Sunday, June 28, 2020

My Patient Had Myositis Ossificans

I had a patient who came in recently with Myositis Ossificans. Myositis Ossificans is a condition where there is formation of bone inside a muscle, other soft tissue or around a joint after an injury. It is more common in younger patients and athletes after a traumatic injury such as receiving a hard kick while playing football.

It can also happen where there is a repetitive injury to the same area, such as my left elbow joint area (more on this later).

Regardless of what caused it, Myositis Ossificans happens when there is an 'error' in the body's healing process. This occurs after fibroblasts (or muscle cells) are accidentally replaced by immature bone cells at the injury site.

This causes a hard lump to develop within the muscle. It starts off as a gradual process and begins shortly after the initial injury.

Unlike other common muscle strains or injuries, patients with Myositis Ossificans will find that their pain worsens as time goes by instead of getting better. The muscle /injured area feels warm, often has a decrease in range of motion, swelling and a obvious lump or bump.

This patient received a big knock on the thigh after an accidental collision while cycling. It was initially thought of as a deep muscle bruise. But when the pain and swelling did not subside, the patient's parents consulted me and I immediately suspected Myositis Ossificans after hearing the history and feeling the 'lump' in the patient's thigh. This was later confirmed by an ultrasound scan by a doctor.
Carrying angle on the left is altered
I, too had Myositis Ossificans in my left elbow. This occurred back in 1994 after I fell repeatedly on my left elbow while cycling.

I had exactly the same signs and symptoms described above. If you look at my left elbow now, it's still looks mildly swollen and a little 'deformed' compared to the right. My left elbow's carrying angle has also been altered.

I can't straighten my left elbow fully (lacking the last 2-3 degrees) compared to my right. Other than that it does not really bother me at all.

It's not difficult to treat once you know what it is and especially if you seek treatment early. Otherwise you may end up with a slightly 'deformed' elbow like mine. Just purely cosmetic, no real deficits.


Rossetini G, Ristori D et al (2018). Myositis Ossificans: Delayed Complicatio Of Severe Muscle Contusion. JOSPT. 48(5): 348-427. DOI: 10.2519/jospt.2018.7567

See the 'lump' near top of picture

Monday, June 22, 2020

Spinal Manipulation Helps With Hip/ Knee Weakness In Otherwise Healthy People

Wow, this article definitely caught my eye as a single manipulation on the spine in healthy subjects increased the lower limb strength, at least in the short term.

The subjects were found to have lower limb musculoskeletal dysfunction along with muscle weakness. Those with knee and hip weakness who are otherwise healthy had large strength gains.

Strength training will hypertrophy muscle and increase strength over a period of six weeks though the authors suggested that weakness can persist despite muscle hypertrophy. They suggested this occurs in the early stages of joint pathology or when there is limb or spinal joint immobility which may then inhibit muscle activation.

The authors also presented evidence of three randomized controlled trials (these are Level 1b evidence of moderate quality) that showed immediate small to large effect size muscle strength gains immediately after spinal manipulation.

The authors suggested that spinal manipulation to particular spinal segments after screening for specific muscle weakness can increase short term strength. This will present a chance for efficient intervention as patients benefit by starting an exercise program to train the new muscle function gained. This provides extra incentives and more motivation for the patients to keep training.

What remains unclear though are the neuro muscular mechanisms through which the spinal manipulations increases strength.

Hmmmm, as you can read, I'm intrigued by the possibilities of increasing strength with a simple manipulation of the spine, but not convinced yet.

I would still suggest that those with true hip and knee weakness (and no other condition) engage in a strength training program.


Wong CF, Conway L et al (2020). Immediate Effects Of A Single Spinal Manipulation On Lower-Limb Strength In Healthy Individuals: A Critically Appraised Topic. J Sp Rehabil. June 2020: 1-5. DOI: 10.1123/jsr.2019-0372.

Sunday, June 14, 2020

Phantom Limb Pain

How many of you have heard of phantom limb pain? The physiotherapists reading this definitely have, but what about my other readers?

Phantom limb pain (PLP) is the feeling of pain in a body part that does not exist (usually amputated because of an  accident or diabetes). Amputees often get phantom limb pain. After amputating a foot, arm or leg from a person, the brain still has that foot, arm or leg mapped. It is not totally clear how and why a person without the physical limb can still have sensations or pain.

