Running Injuries Recovery Time Lines

Picture from Interplay

I feel that we live in an instantaneous society now where you snap your fingers and you want things done. Fast food, fast internet and fast access to pretty much everything. 

I have many patients who are new to running and want to be a great runner, fast. Many runners expect to improve their times with short periods of training and end up doing too much too soon.

Then there are those who are injured and try to accelerate rehabilitation and recovery beyond normal time lines. I would like to caution that effective recovery will take time and cannot be rushed or forced. 

The 2 times that I fractured my spine, I too hoped to heal faster. However, I cannot accelerate healing and rehabilitation beyond what biology will allow. I can only optimize it.

Back to running injuries. I looked at a study that studied average recovery times for common running injuries. When you look at the study the numbers may surprise you and many of the healthcare professionals that read this.

140 runners out of 839 sustained a running injury in this 24 week study (Mulvad et al, 2018). Runners in the study reported levels of pain in different body parts on a weekly basis. The injured runners attended a physical examination by a physiotherapist who provided a diagnosis. Examples are medial tibial stress syndrome (MTSS or shin splints), Achilles tendinopathy (AT), patellofemoral pain (PFP), Iliotibial band syndrome (ITBS) and plantar fascia pain (PF).

The median time to recovery for ALL types of injuries was 56 days. Yes, you read correctly. Actually let me show you the average recovery times the study found.

Plantar fascia - 35 days

Calf injury - 49 days

PFP - 49 days

AT - 56 days

ITB - 56 days

Gluteus medius tendinopathy - 56 days

Shin splints - 70 days

Hamstring - 74 days

Medial meniscus - 89 days

Surprised or shocked? You should know that effective recovery takes time. Tendons, cartilage, muscle  and especially bone will nor respond to any "magic recovery hacks" or when you try do more. They will respond to patience and appropriate loading. 

When you try to rush your rehab, it usually does not shorten the time line. It will increase the risk of flare ups, setbacks and recurrence.

Now please take note that good and correct rehab is not slow, just appropriately paced. Not everyone will take the same time to recover like those quoted in the study. Recovery is not passive, you can still train. Can't run, stationary cycling should be fine. The healthcare professional treating you should be able to give you alternatives, otherwise you should find another. It is definitely not one size fits all. 

The devil is always in the details. Only 140 out of 839 runners got injured. "Recovery" was self reported by the runners based on return to running without symptoms not performance goals.

The study did not review load management, rehab quality or whether the injuries presented early or late. Neither was training age, sleep, stress levels, nutrition nor psychology taken into account.

The goal is to work within and with the time line, not to beat it. You want the recovery to be boring but steady.

Do not believe anyone who tells you they can give you a short cut.

Reference

Mulvad B, Nielsen RO, Lind M et al (2018). Diagnoses And Time To Recovery Among Injured Recreational Runners In The RUN CLEVER Trial. PLoS One. 13(10): e0204742. DOI: 10.1371/journal.pone.0204742

An Alarming Health Trend In Our Children

Picture from QMHC

I have noticed an alarming trend. Quite a few young patients I have seen in our clinic recently have hypertension (or high blood pressure). This is supported by a recent study showing that childhood hypertension rates are rising significantly around the world. 

The researchers analyzed 443, 914 young subjects aged 1-19 from 21 different countries from 96 studies. Sub-group analyses were performed by sex, age, urban versus rural settings, investigation period, BMI group. Ready for the results?

High blood pressure nearly doubled between 2000 and 2020 in children, rising from just over 3 percent to more than 6 percent. Many young children show early warning signs. Around 8 percent had blood pressure levels that suggest they may be at risk of developing hypertension in the future. 

Some children had 'masked' high blood pressure. 9 percent of children and teenagers had normal reading when tested in a clinic. They however, had higher levels when measured at home or when tested with specialized monitors suggesting that they can be overlooked.

They also found that blood pressure increased during early teenage years. Levels tend to peak at around 14 years, especially in boys. Weight plays a major role. Almost 1 in 5 children with obesity had high blood pressure compared to less than 1 in 40 children with normal weight.

This matters since the increase in blood pressure can continue when they become adults leading to a risk of heart and kidney problems. The study also highlights the fact that this condition is more common than realized and more must be done to to detect the 'masked' cases since early detection can lead to early treatment. Preventative action can be implemented in countries where childhood obesity is increasing.

Picture from Nature

The need for reliable detection, consistent measurement and effective prevention needs to standardized as high blood pressure increases among children and adolescents under 19, now that we know the scale of the problem. They are after all our future.

