Sunday, December 9, 2018

Is Drinking Too Much Sparkling Water Bad for You?

In the fridge of our rented house 
One of the houses we rented during our recent trip had some fizzy (or sparkling) drinking water in the fridge. My younger boy tried it and seemed to like it. It was just a novelty to him. At home in Singapore, we drink filtered water and my wife doesn't allow our boys any sodas or fizzy drinks.

On the topic of sodas, some of you may remember I used to drink lots of Coca Cola while I was still competing. Actually until just before my accident. Sometimes I still get an urge to drink them, especially after a long bike ride.

Very few things beat the refreshing taste of an ice cold Coke or 100 Plus after a tough workout. One of my patients tells me he drinks sparkling Perrier water with lemon to get the refreshing sensation without the sugar. He was also concerned about whether the bubbles (or carbonation) was bad for his teeth.
What my patient drinks after exercise
Yes, remember I wrote previously about how endurance athletes had significantly higher rates of tooth erosion.

So I decided to do a little search. Here's what I found regarding sparkling water. Unlike sports drinks, the carbonation in the sparking water will probably not erode your enamel and wear out your teeth (Reddy et al, 2016). Since sparkling water has no phosphoric acid, it won't affect your calcium absorption and leech the calcium from your bones.

Unlike here in Singapore, sparkling water is very popular in the United States of America and Europe. In America, sales of sparkling water from La Croix went from $10 million in 2010 to $667 million in 2016.

So the evidence seems to suggest that plain carbonated (or sparkling) water is just as hydrating and healthy as regular (flat) water. Just be wary of the flavored varieties as some may have added sugar. That's when your dental health may be affected if your consume too much of it.

 If your crave some flavor, I'll recommend adding some fruit. I often add lemons (yes, you read correctly) in my drinking bottle while cycling.
Lemons in my cycling bottle
Other than lemons, at home I like mint and watermelons. But that's just me.



Reference

Avanija R, Norris DF et al (2016). The PH Of Beverages In The United States. J Am Dental Assoc. 147(4): 255-263. DOI: 10.1016/j.adaj.2015.10.019.

Plain sparking water is best

Sunday, November 18, 2018

From Stressful To Pleasant Memories

Guess where we went?
Every time before we travel, I get really stressed. Patients who have not seen me for a while suddenly asking to be seen on short notice. There are also many other things to be done in the clinic before leaving not to mention packing. My wife and kids often bear the brunt of my stress.

Even though we often think of vacation as a time to relax and recharge, traveling with two young boys sometimes come with definite difficulties. Especially when my older boy fractured his arm last year while we were in Brisbane.

This time we made sure to plan for mishaps and disasters. This often leads to bickering over the slightest thing with my wife and leaves me feeling stressed out. Thankfully, my wife does all that planning, taking up time, finances and stamina. I just pay.

The houses we find are often big and beautiful, but ultimately they aren't home. My older boy likes feeling safe and secure and we make sure both of them have that.

We never ever travel red-eye anymore after a particularly bad experience when my younger boy didn't sleep a wink and all hell broke loose when we landed and had to wait a long time at immigration. After the birth of our boys, we only fly with Singapore Airlines as the boys get a toy/ game once on board, are served their child meals first and they can be entertained by the in-flight entertainment system.

Fortunately, we didn't plan hours of walking, sightseeing or other touristy stuff. Too many activities make our boys tired.  In fact, we normally avoid the touristy places and plan plenty of down time. We normally rent houses near rivers or beaches and farm stays. Both my boys especially the little one love farm stays, feeding the animals, collecting your own herbs, vegetables and fresh eggs.

My wife pack lots of snacks so that the boys don't get hungry and have temper tantrums. We often go through pictures taken during the trip and laugh at what we did. Our boys really like this time together as we share new experiences, conversations and laughter.The best memories seem to come from these spontaneous moments.

During stressed times while traveling, which may be due to family, children or indignities of bureaucratic travel, I just need to calm down and think of the happy times.

