Orthotic Modifications for High Arched Feet (Pes Cavus)

Special Topic: Orthotic Modifications for Over Supinated Feet

In most cases I am not designing a foot to correct a “foot type” but to provide a solution for a specific clinical problem. While having a high arched, over supinated, under pronated foot may predispose to certain problems other “foot types” can have many of the same problems.

Some problems that can occur and are related to supination movements (or even “moments”) include:

  •  chronic and repeated ankle sprains
  •  peroneus brevis tendinopathy
  •  peroneus longus tendinopathy
  •  cuboid stress fractures
  • 4th and 5th metatarsal stress fractures
  • 5th metatarsal base or midshaft fractures
  • lateral leg pain (peroneal muscle group)

In many instances with problems like these, immobilization may be necessary for a time. Wobble board training should be incorporated into rehabilitative programs. The purpose of the wobble board training is to have the neuromuscular system adapt the peroneal muscles to performing repetitive firing for stabilization. The angles that the wobble board makes with the ground and the motion and angular relationships that it engenders in your ankle and leg are ideal to training the peroneals to fire appropriately.

The wobble board assists in training muscle strength, balance, and improving joint position sense. There is nothing that beats this 3 in 1 training.

For patients who do not have a dramatic Pes Cavus foot there are a few specific corrections I include in the orthotic:

  • Accurate cast of the foot.
    I do not want a 2D pressure scan. I want to hold the foot in neutral subtalar joint position. And I want to plantar flex the first ray by either light dorsal pressure over the first metatarsal or by slight dorsiflexion of the great toe during the casting.
  • Minimal cast correction.
    I want the cast to reflect the shape of the foot to mirror it so that when I want to alter forces, they will be altered by the shape and adjustments to the orthotic. I want the forces distributed through a large surface area and need conformity between the shape of the foot and the shape of the orthotic.
  • No lateral bevel.no-bevel-post
    This resists over supination directly. It is like an outrigger on a boat. It also changes moments of force going into the foot.
  • 3 degree lateral forefoot wedge.
    This is often used to prevent over supination of the foot after the heel as left the ground or as weight is transferred towards the forefoot.

These are often my starting steps to deal with the problems listed above when they are resistent to treatment.

For a Pes Cavus, high arched, over supinated foot podiatrist Richard Blake, DPM has put a great video on line. It details his 8 steps to deal with this foot type using specially customized orthotics. The modifications made for this problem are not found in over the counter orthotics. And many specialists do not see enough patients with high arches to be adept at treating the problems associated with this foot type. It is important to find a physician that has experience with sports medicine, high arch feet, and biomechanics.
The Blake 8 Steps (only slightly modified) follow:

First an accurate cast is required as described above.

A) Rounding of the lateral border of the cast or via CAD/CAM to have the orthotic better grip the foot.
B) Lateral Kirby Skive. Often 2 to 4 mm.
C) Deep Heel Cup – up to 25 mm.
D) Extended lateral heel cup or “lateral flange”
E) Eliminate “medial heel grind off” and/or add No Lateral Bevel in rearfoot posting instructions.
F) Lateral arch fill to add more surface contact area
G) Narrower orthotic (sometimes) to limit any antipronatory forces. (note: some will go for wide or nomal width for increased stability and contact)
H) Forefoot modifications such as lateral wedgehttp://www.prolaborthotics.com/Products/PathologySpecificOrthoses/LateralAnkleInstability/tabid/138/Default.aspx

Dr. Blake reviews these modifications in a 9 minute video on YouTube: https://www.youtube.com/watch?v=hMhrTmWXfDA

This video is well worth watching for anyone who needs the modifications or anyone who is planning to incorporate them into a patient’s orthotics.

Note: Images Courtesy of ProLab Orthotics

High Arches can make you feel like you are heading for your own personal apocalypse. Turn it down and listen to Arch Enemy with some heavy metal:

Or if you feel like stepping out, you can go retro with John Mayall’s Bluesbreakers:

PRP is Not for Routine Office Use

Those two recommended set of injections at $6,000 per series for your Achilles tendinitis hasn’t sounded very good for the past few years. Ever since a controlled, prospective comparison study demonstrated there was absolutely no difference in the efficacy of PRP over saline injected in the same manner, there has been doubt about the use of PRP in the office. But instead of falling by the wayside, like a bad political candidate, it has spread by meme and scheme far and wide and even infiltrated some of the best offices in the country and world.

