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Perfect Balance – ‘IMPROVES’ framework


We often see clients at Perfect Balance Clinic who are struggling with injuries that have gone on for a long time. The story is where they have seen lots of people before or have not responded to previous therapy or intervention. Within this article, we will show how effectively, Perfect Balance, ?implement the IMPROVES framework to assist this client in getting results quickly.


This case is a particularly interesting case study involving a mid-30-year-old runner with diabetes and ongoing leg pain when running. She had already had months of therapy. ?One of our Osteopaths at Perfect Balance looked to treat her case by implementing our – ‘IMPROVES’ framework.


Her presentation was made slightly more complex as she had ongoing diabetes, although this is not what was causing her issues it does affect the recovery of ‘any’ issues she gets due to blood flow and blood sugar control we will come to this later in our discussion of her injury and recovery


She has been given insoles already and they helped but didn’t get rid of the issue she has, this will be discussed later on in this article also.

When trying to deal with difficult injuries it is important to understand what you are dealing with. Many of the cases we see there has been no clear diagnosis to begin with, leading to a direction which may not amount to much success. Here is this patient’s MRI scan that the Osteopath ordered when they first saw her. The small gray dot outside of her leg cross section (the larger main structure in the image) is a cod liver oil capsule which radiographers use to isolate the area of problem (level in the scan). This makes it very clear where the issue is when you look back at images. The region being scanned is the lower leg – just above the ankle with the tibia (larger triangular bone) and the fibular (just underneath and to the left of this).

Here is her MRI Scan

We have marked the areas for simplicity.

Area 1 – Cod liver oil tablet external to patients leg

Area 2 – Tibia shaft

Area 3 – Fibular shaft

Area 4 – Medial tibial edge

The first steps in our framework were to IDENTIFY the issue she was having…

We did this by carrying out her MRI scan (below) as she had lots of therapy for shin splints before, The Osteopath decided this was the most suitable course of action. She had the choice of being sent back to her GP – 8 weeks waiting list FREE, or paying privately 24 hours and ?200 – she chose the latter.

The Osteopath ?s clinical judgement in this framework is fairly simple – find out WHAT is causing the issue then find out WHY that it is still an issue. The Osteopath looks to always use an objective marker as it helps to make an informed decision. MRI is useful here but it could easily be a second opinion with a consultant, Gait scan, Ultrasound scans… but this depends on the cause of the issue and what the practitioner thinks they would gain from each type of investigation versus the other.

From here the Osteopath knew roughly what we would find on the MRI scan whilst we were waiting we decided to look at the maintaining factors for her issues. This equates to the ?WHY? she has the issue. There are numerous reasons why people get medial tibial stress syndrome but in this case, a simple walking assessment in the clinic and a clinical examination suggest to the Osteopath that we should look at her left to right weight bearing and her gait more objectively some possible reasons why biomechanically or pathologically she has the issue more on one side than the other.

Here are her gait scans…

The issue was her right side and you can clearly see from the gait scan (marked in red) that her right foot spends longer in pronation than her left and also she has a higher peak incidence of heel pressure on both feet but more on the right side again.

To learn more about Gait scan – click here

Summary and what next…

With the information from the gait scan and her condition, we can see that the client will take a while to heal. The client has already had 8 weeks off running now and her shin is much less tender, but she is still tender. The Osteopath discussed insole therapy and her ongoing management with the client as outlined below……

  1. She will need padding under her feet – even trainers with arch supports give her blisters that do not recover well due to her underlying diabetic condition and high areas of pressure with her previous insoles due to the material they were made from
  2. We can improve her toe position and reduce the areas of high pressure under her forefoot using a small device, this should even out the pressure and allow the client to distribute her weight over a larger area in her foot. The Osteopath referred externally as she needs specialist consideration to manage her diabetes better
  3. Her GP will be informed as she seems to be having a progressive neuropathy in its early stages and this may be an indication of chronic poor blood sugar control
  4. Her stress fracture (the white area inside the medial tibial ridge) in the center of circle 4 on the MRI scan above – will possibly take a long time to heal. We are looking at nutritional support once her blood sugar is under control to assist her blood sugar levels AND to help increase healing rate (collagen-rich and Vitamin C rich foods in particular and possible supplementation with BONE UP to assist this if she cannot do this (under dietetic control). When advising on nutritional support we would first consider her baselines and advise based on her condition.
  5. We will look at her core/posture and address her running mechanics once her issue is under better control but now it’s improving she feels more positive that things are looking up


For more information about how we can help

If you would like additional information about a similar condition or to discuss how we may be able to help with your queries please contact us using the form below and we will get back to you as soon as possible.

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