Sunday, June 17, 2018

Don't Force The Teenage Athletes

I read with interest a recent New York Times article about Katelyn Tuohy. A female teenage track phenom with the headline "America's Next Great Running Hope, and One of the Cruelest Twist in Youth Sports."

Although Katelyn had already won titles and set records at sophomore (15-16 years old) level, the article made the point that many previous high school phenoms fail to live up to their early promise because of changes to their physique. The article pointed out that this seems to be a cruel twist in youth sports as girls turn into women.

The article mentioned that it was nearly impossible to predict an elite girl's future success in distance running because the female body changes so much as they continue to grow. Other than a good lung capacity, long distance races require great body weight to strength ratio. The teenage girls are skinny in their early years. Then as they mature and and grow, they may not develop the strength to move their bigger bodies  as quickly.

It's not surprising then that many girls end up with eating disorders, body related issues and end up getting injured. Off the top of my head, I can think of so many teenage athletes I've treated over the years that ended up going down that same path.

Many of the young athletes couldn't understand that it was perfectly normal to have the ups and downs (in their performances) they experience as their bodies change. Girls tend to put on more fat to prepare the body for reproduction. Good if we want to maintain our population, but not good if you're an elite athlete looking to improve your performance.

I had a former classmate PTL in primary school. He won the "Individual Champion" title in our school's track and field meet after winning 100, 200 m and the shot putt (plus the 4 x 100 relay too). That streak started in Primary Four (while he was ten) til Primary 6 (there was no meet from Primary One to Three).

We went to the same Secondary school and he won the 100, 200, 400 m and 110 m hurdles to emerge "Individual Champion" again in Secondary One and Two.

While in Secondary Three (they finally had longer events in track and field), PTL won the first 3 events and finished runners up for the 110 m hurdles event. We shared the "Individual Champion"  title after I won the 1500, 3000 m, 2000 m steeplechase and was 2nd for the 800 m. (Luckily for me, they gave out 2 trophies).

By the time we were in Secondary Four, I won all my four events while PTL didn't win any of his individual events. I ended winning our school's only individual medal at the National School's meet later that year while PTL ran the relays and never competed again after that.

Looking back now I know PTL reached puberty and had his growth spurt earlier than us in Primary school and was physically superior to everyone else. That's how he won all the events earlier. When the rest of us "caught up" hitting puberty later he didn't have that advantage anymore.

Perhaps PTL, having been raised on victories from young, could not comprehend or accept defeat. Early victories may have paved the way for defeat and giving up eventually.

Hence, I will never ever push my kids to excel in sports or something they don't like. I was never pushed when I was a kid. The desire all came from within. However, if they're keen, I will definitely help, support and guide them if I can.

So parents, teachers, coaches and all of you who are involved with young athletes take note of what Kara Goucher said. "Talent never goes away. Once these women/ girls (or boys) adjust to a mature body, the talent can come through again. The obsession with labeling these girls as 'the next big thing' is part of the problem  .... Katelyn is very talented. She will grow and probably slow. But once she adjusts, if she still has the love, the talent will still be there."

Don't push the kids, support, guide and help them if they themselves wish to excel.

Here's a close up of my first Individual Champion trophy. Thanks to my brother who took the pictures for me.

Thursday, June 7, 2018

Beach Running Anyone?

I have patients who get impact associated injuries like shin splints or stress fractures all the time. it's probably the most common running injury we see in our clinics along with knee pain.

Other than deep water running which has no impact, I often suggest going to the beach to get them running again.

Have you tried running on the beach? Research shows that running on sand requires 1.6 times more energy expenditure than running on a firm surface. Try it to believe it. Due to the change in technique you require as well as balancing on the sand, the stabilizing muscles in your hips, knees and ankle are working much harder.

Soft sand is particularly difficult while hard or packed sand (near the edge of the water) is definitely easier to run on. It definitely works different muscles (compared to running on the road) and it requires more focus so you don't sprain your ankle due to the uneven surface and constantly shifting ground.