The British Medical Journal has recently posted an article strongly recommending against the in office use of PRP (platelet rich plasma) outside of PRP Production (from BMJ)established studies.

The article was titled: “How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?” The answer, at this time, seems to lie somewhere between “we have no clue” and “not very”. This study mentions a previous review by the Cochrane review (2014) which examined 19 studies and found insufficient evidence of the usefulness of PRP. This study reviews 10 additional studies and reaches the same conclusion.

The article is readily available and worth a read:

PRP review at BMJ

References:

How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?  Keene,DJ, Alsousou,J, Willett,K BMJ 2016;352:i517
BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i517 (Published 17 February 2016)

Autologous platelets have no effect on the healing of human achilles tendon ruptures: a randomized single-blind study. Schepull T1, Kvist J, Norrman H, Trinks M, Berlin G, Aspenberg P. Am J Sports Med. 2011 Jan;39(1):38-47. doi: 10.1177/0363546510383515. Epub 2010 Nov 3.

 

 

 

Interview/Podcast With Runners Connect

I’ve found what I am sure is the best podcast on running. The podcast is put on by Runnersconnect  and hosted by excellent and ever improving, elite marathoner Tina Muir.

Tina is knowledgeable, ever prepared, sounds great, and conducts a wonderful interview each week. Runners Connect has interviewed many fascinating people from the running community. Among those I’ve listened to are Dan Lieberman, Chris McDougall, Tim Noakes, and Jack Daniels. Each week there is another interview with someone who has a special take on running and from which you can learn.

This week a podcast in which I was interviewed has gone online. RunnersConnect Podcast Interview with Dr. PributThe interview covered a lot of ground. We did not review the questions in advance. Instead we did wing it. Free range always sounds best to me. Tina was well prepared and asked questions that led to many different areas.

I hope you find the podcast interesting. It is likely to contain information you haven’t heard before and likely not quite what you’d expect. If what you wanted wasn’t included, there are so many other great podcasts, I have no doubt you’ll discover a good number that you’ll enjoy.

http://runnersconnect.net/running-interviews/steve-pribut-injuries/

Hyped Plantar Fasciitis Treatment Study is Significantly Flawed

Is There Really A New Exercise Which Will Cure Plantar Fasciitis?

This study showed no benefit at 1 month, 6 months and one year. There was only a benefit noted at the 3 month datapoint, which then disappeared.

Highly touted High-Load Strength Training Shows No Benefit In Long Term

Last fall, you may have read in the New York Times that an article had been published in the Scandinavian Journal of Medicine & Science in Sport (August 2014) discussing the benefit of high load strength training for plantar fasciitis. The NY Times then described the wonders of this “one simple exercise” in alleviating the pain of plantar fasciitis. The implication was that this Screen Shot 2015-08-09 at 8.39.34 AMparticular exercise was the only thing that was going to work. The exercise is done while standing on one foot on a box with the toes dorsiflexed on a rolled up towel. Although if you use a section of the New York Times rather than using the entire paper for your bird cage that may have equivalent effects.

If you take enough data points you might very well be able to prove anything. You may even believe what you see with that limited subset of data. (See the body of work saying there is no human contribution to climate change using limited data sets and cherry picked sources.)

How Large, Precise and Lasting Was the Treatment Effect?

This question is a basic question asked in the American Medical Association’s Guide to the Medical Literature, subtitled “A Manual for Evidence-Based Clinical Practice”. We don’t find the component parts of this question impressively demonstrated in this study.

The main problem is that the article (Rathleff 2014) found a significant improvement ONLY at 3 months (between the group performing the one leg calf raise and those performing a stretch that I’m not fond of). Both groups used “shoe inserts”. Another problem is that was called the control group was a comparison and not a control group. We’ll continue to use their term.

