Wednesday, March 21, 2018

Learning From Tom Myers

With Tom Myers
Reggie and I spent the last 2 days at the Anatomy Trains BodyReading Masterclass with the man himself,Tom Myers.

Having done some Anatomy Trains courses previously, some of what we learnt was revision, but mostly what Tom went through was new, highly enlightening and a different perspective.

Wrestling with Tom
Sharing center stage with Tom on Day 1
Rachel is up for Day 3-4 tomorrow on "Resilience: Taking the strain and coming back stronger." Stay tuned.

Sunday, March 18, 2018

Achilles Tendon Length And Running Performance

My patient's L Achilles

Two years ago, after my marathon running patient tore his left Achilles tendon (AT) and had it repaired. About six weeks after the surgery, his surgical site got infected. The surgeon had to remove the repaired tendon. After the infection was cleared, the surgeon grafted the lateral gastrocnemius (calf) muscle to repair the tendon. 

Needless to say, he couldn't really run let alone think of finishing another marathon. After trying traditional Chinese medicine (TCM) and seeing another physiotherapist for over two years with not much improvement, a fellow runner I've treated before suggested he come and see me.

For runners, the hips, knee and ankle joints generate large amounts of forces during running. The ankle joint (via the Achilles tendon ) contributes remarkably to supply the power required while running.  
R calcaneus bone, where the Achilles inserts

The AT plays an important role in storing and returning elastic potential energy during the stance (foot flat on the ground) phase in walking and running. 
L Achilles inserting on calcaneus

I was wondering how else to help my patient when I came across a research paper investigating AT length and running performance on male Japanese 5000 meter runners (between 20-23 years of age). Their personal best times range from 13:54 minutes to just under 16 mins.

Their running economy was tested by calculating energy costs with three 4 minute runs at running speeds of 14, 16 and 18 km/h on a treadmill with a 4 minute active rest at 6 km/h.

Ready for the results? The researchers found that absolute length of the medial (inner) gastrocnemius (or calf), but not lateral gastrocnemius and soleus muscle correlated with a faster 5000 meter race time and lower energy cost during the submaximal treadmill tests at all 3 speeds tested.

This is after normalizing medial gastrocnemius muscle length with the subject's leg length. That is, the longer the medial gastrocnemius muscle, the better the running performance in endurance runners.

For the medically inclined, note that each AT length was calculated as the distance from the calcaneal tuberosity to the muscle tendon junction of the soleus, medial and lateral gastrocnemius respectively.

Possible reasons to achieving superior running performance may be that the longer medial gastrocnemius and AT store and return more elastic energy (and potentially reduces energy cost) from the ground reaction force compared to a shorter AT.

Have to treat both R and L leg
Reading that paper definitely gave me more clues to treat my patient (and other patients with Achilles tendon and plantar fascia problems). I am happy to say that my patient has since progressed to running up to 12 km.

He is now definitely looking forward to running his next marathon.


Ueno H, Suga T et al (2017). Relationship Between Achilles Tendon Length And Running Performance In Well-trained Male Endurance Runners. Scand J Med Sci in Sp. 28(2): 446-451. DOI: 10.1111/sms.12940.

Sunday, March 11, 2018

Cycling Causes Erectile Dysfunction And Male Infertility?

Helping hands to catch up
While runners often have to deal will claims that running will ruin their knees or wear them out, cyclists are often told that too much cycling can affect a man's fertility. Truth or myth?

Well, here's a study that should keep the naysayers quiet and let us cyclists keep riding. Researchers from University College London looked at 5282 male cyclists and grouped them into weekly cycling time of below 3.75 hours, 3.76-5.75 hours, 5.76- 8.5 hours and over 8.5 hours.

The authors found no link between cycling many miles a week (even for those  riding more than 8.5 hours), and infertility and erectile dysfunction.
Ventilation holes and to keep pressure of delicate areas
According to the authors, this may be partly attributed to better saddle technology (see picture above) which helps to "relieve pressure on nerves that prevent the uncomfortable 'numbness' that can occur when riding for a long time." 

However, cycling is linked to raised levels of PSA (or prostate specific antigen), which can signal prostate cancer. This is due to pressure from the saddle pressing on the prostate, mildly injuring it  causing inflammation and increasing PSA levels. So cyclists who spend lots of them on the saddle may end up getting unnecessary testing if a mildly raised PSA level is due to cycling and not prostate cancer. Again, before you get paranoid, the authors wrote that further research is necessary and the risk is only high in the most avid cyclists.


