Saturday, June 23, 2018

11th Floss Band Course

What a coincidence. Physio Solutions turned eleven earlier this week and at the end of the same week I'm teaching the 11th Floss Band course. Good things come in pairs I suppose.

My Saturday usually starts with an early bike ride. I'm usually out of the house before six in the morning and get back in time to start work in our clinic by 1030 am. I see patients til 1:30 pm so I have about 30 mins to get ready.

Drenched this morning
Thanks to Danny and Amy who have already set up the chairs, projector etc I hook up my laptop to get my presentation ready before I try to eat and drink a little before I start teaching at 2 pm.

Fortunately, the course got up fine today. Despite my early start, I wasn't too tired and was still able to answer the questions that came my way. We had a mix of trainers, physiotherapy students, massage therapists, cross fitters and a couple of physiotherapists attending today.
3D image of skin, fascia and muscle from my slides
We went through the anatomy and function of fascia, Pain Gate Theory etc so the participants can explain how the Floss Bands work.
Too tight says Si Rui
A big thank you to Danny, Amy and Jane who came later for helping to get the clinic ready for the course and also for helping tidy up after. Please contact them at Sanctband Singapore for the next Floss Band course and if you need to get the Floss bands.

Thank you to the participants who came too. Hope everyone found the course useful.

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.

Monday, May 7, 2018

Young Athletes Are Not Small Adults

I've had a few worried parents message or call me on the past two weekends saying that their child has had sharp pain suddenly without any falls or accident. A common area of complaint is in the knee or heel.

After a few short questions and answers I am usually able to reassure the parent that their child is fine and nothing is really serious about the painful episode.

Often these young children/ athletes have growing pain. The long bones grow quite quickly (especially if they are having a growth spurt) and the muscles don't lengthen quite as quickly. When the child is active, this shorter muscle(s) often pull on the bony attachments and cause pain.

Their muscles usually will not have developed enough strength to compensate for the sudden increase in lever lengths.

My older boy who is eight plays football once a week. Other days he's at the playground running, jumping and climbing etc. He's growing taller and  his muscles are not always strong enough to generate the forces required to move his longer and now heavier legs. As a result, he often has this "growing pain" in the night especially after he'e been particularly active.

I just taped my older boy's leg last night
From treating all the young and teenage athletes in our clinics, we observe that it may take up to about nine months for the muscles to develop length and strength after a growth spurt in their bones.
This form the basis of injuries that these young athletes get. If the bones grow longer and the muscles don't quite catch up in length, the muscle will be relatively shorter and hence tighter.

The area most prone to overload is where the muscle attaches via the tendons to the bones. Hence these pain and injuries we see are growth related.  Common areas are where the Achilles tendon inserts in the heel bone (usually known as Severs disease, although it is definitely not a disease), and the patella tendon on the shin bone (Osgood Schlatters disease).

Other areas include the quadriceps tendon into the knee cap (Sindling Larsen disease) and the attachment of the hip flexors onto the pelvis.

It is usually due to overload of the tendon attachment to the bone from doing too much too soon (without rest) that causes these pain or injuries.

Majority of the time, most of these cases get better when the muscles "catch up" with the bone growth by lengthening and getting stronger.

Stretching the muscle may be worse sometimes as static stretching can place more traction forces on the tendon insertion on the bone. We tend to teach our young patients and their parents to use the trigger ball instead.

Correct strength training that is pain free often helps the muscle take load of the tendon attachment. Don't use a load that is too heavy.

Come see us in our clinics if your young or teenage child athlete needs help.

Monday, April 30, 2018

Secrets Behind The Elite Athletes Longevity

Taken with my Iphone 7 from today's Straits Times
Roger Federer is turning 37 later this year, and just recently lost his number 1 world ranking to 32 year old Rafael Nadal. Rafa just won the 2018 Barcelona Open for the 11th time in his career. This after after he won his 11th Monte Carlo title last weekend.

Other than the two of them, Lebron James, Serena Williams, Tom Brady and Shalane Flanagan are way past 30 and instead of slowing down, they somehow seem to be able to stave off physical decline and somehow even get better. I remember meeting Dara Torres at the 2008 Beijing Olympic Games, she was 41 then and won three silver medals at the games.

Ever wonder how they do it? Or better still, what can the rest of us learn from the cutting edge techniques they are employing or simply knowing about what exists.

There are new testing services run by industries that claim to be able to pinpoint what food the athletes should avoid, sophisticated training methods, guarding against injuries and of course new recovery technologies.  Let me run through some of the companies behind the elite athletes' sporting longevity.

