Dr. Christpher Segley aka Doc on the Run

Say you're out hiking in the middle of nowhere and BAAM!  You turn your ankle!  Dr. Segley gives us an amazing interview on what to do if you twist your ankle and think you've sprained it, how to prevent such injuries in the first place, why buying too big of hiking shoes or boots may not be the best idea, he gives us an ankle strengthening exercise, plus offers us a helpful self-test to see if we are at risk of a sprained ankle (see my video below).  Who knew ankles could be so interesting?!!!  In our interview, we never got to the other parts of the body that hikers often injure, so Dr. Segley has agreed to make this a multi-part series!  Subscribe so you don't miss it!

A little about Dr. Segler…

Here's a doctor who walks the walk – or I should say runs the run, as he is an athlete himself!  Dr. Segler dedicates his practice to helping athletes prevent and also treat their injuries without losing the conditioning they've worked so hard for making him the perfect doctor to talk to about figuring out what to do when you are out in the wild and you hurt yourself and need to keep going.  See below for a more detailed bio on this amazing doctor.

Here's what we cover:

These time-stamped notes correspond with the episode [the full transcript is down below]  You can scroll to the area of interest on the podcast player above, or scroll to transcript below.

03:11  We learn what a sprained ankle is and how is it different from a fractured ankle.

04:48  True story about Adam and a sprained ankle while climbing in Yosemite

09:31  What they should have done

10:18  How to assess a twisted ankle

11:55  Why you should keep a compression sock in your day pack or back pack

13:55 How to assess whether it's ok to use it after you've twisted it

14:07 The difference between a sprain and a fracture

17:58  When you should use Vitamin I (ibuprophen) and how much to take.  What are the counter indicators.

20:42  How to prevent a sprain

20:47  How you can ‘ice' down your sprained ankle in a creek to reduce and minimize swelling

21:56  Can your ankle get too swollen for your boot?

22:59  If you've ever had a sprain, you are at higher risk of future sprains even if it's been years.

23:46  How to do a stork-like self-test to check the stability and strength of your ankles (see my video test below)

26:31  How to do a quick exercise to build up your ankle strength and stability.  (see the Doc's video)

27:16  Benefits of a wobble board

28:21  We talk about the pros and cons of hiking shoes versus boots.  Do we HAVE to buy leather?

31:41  Compare synthetic to leather.  How to test if a boot is strong enough by trying to twist the sole.

33:12  Why it's NOT a good idea to buy boots a size too big.

34:42  If you want to use different inserts, bring them with you when you shop for your new pair.  Make sure your toe bends where the boot bends.

35:42  Summary

36:35  Doc on the Run podcast:  what's it all about?

38:15  DocOnTheRun.com website resources.  Worksheet to bring to your doctor.

Kit Demonstrates the Ankle Test

Don't miss the Doc on the Run podcast

Dr. Segler goes deep in each episode to help athletes heal (Hey! We're Adventurers, doesn't that make us somewhat of an ‘athlete'???) without losing conditioning and without giving up the sport they love!  Check out his podcast episodes by clicking on the box to the left!

Author of:
Runner's Heel Pain: Self-Diagnosis and Self-Treatment, House Calls Startup Manual: How to Run a Low-overhead, High-profit Practice and Get Your Life Back
Connect with Dr. Segler on:
Facebook
https://www.facebook.com/DocOnTheRunSanFranciscoPodiatryHouseCalls/
Twitter
https://twitter.com/myrunningdoc
Instagram
https://www.instagram.com/docontherun
Pinterest
https://www.pinterest.com/DrChristopherSegler/
Here's Dr. Segler's Book:

 

Here's the transcript for this episode:

Kit: 00:00 Picture this you've been climbing all morning. And finally you get the reward. You're at the summit and you have a 360 degree view: panoramic. Absolutely gorgeous. You step back to take a selfie and BOOM you twist your ankle. Oh brother! You are eight miles from town. What on earth do you do? That my friends, is the subject of today's bonus episode on how to treat and prevent sprained ankles. I have got such a treat for you! Who would have thought sprained ankles could be so interesting. This interview had started to be a general first aid wilderness episode but we got so engrossed and it was so interesting that we've decided to make this a series instead. In today's interview the doctor's going to teach us what do we do if we should sprained ankle while we're out in the wild.

Kit: 00:44 This is one of the most common mishaps that can happen to us. We'll also learn how to treat it how to tell whether or not we are at risk for a weak or a sprained ankle. He has talked me into adding something to my backpack which is something I very rarely do: I try to be as minimalist as possible. But I learned about a new product today that is new to me in the backpacking world, and it is now going to be part of my day and backpacks in the future. And I also found out that I was fitting my boots improperly. So there's lots of great information here. Like I said, who would have thought sprained ankles could be so interesting? Let's get right to it.