Hollingworth M, Harper A and Hamer M (2014). An Observational Study OF Erectile Dysfunction, Infertility, And Prostate Cancer In Regular Cyclists: Cycling For Health UK Study. J Men's Health. 11(2): 75-79.

Just in case you're wondering, I don't use any of those fancy "holey" saddles, even when I was riding 6 days a week before. Here's my saddle.

Sunday, March 4, 2018

Accessory Navicular Bone

See the "bump" on the left foot?
A patient messaged me recently regarding pain in the left foot. This patient guessed that it might be due to an accessory navicular bone there. The patient had been doing a little more running and weight training in the gym recently and the left foot started hurting. A medial heel wedge recommended by a podiatrist didn't help. Neither did anti inflammatory medication provided by the doctor.

Our feet sometimes give even the most careful athlete/ runner problems. The so called accessory navicular  or "extra foot bone" can sometimes cause a lot of pain and discomfort.

All of us have a navicular bone on the inner part of our foot, near to the center of the arch. Not everyone has an accessory navicular though. I've actually had quite a number of patients complain of pain there. These patients tend to be more active and athletic, although some are not active at all. They often tend to have a little bump in this part of the arch.

Actually I, too have an accessory navicular bone in just my left foot, which so far thankfully hasn't given me any problems. 

This extra bone is usually not noticed until adolescence as the accessory navicular bone starts to calcify. It is then that the bump in the inner aspect of the arch gets noticed. For most people, it never gives any problems. For some, after an injury which often involves a twist, a stumble or fall, the accessory navicular bone becomes painful.

The accessory navicular bone is often attached to the posterior tibial muscle tendon. This muscle is involved when you push off your foot while walking or running. The same muscle that causes the dreaded shin splints. It helps keep the foot aligned and lifts up your arch. Hence you get pain when the tibialis posterior gets irritated from too much contact in the arch area.

My patient had the accessory navicular bone in the right foot surgically removed 30 years ago. Strangely enough, the foot only started hurting after a twisted ankle. My patient wasn't keen on surgery this time as the patient felt that after removing that extra bone, weight bearing on that side seemed altered and was never the same again.

The patient felt that removing the accessory navicular bone threw "the balance" off in the entire right side thereafter. (Surgical intervention requires the accessory navicular bone to be excised and reattachment of the posterior tibial tendon to the navicular).

I asked my patient to come in to our clinic to let me assess it. It was the accessory navicular bone causing her pain.

After treating my patient, the pain subsided . My patient then sent me a picture of the left foot the next day.

Have a look when I put both pictures together. Of course I didn't managed to "get rid" of the accessory navicular bone. The bump just doesn't look as obvious. But I definitely made my patient able to run again.

Tuesday, February 27, 2018

Fans Of The Hip

That's us - fans of learning, lifelong learning
We've done the basic Anatomy Trains course followed by the Arches And Legs and the next follow up course is the Fans Of The Hip course which we're doing currently.

Yes, that's the title of the latest course Reggie, Ting Jun and I are attending. But I'd like to say that we (staff at Physio and Sports Solutions) are fans of learning too. Yes, we are always striving to be better physiotherapists so we can get better at treating our patients.

At lunch, a fellow physiotherapist at the course was asking me why I wasn't  "growing" or opening more clinics. He mentioned that "lots of people" would want to partner us to have more clinics. To which I said we do not wish to be the biggest (physiotherapy chain of clinics), we just want to be the best at treating the cause of  your pain. That's why we keep learning.

Fans of the hip 
The lecturer did a great job explaining how the sacrum sits between the 2 hip bones

Ting Jun is the sacrum sitting between Derek and I (the 2 hip bones) in the picture below. For example if I shift forwards and Derek goes back (to simulate forward and posterior tilt in the pelvis) Ting Jun (the sacrum) will really feel unstable.

See the apprehension in her face
Last day of the course today. Back to work tomorrow.

Sunday, February 18, 2018

Back Pain? Check The Psoas

See the how the Psoas attaches to the spine
Here's a patient who came to our clinic this past week complaining of perpetual low back pain. He seemed more frustrated because he had not been able to do his "normal" exercise for over two weeks. The patient is young medical doctor in his mid thirties and among other things does a thousand sit ups a day (2 sets of 500 each).

At Physio and Sports Solutions, our challenge is always to find out the cause of the patient's problem. (and not just treat the pain). It's quite similar to detective work. We look for clues from the moment they walk into the clinic/ treatment room, how they sit/ stand when we are talking to them.