Everyone in my family is sleeping as I type this, so that I can give them my undivided attention during the other times. So please excuse me not writing until I'm back in early December.
Fireworks at Darling Harbour last night

Sunday, November 11, 2018

Breakthrough Performances And Hot Streaks


A few fellow physiotherapists that I've treated recently commented that they were quite amazed that I've gotten them (and patients) better so quickly that it almost seems difficult to believe.

To which I'd always say that nothing really improves in a straight line. Except our age, nothing really goes up in a straight line. Just like the stock market gyrations, there are days when it rises, some days it drops like a rock or days where it moves sideways.

Success in getting a breakthrough performance (or getting a patient better) is similar. It is almost never about a single monumental shift.

Think of a glass of water that you put in the freezer.  The water starts to freeze when it goes under zero degrees celsius (or 32 degrees Fahrenheit). This does not mean that the energy needed to lower the temperature from three degrees, two, one degree and zero isn't important. In fact, you will never get the water to freeze if all the prior work to cool it down isn't done.

Similarly, breakthrough moments are often the result of many previous actions, which slowly accumulate to unleash a major change.

In order to make a significant change, you need to work persistently to break through inevitable plateaus. Just like the water gradually turning into ice, you are gradually changing and improving as you slog along.

A patient (who used to race aquathlons) recounted the following experience. He and a fellow team mate were stuck at swimming 1:40 minute for the 100 meter swim intervals for a very long time. Without any real change in training, they suddenly got it down to 1:30 minute.

A patient of mine who runs got his kilometer repeats down from 4 minutes to 3:45. Or another athlete shared that he was squatting 100 kg for three months suddenly improved to 120 kg.

Many of my patients are now done with their racing season, while some are tuning up for their last race of the year. For those preparing for the year end Singapore Marathon, remember it's almost time to taper. When you resume training after your break and perceive no change, remember that just like water that is slowly beginning to freeze, you too are putting in the work for your breakthrough performance.

Back to my conversation with the physiotherapist I treated recently. My "hot streak" on getting good results treating patients definitely rest on a foundation of prior work, during which I try to become a better physiotherapist every year (since I can probably not get faster as an athlete).

In a journal, Nature, which was published recently, researchers found that most people have a "hot streak" in their career - a specific period during which an individual's performance is substantially better than his or her typical performance although the timing is somewhat unpredictable.
Talking it through just 2 days ago
Thanks to my wife and fellow colleagues, we regularly discuss and break down segments of courses we've gone for to make it unique to us. We will strive to make sure this "hot streak" of getting patients better as quickly as possible continues.

Putting it all together
Reference

L Lu, Y Wang, R Sinatra et al (2018). Hot Streaks In Artistic, Cultural, And Scientific Careers. Nature 559: 396-339. DOI: 10.1038/s41586-018-0315-8.

Friday, November 2, 2018

Farewell Car Park Party At Holland Village


As we were walking back, my 8 year old boy asked me "why don't you write about the car park party?"

My younger boy was at home with my wife as he was having a fever and my older boy and I happened to walk past the farewell party for the partial closure of the Holland Village car park just behind the old Buona Vista swimming pool.

Incidentally, both of us attended the farewell pool party at the old Buona Vista Pool back when it closed in February 2014. Our patients did their deep water rehabilitation there at the pool after surgery. In fact, I learnt to swim in that pool and I taught my boy to swim in that pool.


The old swimming pool area is now a car park. This car park is going to be a huge mixed development built by a Far East Organization led consortium.

The landscape here will truly change. We will find out how it turns out in 2024. Below is an artist impression of how it will be ......

Sunday, October 28, 2018

Know Change Know Pain

Blue marker indicates cleat postion
My last patient yesterday came in to see me with anterior knee pain. This patient recently changed to a new pair of cycling shoes and started having knee pain since 15/10/18.

Despite resting for a few days, the anterior knee pain was still there after trying to cycle on 19th and 24th October.

This patient tells me "cycling is an almost daily affair" and spends a considerable amount on the saddle.

After asking my patient a few more questions and assessing thoroughly, I was convinced the pain was triggered after changing cycling shoes.