Kit: 01:24 Welcome to the Active Travel Adventure's podcast. I'm your host Kit Parks. Our guest today is a foot and ankle specialist who focuses his entire business on athletes and keeping those athletes active even after injury. I thought it would be cool to bring him on because unfortunately, sometimes when you're out in the wilderness and you're miles from the nearest town to medical care, you're going to need to fend for yourself. Not only is our guest a much in demand speaker at medical conferences on running injuries and treatment, he's the author of Runner's Heal Pain has written a chapter in a medical textbook, and has written and presented countless papers. He's not a doctor just in the academic sense that you sometimes find… he's a doctor who actually walks the walk, or I should say runs, because he's an athlete himself. He's completed 15 Ironman tournaments as an Iron Man.

Kit: 02:07 If you're not familiar with that term, is it insane endurance event. You start by swimming almost two and a half miles then you bike over a hundred miles. And just for giggles you follow that up with a marathon race of over 26 miles — all without a break. He actually did this once in less than 11 hours. And in 2015 he earned the distinction of Ironman All World Athlete. He's also a rock climber, having climbed multiple multiday big wall climbs, such as Lurking Fear on El Capitan– and that was during a storm. He's an avid adventurer who, with a partner in 1995, had a plane drop the two of them in a remote corner of the Alaskan range where they spent a month trying out a new route on Mt.. Debra and Mt Hess. Yes, I realize he's far more hardcore than we are, or at least most of us. But the important thing is he's a doctor who knows what it's like to be out in the wilderness and left to your own devices.

Kit: 02:55 So today I had the honor of introducing you to Dr. Christopher Segler also known as Doc on the Run.

Kit: 03:11 Dr. Segler, to begin with what exactly is a sprained ankle?

Dr. Segler: 03:14 Sure. So a sprained ankle is is basically where you have a ligament that supports the ankle. In most cases, it's one of the ankles on the outside of your ankle. Sort of away from the midline of the body where you feel this lump of bone on the outside of your ankle. There are three little ligaments over there, and a sprain technically is where you have stretched or a very minor strains where you basically overstretched and have developed tiny little perforations in the collagen and that forms the ligament. The worst kind of sprain is where you completely rupture the ligament and that's a grade three sprain. A grade two sprains where there's a partial little rip that you could actually see at the edge of it. But none of that really matters that much as you can't see it. So you know grading ankle sprains doesn't really help you very much, but it's basically where you are walking along and you step on something, sort of on the arch side of your foot or under your big toe that pushes your foot over so that your foot kind of rolls to the outside and you then stretch and strain those ligaments in a way that they actually rip or tear

Dr. Segler: 04:25 And you know that in itself is not such a problem, but when you're on a trip and that happens then it can sort of evolve over a period of hours or days to where it actually gets considerably worse. And once that happens it actually really can disrupt your trip because you can have a very difficult time walking. And it can get progressively worse. A lot of time these things catch people off guard.

Kit: 04:48 So if we twister sprained ankle What do we do? Is there anything we can do?

Dr. Segler: 04:53 There's always something you can do. So the first thing is to be aware that it can happen right? And and then, I mean, I can share a story about how that can happen and this was a there was a trip where I was actually rock climbing with a friend of mine, and obviously I know to about ankle sprains, right? So I treat them, I lecture to physicians about how to not miss subtle ankle fractures that appear to be ankle sprains but are actually teeny tiny little fractures that are really easily missed. You know I've researched those and when I was in residency I won an award for that, so I go to conferences, and they say I'm an expert on this. So I should know of all people. But a friend of mine, his name is Adam, and we were both rock climbing in Yosemite and we're on a very long route.

Dr. Segler: 05:37 It's fairly easy as far as a rock climb goes but it's very very long. So it's definitely an all day rock climb. And we were just sort of starting the day it was super early in the morning and we were a few hundred feet up and Adam was leading. So he was going first and there's this one place where it's pretty easy but it's sort of sloped and he was stepping up from one position to another and he fell and he didn't fall very far… just a couple of feet, but he landed on a sloped surface. And when he did, it rolled his ankle over– sort of classic ankle sprain problem where he just sort of slipped on a sloping surface. And he said he sprained his ankle.

Dr. Segler: 06:22 And so he came back down to where I was and I said, “Well how is it?” And he said, “Well I think it's OK. Just give me a second. I think it's fine, let's just continue on.” So we did. Now Adam has, I guess he's kind of a tough guy. So he has a fairly high pain threshold. He wanted to continue. He probably on some level didn't want to wreck our trip because we had driven all the way to Yosemite to go do this climb that day.

Dr. Segler: 06:48 And so I think you know half of it was Adam just wanted to continue and not really call any attention to himself, and the other part was that he just thought he could ignore it. So the thing is, when you sprain your ankle… when you roll your ankle like that, the first thing that happens is you get natural endorphins that suddenly, like within a few minutes, dull the pain considerably. So part of it may be that Adam just didn't really recognize how bad it was because he had these natural endorphins that protect us from that discomfort. So if you do that, and you're on the way to the car and you're going home it's no big deal.

