Friday, June 23, 2017

Please Help My Swollen Knee

My patient sent me the above picture recently asking for help. Her knee became swollen after a recent run. After icing her knee, she decided to use some "imitation/ copy cat" Kinesio Tapes but that didn't resolve the swelling and worse still gave her an allergic reaction.

Knee joint effusions (or swelling) are usually caused by the knee joint producing more synovial fluid due to aggravating factors causing damage to the joint.

As little as 5 ml of fluid can increase pressure within the knee joint. This can be a source of discomfort and concern for the person affected.

It takes a very small volume of fluid in the knee (20-30 mls) to result in biomechanical changes. The quadriceps will be inhibited as a result (meaning you are less willing to use that muscle) and strength decreases rapidly.

It has also been found that swelling in the knee affects joint mechanics particularly during landing tasks. If someone has effusions in the knee, they tend to land with greater ground reaction forces (or impact) and in greater knee extension (or straightening). This results in more forces transmitted to the knee joint and its ligaments. So you can't run and jump quite as well.

When we see knee joint swelling in our clinics, we try to remove the swelling pronto. Flossing the knee joint, using correct Kinesio taping techniques with genuine Kinesio tapes definitely helps.

My favorite is of course aqua based rehabilitation/ deep water running to take advantage of hydrostatic pressure to help with the swelling. This also allows for quadriceps/ hamstrings strengthening early on without additional loading.

If the patient has more severe effusions, we may suggest altering their gait temporarily (we call this pain free walking), using non-steroidal anti inflammatory medication (NSAIDs) or even suggest they get the joint aspirated (I've tried it, it hurts like crazy).

Once the swelling settles, it will quickly and significantly reduce internal pressure in the knee as well as improve quadriceps strength.

We will quickly select rehabilitation exercises to allow specific quadriceps muscle recruitment without increasing intra articular pressure with knee extension. This is usually done in positions of partial knee flexion (20-30 degrees).

Now you know. Come see us in our clinics if your knees are swollen.


Hart JM, Pietrosimone B et al (2010). Quadriceps Activation Following Knee Injuries: A Systematic Review. J Athl Trg. 45(1): 87-97. DOI: 10.4085/1062-6050-45.1.87.

Palmieri-Smith RM, Kreinbrink J et al (2007). Quadriceps Inhibition By An Experimental Knee Joint Effusion Affects Knee Joint Mechanics During A Single-Legged Drop Landing. AJSM. 35(8): 1269-1275. DOI://

Friday, June 16, 2017

Both Men And Women Equally Unhappy With Their Bodies

Picture by suez92 from Flickr
I do happen to see quite a lot of men and women who are unhappy with their bodies. And lately, some boys and girls too. Previously, I used to treat a lot more women who were unhappy about how their bodies looked so they'll exercise more and get injured in the process. They'll come and see me hoping that I'll make them pain free so they can exercise again.

Their injuries were easy to treat, their mindset much more difficult.

Well, it seems that men are just as likely to be insecure about their looks. I think we're in a cultural shift in terms of the ideal body image. In movies, advertisements and magazines etc, the ideal man is often portrayed and shown to be more muscular than men in the real world.

Don't get me started on the ideal female physique. The fantasy female has a slim hourglass figure with big boobs and a BMI which was in the normal range but close to the underweight category.

A recently published study of 12,716 respondents found that only 28% of men said that they were "extremely satisfied" with their appearance compared to 26% of women.

It is not surprising to note that weight was closely to people's body image. Only 24% of men were extremely satisfied with their weight while 20% women felt extremely satisfied with theirs.

These findings are consistent with the emphasis placed on the importance for being slender for women and appearing athletic and/ or lean for men.

Take note that the subjects had to opt in to take part in the study so this sample size may not be representative of the general population.

And it gets worse for kids. Adolescent boys who were dissatisfied with their body shape were found to be more likely than girls to self criticize and feel distress (Mitchison et al, 2016).

Don't let others tell you how you look affect you. You're stronger than that.


Federicks DA,Sandhu G et al (2016). Correlates Of Appearance And Weight Satisfaction In A U.S. National Sample: Personality, Attachment Style, Television Viewing, Self-esteem And Life Satisfaction. Body Image. 17:191-203. DOI: 10.1016/j.bodyim.2016.04.001.