I'm reminded of a previous post back in 2012 when Rafael Nadal changed his tennis racquet in his quest to serve better. Tennis fans would clearly remember how Roger Federer had problems affecting his back after a racquet change in 2013. In fact, after an extended period on the sidelines because of an elbow injury Novak Djokovic had to make adjustments to his tennis racquet early this year as well.

Back to my cycling patient. Before my accident when Sports Solutions was still at 108 Amoy Street, I used to cycle to work and back daily. I was very aware of the riding position on my bike. Any slightest change in saddle height, stem length or "strange noises" on the bike I would be able to notice it quickly. If you ride you bike regularly enough, you'll know I'm not exaggerating.
Superficial Front Line
After treating my patient's Superficial Front Line, it's back to cycling yesterday (after treatment) and today albeit on the trainer first and a slight change in pedaling technique.
Able to ride yesterday and today
Don't try to make key changes to your cycling, running shoes, swim technique or golf swing etc right smack in your regular season if you're competing. Just like you wouldn't use a new pair of racing shoes without trying it way before the race.

In my opinion, it's much better to use the new gear after your time off at the end of your season after you've not been riding or running etc. Your body will not be so sensitive to the changes. This I've learnt the hard way.

White marks the spot
Just in case you're wondering, we do mark the insert inside the cycling shoe too.

Monday, October 22, 2018

Tensegrity Of The Spine

Lining up half the participants to compare their necks and backs
After Aized and Rachel did Arches and Legs last week, it's the turn of the three amigos this this two days as we do "Tensegrity of the Spine" over the next two days.
Range of movement in the spine

This course is very intense and heavy going as there's a lot of rationale behind the theory involved. Everyone (yes, you read correctly) got lost at some point today, including yours truly.

Let's hope we get a clearer picture tomorrow.

Sunday, October 14, 2018

The Amazing Fiona Oakes

Picture from Livekindly.co
I've never heard or read about Fiona Oakes before. Until my wife told me about her two days ago. She is so unassuming, humble and in her own words "I'm not really a runner". Actually she is a fantastic runner. Fiona Oakes is the fastest woman in the world to run a marathon on all seven continents and the north pole both in cumulative and elapsed time.

I thought I had it bad when I've had three knee operations before but Fiona has had seventeen knee operations and no patella (or knee cap)! Can you even imagine the rehab she has had to go through?

She was told when she was fourteen that she would find it hard to walk properly, let alone run again. It is truly amazing that she is still able to run so well. All this while being a vegan who eats one meal a day while while running an animal sanctuary.

So maybe we really don't need to eat meat and definitely not the sports and dietary supplements that are being marketed at us.

Watch the video, her partner Martin wonders how she can wake up at 3:30 am to start feeding the animals, run 20 km, come back and work all day cleaning and tending to the animals.

This just shows that the human body is truly resilient, amazing and and can perform really tremendous feats when there is a bigger cause (saving animals in Fiona's case).

If you're a runner, you have to watch the film, it's free until tomorrow.


*In case you're wondering why her running shoes look odd (I did) in the Marathon Des Sables, she's taped them up to avoid them falling apart.

Monday, October 8, 2018

Does Exercising Later In The Day Affects Your Ability To Sleep?

Zzz after a hard ride ...
I've written before in a previous post that I'm a poor sleeper. If you're like me, when I pushed myself too hard at training, I actually found it harder to fall asleep. The more I need (and want it), the harder it is for me to get it.

And sleep you know is critical for your mental and physical well being. If you're athlete, sleep is the easiest and cheapest intervention you can utilize to help your performance.

Hence, I was quite intrigued when I saw work from researchers who tested the effects of whether morning or evening workouts will affect your sleep by measuring melatonin levels. Melatonin is a hormone secreted in the pineal gland that regulates sleep and wakefulness.

Melatonin levels start to rise around your bedtime. It helps to lower your body temperature (now you know why it's so hard to fall aslleep when it's been so hot recently) and a rise in sleepiness. Melatonin levels usually peak around 3 am for most people.

The volunteers in the study were tested on three different days. A day with no exercise, a day when they exercised at 9 am or another at 4 pm. Their workout was a 30 minute  run at 75 percent VO2 max. Melatonin levels were measured with a saliva test at 8 pm, 10 pm and 3 am.