Dr. Segler: 07:21 But if you're heading up a long climb or you're heading in an isolated area where there's no cell phone reception and you have a long way to go to your next stop, that can be a problem. So I asked him, he said it was OK, I didn't even really check it because he said it was ok, so I thought, “Well OK, this must be fine.” And we continued on. The problem is, there is a point on that rock climb where you're way up and really high up a few hours in and once you sort of make this one traverse you cannot get back down unless you get to the top. It's very very difficult to get off the climb at that point. So we got there, and Adam said he thought it was OK but it was getting kind of sore.

Dr. Segler: 08:03 But we continued anyway. Within a couple of hours after that, he was having a lot of difficulty. The ankle really started to swell and it got progressively worse pretty quickly at that point. And that was a real problem because it's a very hot day. We were not really prepared to be there for the entire day. We thought we were going to move quickly and we didn't have enough water. So when it's very very hot, you need water. And it was very very hot. And so we both got severely dehydrated and then the last few sections climb, I remember Adam was moving really slowly and he would stop. I would hear him grunt in pain and he would just sort of stand there on the side of the wall just stopping to like kind of recover before you continue on.

Dr. Segler: 08:51 So it got more and more painful as the day went on. That turned into a really serious adventure. So it ended up what was supposed to take us six hours ended up taking us more than 12. And we got down that night were both severely dehydrated and it was not really what we had planned for. And that's the thing, is that this could have been all preventable by a couple of things. First of all, if if we had had any way to do something about the swelling as was starting to happen, it wouldn't have become a problem. If Adam had done some stuff to strengthen his ankles before that, it would not have been a problem. But we didn't do either of those things so he had some ankle instability that put him at risk of this injury.

Dr. Segler: 09:31 And then when it actually happened, we didn't really stop to assess it and do something about it right away. And if we had done something as simple as taping his ankle or even having him put a compression sock on, then it would not have swelled and become as painful as it was, and really put us at risk of a more serious problem. We really did have the risk of getting stranded on the wall and it was way after dark when we finally got down. So repelling off a huge rock climb where we're a quarter mile off the ground, in the dark, is not really ideal but that's what we had to do. And so really, just knowing what to do when this happens really can make a big difference at getting you to your next stopping point without your adventure turning into a misadventure.

Kit: 10:18 So how do we assess it? We're not a doctor. We don't have you there on the trail with us. What do we do? How do we see if this is just something we can blow off, or do we need to stop and address it right then?

Dr. Segler: 10:27 That's a good question. So the first thing is soreness. So if you roll your ankle and it hurts, ten you did something, right? And I have a lot of sort of inherent instability because I had damaged my ankles in a number of ways many years ago. I fully rehabilitated them and I still do lots of active stuff around on trails. I do lots of adventure travel sort things… rock climbing, all kinds of stuff lots of hiking. And I'm not at risk now. But the thing is when you sprain your ankle, first of all it hurts. And so it's really simple: if you feel that lump of bone on the outside of your ankle and you push around and it hurts anywhere around there those are where the ligaments are so the specific location of the ligaments doesn't really matter.

Dr. Segler: 11:12 So if you push around there there's a joint capsule that holds all the fluid in your ankle and any portion of that joint capsule will probably be sore if you sprained your ankle. Now the problem is that it starts to swell within a short period of time. And if you can do anything to decrease the swelling, that will make the biggest difference. The problem with Adam was early in the morning he had sprained his ankle. He was trying to ignore it. He wanted to ignore it, and then it just got worse because he didn't do anything about it. Now at that time, realistically, when we were on the wall, I actually had a pair of compression socks — they were in my backpack.

Dr. Segler: 11:55 Interestingly, on the way home I had Adam put the compression socks on and he improved considerably, just while we were driving home in the middle of the night. But, if we had just stopped long enough to really consider that, and I said , “Well OK, you sprained your ankle. It's probably going to swell. That's predictable. So why don't you just put on this compression sock?” We probably would not have had much of a problem. So it probably would have gotten a little bit worse but not nearly as bad as it did.

Dr. Segler: 12:19 So now yesterday I saw a guy at home who sprained his ankle. And it was two weeks ago: he still has swelling. And so that's all residual swelling from where they had that initial blow up where it was really, really swollen. And you have to prevent that. That's just too much inflammation. And that's what really disrupts people. They get so swollen that it's really painful. It's hard to hike, it's hard to walk, and then it really disrupts your trip.

Dr. Segler: 12:42 So initially if you can just tape it or even use compression socks… like a lot of people they go on adventure travel, they are going to some faraway destination, they're taking a plane to get there. And many people will wear compression socks just on the plane as a preventative thing. And if you have those compression socks, they don't weigh very much. They may not be the most comfortable things but if you put it on as soon as your sprain an ankle,your chances of it is not swelling as much are way better. So that's probably the simplest thing. Lots of doctors would argue that you should tape the ankle to support and protect it, but the truth is, is that even if we talk about it right now about how to exactly do that, it's a sort of technique thing, and it's not easy to remember. Most people are not going to carry a roll of athletic tape with them when they go on a hike.