Mitchison D, Hay P et al (2016). Disentangling Body Image: The Relative Associations of Overvaluation, Dissatisfaction, And Preoccupation With Psychological distress And Eating Disorders In Male And Female Adolescents. Int J Eating Disorders. 50(2): 118-126. DOI:

Sunday, June 11, 2017

Is Running On A Treadmill More Difficult Than Running Outside?

I've had patients travelling this past couple of weeks during their kid's school holidays. The only time they could run was on a treadmill in the hotel. A few of them have asked me why they found running on a treadmill more tiring than on the road or track. 

I thought this was strange as running on a treadmill should not be more difficult than running outside and looked it up. 

And true enough, I found an article in which runners were asked to run on a track and then asked to rate how difficult the exercise felt. They then went on a treadmill without a display unit of the speed they were running and told to set the treadmill at the same pace they thought they had just ran. Almost all the runners chose a speed that was much slower. 

Researchers have found that for most people, running biomechanics are similar whether running on a treadmill or outside (Riley et al 2008).

In fact, running on a treadmill is less jarring than running on the ground outside. A 2014 study (Kaplan et al, 2014) showed that we strike the ground with about 200 percent of our body weight while running on an outside track. This was reduced to 175 percent of our body weight when running on a treadmill. 

Evidence suggest that the hard work associated with treadmill running is psychological. Many studies show that people experience less fatigue, more vitality and greater pleasure waling outside compared to walking on a treadmill. 

Personally I feel it is definitely nicer to exercise outdoors. I don't like running on the treadmill too much. I'd much prefer running outdoors any time. I feel like a caged hamster going on and on in a wheel when I'm running on a treadmill. 

Picture from giphy
However, after my accident, I'm very happy just being able to do any exercise. A run is a run, whether outdoors or on a treadmill.


Kaplan Y, Barak Y et al (2014). Referent Body Weight Values In Over Ground Walking, Over Ground Jogging, Treadmill Jogging, And Ellipticall Exercise. Gait Posture. 39(1): 558-562. DOI: 10.1016./j.gaitpost.2013.09.004.

Kong PW, Koh TM et al (2012). Unmatched Perception Of Speed When Running Overground And On A Treadmill. Gait Posture. 36(1): 46-48. DOI: 10.1016./j.gaitpost.2012.01.001.

Riley PO, Dicharry J et al (2008). A Kinematics And Kinetic Comparison Of Overground And Treadmill Running. Med Sci Sports Ex. 40(6): 1093-1100. DOI: 10.1249/ MSS.0b013e3181677530.

Thompson CJ, Boddy K (2009). Does Participating In Physical Activity In Outdoor Natural Environments Have A greater Effect On Physical And Mental Wellbeing Than Physical Activity Indoors? A Systematic Review. Environ Sci Technol. $5(5): 1761-1772. DOI: 10.1021/es102947t.

Monday, June 5, 2017

Should I Be Using A Standing Desk?

Now, that's a different standing desk. By Liz Henry from Flickr
Sitting kills. That's the headline many of you would have seem or read in the last few years. You've also read or heard that sitting is the new smoking. And if you've been following our blog, I've written before that despite exercising a lot, if you sit too much at work, you can be what is known as an active couch potato. Worse still, all that sitting can negate the benefits of your exercise.

Well fortunately for me, I hardly get to sit much when I'm working in the clinic.

Many of my patients have asked about the benefits of a standing desk. I even found a picture (below) of former British Prime Minister Winston Churchill working on his slanted standing desk.
Kurt Hutton/picture post via Getty
Standing desks have been suggested as an alternative to the ills of sitting. And there's studies to show that working upright (at a standing desk) can help correct your posture and tone your stomach and legs without compromising your focus.

And in kids, standing desks seems to increase their energy levels and reduce hunger.

My take on standing desks? I've seen many of my patients go straight from sitting to a standing desk get different problems. Being unaccustomed on their feet all day long poses new risks. It can inhibit proper circulation and add additional pressure to your hips, legs and lower back. Sort of like jumping from the frying pan into the fire if you ask me.