Lots of NBA players look for Dr Marcus Elliot at P3 in Santa Barbara, California. Dr Marcus Elliot uses 3-D motion analysis and force plates to analyse movements to detect signs of old injuries that cause musculoskeletal problems and limit explosiveness.

At Causeanta Wellness in Scottsdale, Arizona, extensive blood testing is done to detect food allergies or toxin exposures that can affect performance. This is to examine each patient/ athlete at cellular and molecular level before their treatment begins.

At Athletigen, DNA analysis are specifically offered to athletes to offer personalised training and nutritional recommendations to help them perform better and avoid injuries.

For specific improvements in training, Daniel Chao from San Francisco based Halo Neuroscience has developed a headset using transcranial direct current stimulation (zapping your brain with electricity) to stimulate the motor cortex (the part in the brain responsible for muscle movement).

This is suppose to accelerate training gains in endurance events (swimming, running and cycling), power (bench press, squat and vertical jump) and skill (playing an instrument, golf swing and target accuracy).

Outside the sporting world, high performers at Facebook and the US Navy Seals use Halo Neuroscience too.

Over in Melbourne, Australia Catapult Sports is a listed company (on the Australian stock exchange) that provides performance technology to over a thousand teams across 35 sports worldwide. The company builds and improves athletes' and teams performances, optimising standard of play, mitigating the risk of injury and quantifying the return to sports after injury.

Their marquee product is the OptimEye S5, a GNSS-enabled monitor that access both GPS and GLONASS staellites, sourcing real-time data and sports specific insights to avoid fatigue build up. It can measure how far the players ran, their training loads, speed, change of acceleration and much much more. The Golden States Warriors are currently using it.

In order to know when athletes are ready to train again, Helsinki based Omegawave measures electrical activity in the heart and brain to gauge levels in the autonomic and central nervous systems.

Well, now you know where to look if you have the spending power.

My competing days are way past me and I'm not gonna drop thousands of dollars on blood tests or use a home cryo chamber (by Jonas Kuehne from Cryohealthcare) to achieve better peak performance. Going to bed at 8 pm with my boys and sleeping more in a dark room with my phone turned off works well for me.


Bercovici J (2018). Play On: The New Science Of Elite Performance At Any Age. You can find it on Amazon where else.

Picture from Bathroomreader

Sunday, April 22, 2018

The Secret to Living Is Giving

Linden reels the lead runners in on Heartbreak hill
That's a famous quote by Anthony Robbins. And boy is he right!

When Sports Solutions was still at Amoy Street, I'd often notice there were some elderly people collecting used drink cans, cardboard and newspapers to sell.  I asked them how much they got for the cans and newspapers. In case you're interested, it's one dollar for a kilogram of aluminium drink cans and 20 cents for a kilogram of paper or cardboard.

One afternoon while walking back to the clinic from buying my lunch from the Amoy Street Food Centre, I saw an elderly lady struggling with some cardboard. I immediately helped her and offered her some money. She refused my offer so I offered her my lunch instead. She accepted the lunch. I remember feeling good that at least I helped her with a meal.

I'd almost forgotten about that incident until I read about Boston 2018 marathon winner Des Linden's generous act. Linden told 2017 New York marathon winner, Shalane Flanagan that chances are she may drop out (of the race) and offered to block the wind or adjust the pace for Flanagan. After Flanagan took a now famous toilet break near the halfway mark, Linden waited for her and they both then caught up with the elite pack later.

After helping Flanagan back to the pack, Linden also helped Molly Huddle. Helping Flanagan and Huddle somehow distracted Linden from her own plans to give up and she started feeling better. After realizing she was in fourth position then, she figured she probably shouldn't drop out.

Your brain releases dopamine, endorphins and serotonin when you help someone according to research (Sprouse-Blum et al 2010). All these hormones are great to have during a race. Endorphins help reduce pain, dopamine increases motivation and focus and serotonin boosts your mood.

So those surge of hormones probably helped Linden turn her race around.

In Linden's case, there may be oxytocin released too. Our brain releases oxytocin when you feel a bond with another person. This bond reminds you that you're not alone in your suffering. This may help you focus on the bigger picture, not how bad you feel at that moment. Linden later confirmed this post-race when she said, "Today was bigger than one person, it was really all of us pushing each other."

Sports psychologists will explain this as an example of disassociation which means Linden stopped thinking about how terrible she felt during the race and started to think beyond her pain. This helped reduce her perception of fatigue. An excellent example is how you suddenly feel better when your favorite song comes on when you're running. For that moment you've stopped paying attention to the pain and discomfort.

Associative thinking means you are thinking about your performance, checking your form and pace.