At 1 month, 6 months and 12 months, there were no significant differences or benefits of this exercise over the control group which just used one stretch and shoe inserts. If we found an exercise (like flossing) that made us feel better only at age 30 and gave usGraph PF Improvement fewer cavities and better gums but only at age 30, there would be no benefit over other exercises that worked equally well for age 20, 40, 50, and 60. There would be no study or media attention given. But with the dearth of truly useful evidence based sports medicine the insignificant gains significance.

Most would like to use a treatment that enables them feel better in 4-6 weeks and at 4 to 6 months. The 3 month data point as a single marker is not useful.

And what is the relevance of this to runners? The study group and control group were both overweight with a BMI averaging 26.4 in the study group and 27.1 in the control. (Less than 25 is considered normal weight. See CDC Healthy Weight – http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/)

There were not many people in this study. Only 24 in the study group and 24 in the control. Using statistical methodology to determine the minimum number to detect a difference in the functional index which they used they required 23 patients in each group. (While the use of “intention to treat” analysis is laudable, can you imagine an approach to cancer treatment being based on a study such as this with only n=24, several dropouts and improvement over a comparative treatment only present at the 3 month mark? Impossible!)

From Ratliff et. al.  (2015): “Based on a previous trial, we used a common standard deviation of 18, which showed that 23 patients were needed in each group to detect a statistical difference (power 0.80, alpha 0.05) (DiGiovanni et al., 2003).”

They began the study with 24 in each group. There was a higher drop out number on the study group. Looking at the high-load strength training group there were n=22 measured at 1 month, n=18 at 3 months, n=17 at 6 months and n=18 at 12 months. At the 3 month and beyond time points they were below the levels pre-determined for measuring a detectable difference between groups.

So here we have a study of a few people who were improved in comparison with another control group for “one brief shining moment” which quickly passed. Both groups were ultimately better after 1 year but did not demonstrate a superiority of one treatment over the other. The study design is impeccable. The statistical analysis is elegant. But, the subject number is quite low and the results are clearly open to a different interpretation.

Will this exercise be helpful to some people? Yes it will. Will it be helpful to all and is there a unique benefit demonstrated by this research. No, it is not and there is no unique benefit to this exercise. There is only evidence for a briefly lasting one in this extremely small study which was seen only at the 3 month mark. Not before and not after.

So the hype on this study is just that – media hype with no basis in the evidence contained in the study.

References:

DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003: 85-A: 1270–1277.

Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am 2006: 88: 1775–1781.

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation.
J Am Podiatr Med Assoc 2003: 93: 234–237.

Pribut SM, “Current Approaches to the Management of Plantar Heel Pain Syndrome” J Am Podiatr Med Assoc, January 1, 2007; 97(1): 68 – 74.

Pribut SM, “Plantar Fasciitis and Heel Spurs: Plantar heel pain syndrome in runners and athletes” http://www.drpribut.com/sports/heelhtm.htm (accessed August, 2015)

Pribut SM, “The Top 5 Running Injuries: Part 2” Podiatry Management, June/July 2013, 181-192

Pribut SM, “Challenging Running Injuries: Be Knowledgeable” Podiatry Management January 2010, 157-166.

Rathleff MS et. al., “High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up.” Scand J Med Sci Sports. 2015 Jun;25(3):e292-300.

Thomas JL et. al., “Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline-Revision 2010”, J Foot & Ankle Surgery 49(2010) S1-S19.

Running On Empty

Statistician’s Blues

Quick Tips on Running Shoe Lacing

Shoe Lacing Systems

What are laces good for?

Laces help keep your shoes securely on your foot. They should apply pressure evenly and appropriately. Not too tight, not too loose. Just the way the story Goldilocks and the Three Bears would have described it.

Once you have found the perfect lacing system you are sure to discover it changes before very long. Running shoe manufacturers often change the position, orientation and spacing of the eyelets and the lacing system. One would like to believe it is an evolution to greater comfort, efficiency and fit. But appearance and marketability plays at some role.

Over the past few years though, the lacing system that many manufacturers have been adopting returns to a long established standard and is much easier to modify.