Dr. Segler: 13:31 And and it's not realistic, but the compression sock… it's so easy to bring a pair compression socks, and and if you do sprain your ankle and you just put the compression socks, on it will make a huge difference.

Kit: 13:44 if you're not familiar with compression socks, I put a link in the show notes at the ActiveTravelAdventurist.com Web site. I know is at least one of these socks going in each of my packs from now on. What a great suggestion!

Kit: 13:55 Is there any risk of doing permanent damage by walking, like if Adam had kept going going going, could he have done something permanent? Or as long as you eventually make it back you're OK?

Dr. Segler: 14:07 That's a good question. So the short answer is yes, there's always a risk you could do more damage. But, that's only if you really have a fracture. And now fractures do happen. So I will tell you like one of the research studies I did when I was in residency was on this subtle fracture pattern called a lateral process fracture. The specifics of it aren't important, it's just that when I was in med school we were taught that the occurrence of lateral process fractures or how often they actually happen was actually really, really, really rare. And so we were taught that it was 0.86 percent of all ankle injuries involved. One of these little subtle ankle fractures on the outside of your ankle right where it hurts when you have an ankle sprain.

Dr. Segler: 14:55 So what I did was, I got it approved through the University Institutional Review Board. We reviewed three years worth of patients that came through the university hospitals and clinics and looked at a huge number of patient. So it was in the end, after we eliminated all the people who didn't qualify, it was 1480 patients. And all we were trying to do is figure out whether or not these things were really that rare because it didn't seem like they were that rare. And sure enough that it occurs and almost 10 percent of all ankle sprains. So basically, you have a one in 10 chance of actually having one of these subtle fractures.

Dr. Segler: 15:28 So the thing is if you have a standard ankle sprain it doesn't really hurt that much when you start walking on it. It may hurt a little bit. It gets way worse if you keep walking on it just because it keeps swelling and it gets more and more swollen. The tissue on the inside of the joints sort of swells inward and then that swollen tissue is getting pinched between the bones when you move your foot up and down as you walk. So that's what really happens with an ankle sprain. But if you have one of these subtle fractures or if it's a bad one then it's certainly going to hurt a whole lot more. And if you have that, yes, there is a risk that you could do more damage. So if you're concerned that you have one of those because it is really really painful initially, then there is a risk that you can make it worse by walking on it.

Dr. Segler: 16:12 So you don't want to just ignore it. And the biggest mistake we made was that we basically, Adam and I both just more or less ignored it thinking well it will be OK. It's just a minor thing, but it got worse. And so if you have that kind of pain that really is super sensitive and it's really tender when you press on it then you're better off if you if you take it easy.

Kit: 16:35 So if I'm understanding you, if right after we twist it if we have immediate hard pain then we may have done that, that 10 percent fracturing. If it's OK and then progressively it gets worse, it's more likely just a sprain?

Dr. Segler: 16:48 That's true. That's true. So yes, the subtle ankle fractures, the're first of all that's one out of 10 so it's not really common. But it's also associated with a more severe injury like, (for example) you're wearing a heavy pack. You slip on the side of some loose terrain… some scree or something like that.

Dr. Segler: 17:08 And and you have a significant fall. Whereas ankle sprain is, like Adam didn't even fall dow. His foot just kind of flipped over because he was landing on a sloping surface. And and it sort of startled him, but it didn't really hurt that much. But you can imagine that if you, as opposed to just stretching the soft tissue which is basically what an ankle sprain is, if you actually cracked the bone, that's definitely going to hurt more. And then every time you move it it you're moving this fracture… this broken piece of bone. You have jagged bone kind of bumping up against each other where the two pieces are. And that causes a lot of pain. Whereas if you just have an ankle sprain, many times when you're moving it around, it actually starts to feel better just because, I don't know, it kind of pushes some of the fluid out of that area. And it may not hurt that much when you're first moving it. So the more tenderness you have generally the worse it is.

Kit: 17:58 In both cases, or one on the other, is it a good time to take vitamin I or ibuprofen?

Dr. Segler: 18:06 Well yes. So this is, well, good idea. It depends on your goal. So the thing is, is that if you just have a sprain and you, let's say you are somewhere in a remote area, you're on one of these adventure trips, right? And you're not exactly in a convenient area: you don't have cell reception. You're in Glacier, right? If you're, like on your podcast on glacier, if you're in the middle of nowhere on a trail, you have no cell reception, you have miles to go before you get to the next camp, the next stopping point, or a ranger station, and you really need to get there… almost like a self-rescue kind of thing. I think it's better to take ibuprofen because it will significantly reduce the discomfort. Now, although it is a non-steroidal anti-inflammatory, and just because the name we always think it stops inflammation, they really won't stop inflammation that way.