So how can you apply that to your own race? Try cheering on a fellow runner or team mate who's struggling or exchanging high-fives with them or even spectators along the course. This will help you feel more connected to them. That can help you boost your mood and in turn, your performance.

Capitalize on the surge of hormones to be positive for the rest of the race.

Chapeau to Linden for her selfless acts of sportsmanship, she thoroughly deserved her win.


Sprouse-Blum AS, Smith G el al (2010). Understanding Endorphins And Their Importance In Pain Management. Hawaii Med J. 69(3): 70-71.

Sunday, April 15, 2018

Barbells Or Bikes?

Both weight training and aerobic exercises are necessary
I came across this article recently which suggested lifting weights was more beneficial for losing weight compared to hopping on your bike for a ride or going for a run. The article suggested that burning calories via strength training will help you lose more fat than burning the same amount of calories doing moderate aerobic exercises.

Those headlines are good for creating media buzz but I'll say that it's not totally true if you look at that particular study in detail.

Now, before you say I'm biased, bear in mind I've written earlier how strength training is just as important as aerobic exercise. After not strength training for almost nine years, I started strength training again last year after I realize I was losing muscle mass with each passing year.

The study was funded by Les Mills International, a New Zealand company behind BodyPump, a barbell workout class. That means the study was commissioned by Les Mills International, thereby having a vested interest in promoting weight training.

There were only 12 female subjects in that particular study. They were tested during and after a resistance training workout (a BodyPump class) compared to a steady state moderate intensity session on a stationary bike.

In both workouts, the female subjects burned around 335 calories and had increase in levels of Human Growth Hormone (HGH), which is known for rapidly build muscle and to promote fat burning.

The women's HGH levels were 56 percent higher after the weight training session (light to moderate weights with high reps) compared to the steady state cycling session. Now, many previous research has shown increases in HGH levels in response to weight or resistance training, even in the elderly.

That's another reason why I resumed weight training, to make sure I get those doses of HGH, believed to be the elixir of youth, but that's probably another post.

For weight loss, the results were not unexpected as our metabolic rate stays up for a few hours after weight training. This ensures that more calories are being used even after training.

Bear in mind that strength training affects your body differently compared to aerobic (or cardio) exercises even if the calories burnt are similar. The headlines of this article generated by media buzz may claim that strength training is superior to cardio, but current research shows that both are necessary to be healthy and functional.

Actually, another study (Nindl et al, 2014) found that doing two hours of cardio boosted HGH secretion more than one to two hours of strength training.

As runners, cyclists and triathletes, we don't just exercise to burn a certain number of calories. I certainly don't. I do so because I love that adrenaline rush, the release of endorphins that I don't get with strength training. If I can solve some other problems while running, well, that'a a real bonus.

In my group rides, we don't always go at 68 percent heart rate (like the study), we do put the hammer down at times (at Coastal road), or surge up hills when we go up Mount Faber or NTU. I'm sure you do the same while riding with your friends or running intervals.

When we push the pace, our heart rate as well as our HGH levels soar. A study on sprint interval (Stokes et al, 2002) showed that doing just one 30 second sprint interval caused HGH levels to increase more than 430 percent!

Next time you feel your legs burning when your friends try to drop you, it's a good sign you're gonna have elevated levels of HGH.

So run, bike and lift weights, they are all beneficial but don't be too worried about counting how much calories you're burning.

If you're trying to lose weight, don't be too obsessive over what calories you are eating or what you are using.  As human beings, we are athletes, not Bunsen burners. Calories from drinking coconut juice or eating an avocado are processed differently by your body compared to drinking Coke or eating donuts or fried kuay tiao.


Harris N, Kilding A et al (2018). A Comparison Of The Acute Physiological Responses To BODYPUMP Versus Iso-caloric And Iso-time Steady State Cycling. J Sci Med Sp. DOI: 10.1016/j.jsams.2018.02.10.

Nindl BC, Pierce JR et al (2014). Twenty-hour Growth Hormone Secretory Profiles After Aerobic And Resistance Exercise. Med Sci Sp Ex. 46(10): 1917-1927. DOI: 10.1249/MSS.0000000000000315.

Stokes KA, Nevill ME et al (2002). The Time Course Of The Human Growth Hormone Response To A 6s And a 30s Cycle Ergometer Sprint. J Sports Sci. 20(6): 487-494.

Sunday, April 8, 2018

Going Bananas?

Ready to go riding with my bananas
I've written before that sports drinks cannot  totally replace your electrolyte losses during exercise. Moreover, sports drinks are manufactured and may contain flavorings and chemicals that you may want to avoid.

