Friday, July 22, 2016

Will Training When You're Tired Make You A Better Athlete?

Who says I can't lift when I'm tired? Picture from The Pit
My two boys share the same bed with my wife and I. Two nights ago at about 3 am, the younger one's diapers malfunctioned and leaked. I had to help my wife remove the soiled mattress covers while my older kid snored through it all. 

It took me a very long time before I fell asleep again, probably at about 5 am. I was soon awakened by my older boy telling me that he needed to pee ..... 

Needless to say, my wife and I were sleep deprived and tired.

Training when you're tired can be tricky. There's also some evidence to suggest that it increases your risk of injury. Especially since energy levels are depleted and you become slower in your reaction and decision making time. This will probably also impact your ability to perform.

Approached properly, training while tired may actually make you a better athlete suggested exercise physiologist Darren Paul and colleagues in their study. They found that training when you're tired can result in better maintenance of strength and improved postural control.

And not only endurance athletes can benefit from pushing past fatigue during training. 

Soccer players in their research who performed strength or balance exercises at the end of their training sessions (rather than at the beginning) were not as affected by fatigue during their matches.

When you train through fatigue and you learn to push through something difficult, it definitely gives you confidence. It's definitely empowering and shows you that you can do more than you likely thought you could.

Here are some personal suggestions as to how you can train while fatigued without getting hurt in the process and improve your performance.

Always focus on your form. Good form and technique has to always come first regardless of whether you're tired or not. If you need to push through fatigue while training, do it while maintaining proper form. If you're going too hard or too fast but not having good form and technique then you need to slow down. That will minimise your risk of injury. 

Some marathoners I've treated will often do a shorter steady paced run the day before their long run. They may run 10 km at their marathon race pace the day before their long run. They will then have some level of fatigue and glycogen depletion from the previous day's run to simulate fatigue setting in later in a race while doing their long run.

While I was still training for triathlons, brick workouts were the norm. Meaning we often stack workouts on top of each other (like stacking bricks). We often practise short but very quick running after a bike training session which forces our legs to adapt quickly. 

Training through fatigue also mean you do not do three days of interval-like running in a row. If you do that you're definitely walking down the path to injury or illness. You are training through fatigue to gain fitness and to get stronger as a result of that stress. So you definitely need to factor in appropriate or even extra recovery to help your body recover and adapt. Only then can you emerge stronger.
zzzzz ....
So my wife went for a run that morning while I was out walking and putting my son to sleep. I didn't exercise that morning but I managed to run home after I ended work at Physio Solutions that evening.


Paul D, Narciss G et al (2014). Injury Prevention In Football. Time to Consider Training Under Fatigue? Aspetar Sports Med J. p 578-581. See the article here.

Sunday, July 17, 2016

Fear Is Your Biggest Enemy When You're Injured

Now that's gotta hurt (Picture from Ang Kee Meng)
Are you recovering from an injury or recuperating from a surgery? Fear plays an enormous role when you're recovering from an injury, especially a long term injury.

Trust me I've had 3 knee surgeries on my right knee. For a few years after my 3rd knee operation I was paranoid about the slightest pain in my right knee. I made sure I only ran on grass (less impact or so I thought), read every single published article on articular cartilage injuries (my condition) and did lots of deep water running.

I remember every time if someone on the bus or MRT stood too close to me (let alone bump into my knee) I'll give the person a dirty look and move away.

So I'm pleased to share that I'm not the only paranoid athlete/ person around. Researchers suggest fear can determine whether or not an athlete makes a full recovery. Some athletes even have "post traumatic stress" back to the moment they got injured.

In a group of patients recovering from an anterior cruciate reconstruction (ACL) reconstruction, strength of muscles around the knees, functional range of movement, level of activity and intensity of pain were measured over the course of their recovery. Researchers also measure levels of kinesiophobia, pain related fear of movement,

The most common reason for not having a full recovery was the fear of getting injured again. These athletes did not have higher levels of pain than others in the study, they were just plain scared.

