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!


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


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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Heel Lifts and Achilles Tendonitis (Tendinopathy) (repost 2008)

Point / Counter Point: The Truth is Out There Somewhere (or maybe here)

Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though. 

The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.   

With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as  “no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury. 

While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is  no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises. 

Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis. 

For more details:

Website article: Dr. Pribut on Achilles Tendon Injuries

 Previous Blog entry on Achilles Tendon and stretching

Quick Search of Textbook Comments On Heel Lifts:

I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem. 

Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p.  606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region. 

Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient.  I continue  to read Alfredson’s  articles with interest. (And in actuality will recommend his exercises in a manner and when it can be done without causing pain. 2012)

Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”. 

Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”

Noakes “The Lore of Running, Fourth Edition”  Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.

Advice for Outer mid-foot Pain (repost 2008)

Drifting around the web, I came across a description of pain in a runner’s foot which, summarized, was essentially:

“I began having tenderness in my foot, on the top outside at the row of bones and tendons that connect with the baby toe (at about the middle of my foot).  I was also sore all the way up my shin on the outer side of the same leg… so this made me think it was a tendon or muscle issue..(praying its not a stress fracture)”

The answer to this problem follows:

The part of your foot that is indicated as hurt, on the outer part of the foot, includes the 5th metatarsal bone and the peroneus brevis tendon. Right in the middle is certainly the fifth metatarsal bone.

These parts are usually hurt when you invert or turn in your foot. This can happen when you “twist” your ankle in and sometimes ends up as an ankle sprain.

The muscle that the tendon starts at begins up in your leg on the outer side, that’s why it hurts up there. When the ankle turns in, the peroneus longus and brevis tendons are placed under stress and can become injured. The base and sometimes the shaft of the 5th metatarsal bone can become fractured because of the tendon pull. So, this problem could be either an injury to the tendon – (tendonitis, partial tear) and/or an injury to the 5th metatarsal bone – all the way up to a fracture of the 5th metatarsal bone, along with the tendonitis.

Ice, rest, an ankle brace, and possibly a visit to a local sports podiatrist, along with an xray would be a good idea.

Note: Occasionally the cuboid bone is also injured from forces created by the peroneus longus tendon. Additional information on related injuries to the peroneal tendons and to the bottom of the foot are in an article on the “zone of confusion of the midfoot“.

Best of luck with a speedy recovery!

Back To Basics: Tibial Stress Fracture & Frontal Plane Vectors (repost 2008)

The current issue of Medicine and Science in Sports and Exercise (MSSE) has a study which indicates that the frontal plane force vector of the limb is directed more medially (toward the midline of the body) in those who have sufferred tibail stress fractures. The magnitude of forces in the control group were the same as those in the group that had sufferred injury. The conclusion of the authors was that the direction of the forces may be a contributor in the development of tibial stress fractures. This add a specific biomechanical risk factor for tibial stress fractures.

Within a narrow to medium range of normal this may be very significant. At greater deviations from normal, such as with severe genu valgum or varum (knock kneed or bow legged), my guess is that the forces will be too far away from the affected area to matter. So one day another study, with more extremes will have a different result than the current one. Study design and sample populations play a large role in study results.

Studies have already demonstrated the efficacy of the Pneumatic Walker in aiding and speeding healing of tibial stress fractures. Excessive pronation plays a role in overload of the medial muscles of the leg and also will shift the force vectors medially. Well designed custom foot orthotics should effectively shift the vector laterally and could be useful in preventing recurrence. No one factor alone though should be considered enough. Bone density, calcium and Vitamin D needs, and training must be evaluated.

Already, the warnings are in for avoiding too much, too soon and to allow your body, and your bones to adapt to the stresses you want to place them under. Increase your training slowly, gradually, and carefully and make certain to drop back every 2-3 weeks while increasing the training volume (and load).


External Frontal Plane Loads May Be Associated with Tibial Stress Fracture.
Medicine & Science in Sports & Exercise. 40(9):1669-1674, September 2008.