Dr. Segler: 18:52 Like if Adam had taken a bunch of ibuprofen right when he sprained his ankle, it was still going to swell. It doesn't really work as an anti-inflammatory until you've taken it for a number of days. But it will certainly decrease the discomfort. So if the goal is to get somewhere, to get to safety, to get to your next stopping point, I think it's worth doing. However if the goal is to get it to heal as quickly as possible, taking ibuprofen or any non-steroidal anti-inflammatory like, Aleve, Nuproxen, any of those things, it's actually counterproductive because studies have shown that non-steroidal anti-inflammatories can actually decrease the healing time for tendon to bone interfaces. And all a ligament is, is basically collagen that connects two bones. So when you have an ankle sprain, you actually have damaged that interface where the bone touches to the collagen ligament.

Dr. Segler: 19:45 And if you take anti-inflammatories it can slow down the healing process. So if you think you just have a standard ankle sprain and you need to take it for pain control to get somewhere I think that's fine but if you're trying to get it to heal as quickly as possible I think that can be counterproductive.

Kit: 20:01 And Doctor, what kind of dose of ibuprofen would we take if we're just trying to get to the next place?

Dr. Segler: 20:05 Well that's a good question. So the thing is, is that without an assessment you should never take more than the over-the-counter doses. What that means for Ibuprofen is basically 400 milligrams or two of the over-the-counter pills. Anything more than that is a prescription dose. But you know many patients do that. They will frequently just on their own take full strength prescription strength doses which would be three or four of them but that's not a good idea unless you talk to your doctor. Because if you have any kidney problems or any that sort of stuff, G.I. gastrointestinal problems, if you have stomach ulcers, anything like that, that can be a terrible idea to take high doses or prescription doses of ibuprofen.

Kit: 20:42 Are there any techniques you can give us that will help us prevent the injury in the first place?

Dr. Segler: 20:47 Before we talk about how to prevent it, one other thing that actually can really work extremely well if you sprain your ankle, to shut off the inflammation, that's even better than ibuprofen… which doesn't happen everywhere for sure, you know in the Grand Canyon, you kind of only have one choice for water and that's at the bottom of the canyon. But if you're in Glacier, if you're in a number of national parks, if you're in Yosemite, there are rivers, most of which are formed by glacial melt, right? Or are snow melt and they're very very cold, right? And so if you ice the ankle that's one of the best things to stop inflammation. So if you happen to have a mountain stream, that's cold running water, that just sitting with your ankle in the river or stream you know for 10 minutes can make an enormous difference because it constricts all the blood flow and really prevents that inflammation from starting very very effectively. So if you happen to roll your ankle and there is some sort of mountain stream nearby that's cold running water, particularly anywhere like glacier or those types you know in the Himalayas, any of those areas, that can make a huge difference is stopping the inflammation

Kit: 21:56 Is there any risk when you take your feet out of your shoes/your boots and it swells up that you can't get them back in? I guess with the rivers they would stay constrained but if you're resting your feet, is there… is that a possibility when you say it swells?

Dr. Segler: 22:10 There is a possibility that could happen but that's going to happen either way. The boots aren't really tight enough to stop the swelling. Compression socks would prevent that from happening. But if you are going to take your… and a lot of people want to do that. It feels better to take their boots off. But the truth is, is that the best thing you can do, if you don't have access to a glacial stream or you didn't bring your compression socks or whatever, if you can basically just lie on your back with your feet straight up, leaning against a tree or against a rock, or whatever, and you have your feet way up above your heart. That makes a huge difference is stopping the inflammation because the blood flow has to fight gravity and go uphill at that point. And so keeping your boots and your socks on I think is better because any external compression will help also reduce that inflammation that happens after an ankle sprain.

Kit: 22:59 So what kinds of things can we do to prevent problems in the future.

Dr. Segler: 23:02 Right. So the first thing is to figure out whether or not you're really at risk. Not everybody has ankle instability but the first thing is, if you've ever sprained your ankle, you're at enormous risk for developing another ankle sprain in the future. So if you roll your ankles when you're a kid, if you sprain your ankles in college playing basketball, if you roll your ankle one time on the beach walking in the sand, you're at risk. And most patients who have had those sort of remote history of an ankle sprain, some time long ago, many years ago, they always think, “Well that was 20 years ago. Can't be a problem.” And so I see these patients all the time and even when I do Skype consult for somebody, for example, they'll tell me that they sprained their ankle a long time ago but it doesn't matter anymore.

Dr. Segler: 23:46 And I'll say ok and I have them do a very, very simple test. And all I do is I tell them OK: stand in the middle of the room and hold your arms out straight. So it looks kind of like the the the drunk test on the side of the road. And I just stand there with feet together hold your arms out straight now close your eyes and they kind of roll their eyes more or less and say OK. And then I say OK , now great. Now pick up your right foot. So if their previously injured foot is their right foot, the bad one, pick up their bad foot. So that is just suspended in the air. Kind of like looks like a stork, the way they pick up their leg.