Selected Lacing Systems:

  • Traditional
    • Conventional diagonal (Chevron)
    • Conventional Parallel
  • Reduced Pressure Parallel
  • Skip Lacing Pattern
  • Loop Lock Lacing
  • Double Lacing (for wide forefoot and narrow heel)

What Problems Can Laces Cause?

Too loose overall:

  • Foot slips around in the shoe
    • Plantar fasciitis
    • Tendonitis
    • Posterior Tibialis tendinopathy
    • Flexor Digitorum Longus tendinopathy

Too Tight overall

  • Uncomfortable
  • Parallel lacing can help

Anterior ankle pain

  • Nerve compression
  • Tendon compression
  • Cure : lower lace by an eyelet

Midfoot compression or hot spot

  • Pain in midfoot
  • Compresses nerves and tendons
  • Cure : skip lace pattern
  • Make sure you remove the laces from any “tongue guide” loop
skip lace
skip lace

Tight toe box

  • Pinched nerve
  • Neuroma
  • Bunion pain
  • Hammer toes
  • Aggravate incurvated toenails

Band elastic laces

  • Often too loose
  • Too tight
  • Uneven compression

Barrel clips or locks

  • Can feel like big lugs banging up against your foot
  • They can be irritating, aggravating, and annoying

Slipping heel

 

  • Use a lock loop at the top
Lock loop lacing

Wide Forefoot, Narrow Heel

  • Double lacing (2 sets of laces) for each foot

What Causes Injury In New Runners

If we look at the scientific literature, the long and short of it is, we do not have any study that tells us what the risk factors are for injuries in new runners. A relatively new study at British Journal of Sports Medicine  looked at over 900 novice runners, classified their foot type, and put them all in a similar light weight shoe. They found that people with differing foot types all became injured at the same rate, except those that were considered “normal” were injured at a slightly higher rate. A study not long ago showed that runners who were assigned to motion control shoes were injured at a higher rate that those who selected a stability shoe. The study did indicate that assignments to shoes based solely on foot typing was not useful in preventing injury for uninjured runners. (The conclusion was limited to “moderate pronation” not severe pronation according to the author’s summary.) Of course studies like this make for good press.

It is important to realize that these studies do not provide information on how to treat runners that are injured.

All the studies over the years have shown that running is associated with running injuries as skiing is associated with skiing injuries. The studies themselves often vary widely in estimating the risk of running injury. Studies often define injury so differently that the most quoted figures define injury as occurring to between 25% and 65% of all runners over the course of a year. Even our election predictors can predict elections much closer than that. But this does not mean running is high risk especially while so many studies point out the benefit of running.

I still believe that many injuries are caused by overuse and incorrect training. But sometimes correcting that alone is just not enough. It is important to be flexible in approaching running injuries and not have one simple solution or one simple belief system to fix all running injuries. Not every injury is fixed by strengthening your glutes, using a form roller, switching to a forefoot landing style or burning all of your running shoes. But all of the above can be helpful at times. Training, muscle strength, weakness and imbalance, relative lack of flexibility, your individual biomechanics,  nutrition, sleep patterns, and running style, stride, contact, etc. and your running shoes all come into play as factors to be examined while determining how to optimize your running, how to recover and how to avoid future injury. I still advise avoiding the “terrible toos” of too much, too soon, too often, too fast, with too little rest. While we don’t have conclusive advise that this advise works, it does not sound bad at all, and the advise itself comes with very little risk.

I’ll quote from an email (relating to active, recreational runners) that I sent off to a friend earlier today, who has been uninjured for the past few years:

(The study we are discussing) “…means we can’t predict what will cause an uninjured, new runner to become injured.

It doesn’t tell us anything about how to cure any injury that you’ve developed. Or how to prevent an injury you’ve solved from coming back.
All studies lead to the following two conclusions: The best predictor of future injury is past injury. Running injuries are associated with running. But other studies clearly let us know that running is overall very good for you. (Especially if you are not running in pain.)
Once you find success and go a long time with no injury I recommend not messing with success. If you decide to make changes, make them slowly and carefully. And do it with the voice of Clint Eastwood in the background (no, not talking to an empty chair) saying “Do you feel lucky today, kid?”
But yes, the advice that all flat feet should be in motion control shoes is wrong and so is the advice that all high arched feet should be in cushioned shoes.
It is easier to treat an injury than to say with absolute certainty how to never get injured. But often the secret of avoiding re-injury comes from the knowledge of what you did to get rid of the injury.”