The researchers concluded that their results show that physical impairments may contribute to initial functional deficits whereas psychological factors (or fear) may contribute to longer term functional deficits in patients who are still fearful of re-injury. This fear and/ or lack of confidence may be a barrier to future sports participation.

Addressing your fear, alongside the physical injury is critical for your recovery.

Oh, by the way I forgot to mention that I've also fractured my skull before and had a compression fracture in my lumbar spine as well.

Come see us in either of our clinics if you're struggling to recover from your injuries/ surgery from fear, lack of confidence or other physical reasons.


Lentz TA, Zeppieri G Jr, George, SZ et al (2015). Comparison Of Physical Impairment, Functional, And Psychosocial Measures Based On Fear Of Reinjury/ Lack of Confidence And Return-To-Sport Status After ACL Reconstruction. AJSM. 43(2): 345-353. DOI: 10.1177/0363546514559707.

Saturday, July 9, 2016

Hey, Isn't That Alfred Sim (Project SuperStar Winner) At The Floss Band Course Today?

Flossing Alfred Sim's shoulder
Yes, it is Alfred Sim (Season 3 Project SuperStar winner) at the Floss band course at Sports Solutions  today. I had treated Alfred when he was a much younger sprinter years ago when I used to work at the Singapore Sports Council (now known as Singapore Sports Institute). I never knew Alfred was into singing and acting.

Other than Alfred, I also met other old friends, ex colleagues and participants from other courses I've taught.

Telling the class I've got fewer than 3 white hairs ...
As usual, once the theory component was done and dusted, the practical was underway.

Hey Liam, look at Cedric (in white) not Maire
Flossing Maire's lumbar spine
Sharon elbowing Bijun in the face ....
A big thank you to all who came today, it was nice seeing familiar faces in the class, occupational therapist Sharon Seah, KTP hospital Principal Physiotherapist Bijun, Kit Ping my ex colleague from SSC and Alfred Sim of course.

Kudos the Jane, Danny, Amy, Carol for coming early and setting up the place while I was still treating patients. Chapeau to them. Please contact them at Sanctband Singapore if you wish to attend the course or get the Floss bands.

Saturday, July 2, 2016

More Miles Does Not Mean Bad News For Your Knees

Singapore Stan Chart Marathon picture by RunSociety from Flickr
You will know someone who has had to rest from running because of an injury. And you will probably know someone who has been told by the doctor to quit running or their knees will wear out. Hence, it's easy to understand why so many people believe that running is not good for their knees.

I've written before that running does not wear out your knees.

I also disagreed with the author who wrote in the Straits Times (on 240516) on the above topic and I pointed out that there is no sound evidence at all that glucosamine helps with cartilage regeneration.

Here's further proof from a recently published article that didn't set out to study runners. In fact the authors that investigated this "Osteoarthritis Initiative" study had hypothesised that "a history of leisure running may increase the risk for knee knee symptoms and ROA (radiographic evidence of arthritis) even at lower levels."

Runners were grouped into low, middle and high groups if they had done at least 250, 800 or 2000 running workouts in their lifetime. All 2637 subjects in the study had high quality x-rays of their knees done and other methods of assessing knee symptoms.

Only two to five percent of the subjects described themselves as competitive runners showing that the findings are potentially more applicable to the general population compared to other studies.

Eight years after the study, subjects (56 percent female, average age of 64) were given a physical activity questionnaire. 29.5 percent indicated that they had participated in some running at some point in their lives.

The results were the exact opposite to what the researchers expected. This "forced" them to conclude that "A history of leisure running is not associated with increased odds of prevalent knee pain, ROA, or SOA (symptoms of arthritis). In fact, for knee pain, there was a dose-dependent inverse association with runners."

This meant that the people who ran the most had the least knee pain. This was true across all age groups and for running at any stage in one's life. The subjects that were still running had less knee pain (21.1 percent) than those who had quit running (25.3 percent), who had less pan than those who had never ran (29.6 percent).