In fact, while combating the "slip" element, range of motion of joint angles around the hip, knee and ankle were found to similar to running during faster speeds on firm ground (Binnie et al, 2013). That translates to a much higher heart rate, increasing your oxygen debt and blood lactate levels. Meaning you get fitter, stronger and faster quicker.

So incorporating sand running into your training can definitely help improve your race times.

Another article found that soft sandy surfaces reduced muscle soreness and fatigue (Binnie et al, 2014) due to almost four times less impact versus a firmer surface. Because of the softer surface, there's also less stress on our joints which can lessen impact and helps prevent injuries.

When running on firm ground, less of the elastic energy which is stored in our tendons is absorbed, so you don't have to work as hard. When running on sand, it absorbs the forces, meaning you have to generate more forces with your muscles to run.

Researchers found that there was almost four times less impact forces on soft sand compared to firm ground with every single foot strike. This is really good if you need to reduce load through the legs but still want to get in a hard workout when you run. 

Research also suggest that runners who ran on the beach (especially on soft dry sand found farther away from the water) had less muscle damage and inflammation compared to running on grass (Brown et al, 2017).

Due to where I stay, I hardly get to run barefoot on the beach. When I do, which is often during our family's holiday trips, I always start much slower than my usual runs. I also do not worry about the time or distance that I clock. In fact, I often do some short hard sprints (because of the lower impact) to get my heart rate up even higher.

Hearing the waves crash also helps to calm and clear my mind, which is a nice bonus.


Binnie MJ, Dawson B et al (2014). Effect Of Sand Versus Grass Training Surfaces During An 8-week Pre-season Conditioning Programme In Team Sport Athletes. Eur J Sp Sci. 32(14): 1001-1012. DOI: 10.1080/02640414.2013.879333.

Binnie MJ, Peeling P et al (2013). Effect Of Surface-specific Training On 20-m Sprint Performance On Sand And Grass Surfaces. J Strength Cond Research. 27(12): 3315-3520. DOI: 10.1519/JSC.0b013e31828f043f.

Brown H, Dawson B et al (2017). Sand Training: Exercise-induced Muscle Damage And Inflammatory Responses To Matched Intensity Exercise. Eur J Sp Sci. 17(6): 741-747. DOI: 10.1080/17461391.2017.1304998

Lejeune TM et al (1998). Mechanics And Energetics Of Human Locomotion On Sand. J Expt Biol. 201: 2071-2018.

Sunday, June 3, 2018

"Collapsed" Arches And Tibialis Posterior Muscle Pain

I had a really interesting case involving a triathlete/ runner recently. She had terrible pain in her arches and couldn't even walk around barefoot at home. It had started after she increased her run training recently. The orthopaedic surgeon she consulted had prescribed two pairs (yes two, you read correctly) of orthotics. And he said if they failed she would require surgery. A soft pair for her training and a hard pair while she was wearing her work shoes for her "collapsed arches".

She was advised not to run but was given the green light to bike and swim. Unfortunately, both times she wore her soft orthotics for cycling (and not evening running) her arches hurt after only fifteen minutes and she had stop riding. Even after icing her foot after the ride, her foot still felt sore the next day.

Upon further questioning, she told me she didn't use the orthotic  and was able to walk pain free for 2-3 hours a few days ago in her Havaianas flip flops (or slippers).

However, after she biked again yesterday morning for only ten minutes, the pain came straight back with a vengeance.

When I examined her, her foot was was fairly flat and she had no arches. Her pain was mostly on her navicular bone and it was very tender to touch. I took a quick look at her soft pair of orthotics and noticed that the medial (inner) side of the orthotic was highly built up.

