Friday, October 18, 2019

Is Your Running Style Causing Your Running Injury?

How's my running gait?
I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.
Picture A- Injured runner with CPD and right hip adduction 
Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.
Contralateral pelvic drop
CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.
Injured runner (L) heel striking, forward trunk lean vs normal
Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

Thursday, October 10, 2019

Clam Shell Exercises?

Clam shell exercises?
My patient came in complaining of knee pain after running. She had seen another physiotherapist who after treating her knee, prescribed clam shell exercises for her to do as well. But she still had knee pain after running and climbing stairs despite doing them regularly.

How many of you have been asked to do clam shell exercises to make your Gluteus Medius (or hip) muscles stronger? If you have, maybe you need not bother any more.

Latest research (Moore et al, 2019) shows that clam shell exercises do not activate your Gluteus Medius as much as you think.
Right Gluteus Medius muscle
The Gluteus Medius muscle is very important for female runners, especially if they have knee pain. You can treat their knees but their pain will not go away until you have addressed the weakness  in their Gluteus Medius muscle.
View from the back, Left Gluteus Medius
In that small study, three sets of six common lower limb exercises were performed by ten healthy adults after a short warm up. They did single leg squats, single leg bridging, hip abduction (lifting) in side lying, clam shell exercise in side lying, running man exercise (simulates running motion of running one leg at a time) and resisted hip abduction-extension exercise.

The participants had electromyography or EMG electrodes to measure muscle activity attached to all three parts of the Gluteus Medius muscle (in front, middle and posterior).

Results showed that clam shell exercises were not effective in activating any part of the Gluteus Medius muscle. Highest levels of overall activity were seen in the single leg squat, single leg bridging and the resisted hip abuction-extension exercise.

Other than the knee, you need to know that weakness in your Gluteus Medius can also contribute to pain or problems in your Achilles. Make sure you are doing the strengthening correctly.


Moore D, Pizzari T et al (2019). Rehabiliation Exercises For The Gluteus Medius Muscle Segments: An Electromyography Study. J Sp Rehab. DOI: 10.1123/jsr.2018-0340.

Tuesday, October 1, 2019

Head, Neck And Jaw

Taking turns for a quick assessment
After Aized and Rachel attended Fans of the hip last week, Reggie and I attended the Head, Neck and Jaw course yesterday and today. This is the next course offered after we did the Shoulders and Arms course earlier in April this year.

Reggie, the center of attention
Wow, time really flies, it's already October today.

It was a really interesting course looking at everyone's head, neck and into their mouths. Yes, you read correctly, we got to stick our fingers inside each other's mouths.
All five different necks
We learnt about the Masseter and Temporalis which are on our face and skull, we also learnt how to treat the Medial and Lateral terygoids, which are inside our mouths and how they connect to the neck.

Showing me my Lateral Pterygoids
Yes, we got right into each other's mouths.
Medial , Lateral Pterygoids
Back to work tomorrow. And if you need to get your head, neck or jaw treated .....

Friday, September 27, 2019

Magnesium Supplements For Muscle Cramps?

Available from my local pharmacy
A patient came in today saying she went to a local running store and was advised to take some magnesium supplements as she cramps occasionally while racing. So she went ahead and bought some. She wanted my thoughts on whether they truly work since they seem to be the latest "silver bullet" that most runners seem to be taking.

Magnesium is an essential nutrient that's actually found in many of the foods we're already eating. It is actually abundant in our bodies. Our bodies need it to create new proteins, for energy production in cells, DNA synthesis etc. As it is essential, our bodies store it in our bones, where it can easily be accessed if needed. Since our bodies cannot produce it, we need to get it from our diet.

An adequate magnesium is needed for a healthy pregnancy and to produce enough milk after giving birth. It is also useful if you take diuretic drugs, proton pump inhibitors and if you're diabetic.

