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The double-edge sword of bracing and support during rehab

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years.

A reader asked this question about arch supports recently, and I eventually fleshed out the answer for an update to my ginormous plantar fasciitis book (because it wasn’t detailed enough already). But this topic is relevant to the many forms of temporary support during rehab, for all kinds of problems: crutches, slings, braces, wraps, tapes! Even surgical implants. Support and stabilization are sometimes critical to recovery. They might be the most important factor in “calming shit down” before “building shit up” (Greg Lehman).

Arch support comes in many forms, like these “shoes” for dancers. With many forms of support, the difference between short dependence & long-term utility can get very blurry.

Q If strengthening is the a good way to deal with plantar fasciitis, would continual use of arch supports work against that goal? Do they make you weaker?

A It’s not natural! Occasionally people express this concern about the idea of artificially propping up the arch of foot: they would like their arches to be ready for anything, with or without shoes!

Support always creates dependency and weakness, by definition. If something is providing meaningful support, then obviously there’s less work for your body to do — and therefore less functional stress to adapt to.

And that’s just fine when the support is something you don’t have to worry about living without. For instance, no one worries about how wearing clothes to protect ourselves from the elements is going to make us soft — no one with normal priorities, anyway. Unless you are planning on taking up a barefoot lifestyle, you no more need to worry about dependence on arch support than you need to worry about being dependent on hats, snow shovels, or any other readily available tool that makes life easier.

That said, arch support specifically is in a grey zone.

Do you want to tolerate dependency on arch support? Do you want to recover enough to be pain free with arch support? Or without? In a rehab context, we usually want to treat any kind of artificial support as a crutch to be disposed of as soon as possible … but some artificial support can be awfully handy long term. And in some cases it’s downright difficult to get away from.

For instance, many people with plantar fasciitis manage to achieve good control of the condition, and yet they remain permanently vulnerable to flare-ups, no matter how strong they are, and continuing to use arch-support might decrease that risk. Such a patient can challenge their arches to be fully functional without support … but doing so puts them at the outer limits of their load tolerance. Maybe just easier to keep using the crutch in such case.

One catch: is that support actually supporting anything?

In many cases, support is mechanically obvious: a cast really does provide meaningful support for a badly broken arm. Duh.

Not every broken arm needs support. Some do, some don’t. It's actually amazing how well some fractures can heal without casting. That hasn't prevented many of them from getting bundled up anyway.

Providing patients with the “illusion” of support has been a common theme in medicine and rehab over the last century.

The best and weirdest example of this is spinal fracture bracing (both internal and surgical fixation), which I learned entirely too much about when my wife broke her back spectacularly in 2010. Incredibly, it’s not at all clear that any form of spinal bracing actually provides meaningful, literal support — not even titanium screws, posts, and bars. It probably just doesn’t work.

You have to take these on a case-by-case basis, but there are many examples of bracing and stabilizing that may not provide enough support to matter. One of the best common examples must be iliotibial band straps — basically just an big elastic band worn above the knee — which are probably provide only sensory reassurance, not physical support. Another example is taping, which mostly isn’t meant to be supportive in the mechanical sense but is definitely closely related … and there’s no convincing evidence that it’s helpful in any way.

And, fascinatingly, the illusion of support may actually have value in its own right. “Feeling safer” can actually matter.

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