I told my patient I thought it was probably the orthotic irritating her navicular bone since it flared up within such a short time of using it while riding her bike.
Here's how the Tibialis posterior irritates the navicular bone
Other than her navicular bone tenderness, her tibialis posterior muscle was sore upon palpation all the way up her shin. Yes, the tibialis posterior muscle is the very same muscle that causes the much dreaded shin splints in runners.

To make the long story short, I treated her and she's back running happily with no pain. What did I do? I treated her lateral, spiral and superficial back line.

Spiral Line

Sunday, May 27, 2018

Can You Keep Running With Bad Knees?

Picture by richseow from Flickr
I often get this question from my patients. Will running wear out my knees? And my answer to them is a definite no. Not if they don't have a preexisting knee condition.

It's been proven beyond reasonable doubt that running does not wear out your knees. Numerous studies found no evidence that runners were more likely to develop knee osteoarthritis while comparing groups of runners versus non runners.

In fact, runners seem less likely to develop knee problems due to the reduced weight and the ability of articular cartilage to get stronger due to the running (Williams, 2013).

No this is without doubt good news for runners without any knee problems.

What if the runner already have a knee osteoarthritis, where the natural shock absorption between the knees have worn out? If you keep running will you hasten the progression of the osteoarthritis?

Just because running doesn't wear out your knees and/ or cause osteoarthritis, that doesn't mean you're immune to it.

Personally I think that logic suggests that if the knee joint is already compromised, it is likely that the stresses that result from running could possibly worsen the wear and tear despite little evidence on the topic so far.

Hence, this newly published study which studied almost 5,000 subjects for nearly ten years is worth a read. In that group, there were 1,203 people over 50 years old who had osteoarthritis in at least one knee. 138 of these 1,203 people happened to be runners throughout the study period.

The subjects went through many diagnostic tests, including x-rays to find out how severe their knee osteoarthritis was. These tests were repeated four years later. Those who ran during this period of time did not have a faster progression of symptoms  than those who didn't run. There was little evidence to suggest that running was harmful in this study group.

This was contrary to what the authors expected. Running was not associated with worsening knee pain nor did their x-rays showed any worsening. In fact, the authors suggested that the runners had more improvement in knee pain compared to the non runners, suggesting that there may be a benefit to running from a knee health perspective in people who have knee osteoarthritis.

While comparing x-rays for "joint space narrowing", which indicates that the bones are getting closer together because the cartilage is disappearing, 23.6 percent of the non runners got worse in the study period, compared to 19.5 percent of the runners.

39.1 percent of the non runners had improvements in the knee pain compared to 50 percent of the runners. After adjusting for age, BMI etc, the runners were 70 percent more likely to see improvement in their symptoms.

Now before all you runners and non runners with osteoarthritis get too happy and carried away and start running like there's no tomorrow, bear in mind that there isn't much information as to how much distance the runners covered or any other differences in the running versus the non running group.

Please note that the runners were not told to go forth and run as much as they wanted. They were not given any specific instructions at all about running. The runners were presumably following their own urges to run and common sense plus advice from their doctors/ physiotherapists.

There was no mention whether they ran less frequently or shorter distances than they were used to. Did they have to stop and walk if their knees started hurting while running?

I've seen many patients with reduced and compromised mobility due to an arthritic knee and hence would hesitate to suggest they start running especially if they were not already runners to begin with.

I do observe that once the patients have osteoarthritis, it generally leads to a reduction in their physical activity which may then lead to an elevated risk to other chronic conditions like heart conditions and diabetes. I would definitely suggest they remain active through stationary bike riding (for safety reasons) and of course aqua based rehabilitation/ deep water running.

This study doesn't tell us that you can run through osteoarthritis with no consequences. It does however, offer some tentative support for letting your symptoms be your guide. It doesn't mean quitting for the runner with osteoarthritis. If there is no swelling and no pain, you can probably still run. But definitely, please modify the distance, intensity and frequency that you run.

It may mean substituting a bike or swim session for the run occasionally, trying a different shoe, different surface and/ or including a weight training session to get yourself stronger. If you can still find a running routine compatible with your osteoarthritis symptoms, the results of that study should reassure you that you're not making your knees worse by running.