It is suggested that adults need 300-400 milligrams a day and you will get enough if you eat enough legumes (chickpeas, black and kidney beans), nuts, seeds, veggies (broccoli, cabbage, asparagus, kale and spinach), fatty fish (tuna, salmon and mackerel) and some fruits (avocado, bananas, figs and raspberries).

It is estimated that 10-30 percent of people in developed countries may have a mild deficiency in magnesium (DiNicolantonio et al, 2018). Severe deficiencies are uncommon but easy to spot. Symptoms include loss of appetite, vomiting and fatigue and following that numbness, muscle cramps, seizures, personality changes and heart artery changes if the deficiency continues.

It is why those who sell these supplements tell athletes to take them - to prevent muscle cramps! But note that the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Note that the muscle cramps that occur when you have a magnesium deficiency happens with activities of daily living (not while exercising/ racing). Not only the muscles in your feet and legs cramp, but also your facial and masticatory (chewing) muscles.

Those who sell magnesium tablets, body sprays, serum and bath salts will tell you their products will boost recovery, energy levels and promote DNA synthesis, bone strength and other important body functions. When something sounds too good to be true, it probably is. If you eat a healthy diet of the food listed above that is rich in magnesium, then you wouldn't need any magnesium supplements.

You will not benefit from taking magnesium supplements unless you're deficient. This can only be verified via a blood test.

If you are lacking magnesium, you can either eat food sources rich in magnesium or take supplements. There is no evidence that any form of magnesium (whether it is magnesium oxide, aspartate or citrate) is more easily absorbed by our bodies. So don't buy the most expensive brand or version of it.

As for magnesium creams, oils, sprays, flakes and bath salts etc, evidence suggest that they are not as effective as claimed (Grober et al, 2017).

So if you have done a blood test and have a magnesium deficiency, load up on magnesium rich food or go ahead take a cheap supplement.

"So that means I wasted my money" went my patient? Now you know. And you've read what causes muscle cramps.


Grober U, Werner T et al (2017). Myth Or Reality- Transdermal Magnesium? Nutrients 9(8): 813. DOI: 10.3390/nu9080813.

DiNicolantonio JJ, O'Keefe JH et al (2018). Subclinical Magnesium Deficiency : A Principal Driver Of Cardiovascular Disease And A Public Health Crisis. Open Heart. 5:e000668. DOI: 10.1136/openhrt-2017-000668.

Friday, September 20, 2019

Shin Splints Back In 1415!

R shin(top) shows obvious wear
I had a runner who came to see me this week. She had recently done a marathon in Australia and recently got back to training again after a break. She said she had been asking a fellow runner with shin pain to come see me. This friend of hers had been suffering from shin splints for the past six months!

Just in case you thought that was long. I saw an article that showed a case of documented shin splints from way back in the year 1415. Yes, you read correctly, it's 1415.

Researchers found a skeleton from a graveyard in Greece that showed medial tibial stress syndrome (or shin splints). They estimated that the man died between 500-800 years ago and was between 20-30 years old.

The researchers mentioned that shin splints are commonly thought to be an exercised induced injury. and that shin splints are most common in new runners.

Osteoarthritis in the ankle
The skeleton also showed signs of osteoarthritis in the ankle joint (which is rare); this suggest that the man probably engaged in some repetitive loading of his lower limbs. An indication that perhaps even in those days they participated in running as well.


Protopapa AS, Vladchadis N et al (2014). Medial Tibial Stress Syndrome: A Skeleton From Medieval Rhodes Demonstrates The Appearance Of The Bone Surface- A Case Report. Acta Ortho 85(5): 543-544. DOI: 10.3109/1753674.2014.942587.

Friday, September 13, 2019

My Patient Was Told Her Knee Alignment was "Off"

Have a look
My patient came in complaining of pain in both her knees after running. She had been to another physiotherapist who told her that her "kneecap alignment was off". He proceeded to give her some strengthening exercises for her quadriceps and asked to return for another session. He checked on her exercises and did some ultrasound and "electric current" therapy.

