Several weeks ago, I learned about a fairly new company based out of New York that was created by Dr. Barry Katz, a former basketball player and lover of the sport who happens to also be an orthopedic radiologist. His company, Ektio, markets a basketball shoe that doesn’t have an NBA stars face on it or a flashy marketing campaign, but rather claims to include revolutionary design technology that is specifically aimed at reducing ankle sprains by a mechanism that would specifically limit excessive inversion of the foot, the ankle movement that is responsible for 95% of basketball ankle sprains. It seemed like an intriguing concept to me and I quickly began researching the ideas behind the shoe’s technology, the substance and data behind the claims that were being marketed, and the overall ingenuity in the product design.
Through the process of researching and learning about the shoe’s concept, design, and reliability, I was given the opportunity to speak with/interview both Dr. Barry Katz as well as former NBA star and hall of famer, Rick Barry, who is an advocate and spokesman for the company. Though empirical data always means a bit more to me than testimonials and spoken claims, it was great to get a chance to ask more questions and truly gain insight into the goals of the company and the driving forces behind the design.
So before we jump right into examining the shoe and the claims regarding ankle sprains that are described by Ektio, let’s quickly review ankle sprains with a specific look at ankle sprains in basketball.
When one hears the phrase ankle sprain, most athletes/exercise enthusiasts can envision an individual “rolling” his or her ankle and then enduring that terrible sharp pain that may seem to nag forever when trying to plant, pivot, run, etc. Just like most topics in sports medicine, anatomy is essential in breaking down and understanding ankle sprains.
The four main movements that the ankle joint is responsible for are:
1. Dorsiflexion (Pointing your foot upwards towards the shin)
2. Plantarflexion (pointing the food downwards like pushing on a gas pedal)
3. Inversion (Turning the ankle inwards so the side of your foot is facing the ground)
4. Eversion (The opposite of inversion where the ankle turns the foot outwards)
The ankle joint, which is also sometimes referred to as the talocrucal joint, is a hinge joint that is located at the distal end of shin bones (the tibia and fibula) and the upper part of one of the foot bones called the talus. The ends of the shin bones form a deep socket called the maleolar mortise. This deep pocket serves to both stabilize the joint and act as an anatomic pulley to help produce the characteristic motion of the ankle.
In addition to the bony stabilization of the ankle joint we also have a lot of ligamentous structures that work to help hold the bones together in a stable pattern and endure the many stressors we put on our bodies.
As previously mentioned, most ankle sprains occur as inversion injuries because of the way we tend to twist/roll-over on our weight-bearing leg when we have shoes on. The twisting motion at the joint puts a lot of stress on parts of the lateral ligaments (outside) called the anterior talofibular (most commonly injured) and the calcaneofibular (second most commonly injured). These injuries most commonly result in the pain and swelling on the outside of the ankle that people experience with sprains.
The less common ankle sprains involve eversion injuries, which occur when we roll out ankles outwards and overstretch a ligament called the deltoid ligament. This will commonly cause pain, swelling, and may cause instability on the inside portion of the ankle.
For more information on the classification of ankle sprains and common treatments, you can check out a previous article I wrote a couple of years ago in response to our beloved, Rob Gronkowski’s “high” ankle sprain right before the playoffs.
Now with a better understanding of the anatomy, we can discuss ankle sprains in basketball and the thought/theory behind Dr. Katz’s technology. A 2010 study published in JBJS regarding the epidemiology of ankle sprains indicated that incidence of ankle sprains in the US 2.15/1000 people per year. They also stated that overall, there is no difference in incidence between males and females, but that when one examines the population between the ages of 15-24, males have a much higher incidence (7.2/1000 people) as compared to females.
The study also showed that 49.3% of all ankle sprains were related to sports and of those ankle sport-related ankle sprains, an overwhelming 41.1% of them were basketball related. To further illustrate sport-specific data regarding ankle sprains, a study from the British Journal of Sports Medicine that examined sport-related ankle sprain epidemiology reported that 70% of basketball players described a history of ankle sprain and that 80% of them reported multiple sprains. With the rapidly growing popularity and marketing of basketball over the past several years, this number is likely a bit higher and the number of chronic ankle injuries may be under-represented.