Lo GH, Musa SM et al (2018). Running Does Not Increase Symptoms Or Structural Progression In People With Knee Osteoarthritis: Data From The Osteoarthritis Initiative. Clin Rheumatol. DOI: 10.1007/s10067-018-4121-3. Epub.

Williams PT (2013). Effects Of Running And Walking On Osteoarthritis And Hip Replacement Risk. Med Sci Sp Ex. 45(7): 1292-1297. DOI: 10.1249/MSS.ob013e3182885f26.

Oh my aching knee .....

Saturday, May 19, 2018

He's Back!

Recognize this handsome, young man? If you're Singaporean, you definitely will. The only Singaporean to ever win an Olympic gold medal.

Well he just came back to sunny Singapore and will be back for a little while. And Sports Solutions or Physio Solutions is always one of his first port of call.

Welcome home Jo! Always a pleasure to see you.

Wednesday, May 16, 2018

Oops, Rachel Did It Again

Where's Rachel?
Actually it's nothing bad as you may think from the heading. Rachel just helped her alma mater VJC win a sixth consecutive girls 'A' division football title.

If you may recall, Rachel played a big part helping VJC win the same title last year.

I had another teacher from Raffles Institution (formerly Raffles Junior College) see me for treatment in our clinic today. When I mentioned Rachel was away at Jalan Besah stadium helping the VJC team she instantly remembered Rachel's prowess as the former VJC player who "destroyed" Raffles 10-1 in the semi finals after bagging a hat trick in that match. And she is not a Physical Education teacher.

Wow, Rachel is still famous nine years later.

The players thanking their supporters
As with the previous year, Rachel had been helping out at VJC treating the school athletes most Wednesday afternoon's prior to yesterday. Let's see if they can go 7-peat. We'll let them enjoy the win for now.

It's even in the newspapers today under the Sports section on page C8.

Saturday, May 12, 2018

Diagnosed With Hip Impingement But Still Completed the 6 Majors

My patient came and showed me her Abbott World Marathon Majors medal today. Yes she's completed all the six AbbottWMM races in Tokyo, Boston, London, Berlin, Chicago and New York City. All while having hip and low back pain and being diagnosed with FAI or femoroacetabular impingement (or simply hip impingement). She was actually comtemplating surgery to "solve" her problem.

You must be wondering what FAI is. It is a hip condition which occurs when there is a mechanical mismatch in the ball and socket hip joint between the "ball" in the hip and "socket" know as the acetabulum. There are usually three types of hip impingement as drawn by Aized below.

2 of the three types of hip impingement - CAM, Pincer 
Many normal people have "bumps" or slightly deeper sockets and these can potentially cause femoroacetabular impingement. This is the way we are made and develop. With sports or other aggravating movements, there can be increased friction between the acetabular socket and the femoral head leading to pain and decrease in range of motion.

FAI often presents as hip/ groin pain and limited range of hip motion, which is exactly what my patient has. Pain is often provoked with prolonged sitting, crossing legs, walking as well as during and after sports or exercise depending on the type of impingement. Pain can be felt deep in the groin and sometimes at the side of the hip or buttock.  There is usually a restriction in hip flexion and internal hip rotation.

Physiotherapists reading this will think of the L1-2 lumbar distribution to the lower back can cause similar pain and symptoms in the hip and groin. At least that was what I thought of straight away when checking and treating her lumbar spine made her better. Instead of treating her pain, I tried to find the cause of the problem and treat it instead. That's what we always do in our clinics.

To make the long story short, she didn't have her hip surgery. Laura was able to finish the 2018 London marathon to complete her 6 majors in a speedy 3:42 hrs (though she thought it was "slow").

She was the center of attention our clinic earlier today when everyone present admired her medal after she took her picture with me.

Here's a close up of her medal.