The results showed that those who did the 4 pm exercise session had much lower melatonin levels at 10 pm and 3 pm compared to the 9 am exercise group. It means that those who exercised in the afternoon (or those of you who can only train after work) will have a tougher time falling and staying asleep. End of story, period?

Not really. Don't worry if you're like most other Singaporeans who mostly have time to train only after work hours.

Melatonin is just one part of the equation in your quest to fall and stay asleep. Melatonin levels may not be the main reason why you cannot fall asleep.

For you to get a good night's sleep, it may depend on what you you eat/ drink, the wavelength of light emitted by your smart phone, the temperature of your room, your exercise routine/ intensity and not just your workout time rather than just your melatonin levels.

If you're going for a "relaxing" evening run, and clearing your head over stresses you've encountered during the day, it's gonna be a lot easier than doing sprint intervals. Although some runners may even say that the intervals make them tired and thus make them sleep better. This alone may be far more important than melatonin levels.

Another factor that is not addressed in the paper by the authors is whether genetically you are a "night owl" or a "lark"? The New York Times has a good article on how there's a strong basis on a person's natural inclination with regards to the times of day when they prefer to sleep or when they're most alert.

Some of you reading this now (after exercising late in the day and not sleeping) are likely to be "owls" and not likely to get up early to exercise since you sleep later. This may may due to your circadian wiring rather than exercise timing. So shifting your exercise timings to the morning may "rob" you of your morning sleep without helping you to fall asleep earlier.


Reference

Carlson LA, Pobocik KM et al (2018). Influence Of Exercise Time Of Day On Salivary Melatonin Responses. Int J Sp Physiol Perform. 30: 1-13. DOI: 10.1123/ijspp.2018-0073.

*Picture by Jeremy Ong

Sunday, September 30, 2018

First She Wins 100 Km Race, Now PS Summits Cho Oyu (8201 Meters)


Remember PS, winner of the Cameron Ultra-Trail 100 km race who saw me for her plantar fasciitis three days before her race on 25th July 2018?

Here's another feather to her already impressive list of achievements. She recently climbed to the top of Cho Oyu, a 8201 m high mountain!


She sent me this message last night. Still pain free after seeing just two times for her plantar fasciitis. Once before Cameron Ultra-Trail 100 km race and once after she came home from the race.

Well done PS!!! Come home safely soon.


Sunday, September 23, 2018

Popping Vitamins Or Other Dietary Supplements?


I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


References

Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.


PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.

Sunday, September 16, 2018

Mid Life Crisis In The Older Athlete?

Singapore National Games 2012 by RS from Flickr
I had a patient who recently turned 50 years young and decided that she would like to finish running a marathon. She had never ran much before (unless you count physical education classes in school) and she would consider herself pretty much inactive previously. She started training with a local running group, and within 6 weeks of training got injured and ended up seeing me in our clinic.

Here's a trend I've been noticing, a fair bit of participants in local races are above the ages of 40. I just looked up the results of the 2017 Singapore Triathlon and the 2018 Singapore OCBC National Road Race Cycling championships. The 40-49 age group has the largest number of participants and among the most competitive. I didn't look up the statistics, but with the number of participants we've treated in our clinic, I'm sure this is similar for the Spartan races too.

If you look up the 2018 Boston marathon results in April this year and last year's New York marathon the statistics are similar.

Research backs this up too. A research paper by Hoffman and Fogard (2012) found that the average age of participants in a 100 mile trail race was 44 years.

My 50 year old patient calls this urge to run her her first marathon her "mid-life crisis". I looked up "mid-life crisis". This concept was first presented in 1957 by Canadian psychologist Elliot Jacques to the British Psychoanalytical Society and later published as "Death and the Mid-life Crisis" in the International Journal of Psychoanalysis in 1965.

His theory was that as we approach middle age, we begin to realize our own mortality (or death) and we begin to freak out. As we grow older, we start to focus on how much time has passed, how much is left and what to do with whatever time is left. That can create anxiety and that anxiety can be multiplied by anxiety, depression and stress.

My 50 year old female patient says that unlike what you usually read or see in movies (where the older white guy buys a sports car and dates a younger girl in a desperate bid to feel young again), her "mid-life crisis" is to take on physical challenges.