Dr. Segler: 24:21 And basically standing there with their arms outstretched bouncing on the right foot with their eyes closed and they may kind of wobble a little bit but they can more or less just balance. And I'll wait until it's been about 10 seconds just to confirm that they can actually balance OK in that position, balancing on one foot. Then I say, OK great. Now put your right foot on the ground, you know, your bad foot. Pick up your good foot, your left foot, hold your left foot up in the air with your eyes closed, your arms outstretched, to see if you can balance. And though usually they keep putting their foot down, losing their balance repeatedly and because their arms are outstretched, they can see how far their arms are swinging before they catch their balance. And at that point what's happening is they actually tore the nerve fibers in the joint capsule when they rolled the ankle so they can't really tell the position of the ankle anymore.

Dr. Segler: 25:08 And so the ankle to them feels weaker but it's really just that they've lost what we call proprioception or the ability to determine the position in space based on the ankle moving. And that happens every time you roll your ankle. So if you roll your ankle, you don't have the ability to feel that anymore. And so you know somebody like Adam that has maybe sprained his ankle before and he falls, he lands on the surface, and it starts to roll his ankle, he doesn't notice it's rolling until he feels that he's falling because his vestibular system, or the balance center in his middle ear, actually picks up the motion of him sort of moving sideways to start to fall.

Dr. Segler: 25:48 And then it's too late. Your the muscles around the ankle, the peroneus brevis tendon, those things actually stabilize your ankle, they can't pull your foot back under you at that point, and you roll your ankle. So if you do that test where you balance on one foot with your arms outstretched and your eyes closed and you can tell that one foot is considerably weaker than the other, or you have a lot of trouble trying to balance on one foot, then you can do some simple exercises to really strengthen that ankle and actually get that sort of proprioception, or the ability to tell a position without thinking about it, you can get that back by using the stretch receptors in the muscles and it's really just a simple routine.

Dr. Segler: 26:31 So there's there's basically a couple of really simple exercises. One of those is where you cross your feet. So like if you're sitting in a chair with your legs outstretched and you cross your legs and you put your little toe joints together and then you push it will stabilize the the the ankles the muscle that supports the ankle the peroneus brevis tendon primarily. And I could actually send you a video that you can put on the Web site if you'd like, or link to it but it's just a short video there may that shows you exactly how to do that. And that's something you can do while you're sitting on a plane while you're sitting at your desk. If you do that that I think is the one exercise that can cause the most increase in strength for anybody with ankle instability. Then for people that have really sprained their ankles, I give them a very specific rehabilitation thing that's like phase one, phase two, and phase three.

Dr. Segler: 27:16 Phase three is where you use a wobble board to deliberately train your ankle to become stronger. And I can send you that as well if you want to supply it for people who listen to the podcast The phase three part is what really strengthens your ankle and makes you more or less immune to those kind of sprains that otherwise you'd be so susceptible to.

Dr. Segler: 27:38 And literally like spending three minutes a day you could strengthen the ankles in just a couple of weeks. So you'd be at dramatically lower risk for having these kind of problems.

Kit: 27:50 If you go to the ActiveTravelAdventures.com Web site, I'll post the video that Dr. Segler talked about for the exercise. I've also posted a video of me doing the self test like the stork to see what my ankles look like. And also have a link to the wobble board. You can find it on the site by either looking up Bonus Episode number two, Dr. Segler, ankles or any of the key search terms should be able to pull it up for you. Just type any of those terms in the magnifying glass search bar.

Kit: 28:21 What's the deal on having the shoes having the ankle support? I've always worn like the Merrell trail shoes so they're like a sneaker on the top but then have the trek on the bottom. How important is it to have ankle support?

Dr. Segler: 28:33 Well that's a good question. You know so here's the thing. So I actually really wondered about that. And when I was a student in med school, I actually did a research study and because I wondered about this. It was supposed to be about climbing injuries. But the truth is, this study was really about hiking to rock climbs. And so what I did was, I did a study on frequency and mechanisms of injury among rock climbers. And it was the largest type of that sort of study ever done. I actually got a grant from the American Alpine Club to do that investigation.

Dr. Segler: 29:09 And that's the thing is, that it's really about the hiking to the climb because I had the suspicion that climbers don't necessarily get injured that much from falling.

Dr. Segler: 29:17 It's really from tripping and slipping and spraining ankles and stuff like that while they're riding a heavy pack, wearing relatively lightweight hiking shoes, on their way to the climbs. And many times there's no trail. It's usually some kind of unstable surface. But what I did was I basically sent out surveys to 3500 members of the American Alpine Club and then it got back 603 completed questionnaires. Now the thing is is that the really interesting thing for everybody listening to this is that 80 percent of climbers who reported spraining an ankle while hiking to the base of a climb were wearing those sort of lightweight hiking boots or hiking shoes that you're talking about. And the overwhelming majority of people who fractured an ankle while hiking also were wearing lightweight hiking boots. So lightweight hiking boots are very popular because they breathe. They usually have uppers that are sort of mesh or some lightweight material so that they are comfortable when they're hot and they're light weight. Right?