And unfortunately, research shows that sitting once or twice throughout your work day will not offer you enough relief. So don't switch to a standing desk if you've been sitting all day straight away, make sure you gradually phase it in.

What are the alternatives? I prefer the stability ball or better still the saddle stool with adjustable height so that you can perch on it if you're not quite used to standing yet.
Our clinic's saddle stool
There's also the desk cycle, though I definitely haven't tried it yet.
Desk cycle

Commiassaris DA, Konemann R et al (2014). Effects Of A Standing And Three Dynamic Workstations On Computer Task Performance And Cognitive Function Tests. Appl Ergon. 45(6): 1570-1578. DOI: 10.1016/j.apergo.2014.05.003.

Garcia MG, Laubil T and Martin BJ (2015). Long-term Muscle Fatigue After Standing Work. Human Ftr and Ergo Society. 57(7): 1162-1173. DOI: 10.1177/0018720815590293.

Monday, May 29, 2017

Steroid Injection Not Better Than Placebo For Low Back Pain

Picture by Army Medicine from Flickr
It seems like another of my patients has been asked if he wanted a cortisone (or corticosteroid) injection for his low back pain after I wrote about my shoulder pain patient last week who was asked by another doctor to get a steroid injection.

Evidence that they (cortisone or corticosteroid injections) work no better than placebo is mounting though.

The article referenced below is a systematic review. A systematic review is a computer aided search for all randomized and clinical controlled trials, meaning it's top of the line in terms of quality.

Researchers pooled data together from 30 placebo controlled studies of epidural steroid injections for radiculopathy (back pain that radiates to legs) and eight studies for spinal stenosis (back/ neck pain caused by narrowing of the spinal canal).

For radiculopathy, the steroid injections provided only short term relief. Over time, they were not more effective compared to placebo injections. They also did not reduce the need for surgery later for patients with more severe conditions.

The pooled data was similar for spinal stenosis.There was only some moderate temporary pain relief after the corticosteroid injections. There were no differences between steroid injections and placebo injections in pain intensity or functional ability lasting six weeks or longer after the injections.

The authors did note that some studies did not have many subjects while others had shortcomings their methodology.

The researcher in charge also suggested that there was probably some financial motivation to carry on using steroid injections despite the lack of evidence for its effectiveness. There is also a worry among professional societies (for doctors) due to implications for insurance coverage.

Other mentioned less selfish reasons is that doctors see their patients in horrible pain and concede that they do get some pain relief after the injections.

Please come to our clinics if you need help with your low back pain. We definitely do not give steroid injections.


Chou R, Friedly J et al (2015). Epidural Corticosteroid Injections For Radiculopathy And Spinal Stenosis: A Systematic Review And Meta-analysis. Ann Intern Med. 163(5): 373-381. DOI: 10.7326/M15-0934.

Sunday, May 21, 2017

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck
I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement
Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.


Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Saturday, May 13, 2017

Rachel Plays Her Part Helping VJC Win 5th Straight Football Title

On Sunday night (7/5/17), my colleague Rachel asked me if she could leave work early on Tuesday 10/5/17. She wanted to watched her alma mater play in the 'A' division girls football final against Meridian Junior College.

Rachel was top scorer before in her time at Victoria Junior College (VJC) when she herself represented VJC. As I wrote previously, she scored a hat trick when VJC beat my alma mater's team 10-1 in the semi finals of the same tournament eight years ago.

When I introduced her to a physical education teacher from the losing school, he immediately remembered the trashing our school received and he was in awe of her. Still famous as ever eight years on. Well done Rachel!

Of course she could go! She had been volunteering her time (with the clinic's blessings) most Wednesday's afternoons at VJC since the beginning of the year.

On days before a match, if you come to our Holland Village clinic you might be lulled into thinking VJC was near our  clinic (and not in Marine Parade) or that our clinic was a mini VJC gathering place.

Definitely businesses near our clinic like Sunday Folks and The Daily Scoop have benefited when the students come for treatment as they go there after treatment.

So congratulations to VJC for the fifth consecutive football title and Rachel Wong for a job well done!
Rachel with the victorious team.
Note: Rachel also treats students competing in other sports and not just the girls from football. So perhaps next year we'll see more VJC students in our clinic this time of the year?