Now to round this off we just need to find some music that offers good, sound advice. Maybe something with scientifically proven advice…. or reflect on “Is It Too Much”?

The Science of Bone and Tendon Injuries (slideshare)

Perhaps one day I’ll break this up into 5 slideshares and 5 articles. But for now, here are the slides from a lecture presented at the Sports Medicine Section of the  American Podiatric Medical Associations Annual Scientific Conference.

I believe that basic science and research is an important component for advances clinical medicine. This lecture highlights some of that research from barebones systems biology to mechanotransduction. Cell mechanics, structure and biology are where the action is.

 

Slideshare: Overuse bone and tendon injuries – science and theories of tomorrow

A Quick And Simple Look At Lateral Ankle Injuries: @slideshare

We may be trying out slideshare and seeing if it is popular or not. The first lecture is just a test case. It was developed for non-specialists, biomedical engineering students, as a model look at an injury. The lecture is not comprehensive, but gives an overview of the anatomy, structures affected, the “Ottawa criterion”, PRICE (protection, rest, ice, compression, elevation, and what systems connect together for proper ankle functioning and stability.

Check it out here and with Creative Commons (attribution) you are free to download it:

A Quick and Simple Look at Lateral Ankle Injuries

You may also view, at my running injuries website, a short article on ankle sprains with a rehab protocol.

Is Exercise Bad For You? Shocking News Reports!

Some say a meta-analysis is like a large pile of small, weak, and insignificant studies lumped together into one ugly mess. Sort of like a stew made up of left-overs that might be getting a bit moldy. Others say that by aggregating studies which alone would be too small to amount to anything of significance, the data can gain significance by having a larger number of subjects from different studies put together to be counted.

Couch Potato
Couch Potato

Study Title: Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence?

Study Citation: Bouchard, C, Blair, S et. al. (2012) Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence?

Study Premise: There is a variability in peoples response to exercise. Some may experience adverse response to exercise. The authors state no study has addressed adverse changes in cardiovascular and diabetes risk factors can occur. The risk factors chosen to be studied include: “Sixty subjects were measured three times over a period of three weeks, and variation in resting systolic blood pressure (SBP) and in fasting plasma HDL-cholesterol (HDL-C), triglycerides (TG), and insulin (FI) was quantified.”

Study Conclusion & Media Announcements: Adverse response to exercise may occur. Some individuals do not respons positively in the measured according to the authors this analysis of 6 previous studies (a meta-analysis) revealed the shocking truth that some overweight people did not have a positive response to exercise and the variables mentioned above worsened. 7% had two variables worsen over the course of an exercise program.

Analysis: Why should one expect 100% positive response to any intervention? The fact that 90% had a positive or non-adverse impact on risk factors is an overwhelming number of individuals for whom exercise is likely quite good. Emphasizing the negative in which case “the minority is the new majority” seems to be the in thing to do in current culture and society. In everything from politics to social policy a majority may be declared at 40% (the U.S. Senate) or at 12-17% as was seen in misused statistics during health care reform debates. The fact that 8% to 12% is neither a majority, nor a vast number, and the “adverse events” were not death, disease or morbidity and mortality should alert those reading this article and the large headlines in the paper that hyperbole is at play.

There is an overwhelming amount of information that says exercise is good for you in many, many ways. In many cases exercise is the missing link to the best health you can have. Exercise is something that almost everyone should be undertaking (to avoid the undertaker). In fact a famous saying goes “where there is no exercise, the people perish”. Well, maybe it was “where there is no vision the people perish”.The reality is that where there is no exercise the people develop sarcopenia (muscle wasting), osteoporosis, obesity, depression, diabetes, high blood pressure, and dementia. So whether or not your high blood pressure goes down and your HDL-C goes up, there are many positive benefits to be achieved by exercising regularly.