Clinical Biomechanics  Volume 19, Issue 1, January 2004, Pages 71-77
The role of selected extrinsic foot muscles during running
Kristian M. O’Connor and Joseph Hamill

Effect of Inverted Orthoses on Lower-Extremity Mechanics in Runners.
Medicine & Science in Sports & Exercise. 35(12):2060-2068, December 2003.

Achilles Tendon Stretches: Do’s and Don’ts (repost)

Achilles tendinitis prevention and recovery are issues faced by many runners. As anyone knows who has spent time on my web site, I am not a fan of excessive stretching for this problem. In individuals who are experiencing pain, I advise against the stair stretch, particularly if you’ve been trying it already for 6 weeks or more and found only more pain, and no improvement. In early cases of pain, I like to restrict stretching, than  graduate to the wall stretch, and then the wall stretch with a bent knee.

Roxanne Darling of Beachwalks with Rox does an excellent job of demonstrating a variety of stretches from the hard to the easy. For those without pain, you may carefully follow Rox’s example of the stair stretch if you’d like. If you have pain, skip that one for now and start with the straight leg, wall stretch and about 3 weeks – 4 weeks later add the bent knee portion. Read the article on Achilles Tendonitis (and Achilles Tendinopathy). A small portion of that article is summarized below. In the meantime, if you need a little downtime and some chilling, visit Beachwalks With Rox for words of wisdom, thought and relaxation.

Stretching With Rox

Achilles Tendonitis / Achilles Tendinopathy Brief Summary of Treatment

Full Text (Achilles Tendonitis)

Exercises to Avoid
Excessive stretching is not good for your Achilles tendon. The stretch that I most often recommend is the “wall stretch”. I do not recommend the “stair stretch”, the “incline stretch”, or the “put a towel around your feet and pull up until it hurts stretch”. If any of these are working for you, that’s great, you don’t need any advice. In most cases, for the patients I see, these stretches put too much tension on the already tender achilles tendon. Contracting the muscle when it is in a stretched position, as initial therapy of an injured achilles tendon is not a good thing. However, as seen in Rox’s video, she demonstrates some super stretches, and if you are not in acutely painful phase, you may cautiously give them a go. But, if you have found the stair stretches to be painful and counter productive, skip them, and look at the others.

Treatment Outline:

Relative rest
Cut back mileage
Lower intensity
Avoid hills, speedwork, plyometrics

Avoid over-stretching
Gentle stretch after warm-up
Start with Straight leg calf stretch, build up much later to bent leg, consider eccentric stretch later.
Ice Massage 10 to 20 minutes after exercise

NSAIDs (note: some recommend avoiding NSAIDS)
– Aleve, Motrin, Ibuprofen, etc. 10 – 14 days.

Check Running Shoes
– Replace if heel is worn
-Replace if excessive heel shock absorption (soft air sole cushion, excessive gel shock absorption)
Replace if shoe is excessively stiff at the “break point” (ball of foot).
Consider using a “heel lift”

Physical Therapy Modalities
HVGS (electrical stimulation)
Exercise instruction: Strength and flexibility

Current Concepts of Achilles Tendonitis and Achilles Tendinopathy

While Achilles tendon problems are widespread, the terminology used to describe them is often inaccurate and is undergoing a significant transition. First to be precise we must consider where along the course of the tendon does the problem exist. This may be in one of three main areas:

1. Insertion
2. Musculo-tendinous Juncture
3. Non-insertional (main body of tendon)

While the term that most people use and that most individuals will search for on the web is “tendonitis”, most Achilles tendon problems could better be called a tendinopathy and more specifically a tendinosis and are a non-inflammatory problem of the tendon. Inflammatory cells are not found on microscopic examination.