So, most recent medical research continues to "exonerate" running as a cause of knee osteoarthrits. You now have more "ammunition" to show the naysayers who tell you to stop running or your knees will wear out.


Lo GH, Driban JB et al (2016). History Of Running With Higher Risk Of Sympyomatic Knee Osteoarthritis: A Cross-sectional Study From The Osteoarthritis Initiative. Arthritis Care and Research. DOI: 10.1002/act.22939.

Wednesday, June 22, 2016

Help! Both My Knuckles And My Knees Crack

Message from my patient
Have a look at my patient's reply in the WhatsApp message above when I asked about how her knee was. She came to see me earlier last week for "extreme pain" in her L knee. Couldn't run, couldn't jump.
Have a look at her battle scarred knees
I often get this question from my patients. "My knees keep popping or cracking when I squat, sit to stand etc. Is that a problem"?

I've also had patients ask me about knuckle cracking. Common urban legend suggest that too much knuckle cracking leads to arthritis of the hand joints. Worse still, there are also medical/ health professionals who will suggest that with the clicking/ grinding/ cracking in your joints, you have take glucosamine supplements to prevent osteoarthritis. Do not be fooled. You know my thoughts on glucosamine.

Well, let's settle this once and for all and set the record straight.

Within a joint, the joint space is filled with synovial fluid. The synovial fluid lubricates the joint. It also reduces friction in the joint when you move. There are also gases such as oxygen, nitrogen and carbon dioxide in the synovial fluid.

When you manipulate (crack or pop) a joint, you stretch out the space between the bones that make up that joint. This expanding space creates a negative pressure, causing the synovial fluid and gases to rush there. The larger bubbles collapse into microscopic bubbles, leading to that characteristic popping sound, and that's what you hear. The joint often feels better as the joint space is widened and the bones are repositioned better (*see reference I copied below from the article). The joint often has better range of motion too (see my patient's WhatsApp message above).

Do not mistake joint cracking/ popping or manipulation with joint crepitus. Joint crepitus feels a little like grinding you may hear/ feel when a bone moves against articular cartilage - the lining of the bones. Crepitus happens most often in the knees and has also been described as a crunching, grinding or popping sound. I often tell my patients that crepitus with no pain is usually harmless.

Many of my patients also confuse joint cracking with the snapping sound our tendons make when tendons slide between muscles or over bones. Tendons are like rubber bands stretched between muscles and bones to connect both of them. Hence, when a joint moves, the tendon snaps over the bone and can often make a popping or sliding sound. It's very common to hear these sounds in the knees and ankles when you go from sit to stand, squatting or walking up and down stairs.

There is no need to worry about these crunching, clicking, popping or sliding sounds unless they are accompanied by pain. Now you know.


deWeber K, Olszewski M and Ortolando R (2011). Knuckle Cracking And Hand Osteoarthritis. J Am Board Family Med. 24(2): 169-174. DOI: 10.3122/jabfm.2011.02.100156.

*During an attempt to crack a knuckle, the joint is manipulated by axial distraction, hyperflexion, hyperextension, or lateral deviation. This lengthens part or all of the joint space and greatly decreases intra-articular pressure, causing gases that have dissolved in the synovial fluid to form microscopic bubbles, which coalesce. When the joint space reaches its maximum distraction (up to 3 times its resting joint space distance), joint fluid rushes into the areas of negative pressure. The larger bubbles suddenly collapse into numerous microscopic bubbles, leading to the characteristic cracking sound. The maneuver leaves the joint space wider than it had been and synovial fluid more widely distributed. The stretching of joint ligaments required to produce the widened joint space also leaves the joint with greater range of motion. 

Thursday, June 16, 2016

Ankle Sprain? No, It's Cuboid Syndrome

R cuboid bone in the foot
I had a patient who came to our clinic today complaining of pain in the outside of his left foot. He thought he had sprained his ankle about 3 weeks ago while playing football barefoot. He rested, iced it  etc but it did not seem to get a lot better.