Dr. Segler: 30:16 So they're they're not heavy, and they're more comfortable, but they don't protect you very well. So heavyweight backpacking boots are way more protective. They're also a lot stiffer. They're hard to get used to. You are more risk of getting blisters if you have those and haven't really broken them in. But after that study, I started really put in a lot of effort into encouraging people hiking and rock climbing to wear more sturdy boots. And I think that they actually do really decrease your risk of having an injury if you have more stable heavyweight backpacking boots. So if you pick up the shoe and you hold it in your hands, you try to twist the sole out of shape. It's virtually impossible to twist it out of shape.

Dr. Segler: 30:59 It's also very very difficult to bend the sole out of shape as if you're pushing the toes up. But with lightweight hiking shoes and hiking boots is very easy to do that. So I believe they will protect you because they do provide a lot more support provided they're laced up and they're laced appropriately. If you have them loosely laced or you don't lace the top laces they actually really won't help you as much. So then at that point you have a more stable platform underneath you but it doesn't really protect you from ankle sprains So I think that it's important to really think about your footwear, and if you're doing a lot of hiking on the trip, if you can wear the heavyweight boots it actually will protect you some.

Kit: 31:41 I'm actually just shopping for some. I'm getting ready to prepare for a trip out to the Himalayas where they are recommending that I wear boots, and at the stores I'm seeing more of the synthetic material instead the leather. Does make a difference? I mean does leather provide a benefit that the synthetics don't?

Dr. Segler: 31:55 That's a good question. So in the past I would have said 20 years ago for sure leather was better. But lots of companies now, like La Sportiva and some others, they have really made big strides in terms of increasing the stiffness of heavy weight backpacking boots that are made of synthetic materials. So there's a benefit to everything right? So the synthetics are usually lined with Gore-Tex or something. They're basically waterproof if they do get wet, they dry out faster. If leather boots get wet, they stay wet. If they're wet and they're Gore-Tex leather boots, it doesn't matter your feet don't get cold or wet but the boots are way heavier if they're soaking wet. And you may not think that's a big deal but if you're hiking in the Himalayas and you're hiking 10 miles you have to pick your foot up and put it down a lot of times.

Dr. Segler: 32:41 And you know that increased weight does make a difference over time. So the synthetic materials are generally lighter. And you can tell because if you try to twist the boot out of shape — you find like the biggest strongest guy in the store and ask him, see if he can bend this thing… so bend the sole and it won't bend, and you squeeze the heel counter the part of the back of the boot that goes around your heel and it's rock hard and very very stiff, then it's going to be just as supportive as a really heavy weight backpacking boot that's made of leather.

Kit: 33:12 What advice can you give us about choosing the right pair of boots?

Dr. Segler: 33:23 That's a great question. So the thing is, as many people are concerned that they're going to get blisters or black and blue toenails. And so one common error is that they'll get shoes that are too big. Many times they'll say well maybe I'll get them that are big because I'm going to wear two or three pairs of socks with them. We don't need to wear two or three pairs of socks unless you're going someplace where it's 40 below zero. So if you have boots that fit you appropriately you're at a lower risk of getting problems. So if you get boots that are too big, first of all you have to remember that the shoe break or the curvature that's under the ball the foot is in the wrong position. So when you walk when your heel comes up off the ground your toes are still on the ground and your foot's bending at the ball the foot that's where you want the curvature of the shoe.

Dr. Segler: 34:01 If you get a shoe that's one size too big for you the curvature is out in front of you. And those patients then that have boots that are too big they're basically kind of like vaulting off the end of the shoe and it makes things awkward and it can put you at risk of all kinds of different overuse injuries. So it's really important to make sure they fit appropriately. Now most stores, if you go into some store that specializes in hiking boots and that sort of stuff, they'll have people that are knowledgeable about how to fit you correctly and they'll check you and make sure you get the right size shoes. Obviously you don't want your toes banging up against the inside of the boots, but you also don't want them too big. So I would just caution people to make sure that they're getting the right sized boots by getting an appropriate fitting.

Kit: 34:42 Should we get rid of the inserts that come with them and put something else in?

Dr. Segler: 34:45 I don't think it matters unless you have foot problems. So that's a very popular thing to do. There's a whole range of over-the-counter inserts that are really good. There's lots of different ones available and they can provide more support.

Dr. Segler: 35:00 It just depends upon whether or not you need them. And the other thing is, that if you're going to do that, you should definitely do it when you buy the boots. Because the inserts that come in most hiking boots are thinner than the over-the-counter orthotics or over-the-counter inserts that go in the shoes because they're designed to have more support. So because they have more support they have more material underneath you. And if you get boots that fit you perfectly and then you buy some inserts that are thicker by three or four millimeters and you put them in your shoes and suddenly it lifts you up and you may be hitting your toes against inside of the toe box and you have less room in the shoes. So then you've just sort of by buying the inserts may have made your shoes effectively like a half a size too small.