Her goal is not to cling on to whatever is left of her "youth" or be young again. It is more about building up for the years ahead. Sounds like a good mid-life crisis to me.

Whether you are a young and older athlete, and starting a new game or beginning to exercise, pace yourself and start gently. There are big benefits from minimal running. However, if you do get injured, come and see us in our clinics.


Reference

Hoffman MD and Fogard K (2012). Demographic Characteristics Of 161-km Ultramarathon Runners. Research in Sp Med. 20(1): 59-69. DOI: 10.1080/15438627.2012.634707.

Sunday, September 9, 2018

Heat Acclimatization Can help Exercise Performance


Other than the heavy rain the last two days, it's been very hot recently. I used to love training and racing in the heat. Living in sunny and super humid Singapore meant that we're used to such conditions.

I'll often train in the hottest part of the day so that when race day came, whatever sweltering conditions encountered (on race morning) will seem like a breeze. There was a year (2001) when the Osim Singapore Triathlon was held in Sentosa and it was 38 degrees Celsius on race day and I used that advantage to finish 3rd overall behind Dimitry Gagg (former World Triathlon Champion in 1999).
On the podium with Dimitry Gagg in 2001
Turns out I may have been right in getting an edge over my competitors. And you can use that to your advantage too.

Heat is now hot! This shift towards heat training has been trending for the past few years. From running marathons to even climbing mountains, athletes around the world have been trying to get potential performance benefits of heat training.

Many of these heat studies started because of the 2008 Beijing Olympics. Many runners were preparing for the sweltering conditions and that lead to a whole lot more research done on heat acclimatization.

There are even studies of using heat therapy to fight heart disease and repair muscles.

Most heat acclimatization protocols help athletes perform better in the heat. This includes lowering core body temperatures, increasing perspiration rates and increasing volume of blood.

And what if after all that training in the heat race day wasn't hot? What if race day turns out to be as cold as the 2018 Boston marathon?

Fret not, results of a study (Lorenzo et al, 2010) on whether being well adapted to heat might affect your performance in cool conditions put that worry to rest. Scientists had cyclists train for ten days in 41 degrees Celsius (105.8 degrees Fahrenheit). Their VO2 max improved by 5 percent while their one-hour time trialing performance improved by 6 percent! This was when they were tested at 12.8 degrees Celsius (55 degrees Fahrenheit). Just in case you were wondering, they improved by 8 percent in hot conditions for both VO2 max and the one hour time-trial.

Control group cyclists had no improvements in V02 max, one-hour time trial performance, lactate threshold and other physiological parameters.

Suddenly, hot rooms, saunas and even non breathable training suits were the latest must haves and even suggested to be a cheaper and more convenient alternative to altitude training.

When it is too hot, it is a shock to our system. This is similar to what happens to our system when we exercise or train in altitude.

When we exercise in altitude, the decrease in oxygen triggers the body to produce more red blood cells. Heat training increases the volume of blood plasma in our bodies and this help send more oxygen to our muscles.

However, it is not totally certain that increasing blood plasma volume may lead to improved athletic performance. What may happen from the resulting dilution of blood is that it may trigger a natural response for the body to produce new red blood cells - just like altitude training.

Training in hot conditions does not only change blood plasma. Other benefits include psychological resilience (or the ability to endure) and altered perception of high temperature. Just like what I intended for by training in the hottest part of the day.

Before you head out and train yourself silly in the heat, make sure you gradually increase your intensity and heat exposure. Drink enough but do not overdrink.


Reference

Lorenzo S, Halliwill JR et al (2010). Heat Acclimation Improves Exercise Performance. J App Physiology. 109(4): 1140-1147. DOI: 10.1152/japplphysiol.00495.2010.

Saturday, September 1, 2018

Can Your Calf Muscle Cause Your Knee To Hurt?

Now that's some very defined soleus muscles
Really? You must be wondering how and why after looking at the title of this week's post. Well, my last patient today had knee pain caused by her soleus (or calf) muscle. She had recently been doing a lot of step ups in her gym classes and her knee pain started soon after.