Reference

Zhou J, Shan S, Wu J et al (2025). Global Prevalence Of Hypertension Among Children And Adolescents Aged 19 Years Or Younger: An Updated Systematic Review And Meta-Analysis. The Lancet Child & Adoles. 10(1): 11-21. DOI: 10.1016/S2352-4642(25)00281-0

New Research On How To Heal Your Tendons

Loading both quads and Achilles tendon

We have been doing it all wrong. Yes, whatever I written previously in this blog about tendon healing is mostly outdated, except maybe this post on collagen.

We have known about this in our clinics since March this year. Having tried it myself plus teaching our patients with good results, the time is right for me to share this information.

If you have tennis or golfer's elbow pain, jumper's knee or pain in your Achilles tendon, this post will definitely interest you. Before you read further, you need to know that almost all common advise regarding tendons that we knew previously are now mostly inaccurate.

Remember Professor Keith Barr? I wrote about his gelatin collagen research back in 2019. His latest research shows us it's time to ditch outdated treatment and start using a research backed approach to healing tendons. He shared his research in an interview with Tim Ferris. You can also listen to the podcast.

Keith Barr shared that the key to tendon repair is not rest or doing eccentric exercises like we have been taught for the past 20 years. It is targeted low load isometric training.

What tendons need is mechanical load and not rest from injury. Not extreme weight to load it but gentle controlled tension to stimulate and rebuild and realign the collagen fibers correctly. Tendons do not respond well to high reps or dynamic loading especially after injury.

With chronic injuries, tendons develop strong areas to shield (or protect) the damaged areas, so longer isometric holds will make the stronger parts fatigue, redistributing load to the weaker, injured parts to be loaded and get stronger.

With isometric contractions, you are simply holding a contraction without movement, for example like a wall sit to train the quadriceps tendon. This gives the tendon just enough stimulus without wearing it out.

Loading R patella tendon and L Achilles

The effective dose to load your tendon is 10 minutes of your time, according to Dr Barr's research.  You just need to feel tension through the tendon, not necessary to be very heavy. 

Remember it's a contraction of the tendon and not a stretch. Done too long, the tendon fatigues and it's not helpful anymore. Here are the specifics. Hold the contraction for 30 seconds. Rest 2 minutes and repeat 4 times. Total of 10 minutes. You can repeat this again 6-8 hours later to make it twice a day.

The isometric holds provide the stimulus and you can help by taking collagen to help rebuild tendon tissue. Barr's recommendations to double collagen synthesis are 15 grams of hydrolyzed collagen taken with 200-250 mg of vitamin C, 30-60 mins before your isometric holds. Choose collagen from skin sources (bovine hide of fish skin) as bone can contain heavy metals.

If you're injured or have just had surgery, you can start loading immediately after injury or surgery. Dr Barr explained how patients that had correct loading 2 days after injury recovered 25 percent faster compared to those who started at 9 days after injury (Bayer et al, 2018).

Please watch the almost 2 hour video here if you want to find out more. It's really interesting. Or you can listen to the podcast on the Tim Ferris show. I listened to the whole podcast first before watching it.

Reference

Bayer M, Hoegberget-Kalisz M, Jensen M et al (2018). Role Of Tissue Perfusion, Muscle Strength Recovery And Pain In Rehabilitation After Acute Muscle Strain Injury: A Randomized Controlled Trial Comparing Early And Delayed Rehabilitation. Scand J Med Sci Sports. 28. DOI: 10.1111/sms.13269

What Equipment Causes Running Injuries?

Take your pick

Now that we are nearing the end of the year, I am seeing more runners who are preparing for the Singapore Stan Chart Marathon. Most of them are not seriously injured, just having slight niggles and wanting to fine tune their legs now that they're tapering before the race.

Others come in to discuss pacing strategies, nutritional needs during the race or whether they should be taping their muscles and joints to run more efficiently.

I came across this interesting research paper earlier this week about how running equipment that you use can predict injury in adult runners. In that study, the authors set out to investigate if runners who are using equipment while running have a higher chance of sustaining  running related injuries (RRI) compared with runners not using running equipment.

Running equipment in this study refers to insoles, ankle and knee tapes, ankle and knee braces, compression garments, jogging/ running strollers and backpack.

7347 adult runners were followed for 18 months in that study. The runners were categorized into groups that were using multiple types of equipment or expressing uncertainty about use.

51 percent (or 3713) of the runners studied sustained a RRI. The researchers found that runners who were using knee braces, knee or ankle tapes, compression socks, insoles or multiple items had higher injury rates. 

Running stroller users however were less likely to get injured. There were no meaningful associations found for ankle braces, backpacks or users uncertain about use.