Clinically there may be two differing entities in acute achilles tendinopathy:


o Inflammation in the tissue surrounding the tendon
o Often 2 – 6 cm above insertion

o Possible crepitus with long standing injury (paratenon with fibrin exudate)
o In chronic tendinopathy approximately 20% of the injured peritendinous area are scar forming myofibroblast cells.

o Impairment of circulation with resulting damage to tendon structure
o Focal areas of tendon degeneration

Much future research and better understanding of these injuries is needed. In spite of the vagaries of scientific understanding of these entities a successful approach using training modification, stretching, strengthening and appropriate return to exercise may be undertaken. At this time there are few significant clinical studies with valid results for treatment. There is often disagreement on approach and much is likely to be changed in the future. At this point treatment and treatment recommendations for this problem remain an art practiced with varying degrees of success. When evaluating new research, it is hard to recommend major paradigm changes in thought and recommendations based on studies of fewer then 20 cases or even 50 cases.

Viva La Différence: Exercising Sitting Down vs. Standing Up (repost 2007)

The New York Times had an article today which discusses how bicyclists come in all shapes and sizes. Gina Kolata mentions that that many cyclists did not meet her conception of what an in shape cyclist would look like. The reality is that runners come in all shapes, sizes and ages also and this can be seen at many marathon events. The other part of the reality is that elites among both runners and cyclists have different morphological characteristics including a lower body fat content, higher MVO2 and various other items.

But, there is hope for all of us. George Sheehan once said “We are all athletes, some of us are in training and some are not.”

“When I first got into cycling, I would see cyclists and say, ‘O.K., that’s not what I perceive a cyclist to be,’ ” said Michael Berry, an exercise physiologist at Wake Forest University. Dr. Berry had been a competitive runner, and he thought good cyclists would look like good runners — rail-thin and young.

But, Dr. Berry added, “I quickly learned that when I was riding with someone with a 36-inch waist, I could be looking at the back of their waist when they rode away from me.”

He came to realize, he said, that cycling is a lot more forgiving of body type and age than running. The best cyclists going up hills are those with the best weight-to-strength ratio, which generally means being thin and strong. But heavier cyclists go faster downhill. And being light does not help much on flat roads.

But on the other hand, there are differences that make cycling a bit more forgiving:

“In running, when you see someone who is obviously overweight, they will be in trouble,” Dr. Hagberg said. “The more you weigh, the more the center of gravity moves and the more energy it costs. But in cycling, there are different aerodynamics — your center of gravity is not moving up and down.”

The difference between cycling and running is like the difference between moving forward on a pogo stick and rolling along on wheels. And that is why Robert Fitts, an exercise physiologist at Marquette University who was a competitive runner, once said good runners run so smoothly they can almost balance an apple on their heads.

One Sport, One Love (repost)

Over the past several years the concept of well rounded young athletes playing 3 sports over the course of a year has died. Most want to be specialized in one sport. Whether the sport is soccer, baseball or running, we rarely see the child athlete playing football or soccer in the fall, basketball in the winter and baseball or track in the spring.

In fact, school centered sports is no longer the norm. Travel sports rules. Year long focus on one sport is it. This has resulted in more overuse injuries than there should be. It has also resulted in more teens having the “Tommy John” elbow surgery and even for parents to seek it to see if it may make what started as a normal arm, pitch faster. Read Fit Young Pitchers See Elbow Repair as Cure-All in the New York Times for a current journalistic perspective on the surgery aspects of this. The article neglected to mention the year long focus on pitching as the root cause.

…it is becoming more commonplace among teenage pitchers who are injuring their arms through overuse at what surgeons call an alarming rate.

Some parents and young pitchers, hoping for college scholarships or multimillion-dollar professional contracts, misguidedly view the surgery as a performance-enhancement technique instead of a last-resort corrective procedure, said Matt Poe, a speed and strength coach in Nashville.

Often, pitchers who are pushed the hardest and sustain the worst overuse injuries are the most talented, doctors said. In the late 1990s, Dr. Andrews said he performed 5 to 10 Tommy John operations a year on high school pitchers. This year, he said, he may perform 75. Last month, he operated on a 14-year-old.

And for two interesting pages the article goes on.

“I don’t think there’s as deep a talent pool anymore,” Dr. Petty said, because so many kids are coming out of high school with what he called “100,000-mile arms.”

It’s not the talent pool. Pitchers have always been in short supply. High schools have made do with very few pitchers for years. But, not until recently did they only pitch for most all of the year.