He then went to a Sports Doctor who diagnosed him with an ankle sprain and suggested that he see a Physiotherapist, which he did, but the one he saw did not make his ankle any better.

He still had most discomfort/ pain on the outer part of his left foot/ankle. Pain was worse during the push off phase of walking. He also couldn't run properly without pain.

However, his ankle proprioception (or joint position sense) was also not affected. Usually for ankle sprains, a patient's proprioception is usually worse on the affected side.

After a thorough assessment I found his ankle joint to be stable and free of pain. His pain increased on firm palpation of his left cuboid bone. The left cuboid also was sitting in a lower position compared to his right foot.

I explained to him that he did not sprain his ankle but instead there was probably a subluxation (or mild dislocation) in his cuboid bone. (I had actually seen two other cases of cuboid syndrome in the last few months).

The cuboid bone sits at the outer aspect of the mid foot and his connected to adjacent bones by strong connective tissue and ligaments (see picture above). During certain weight bearing activities like running, excessive forces placed on the cuboid bone (from the peroneal longus muscle especially) can sublux (or dislocate) the cuboid bone. This is exactly what happened to my patient. I've also seen this condition fairly frequently in ballet dancers that I've treated before.

How did I treat my patient? After the diagnosis, this is the easy part, or so I thought. I got him to lie on his tummy and gently tried to coax (or mobilise) his cuboid back into where it should be sitting. For some strange reason, it took a lot longer than I expected. My last two patients with cuboid syndromes had their cuboids back into position in less than five minutes.

It took me almost 20 minutes before my patient, his mother and I heard a loud click (of course I felt it with my hands too) suggesting I had relocated the bone.

I got my patient to stand up and try and he gave me a big smile after trying to walk and run. Job done, next patient waiting .....

Have a look at the reference below if you want to know more about cuboid syndrome.


Durall CJ (2011). Examination And Treatment Of Cuboid Syndrome. A Literature Review. Sports Health. 3(6): 514-519. DOI: 10.1177/1941738111405965.

Sunday, June 12, 2016

Which Drink Hydrates You Best?

Ever wondered which drink is best after a hard training session or race? I've written before that as a recovery drink, chocolate milk is as effective as Gatorade and even superior to Endurox.

Quite a few factors affect how quickly you pee out a certain drink. Drinks with more calories or electrolytes tend to stay in your system longer. How much you drink at a time also plays a part according to an article I read.

Researchers recruited 73 subjects to test 13 different drinks. Each subject tested water and three other beverages. At each session, the subjects drank a litre of the chosen beverage and collected their urine for the next four hours.

A "beverage hydration index" showed how much of that drink was retained after two hours compared to a litre of water.

Picture from American Journal of Clinical Nutrition

Looking at the picture above, you can see that a higher bar means more fluid retained. The dotted line represents twice the coefficient of variation away from water (meaning you can be real sure of a positive result).

The chart shows that milk stays longer in the body probably because of its calorie content. Milk and an oral rehydration solution (or sports drink, due to its calories and sodium) also stays in your system.

Personally, I was quite surprised that tea, coffee and beer did not seem to produce significantly more urine.

In fact coffee seems to have the lowest reading in the chart. The authors suggested that the diuretic properties of alcohol may be counterbalanced by its retention promoting calories (although another previous study that compared regular and alcohol free beer showed that regular beer drinkers had 12 percent more urine).

The authors also pointed out that larger doses of caffeine or alcohol may trigger more urine

Well, now you know not all drinks take the same time to reach your bladder. Choose your drinks wisely after your hard training session or race.


Maughan RJ, Watson P et al (2016). A Randomized Trial To Asess The Potential Of Different Beverages To Affect Hydration Of Different Beverages To Affect Hydration Status: Development Of A Beverage Hydration Index. Am J Clin Nutr. 103(3): 717-723. DOI: 10.3945/ajcn.115.114769.