Runners' knee or patellofemoral joint pain (pain under the kneecap) is very common in runners. I've written before about how this may be due to heel striking, heavy landing and hip dysfunction.

There is also some evidence where the length of the soleus muscle can influence patellofemoral joint pain (PFP). It has been suggested that in runners with PFP, there is a greater activation in the muscle compared to runners without knee pain (Piva et al, 2005).

See soleus after you cut away gastrocnemius
Your calf muscles consist of the more superficial gastrocnemius muscles and the deeper soleus muscle. If you peel off the gastrocnemius muscles, the soleus muscle lies underneath. Together they end as the Achilles tendon finishing at the heel bone (picture above).

The soleus muscle is largely thought to help with our posture as it is mostly made up of Type I slow twitch muscle fibres. The gastrocnemius muscle is made up of mainly Type II fast twitch fibres.

The fast twitch muscles of the gastrocnemius allows you to sprint. However, the gastrocnemius muscles tire easily.

The slow twitch soleus muscle is very important for your walking and running. Since they're more fatigue resistant, you use them a lot chalking up mileage whenever you run.

One of the main functions of the calf muscles is to absorb shock. If they're overused, they can't absorb shock well, your knee takes more of the load and you get knee pain.

A very simple way to take load off your soleus muscle is to take smaller steps when walking or running. Increasing your step rate, especially while running will ensure you're not over striding and heel striking. This reduces impact loading and lessens your chances of knee pain.


Reference

Piva SR, Goodnite EA et al (2005). Strength Around The Hip And Flexibility Of Soft Tissues In Individuals With And Without Patellofemoral Pain Syndrome. JOSPT. 35(2): 793-801. DOI: 10.2519/jospt.2005.35.12.793.

Sunday, August 26, 2018

Don't Turn Childhood Into A Race

Picture by RS from Flickr
I didn't expect my article on not to force your teenage athletes to be so well received. I received many requests to share the article and comments from readers and patients alike.

And in the clinic, there were patients who asked me about that article. Turns out one of those conversations became the inspiration for this week's post.

One of my patients had been deciding whether or not to go for football practice. Not her or her husband but their two boys. The commitment required though makes it seem like the whole family is involved. Even their helper help to pitch in by making sandwiches and sports drinks (although I thought they were a little young for sports drinks).

The twice weekly practices, requiring a 30 minute drive one way ends quite late on a week day leaving just enough time for dinner and bedtime (but not homework). The Saturday or Sunday practice often conflict with family lunches, birthday parties and family time for just lazing or goofing around at home.

Their boys are only six and eight and I feel they shouldn't be on such a "rigid" supervised program for sports (but that's just my opinion).

I've read from articles in Red Sports and the Straits Times that increasingly for children in Singapore, kids start playing organized team sports younger. They are often encouraged to specialize in a single sport sooner than later. Especially those kids who are hoping to enroll in a school of their choice under the Direct School Admission (DSA) scheme.

This creates pressure for kids to be proficient and exceptional only at one sport. When I was in primary school, I played table tennis, football, basketball, badminton and also competed in the running events during my school sports day and won medals for all of them.

Now, I'm not disputing the fact that sports are very good for kids. When kids take part in sports, it teaches them teamwork, sportsmanship, improves their self esteem while letting them try risk taking (safely). And of course it makes them healthy and strong. Both physically and mentally.

I, for one have seen first hand (while treating these young athletes) that these children/ teenagers who focus too early on a single sport lose interest when the going gets tough. They're often more prone to injury, stress and burnout.They sometimes fail to develop basic movement skills. Just watch a bunch of young elite swimmers (no disrespect intended) play basketball or football.

In today's Straits Times, in an article on why we should not turn childhood into a race for results, the author wrote about how US Olympian Katie Ledecky describe swimming as "really just for her still a hobby". She has by the age of 21 won five Olympic gold medals and a silver, owns six world records and a US$7 million dollar deal with a swimwear company.


She was quoted in a New York Times article saying "I feel lucky that I could enjoy swimming," and "people need to relax ... and take a step back and realize that you don't have to be great at this young age. It's not about immediate results". Ledecky said she recalled she had not raced in events longer than 25 yards (22.9 metres) until she was eight years old.