The researchers concluded that certain running equipment may mean higher susceptibility to injury rather than preventing it. Running equipment should not be assumed to be protective without individual assessment or professional guidance.

This study surprisingly showed that using different types of braces and strapping did not help decrease susceptibility to running injuries. Some previous research have shown that knee braces or custom made insoles may help prevent or alleviate knee pain, ankle sprains and shin splints. Other research found that runners using insoles had nearly double the odds of RRIs compared to those not using them.

However these findings often vary due to different study designs, participant groups and types of injuries addressed. 

Perhaps a lot of new runners use them after seeing online influencers tout different types of running equipment and supplements that may help one run faster or prevent injuries. Naturally, there is still a lack of knowledge regarding the use of different types of running equipment.

It will be better for runners who are having niggles or mild running injuries to get treated for underlying training or biomechanical issues instead of using selected equipment (like tapes and braces) to prevent injuries. 

I personally think that runners using self prescribed equipment like tapes and braces may already have seen a healthcare professional for their existing pain and injuries and are using them to tide them through the recovery period to allow them to train. I have patients who have recovered from running injuries but will still tape themselves to "prevent" re-injury or simply for placebo effects.

Yes, using equipment may worsen existing problems rather than offering protection so please get a healthcare professional who can evaluate and treat the cause of your running injury or pain. That would be more effective.

Reference

Pedersen MK, Rasmussen FK, Lindman I et al (2025). Use Of Running Equipment Predicts Running-Related Injury in Adult Runners: A Cohort Study Of 7347 Runners From The Garmin-RUNSAFR Running Health Study. Trans Sp Med. 6630254. DOI: 10.1155/tsm2/6630254

Grow New Teeth?

Picture from Amazon

Last week I wrote about how consuming too much energy drinks can cause erosion in our teeth. I grind my teeth a lot when I sleep and have been using a night splint for the last 20 years. Also, I used to drink a lot more Coca Cola, sports drinks and consume energy gels back when I was competing. So I am worried about the erosion in my teeth.

If we fall and our bones break, the bones have the ability to heal and grow back. However with our teeth, the same cannot be said. Once you lose a tooth, that's it, unless you put in a dental implant to hold an artificial tooth on top.*

What if I told you now that growing back teeth may be a possibility in less than 5 years. Japanese researchers are now experimenting with an experimental drug that may regrow human teeth.

This is after years of study around Uterine sensitization-associated gene-1 (USAG-1), an antibody shown to inhibit the growth of teeth in ferrets and mice. However, back in 2021, the researchers found a monoclonal antibody (usually used in fighting cancer) that disrupted the interaction between USAG-1 and molecules known as bone morphogenetic protein or BMP. 

Suppressing USAG-1 benefits tooth growth. And believe it or not, ferrets have a similar dental characteristics to humans. Both develop 2 sets of teeth in a lifetime, a temporary set or "baby" teeth followed by a permanent adult set.

The researchers have started trials on humans. It will last 11 months and focus on 30 males between the ages of 30 and 64 with each missing at least one tooth. The drug will be administered intravenously to assess it's effectiveness and safety. Previous animal studies did not show any adverse side effects.

The researchers are hoping that if the trial goes well, they can administer this treatment to patients between the ages of 2 to 7 who are missing at least 4 teeth. The end goal will be to have tooth regrowing medicine by 2030. 

Although the current treatment will be focused on young patients with congenital tooth deficiency, the treatment will eventually be available to anyone who is missing a tooth. Human trials began last September 2024. Let's wait and see.

Reference

Murashima-Suginami A, Kiso H, Tokita Y et al (2021). Anti- USAG-1 Therapy For Tooth Regeneration Through BMP. Sci Advances. 7(7): eabf1798. DOI: 10.1126/sciadv.abf1798

* Thanks to Dr Winston Tan and Dr Dr Frank Liew who have been looking after my implants and teeth all these years.

Too Much Energy Drinks Causes Tooth Erosion

Guess what I'm drinking in my 2 water bottles in 2001?

My patient who is a dentist tells me he is seeing a lot of younger patients having erosion in their teeth.  The features of their particular erosion is non-bacterial acid induced loss of dental hard tissue. A notable contribution is due to increased consumption of acidic drinks, especially energy drinks. 

Fortunately, I never had any Red Bull or Monster in my water bottles when I was still training seriously or racing.

Like I wrote previously, energy drinks are thought to be beneficial for performance. My platoon mates in the army when we were doing national service, would frequently load up with energy drinks such as Red Bull. There was no Monster drink then. They would consume it especially in the morning before physical training and Standard Obstacle Course (SOC) training sessions. Those who were less fit tended to count on those energy drinks. One of them commented that without Red Bull he would definitely fail his fitness tests.