Interestingly, it does not just happen in the arms and legs. Phantom breasts, penises and tongues have been reported too (Davis 1993).

Other than pain, patients say sometimes they feel 'it' tingles or itches too. Often PLP symptoms become worse when the person becomes stressed.

PLP tells us about the representation or map of the limb (the 'virtual limb' inside the brain). This is known as the homunculus. Those of you who attended my Kinesio Taping or Floss Band courses would have already heard of this.
The homunculus
It's been a while since I've treated an amputee, but I read about this very interesting case of a woman with PLP. This woman, named RN in the study was born with only three fingers on her right hand. When she was 18, she got into a car accident and several bones in that right hand was broken. Six months later, her doctors decided to amputate that hand.

After amputation, RN reported having pain as though her hand was still there. You would expect her pain to be in the hand with the three fingers she lost. However, she reported feeling five fingers on her painful phantom hand. And they were not five normal fingers. She said her thumb and index finger felt shorter than the rest, but there was definitely five fingers.

RN lived with this phantom hand for many years before seeking help. She was 57 before she saw Dr Ramachandran (a pioneer for phantom limb research). Like what we learnt from David Butler, Dr Ramachandran treated her with the mirror box. After the mirror training, RN reported that her two smaller fingers had grown to normal size. She now feels that she had a normal right hand, that happened not to exist.
David Butler and the mirror box
Super interesting right? RN never had a normal right hand. You would think that her brain wouldn't have the map (or homunculus) to tell her how it may feel like.

To quote Dr Ramachandran : "The amputation of her hand appears to have disinhibited these suppressed finger representations in her sensory cortex and allowed the emergence of phantom fingers that had never existed in her actual hand."

In other words, the brain has a ready-made map (or homunculus) for a normal hand, that was tweaked to accomodate RN's condition. Once the physical hand was amputated, that map was restored.

*pictures taken with my iPhone XS from David Butler's Explain Pain book.


Davis RW (1993). Phantom Sensation, Phantom Pain And Stump Pain. Archives Phy Med Rehab. 120: 1603-1620.

McGeoch PD and Ramachandran VS (2012). The Appearance Of New Phantom Fingers Post-amputation In A Phocomelus. Neurocase. 18(2): 95-97. DOI: 10.1080/13554794.2011.556128.

Saturday, June 6, 2020

This Is What Our Physiotherapists Can Do

2:08 pm - wearing socks
Here's a patient I saw this past Thursday in our clinic. He was complaining of right sided low back pain after sitting at home all day long during the circuit breaker working on his laptop. You can see from the picture above that the picture was time stamped at 2:08 pm this past Thursday.

After a quick assessment, I treated his feet. Yes, you read correctly. I didn't go anywhere near his back. Have a look at the picture at 2:31 pm. Since he wasn't a new patient, my receptionist only book a 30 minute follow up session for him. New patients get 60 minutes in our clinics.
2:31 pm - took off socks
You can see he's wearing blue socks in the first picture while I was assessing him. He took off his socks as I was treating his feet. You think his socks caused all the difference? Nah, I was pulling your leg.

Have a closer look when I put the two pictures side by side below. Click on the pictures for a bigger version.
Before and after
How's that after just 23 minutes of treatment (including assessment)? Notice his feet are not pointing outwards as much. His knees are also not as hyper extended. His pelvis is level and and not tilted forward like before. His upper body is more upright with respect to his hip as compared to earlier. And his neck is not poking forward as much with respect to his upper body.

My patient was shocked when I showed him the pictures I posted here. And by the way, his back wasn't hurting anymore when I was done treating his feet.

This is what our physiotherapists in our clinics can do with our hands when we treat patients. Not a chance that video/ tele consults can do this.

Monday, June 1, 2020

Exercise As A Remedy For COVID Stress

Today is the last day of the circuit breaker (CB) or lockdown period in Singapore. Finally, light at the end of the tunnel.

During the CB, I've noticed a lot more people in my neighborhood running than before, and many you can tell, never really exercised regularly previously. But good for them, at least they are exercising now. I guess with all the free time, gyms closed and not wanting to lose their sanity, many people go walking and running.