Kit: 35:42 Before we sign off is there anything else important that we should know about the treatment and prevention of sprained ankles?

Dr. Segler: 35:49 I think that's the main thing. I mean the reality is, is you know you don't need to go prepared with splinting materials and planning for every disaster, right? You have to carry everything you take when you go on an adventure trip and you want to make sure you're prepared, but taking some compression socks is really the simplest thing you can do. Knowing that you can basically ice it by soaking your foot and ankle in a in a stream or elevating it if you do actually sprain it. That's really all you need. But then it's really just doing that self-test at home to see, “Am I or am I not really at risk for problems?” And if I am, then really just trying to do some quick exercises. Just really like, truly like, a couple of minutes a day to get some more ankle stability can go a long way to preventing the kind of problems that could otherwise wreck your trip.

Kit: 36:35 Doctor, you also have a podcast can you tell us about that, please?

Dr. Segler: 36:41 I do. So, I have a podcast called the Doc on the Run podcast, and mostly I treat injured runners and triathletes. So I see all kinds of patients. I mean, one of the people yesterday was a rock climber. I see lots of different patients. People get injured hiking and everything else. But basically what I do is, I I just realized a long time ago that a lot of times when you go to the doctor they tell you something that just doesn't sit right.

Dr. Segler: 37:07 In fact, my my first episode of that I was racing motorcycles professionally and I had damaged my knee and the doctor actually said, “Well if it only hurts when you're riding motorcycles you just quit riding motorcycles.” And then what I learned was that doctors would also tell people, “Well if it hurts when you're running you should just swim. Or if it hurts when you hike you should just do something else.” And the reality is, it's not the doctor's job to tell you what to do. It's the doctor's job to get you back to your activity whatever that is. If you want to hike and you have problems hiking you need somebody that's going to help you get there. And if you want to hike 10 miles a day, then your doctor should help you get to hiking 10 miles a day. So basically I created a podcast to help people understand how to deal with those injuries and how to continue maintaining activity while they're injured so they don't lose all of their fitness. I mean because, let's face it if you're going to go on a long trip you spend a lot of time training, them when you get injured, you lose all of that fitness. And that can be very very frustrating.

Dr. Segler: 38:04 I created a podcast to try to help people understand all these different kinds of injuries and help them figure out how to maintain their activity so that they can get back to those those activities as quickly as possible.

Kit: 38:15 I noticed on your DocOnTheRun.com Web site you have lots of resources. How about telling us a little bit about those please?

Dr. Segler: 38:23 Yes, there are lots of resources. There are lots of different videos, lots of sort of self-diagnosis tools, lots of worksheets to help people figure out what to do and and even some worksheets like one I think came out, well it's coming out tomorrow actually. Basically the idea of when you go to a doctor and they tell you that you need a fractural walking boot, for example. It's basically a worksheet where all you do is printed out, and it tells you what questions to ask your doctor. And that can be useful for anybody with any kind of injury when they want to get back to activity. Because you have to sometimes, when you go to the doctor, you have to get them to slow down and to actually pay attention to what your desired activity is.

Dr. Segler: 39:07 So if you say, well I sprained my ankle and the doctor says just take six weeks off, but you're leaving for a trip to go to Glacier National Park in four weeks. That's not really going to work. And so you need to sort of get the doctor to slow down and say, “OK wel,l if I want to go to Glacier do this hike in four weeks, how do I get there?” And it's really just a lot of resources like that where you, a way to help you manage your doctor's visits and get the information you need from the doctor. Because the truth is, it's the doctor's job to go to school, get all the training, learn all this stuff that it takes to help you get better. It's your job as a patient to go to the doctor ready to extract all that information from the doctor. And that's what you really have to do when you go see a doctor, when you have all these injuries and you want to stay active.

Kit: 39:46 I'll be sure to put a link to that in the show as well. And I'm also going to put all of your social media contacts but is there a best way for people to reach out to you?

Dr. Segler: 39:54 Well the best way is just to, you can go to the Web site to DocOnTheRun.com and send an e-mail through there. You can also e-mail me directly it's just Dr. Segler D-R-S-E-G-L-E-R@DocOnTheRun.com [drsegler@docontherun.com].

Kit: 40:08 Dr. Segler We really appreciate your time. You've given us some great information and I hope we can get you back on another episode.

Dr. Segler: 40:13 Allright that sounds great. Thanks.

Kit: 40:15 I hope you got as much information out of this program as I did. And please visit DocOnTheRun.com and also check out his podcast. I'll have links to both on the Web site and at ActiveTravelAdventures.com. If you know a hiker or a runner, be sure to share this episode either on Facebook or via email. I'm going to be covering more what to do when something goes wrong on the trail as future bottoms episodes. So if you have questions don't hesitate to e-mail me at Kit@ActiveTravelAdventures.com on that or any ideas for future episodes. I love hearing from you and love your feedback questions and ideas. I'll see you next Thursday. Until next time Adventure on!