And if you're like me and prefer eating real food and drinking lemon water (or just plain water) rather than sports drinks while exercising, then you may be doing enough to replace the carbohydrates to fuel your exercise and even speed recovery.

A preliminary study in 2012 found that cyclists performed better for a strenuous bike ride if they had a banana or sports drink compared to water. The cyclists also had lower levels of inflammation after the ride. That study did not show why and how the carbs were aiding recovery.

The same authors did a new study that was recently published using more sophisticated techniques to track molecular changes inside the cyclist's bodies.

The subjects' underwent a intense 75 km bike ride inside the laboratory. In one ride, they drank only water while in another ride, they had water, eight ounces of a sports drink or half a "Dole" banana every 30 minutes.

The subjects' blood was tested before during and immediately the ride and even 45 hours after the ride. Inflammatory blood markers and metabolites were assessed during and after to test how much stress was taken by them.

When the cyclists' drank only water during the ride, relatively high levels of inflammatory markers were found. These same markers were much lower if the cyclists' had consumed the banana or sports drinks. Metabolite profiles were less stressed regardless of whether they had the banana or sports drink compared to without.

One obvious difference was those cyclists' that ate the bananas had blood cells that produced less COX-2 (a genetic precursor of an enzyme). This was not seen if they drank only water or had the sports drink.

For those interested, COX-2 enzyme stimulates prostaglandin production, which increases the intensity of inflammation. Those of you who take inflammatory medication like Arcoxia or Celebrex tablets note that they are COX-2 inhibitors. They help reduce inflammation.

This study suggest that bananas might perform comparably although it is unknown how bananas affect the cells' gene expression. So instead of popping pills like Arcoxia and Celebrex prescribed to you, you may want to eat more bananas and ginger.

It was calculated by the researches that half a standard banana provided similar carbohydrates as a cup of sports drink and the cyclists' had half every 30 mins. Bear in mind your needs may be different. Some cyclists' also complained of feeling bloated after eating that amount of bananas.

So be warned before you go bananas over ingesting bananas in your next long ride or race.


Nieman DC, Gillitt ND et al (2012). Bananas As An Energy Source During Exercise: A Metabolomics Approach. PlosOne. DOI:10.1371/journal.pone.0037479

Nieman DC, Gillitt ND et al (2018). Metabolic Recovery From Heavy Exertion Following Banana Compared To Sugar Beverage Or Water Only Ingestion: A Randomized, Crossover Trial. PlosOne. DOI:10.1371/journal.pone.0194843

*Note that Dole Foods which sells bananas funded both studies. However, they company did not have any involvement in study design, data collection, analysis, decision to publish or preparing the article.

Monday, April 2, 2018

Super Mum Rachel Yang Goes To Commonwealth Games

I first treated Rachel Yang back in the year 1999. She was then representing Hwa Chong Junior College in Track and Field throwing the javelin. Not many of you know that she started as a javelin thrower right?

Since then, she has switched to pole vaulting, become a (super) mum, did her MBA and even won medals at the last 2 SEA Games despite tearing her ACL, hurting her back (to put in quite mildly) and numerous other niggles.

Chapeau to her and her never say die spirit. She's an awesome inspiration (to me) and many, many others to say the least.

Here's wishing her (and the rest of Team Singapore athletes) all the best at the Gold Coast Commonwealth Games starting in the next few days.

Saturday, March 24, 2018

Storm Before Floss Band Course

Storm outside our clinic
There was a big storm before the Floss band course today and maybe that's why the turn out was less than normal. But it certainly didn't dampen our spirits. We had a chiropractor, physiotherapy students, a Singapore Cycling Association coach, another strength and conditioning coach from CrossFit Fire City and personal trainers.
Flossing Ben's knee
As usual, I took the time and effort to explain Tensegrity, what and how our fascia functions and the Pain Gate Theory (by Ronald Melzack and Patrick Wall, 1965) so that the participants understand how the Floss band works. And they can in turn explain to their patients, athletes and friends what the Floss band does.
Can't touch my head
A big thank you to Amy, Danny, Ekina and Jane for coming to get the clinic ready for the course. That allowed me to eat after I saw patients in the clinic from this morning. And for packing up after, so I can see another patient.

A big thank you to everyone who came despite the heavy storm before. Hope everyone learnt useful strategies that you can use use in your own area or work, play and training.

Please contact them at Sanctband Singapore for the next Floss band course and if you need to get the Floss bands.

A big thank you to everyone who came despite the heavy storm before. Hope everyone learnt useful strategies that you can use use in your own area or work, play and training.

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.