Chronic ankle problems typically result in increased residual symptoms such as pain, muscular weakness, instability (ease of giving way), swelling, stiffness, and crepitus (cracking). Furthermore, numerous studies have shown that recurrence seems to be fairly high, giving way to an athlete who seems to perpetually be sidelined with ankle troubles.
While this is certainly not surprising to anyone who has ever played basketball, it definitely shows that from a sports medicine standpoint that focus on ankle injury prevention in basketball is critical to keeping player on the court and healthy. Sure, we can treat ankle sprains rest, ice, elevation, compression, anti-inflammatories, braces, or even surgery, but the best way to help an athlete is to prevent them in general.
This is where Dr. Katz thought he could do something to help. With his experience playing basketball and his knowledge of orthopedic anatomy, he realized that the best way to approach ankle sprains is by redesigning the most critical piece of equipment that a basketball player uses, the shoe.
In every sport, footwear is critical to performance. We have sport-specific footwear for everything from wrestling to ballet, yet with ankle sprains being so common in basketball, the basic design of the shoes have not really changed too much over the past decade.
Since the advent of “Chuck Taylors,” basketball shoes have always been high-topped shoes with hopes of adding extra ankle stability. While the higher support does help in reducing the rolling over motion of the ankle, it doesn’t really help too much with preventing inversion, which as we’ve mentioned before is the culprit to 95% of basketball sprains.
Dr. Katz describes the importance of shoes in ankle sprains, by indicating that the reason one commonly sprains an ankle is that the foot is a separate object from the shoes. When the shoe becomes inverted, the ankle slides within the shoe, resulting in the lateral side of the foot being almost parallel to the floor. His solution to this problem was to add several strategically placed straps within the shoe that aim to secure the wearers foot to the shoe.
More specifically, the first strap wraps around the walls of the shoe to support the lateral components of the ankle, whereas the second strap lays directly over the ankle mortise to prevent the wearer’s foot from moving within the shoe, thus attempting to eliminate the aforementioned phenomenon of the foot sliding within the shoe.
In addition to the two straps, the sole of the shoe has a lateral piece of rubber placed on the outside of the shoe that acts as bumper, to help prevent roll-over injuries.
So does the shoe work? Well, from the limit data that is available, it appears that the shoe does a pretty decent job at preventing inversion of the ankle. After being sent the draft of an unpublished study performed at Drexel University, the technology applied to the shoe certainly looks promising. The study was limited, using only five subjects and examining the right ankle. Subjects were tested in both their standard basketball shoe as well as the Ektio shoe and an Ankle Flexibility Tester (device that allows cyclic load-unloading torque to be applied) was applied to test inversion, eversion, and internal/external rotation.
Their results indicated that the shoe limited inversion of the ankle to less than 30 degrees, which is significant in that most ankle sprains occur at angles of inversion greater than 30 degrees. Furthermore, it appears that the increased stability with the Ektio shoe in terms of limiting inversion was between 14-20% as compared to the standard shoe. While there was a statistically significant increase in stability limiting ankle inversion, this study did not seem to significantly limit any of the other 5 motions in the ankle, which are essential in performing the required movements for success in basketball such as pivoting, shifting running and jumping.
Though the study is certainly interesting and promising for this new technology, it is significantly weakened by the small sample size and could certainly display an increased power if more subjects were added to the study design in the future. Furthermore, it was not indicated whether the standard basketball shoe was the same make/brand on each of the players. In a study examining shoes, this is an important variable to address.
This leads one to ask another question, if the shoes are limiting inversion, do the wearers feel that the shoe is any different than the standard shoes they are used to? I was given the opportunity to speak with former NBA player, hall of famer, and spokesperson for Ektio, Rick Barry, who indicated that he didn’t feel any difference in wearing the shoe. He stated that when he was contacted about the shoe concept, he was intrigued and wanted to try it out. When he realized how the shoe felt and the fact that it seemed like it could make a real difference in terms of preventing ankle injuries, he wanted to get on board to promote it. Mr. Barry also joked with me, stating that he can with certainty say that the shoe doesn’t feel much different than other basketball shoes because his youngest son, who’s quite picky, wears them without any complaints.