Next is asking the patient many questions about their condition, their exercise routine (if they have one) and their daily routine followed by a physical assessment.

When he told me about his 1000 sit ups a day routine (in addition to his 12-14 hours of desk bound job), I knew that this was a key component to his pain.

Physical assessment revealed exquisite discomfort to his Psoas and Illiacus muscles among other things. Now the Psoas muscle has been described as "the most important and vital skeletal muscle" in the human body for it connects the spine to the legs.

It is structurally the deepest muscle we have in the core/ tummy. They start at the thigh bone (see picture above) and finish at the 12th thoracic vertebrae and all five lumbar vertebrae. That's how it can cause your back pain!

Any force on the Psoas muscle (muscular contractions) is also thought to support our internal organs and work like hydraulic pumps allowing blood and lymph to pushed in and out of the area. Organs stimulated include the intestines, kidneys, liver, spleen, pancreas, bladder, stomach and the reproductive organs. This is why after my accident, every time my stomach hurts (usually from eating something that my stomach doesn't like), my back hurts too.

These deep organs are often referred to as viscera, and communication from theses organs to the brain is called visceral messaging. (My colleagues Sham, Ting Jun and Aized can do visceral manipulation if you need).
Connection between the diaphragm and psoas
Here's another remarkable fact. Your diaphragm (main breathing muscle) is connected to the spine where the Psoas muscle attaches. The diaphragm's medial arcuate ligament also wraps around the top of the Psoas along with fascia that connects to the other hip muscles.

These connections connect your ability to walk, run and breathe and also how you respond to fear and excitement - a direct influence on your fight or flight response.

So I addressed my patient's Psoas problem and got rid of his back pain without even touching his back.  As a medical doctor he and his previous physio had been attempting to treat his back for over a month with no real improvement. He was totally amazed as everyone else had told him it was his back that gave him problem.

Having back pain and not better after your back is treated? Make sure you get your physiotherapist/ healthcare practitioner to check your psoas and your internal organs/ viscera (although your healthcare practitioner may think you're nuts if they're not trained in that area).

Sunday, February 4, 2018

Kaboom! Went The Bulb

You wouldn't have guessed it from the group picture above. Just before we ended yesterday's lesson, the bulb on the projector exploded with a loud pop! Gave all of us a shock. I kid you not.

I was afraid I had to buy a new projector for today's Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques (previously know as Kinesio Taping Level 2 or KT 2).

Thank goodness for Amy from Sanctband who kindly agreed to loan me their projector. She went back to the office yesterday and Audrey (who lived nearby their office) picked it up for me. Thanks to Amy and Audrey again!
Diyanah and Audrey my saviour
Other than that the course went smoothly. I had to go through the last bit of yesterday's content to catch up, but it worked out well in the end.

Here are some more pictures from the course.

Working hard
The RI teachers and Sham
Thank you all for coming to the course. Next course is on 16-17th June. Call or email us for details or you can sign up here.

Saturday, February 3, 2018

Incredulous At The Kinesio Taping Course

Agog ...
Yes, that's Mona listening, mouth agape with incredulity at how wonderful our epidermis, dermis (skin) functions when I was explaining about how Kinesio Taping works.

Well, after my re-certification as a Certified Kinesio Taping Instructor earlier in January this year, I felt ready to teach again. I wrote earlier  last year that I wouldn't teach again until I've clarified my doubts (after Kinesio Taping International tweaked the course) so as not to shortchange the participants attending the course.

After going through the basic concepts, it was time for the practical.

Discussing which direction

MDT 12 'o clock with Ryan and Tricia
We will do Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques (what the course is now called, previously Level 2) tomorrow. Stay tuned.

Wednesday, January 24, 2018

Patient Has Neck Pain, But I Treated Her Leg

Last year I wrote about how your hips are connected to your shoulder, which turned out to be a really popular post.

Well, today I had a patient who told me she had neck pain as well. This was after I treated her for her plantar fasciitis problem and knee pain. I had only 2 mins left before my next patient. Here's a screen shot of the video I took before I treated her neck pain.
Before -12:58 pm
Here's the before video.

After treatment at 1:05 pm. Here's the screen shot of the video after at 1:05 pm.

After - 1:05 pm
Believe it or not I treated her leg, yes you read correctly. Watch the video how her neck range changed, without me going near her neck at all.

Many thanks to my patient for allowing me to post the images and videos.

Want to know what I treated? Here's a clue, look at the picture below.