Exercise and diet are both vital to overall health. All of the individuals in the studies this meta-analysis selected to include were overweight. Improper diet plays a large role in being overweight or obese.

Successful implementation of a healthy life plan should actually include more than a mere exercise program. It needs life habit modifications that would include good sleep habits, healthy diet, and avoiding the excessive consumption of things that are bad for you (too much alcohol, drugs, etc.). But exercise may be the largest change that is easy to make. Diet is also critical and often needs a tune up. Let’s sum this up in one sentence!

You can exercise and have a great shot at doing as well as you can or you can sit on a couch and take your chances!

Notes:

  • The study group only included overweight people with a BMI from 25-30
  • Normal variablility in tests – is greater than zero

References:

Bouchard, C, Blair, S et. al. (2012) Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence?

Bouchard C, Rankinen T (2001) Individual differences in response to regular physical activity. Med Sci Sports Exerc 33: S446–S451

deMello, V et. al. Insulin Secretion and Its Determinants in the Progression of Impaired Glucose Tolerance to Type 2 Diabetes in Impaired Glucose-Tolerant Individuals
The Finnish Diabetes Prevention Study.
Diabetes Care February 2012 vol. 35 no. 2 211-217. Published online before print December 30, 2011, doi: 10.2337/dc11-1272

Study Notes

an adverse response was recorded if an increase reached 10 mm Hg or more for SBP, 0.42 mmol/L or more for TG, or 24 pmol/L or more for FI or if a decrease reached 0.12 mmol/L or more for HDL-C. Completers from six exercise studies were used in the present analysis: Whites (N = 473) and Blacks (N = 250) from the HERITAGE Family Study; Whites and Blacks from DREW (N = 326), from INFLAME (N = 70), and from STRRIDE (N = 303); and Whites from a University of Maryland cohort (N = 160) and from a University of Jyvaskyla study (N = 105), for a total of 1,687 men and women. Using the above definitions, 126 subjects (8.4%) had an adverse change in FI. Numbers of adverse responders reached 12.2% for SBP, 10.4% for TG, and 13.3% for HDL-C. About 7% of participants experienced adverse responses in two or more risk factors.

The Answer for Severe Ankle Sprains: Put A Cast On It (repost 2009)

Dancing to the tune of “Put A Ring On It” you get carried away and find that you’ve tripped over an object lying on the carpet. Or more likely, you’ve stepped in a hole, stepped wrong coming down stairs or twisted your ankle on an uneven trail while running. Of course basketball is especially known for a notoriously  high number of ankle spains.

Once it is determined that it ranks as “bad” what should you do? The Lancet compared a Bledsoe boot, Aircast Splint, Circular Wrap, and a plaster cast as treatment for “bad” ankle sprains and found the cast best, followed by the AirSplint. “Bad” sprains were Grade III which includes complete tear of a ligament. The assessment included an x-ray, since the patients included were unable to bear weight on the ankle. The Ottawa Criteria were used.

The conclusion was that in this group, the casting was superior to the other methods of treatment. The duration of cast use was 10 days. The investigators noted other studies have used time periods of up to 6 weeks, and the exact time needed to assist healing is not known. Noted also was the possibility of long term and even permanent injury resulting from an ankle sprain.

In my office, I have long used the AirSplint Pneumatic Walker for this condition with good results. The authors of the Lancet study noted that in some cases the ankle sprains resulted in long term, and occasional permanent injury. Rehabilitation methods were not compared and studied. A podcast interview with the lead author was interesting. Citations of animal studies indicating improved healing with motion were noted. But the author felt that they would all change their clinical practice based on their study. Happily I have treated humans, not rabits, and learned from it. I’ve been using similar therapy for a long time, and don’t need to make dramatic adjustments. The lesson here though, could be for emergency rooms around the globe to learn more about and improve their treatment of ankle sprains. Bad treatment has led to the saying “a sprain is worse than a break”. With appropriate treatment, rehabilitation, and follow up. It doesn’t have to be so.

For more general information on ankle sprains see: Dr. Pribut on Ankle Sprains

Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke,
The Lancet, Volume 373, Issue 9663, Pages 575 – 581, 14 February 2009. Article Direct Link

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