My observations mirror those of studies published. Kids who wait until their older teenage years to specialize are better all round athletes and more likely to stick with sports and continue to be active throughout their life.

So what's the solution? Try to do everything in moderation. If your child is keen on a single sport, try mixing other activities on their off days. Make sure they have off (or total rest) days.

My own two boys do lots of outdoor free play- climbing, jumping and running around in the playground nearby. Other than football once a week for the older boy (at his request) there are no other art, music or other enrichment activities for both of them.

I suggest that your child should not be involved in more hours of organized sports than their age. Expose them to as many different options as possible while waiting as long as you can to find a sport for them to specialize. Then you can support them as much as possible.

We also value adventure in our family. My wife and I hope that our boys will be competent and enthusiastic outdoors. So we try to make sure they're climbing, hiking, going for nature walks and biking. Travelling and farm stays (which the boys love) will remain an essential time for our family and this keeps us connected and is a welcome change to our over scheduled wired and connected world.

Competitions? Do your best to keep them in perspective. Your goal as a parent is not to raise an Olympic athlete but to raise a nice child that grows into a nicer, well balanced human being who will contribute to society.

ST article 260818

Sunday, August 19, 2018

McConnell Taping Versus Kinesio Taping

Me holding court
Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques started with me reviewing material we had gone through yesterday.

After that we went straight into material for Day 2 and some of the questions the participants asked was how Mechanical Correction taping from Kinesio Taping would fare against Jenny McConnell's McConnell taping for the knee. Yes, Jenny McConnell's taping technique was first published (and made famous) in the Physiotherapy Journal way back in 1986. I remember reading the article and using the taping technique before.

McConnell's taping (L) vs Kinesio Taping
Here's a close up of what I did for Michelle's knees.
McConnell's on the (L)
No prizes for guessing which came out tops.
Michelle's happy
We had many fruitful clinical discussions on applications for the Medial Collateral Ligament (MCL), pes anserinus area, the Achilles tendon and of course the plantar fascia.

With the physiotherapy students
The four Physiotherapy students from SIT requested taking a picture with me after the course. Thanks for coming Sara, Mark, Priscilla and Dominic. The pleasure is all mine.

Group picture

A big thank to all for coming, especially to Nada and Faisal from Saudi Arabia, Tim from Loue Bicycles, Nisa and the Physiotherapy students and teachers, hope it was useful for everyone.

Saturday, August 18, 2018

You Two Came All The Way From Saudi Arabia?

Nada from Saudi Arabia
We have 2 overseas participants this time, all the way from Saudi Arabia as Sports Solutions hosted Day 1 of the Kinesio Taping Asessments, Fundamental Concepts and Techniques course today. Thanks to Nicole Montes from Kinesio USA for putting my course details on their website.

Tensegrity model
We began our day with some lessons on anatomy and discussions on how the tape works, the homunculus, the tensegrity model and the Pain Gate Theory amongst others. Yes, I did explain about the how that original 1965 paper by Ronald Melzack and Patrick Wall may still be very relevant in some ways presently.

After all that talking, it was of course time for the practical.

Where's his head?

Here you go
Stay tuned for Day 2 tomorrow.

Friday, August 10, 2018

Fat Pad Most Painful In The Knee?


I had a patient who came to our clinic recently complaining that his MRI showed that his patella (knee cap) cartilage had "worn out" completely but he didn't have any pain prior to that. He had actually gone to do his MRI under his doctor's insistence for investigating something else.

His  MRI results was like in his words "opening a can of worms" telling him what's wrong with his knees and perhaps that's why he started having pain after that.

After his ranting, I had to explain very thoroughly about the structures in our knees that cause the most pain. The information I gave him was derived from an article published quite a while ago in the American Journal of Sports Medicine but still very relevant today.

The doctors in that study came up with a simple method to document the various sensations felt inside a single subject's knees one week apart. Right knee first, followed by the left a week later. (Note that the subject had no prior knee pain).