Though anecdotal evidence is nice to hear, it’s always better to see empiric data. This is were a study from the Hospital for Special Surgery comes in. They examined the Ektio shoe versus bare feet, standard basketball shoe, and a standard shoe with an ankle brace, while participants were engaged in normal basketball activities such as running, jumping, and pivoting and recorded muscle firing patterns in the gastrocnemius/soleus complex, the tibialis anterior, and the peroneus longus muscles. From this data, they concluded that there were no significant differences between the Ektio shoe and the standard shoe or barefoot, which indicates that there seems to be no compensatory stress on any of the other aspects of the ankle or leg as a result of the limitation of inversion to less than 25-30 degrees. It also may suggest that the athlete is not performing any differently on the court while wearing this shoe.
Despite the small size and the rawness of the data presented in these preliminary studies, the concept of the shoe and the construct of the technology is promising to hopefully help in reducing ankle sprains in a sport in which ankle sprains affect more than half of the participants.
Through my conversation with Dr. Katz and Rick Barry, it seemed that these individuals truly want to create a shoe and promote a product that not only performs well on the court, but also helps to keep the athlete safe. Rick Barry said, “Any current player would be stupid not to want to get their hands on these.” He indicated frustration with the fact that it is difficult to get a shoe to be worn in the NBA because of the multi-million dollar contracts that larger companies can offer teams and players to wear their product.
So what’s next for this product and the future of Dr. Katz’s technology? I asked Dr. Katz if he thought about expanding his design construct to other sports and possibly performing a larger study. He told me that he certainly would like to expand and modify his construct to apply to other sports where ankle injuries are prevalent such as football. Furthermore, he stated that he also has an interest in including his construct in military combat boots to help prevent ankle sprains in our soldiers who currently are exposed to difficult terrain and incredible stress on the ankle and legs.
Overall, the Ektio shoe seems to be a promising product with a well thought out design and construct. It is refreshing to see a shoe being marketed by a small company with a specific goal of helping keep the athlete safer as opposed to the more common, overly expensive shoes with flashy colors and an athlete’s name branded all over them. Though I cannot say whether or not the data from the preliminary studies will continue to hold true in a more comprehensive study with more participants and tighter controlled variables, the preliminary data certainly is interesting and something to keep an eye on as Dr. Katz continues to try to gain ground in the tough world of marketing a sporting equipment.
My goal in writing this piece was not to promote a particular product, or state that every athlete needs a particular shoe. This is certainly not true. Every player is slightly different in terms of his or her ankle construct and biomechanics, and should select equipment that best suits his or her needs. It is, however, my opinion that being best informed about the options that are available, especially the ones that do not get billboard or magazine advertising, is essential in selecting the most appropriate products for one’s physical and structural needs. Reducing ankle sprains in sports (especially basketball) has been an important topic in sports medicine for quite some time. As with any sports injury, there are no products that can completely prevent something from occurring and we must be aware of injuries as they occur and treat them in the best ways possible. Adequate training both on and off the playing field or court, as well as appropriate rest and recovery are critical in any sport. Adjunctive products may offer benefits in prevention and management of injuries, but always remember to seek adequate assessment of any injury by a qualified health care professional.
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Moore, KL, Agur, AM. (2007). Essential Clinical Anatomy. Philadelphia, PA: Lippincott Williams & Wilkin.
Plowman, SA., Smith, DL. (2008). Exercise Physiology for Health, Fitness, and Performance. Philadelphia, PA: Lippincott Williams & Wilkin.
Yeung MS, Chan KM, So CH, Yuan, WY. An epidemiological survey on ankle sprain. British Journal of Sports Med (1994); 28(2): 112-116.
Waterman BR, Owens BD, Davey S, Zachhilli, MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. Journal Bone Joint Surg Am (2010); 92(13): 2279-2284.
*Note the Drexel and the HSS studies that were mentioned are not published in any journals as of yet and were raw data that were provided by Dr. Katz.