Monday, January 22, 2018

Oops, Just Pooped During My Run

*Wouldn't wish this on anyone
Do you often need to go to the toilet just before your race? For lots of runners, the urge to go to the toilet happens during the race as well. I've occasionally needed to when I was racing, especially before a big race. But thankfully, never during an important race.

Well, you'll be surprised to know that the cause of you going to the toilet may be coming from your head.

A recently published study done only on 150 runners suggest that runners' gastrointestinal (stomach) problems during training runs and races were significantly related to their stress and anxiety levels. The runners were followed up for 30 days in this particular study.

This is after accounting for other known causes of stomach issues such as caffeine, medication, carbohydrates consumed during the run and workout intensity.

There is previous ample evidence that running intensity is closely linked to gastrointestinal issues. The faster (or eventually further) you run, the more blood is diverted temporarily from elsewhere (such as from digestion areas) to running muscles.

In this study, the runners who reported more anxiety and stress in their daily life were more likely to have flatulence, stomach distress and mid-run pit stops while running.

Other than running intensity and other contributing factors tracked, the major reason from this study showed that the runners' reported level of stress and anxiety was the other major factor linked to "on the run" gastrointestinal problems.

Bear in mind that the runners' in the study were not stressed about their running. From the questionnaires, the reported stress were based on people recalling their daily lives, not a specific activity such as work, or in this case, exercise.

So if you're having stomach issues before, during or after a stressful or anxiety provoking event, it makes it more likely that your stomach symptoms (and the need to use the toilet) are stress and anxiety related. Make sure you try to use the toilet before you run.


Wilson PB (2017). Perceived Life Stress And Anxiety Correlate With Chronic Gastrointestinal Symptoms In Runners. J Sports Sci. Dec 1:1-7. DOI: 10.1080/02640414.2017.1411175.

*Took the picture off the computer from

Friday, January 12, 2018

Drill Bit Left In Ankle After Operation

11:42 am -before treatment
Have a look at the picture above. My patient came to our clinic with "problems" in his right ankle. He fractured the ankle in 2010, had pins and plates inserted (but the surgeon did not suggest physiotherapy after that).

He resumed running and football after that and subsequently needed an ankle reconstruction last year as another surgeon told him all his ligaments were now torn and the ankle unstable. Again there was no referral for physiotherapy after this second operation.

One year later, he still had lots of pain in his ankle and lack of range of motion. He saw another surgeon for a second opinion and the MRI was inconclusive. He underwent another operation and in the operating theater, the surgeon found a bone spur in front and a broken-off drill bit left behind! Yes, you read correctly, a broken-off drill bit from the earlier operation ??!!!

Finally, this third surgeon he saw referred him for physiotherapy.

11:55 am 
Well, it took me about 13 mins to change his right ankle if you look at the time difference between both pictures. Actually it was less because I treated his left leg too, before re-assessing him.

Now if we put both pictures together, you can definitely see the difference.

See the difference?
Having a difficult time before or after your operation? Come and see us in our clinics. We'll definitely be able to help you get better.

Sunday, January 7, 2018

Job Done

It was raining cats and dogs this morning when we returned for Day 2 of the re-certification of the Kinesio Taping Instructors course. This was the last re-certification course available for this period for Instructors as there had already been courses in Albuquerque, Prague and in Brazil in the past 2 months.

Being the model for Graceann
The other Instructors present had become familiar faces and we discussed different teaching strategies. It was good for me to meet the other Instructors in Asia as previously I'd only done the re-certification courses in Albuquerque and Venice. We watched some videos and had the practical sessions to clear our doubts.
Getting my cert from Graceann
My 2 students before and now fellow Instructors
Well, my certification will qualify me to teach for the next 3 years til end 2020. And the next course I'll be teaching will be at Sports Solutions on 3rd-4th February 2018. You can sign up for the February course here.

Next course will be on June 16th-17th 2018.

Here's my cert

Saturday, January 6, 2018

Day 1 Of Kinesio Taping Instructors Recertification (CKTI) In Hong Kong

Study time

3 years have gone by since Venice and here I am in Hong Kong doing my Kinesio Taping re-certification for Instructors. This is my 3rd re-certification after Albuquerque in 2011 and Venice in 2014.

My name tag
Dr Kenso Kase was unfortunately not present this time and since there are some changes to the course, we spent the whole day with Dr Graceann Forrester (who originally certified me as an Instructor in 2010) going through the new slides while sharing some laughs of course.

Going through the slides with Graceann
Graceann did a really good job explaining the new slides and changes.

Graceann at the break
Stay tuned for day 2 of the Instructors re-certification.