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.