They would arthroscopically poke/ palpate (using a specially built spring loaded device) different structures inside the knee while video recording the procedure and record what the subject's response was. Force used was between 0 to 500 grams. All this done without intra articular anesthesia. Ouch! That must really hurt.

The doctors only injected local anesthesia at the portal site (incision). The first author inspected both knees arthroscopically. He asked the patient when he poked at different structures and graded the sensation as follows (0) no sensation; (1) was non painful awareness; (2) slight discomfort; (3) moderate discomfort and (4) severe pain. This was done with with a modifier of either accurate spatial localization (A) or poor spatial localization (B).

Ready for the results? They were exactly the same for both knees. Even though it was done one week apart.

Palpation of the patellar articular cartilage in the three under surfaces (central ridge, medial and lateral facets) resulted in no sensation, or a 0 score, even with a strongest force of 500 grams. Palpation of the odd facets elicited a score of 1B. Asymptomatic grade II or III chondromalacia (wearing out) of the central ridge was identified on both patellas of the subject!

Palpation of the articular cartilage surfaces of the femoral condyles, trochlea, and tibial plateaus at 500 g of force universally produced a sensation of 1B to 2B.

The sensation from the meniscus ranged from 1B on the inner rim of the meniscus to to 3B near the capsular margin.

Sensation from the  cruciate liagaments (Anterior, posterior cruciate ligaments) range from 1-2B in the mid-portion of the ligaments and 3-4B at the insertion sites.

Palpation of the suprapatellar pouch, capsule, and the medial and lateral retinacula produced a score of 3A to 4A (moderate to severe localized pain) at relatively low levels of force (about 100 g).


The most painful structures were the anterior synovium of the knee, the fat pad and the joint capsule - 4A.

The human knee can be very complex, especially our patellofemoral joint (patella and the femur). The three asymnetrical surfaces on the underside of the patella (or knee cap) has to work together with the femur as it accepts, transfers and dissipates loads between the bones.

We know from previous research that various structures in the knee send neurosensory signals (or messages) to the brain. It is theses signals that result in us feeling pain.

Even though my patient's patella cartilage had worn out (just like the subject) there shouldn't be any pain there as articular cartilage doesn't have any nerve supply. No nerve endings means it is unable to detect pain.

Even the ACL and meniscus wasn't really that sensitive to the poking. This observation may provide an explanation for the often poor localization of structural damage that many patients experience with a cruciate ligament or meniscal injury.

Now you know, worn out articular cartilage doesn't cause you pain. The pain you have is likely to come from other structures.



Reference

SF Dye, GL Vaupel and CC Dye (1998). Conscious Neurosensory Mapping Of The Internal Structures Of The Human Knee Without Intraarticular Anesthesia. AM J Sp Med. 26(6): 773-777. DOI: 10.1177/03635465980260060601.

Wednesday, August 1, 2018

PS Sim - Winner Of The Cameron Ultra-Trail 100 Km Race

Picture from PS Sim
PS kindly agreed to not remain anonymous anymore so I can finally write here that she is the runner who won the Cameron Ultra-Train 100 km race despite having plantar fasciitis (for the past six months at least). She came back to our clinic today to allow me to finish assessing her and treat the cause of her pain.

Actually, after my previous post, I've had questions from some readers already asking me what I did for PS and her plantar fasciitis.

Here's a summary of what I did for those asking. No ultrasound, no ESWT (shock wave) needed, no orthotics and no other gimmicks.

Just plain old accurate body reading and thorough assessment after the body reading pointed to clues around her hips being one of the main reasons to her pain in her plantar fascia. Other contributing factors also suggest that changing shoes and her foot type may have triggered it.

So, of course I started treating her hip first and also taught her what to do to prevent it from recurring. She needs to work at this still for the time being.

 I wrote in my last session with her that I only had time to treat parts of her foot along her Superficial Back Line (SBL) and The Spiral Line.
Superficial Back Line

I did more work on her SBL and also treated fascia along her Superficial Front Line today. After that I had to change her pelvic rotation and suggested she may want to try taping her foot (in case she was planning on starting training again).

Happy to discuss if anyone has questions.
Spiral Line
Congrats to PS once again for a race well won and to Melvin for winning PS.