Some of them would also mix Red Bull with alcohol when they book out on Fridays so they can party the night away.

This was similar when I was in university. Some of my classmates did the same when cramming for an exam or writing a paper.

Energy drinks from the study

A paper published last year (Martinez et al, 2024) was investigating the pH of energy (pictured above) and pre workout/ sports drinks (below) and the consumption frequency and habits among amateur athletes. Their study analyzed the pH of 67 commercially available energy drinks and pre workout/ sports drinks. There were 43 energy drinks and 24 pre workout/ sports drinks.

Pre workout/ sports drinks

The authors also did a survey among 113 amateur athletes who completed an anonymous questionnaire to find out about the use of different beverages during various sports activities. The participants participated in strength training, endurance sports and some of them participated in both. They reported consuming energy and/ or pre workout/ sports drinks before, during or after workout.

Ready for the results? The average pH for the beverages studied was 3.3. The pH level at which enamel erosion begins is approximately 5.5, which is known as the critical pH. When the pH in our mouths drop below this level, the enamel starts to dissolve, leading to tooth decay.

51 percent of the participants surveyed said, they consumed at least one of the beverages studied. Most participants aged ≤ 29 consumed them 3-5 times each week while the older participants consumed them 1-2 times per week.

Shocked? The study showed that ALL the  energy drinks and the majority of pre workout beverages evaluated have erosive pH levels that can damage tooth enamel. Please remember this when using energy drinks or pre workout/ sports drinks. 

I always carry water with me during my bike rides instead of energy or sports drinks. Drinking plain water after your sports drinks is a good way to mitigate the erosive nature of the energy drinks. You may also want to brush your teeth when you get home.

Reference

Marthiez Lm, Lietz, LL, Tarin CC et al (2024). Analysis Of The pH Levels In Energy And Pre-Workout Beverages And Frequency Of Consumption: A Cross-Sectional Study. BMC Oral Health. 24,1082. DOI: 10.1186/s12903-024-04843-0.

Take your pick

Nose Strips Help You Race Faster?

Picture by Tim de Waele, Getty images

A patient just asked me about nasal (or nose) strips. She had seen lots of runners using them recently and wonder if they can help her run faster. 

I remember getting a couple of Breathe Right nasal strip samples in my goodie bag in a triathlon race that I took part way back in 1999. I had never used them before and I thought there's no harm in trying them in the race. 

Paula Ratcliffe in her heyday- M Hewitt, Getty images

I actually won that race but felt that the nasal strip did not help much except giving me a funny tan on my nose as race day was blistering hot. I remember seeing Jan Ullrich and Paula Radcliffe wear them when they were racing as well. 

Picture by O Docelin, Getty images

I noticed them again during the Tour De France this year (pictured above). Many cyclists were seen using them, some even using custom decorated ones. 

Bastille Day -Tim de Waele, Getty Images

So are these nose strips worth wearing? Do they help improve your sporting performance? Yes they do help with the "negative pressure" that builds up and blocks your nostrils during heavy breathing. They do improve airflow by enlarging your breathing passageway. 

However, what really matters is the amount of oxygen that gets into your bloodstream and not the amount of air you breathe in. For most people, the normal air you breathe in will mostly saturate your blood's oxygen carrying capacity.

A recent systematic review concluded that nasal strips do not help with VO2 max, rates of perceived exertion or heart rate response (the body's response to exercise).

If you're eating an energy bar on the bike or run, the nasal strip can help increase the ease of eating and trying to breathe at the same time. They can increase the comfort of breathing, especially if you have a deviated septum, some nose congestion or allergies, but they do not offer a performance advantage.

There is no real 'downside' and at best a placebo effect for those using them. I personally think it is more of a fashion statement if you look at the pictures from the 2025 TDF.

Should you try the nose strips? Yes, if you suffer from specific nose structure issues or want to use them as a fashion statement. They are not expensive and a good placebo effect is a legal performance enhancer.

References

Dinardi RR, Ferreira CHS, Silverira GS et al (2021). Does The External Nasal Dilator Strip Help In Sports Activity? A Systematic Review And Meta-Analysis. Eur Arch Otorhino. 278(5): 1307-1320. DOI: 1007/s00405-020-06202-5.

Illidi CR, Romer LM, Johnson MA et al (2023). Distinguishing Science From Pseudoscience In Commercial Respiratory Interventions: An Evidence-based Guide For Health And Exercise Professionals. Eur J Appl Physiol. 123(8): 1599-1625. DOI: 10.1007/s00421-023-05166-8