After the two sessions, she didn't get any better doing the quadriceps exercises and was referred by her friend to see me. I told her that all of us have highly variable alignment in our knees and she shouldn't worry too much about what the other physiotherapist told her.

Yes, just in case some other healthcare professional tells you the same, there is a very good article published on this topic. In fact the article is a systematic review, which means a search aided by computer for all randomized and clinically controlled trials. When it comes to quality, there is none higher than a systematic review or meta-analysis.

The systematic review concluded that healthy knees have a highly variable alignment, although this may be due to variables when doing x-rays/ MRI scans, measuring techniques and the people studied.

The exact role of knee joint alignment in development of knee pain/ symptoms remains unclear.

So we should not be telling patients that their knee joint alignment is in any way abnormal at all, not if we do not even know what normal alignment is.


Hochreiter B, Hess S et al (2019). Healthy Knees Have A Highly Variable Patellofemoral Alignment: A Systematic Review. Knee Surg Sp Trauma Arthr. pp 1-9. DOI: 10.1007/s00167-019-05587-z.

Is this knee's alignment abnormal?
I know some of you will be asking what did I do to make my patient better? After assessing the knee joint, I usually make sure there is no hip dysfunction or shortening in the calf muscles. In this particular patient's case I started with her Superficial Back Line (SBL) and her Spiral Line.

Superficial Back Line
Since she runs, I made sure I checked her running style/ technique too.
Spiral Line

Friday, September 6, 2019

My Patient Has A Cyclops Lesion!

How the cyclops lesion looks on MRI
Two to three months after her anterior cruciate ligament (ACL) reconstruction, my patient presented with pain at the front of the knee especially when trying to straighten her knee. There is sometimes an audible clunk with the  straightening.

Her quadriceps muscles were weakened and she can't straighten her knee fully. There is often mild swelling too. There is also some soreness at the back of knee in the hamstrings and calf area.

If you haven't read the heading above, would you be able to guess what problem my patient has? There is a 4 percent chance of this happening after an ACL reconstruction.

For those not familiar, a cyclops lesion is usually a localized form of arthrofibrosis (or scar tissue) in the front of the knee joint. The cyclops lesion is a stump of tissue at the front portion of the intercondylar notch, which sits above the tibial tunnel that is drilled for the graft. The cyclops lesion usually gets impinged between the tibial and femur when straightening the leg.
intercondylar notch
How does the cyclops lesion come about? One theory suggest that it may be a remnant of the previous torn ACL stump that remained after surgery. Another theory suggest it may be fibrocartilage formed after drilling the tibial tunnel or from broken graft fibres.

Femur on top of tibia
There is also some evidence to suggest that the cyclops lesion may be a result of inappropriate surgical technique during the ACL reconstruction (Delince et al, 1998). So make sure your choose your surgeon carefully.

So how do we manage the cyclops lesion for the patient? Best way to avoid getting it is to work on regaining full knee extension immediately after the operation.

Once the tell tale signs are present (in the first paragraph of this article), not much else can be done. Yes, you read correctly, there's nothing much a physiotherapist can do. From experience, no amount of pushing, joint mobilizations, exercise or injections etc will help.

The only available option is to refer the patient back to his/ her surgeon to order an MRI to rule out or confirm the cyclops lesion. If it is a cyclops lesion, the best and actually only option is to have a knee arthroscopy and remove that naughty piece of scar tissue. This has shown to have good results (Sonnery-Cottet et al, 2010), especially if aggressive straightening commences after removing the cyclops lesion.


Delince P, Descamps PY et al (1998). Different Aspects Of The Cyclops Lesion Following Anterior Cruciate Ligament Reconstruction: A Multifactorial Etiopathogenesis. Arthroscopy. 14(8): 869-876.

Sonnery-Cottet B, Lavoie F et al (2010). Clinical And Operative Characteristics Of Cyclops Syndrome After Double-bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy. 26(11): 1483-1488.
Picture from