do an end-to-end suture. You can actually use your retinaculum to help you reinforce it. I always augment it with a graft.

    I'm going to show you a little bit of the – a primary repair is probably the easiest thing. We used to call this the triple arthrodesis of the ligament repair. You get the two ends of the tendon together, you put three sutures in it, you got it.

    Here is the tendon – here's the actually – it's attenuated and you open it up. And once you find, it's really loose. You want to tighten it up. You actually put it end-to-end and repair it, and suture together. And then you'll put them in a boot, in a slightly inverted and that will heal quite nice, and especially young person. And here it is repaired.


    The deltoid ligament, don't forget about the deltoid ligament. The deltoid ligament is something that can be ruptured in an ankle sprain depending on how they come down. I'll show you one of those. The anterior talofibular ligament, calcaneofibular ligament which is extracapsular, the anterior inferior talofibular ligament is that high ankle sprain is the hardest one to repair – to overcome. And the posterior talofibular is very uncommon and the interosseous talocalcaneal ligament are the ligaments that you can address surgically.

    This patient was a 19 year old who came into the emergency room, who came in like this in fire rescue. What you see is the splint on. He was playing basketball. He came down. His foot hit his friend's foot medially and the whole foot – and the whole ankle dislocated. What's amazing is that there's not one ankle fractured here.

    So this was realigned, not a fracture. He swelled incredibly but what he did do is ripped every part of the deep and superficial deltoid. That ligament was completely gone. So you could've said, "Oh, good. No fracture, so let's just put him in a cast and/or a boot and, you know, because he didn't actually have any bone injury." But I was thinking, well, if you just put him in a boot because that was suggested, that would be tragic for this guy because he would have complete subluxation of the subtalar joint.

    He would have pronation of the foot, weak deltoid, weak posterior tendon, and so I believe that you need to go in. And here it is the deltoid ligament, completely ruptured, right down to the – you could see the medial mal that you got in there once the ankle joint – what we did is an end-to-end repair of both the deep and the superficial deltoid.

    And I used a holograph matrix which is very strong. I do it for two reasons. One, it has incredible strength. One, it reduces scar. And a guy like this young, 19 year old, he's going to get back into activity very fast. So we had him six weeks actually, four weeks in a CAM boot, two weeks in physical therapy, rehabbing, and by six weeks, he was like, "I'm done, I'm going back to playing basketball," which he did.


    Ankle joint ligament repair, this is a man who played soccer for almost all his life and now he has no ankles, medial or lateral. The deltoid was gone. He had osteophytes in the joint. I'm just going to run this really quick. That's taken out a little osteophytes from the medial ankle, this little round. They look like little round balls of bone that have cartilaginous surfaces to them. They've been there very long. That's a long standing osteophyte.

    And then I – of course, the acellular dermal matrix. Now, I'm making my own ligament. I want to show you how you do that because as I told you earlier, I don't really use any of the tendons anymore. I repair with the acellular dermis so we're going to measure for the deltoid. And then now, I'm making my anterior talofibular and calcaneofibular ligament.

    And so I measure it out, the length that I need. And then I draw a hole in the fibula just like you learn on the Chrisman and Snook. And then I'll – here's the – I tie the actual – the graph tenodesis into the talus. And now what I'm rerouting it through is the fibula so I'll draw a hole there. And then I'm going to come out. There's the made ligament coming out of the fibula and I'll put it under the peroneal tendon. You can see the peroneal tendon, that white shiny, is the peroneal tendon. Now it's locked under the peroneal tendon. I'm going to close up the retinaculum there. Of course, you have to, right?

    And then, I'm going to put a little draw hole in the calcaneus and I'm going to anchor that into the calcaneus. So I have my two ligament repair without actually causing any distraction to the tendons or other tendons that need to be strong and healthy and this is such a strong ligament repair. The rerupture rate is very low and the actual material, the acellular dermal matrix is so strong that I feel very confident.


    Within about four weeks, these are walking. They're in physical therapy. They're in their CAM boot walk – like physically putting full weight on it because the repair to me is so strong. And this is just him going back and forth.

    So combined ankle joint, instability subtalar joint instability, remember that you have surgical approach to reinforce your ligaments, your anterior lateral ankle joint ligaments, which include the talus and the tenodesing sling. Don't forget about your interosseous talocalcaneal ligament reconstruction with your ligamentous reconstruction of the peroneus brevis to recreate ATF if you're – or if you're going to use the brevis, as I said, I always use an acellular matrix.

    But you can reconnect all these ligaments via primary repair if you get them early and young enough. And this is just a quick what happens in the sinus tarsi with chronic subtalar joint instability. You'll see this – you'll open it up and you'll start to see some fat. And then as you open it up, you have this large amount of fatty necrosis within the subtalar joint with no evidence of any kind of ligament.

    And once again, because I – and I don't have stock in this material. I just want to make disclaimer on that but I do find this to be very strong. I use this as a soft tissue into position there and then I then will repair it primarily. And you can see that there for scar formation and then the retinaculum closed over, and these people get well very fast.

    I have somewhat of a protocol where I'll splint the ankle at 90 degrees, maybe slightly inverted, non-weight bearing. I'll put them in a CAM boot. I usually don't cast anybody really. I get them moving in two weeks possibly and then I start to get them walking about four to six weeks, depending on the person. And then full activity within three to six months depending.


    Don't forget there's complications to everything we do. You have the residual instability. You have the ankle joint mechanics that may change and become arthritic. Overtightening is really a big problem, abnormal subtalar joint motion leading to pronation. You might have nerve, paresthesia, stiffness, and that horrible disease, complex regional pain syndrome or RSD, and then there's other alternatives now to a lot of these repairs. You have all the biologics that you have that we didn't have before. The free tending grafts and a combination thereof.

    So I'd like to thank you for being here and hanging in there at the end. If you have any questions, I think I can have them now for a minute or two. Yes?

    Unidentified Male Speaker: [Off-Mic]

    Marie Williams: It's two-fold. If it's a young healthy athlete and you have a really bad rupture, and maybe if they've done it one or two times before, I'll repair it. If it's someone who's not at – like a weekend warrior type athlete and yet it's not a big deal, I don't really do surgery on them, unless it becomes a chronic instability with pain. I have people coming in and going, "Look, I've been in physical therapy. I've done all my things right. I'm strengthening but my ankle continues to give way. And now, I'm on my fifth ankle spring," I'll repair it.

    Unidentified Male Speaker: [Off-Mic]

    Marie Williams: Yeah, that's a good question. I don't always scope my ankles. Maybe I should. I do know that they always have synovitis and I know that with ankle scopes, and I do have fair amount more from a clean-up and clean out point of view, where you go in and you actually do get the synovitis out. I'm not really open in the ankle or scope in the ankle to do any type of ligament repair even when I open them and I will sometimes combine the procedure but it just depends on the clinical presentation and problem.

    All right. Have a safe trip back if you're going back. Do you have another question? I didn't – okay, good. All right. Thank you.

    TAPE ENDS [34:40]