You can probably guess that quarantines and lockdowns or similar measures to combat plagues are associated with poor mental health. Past quarantines resulted in lingering stress levels, confusion and mounting anger (Brooks et al, 2020).

A recently published study (though not peer reviewed) done in the early stages of the lockdown (in USA) suggested that benefits of exercising extended beyond just physical benefits and help us mentally too (McDowell et al, 2020).

The study found that people who managed to keep exercising during the lockdown were less depressed and more mentally resilient compared to those whose activity levels declined.

Data from manufacturers of activity trackers showed that most people's daily step count decreased from March since most countries were under lockdown during that period.

In that study, researchers asked about 3000 non smoking subjects probing questions about their personal lives. Multiple questionnaires about how often they exercised and how many hours were spent sitting before the pandemic began.

This was compared to the lockdown period in April. Subjects were asked if they were fully self quarantined at home or did they get a chance to go outside while following social distancing rules.

They were also asked about their current mental health, whether they had symptoms of depression, anxiety, loneliness or if they were generally happy.

After collating the replies, the researches split the subjects into groups based on whether they previously had or had not met the standard exercise guidelines of 150 minutes per week of moderate exercise now compared to before the lockdown. The researchers then compared exercise routines and moods.

No surprises that the researchers found that those who managed to exercise were more cheerful and vice versa. The people  who previously had been active but because of the lockdown rarely exercised were more likely to be depressed, anxious, lonely and worried compared those who still managed get in 150 minutes of exercise a week.

Those subjects in full quarantine were the most affected as few managed to maintain any exercise routine and they reported feeling sad, depressed and solitary.

After looking at the study in detail, I noticed that most of the respondents were middle class well educated whites. Not many of other races were represented.

Because this study relied on their memories of the exercise routines, the findings may not be totally reliable as it covers separate but temporary parts of their lives during the lockdown. We can perhaps infer that exercise and their moods were linked.

I can definitely testify that exercise can improve moods and well being. If you haven't been able to exercise and get out much during the CB, bear in mind that we still have to exit the CB in stages.

Stay safe.


Brooks SK, Webster RK et al (20120). The Psychological Impact Of Quarantine And How To Reduce It: Rapid Review Of The Evidence. 395: 912-920. DOI: 10.1016/S0140-6736(20)30460.

McDowell C, Lansing J et al (2020). Changes In Physical Activity And Sedentary Behaviour Due To COVID-19 Outbreak And Associations With Mental Health in 3,052 Adults. Cambridge Open Engage. DOI:10.33774/coe-2020-h0b8g.

See if you can guess where I took the following pictures during my solo CB rides.
Guess where this tank is?
Abandoned guard tower
Not in use water tank?

Saturday, May 30, 2020

New Updates On The Effects Of Prolonged Sitting

All on screens while sitting
I first wrote about the ill effects of sitting or being an active couch potato back in 2014. Subsequently, there were more and more research about the negative effects of prolonged sitting, suggesting that sitting is the new smoking. There were also suggestions that not all sitting is bad.

Previously, most of the data suggested that these effects were independent of your exercise habits. Even the fittest people were at risk of heart disease if they spent large amounts of their time sitting in front of desks or watching television.
Now, this is not prolonged sitting
One suggested reason why prolonged sitting is bad is that there is reduced blood flow to your legs. Your blood vessels become stiffer and less able to expand and contract in response to changes to your blood flow. Over time, that makes you more prone to atherosclerosis - a hardening and narrowing of your arteries, leading to heart disease.

Time for an update. New published research from Japan (Morishima et al, 2020) suggests that endurance training might well have some protective effects. There seems to be some differences between the current and previous study.

In the current study, the researchers studied a group of competitive cyclists versus a control group that did no endurance exercise. Before exercise and three hours later, there is almost no change in the blood flow to the legs of the competitive cyclists while it dropped by half in the matched controls.

Previously, another recent study by Garten et al (2019) that showed that endurance exercise had no protection for trained athletes. If you examined the data more carefully, you will notice that the "trained" group had an V02 max of around 50 ml/kg/min. This level is above average for young adults but not fantastic.
Nah, I'm not one of the cyclists in that study
In the latest study by Morishima by et al (2020), the competitive cyclists had an average V02 max of 61 ml/kg/min. This is considered excellent, and they have been training for five years and rode an average of 600 km per week.

The earlier study assessed micro vascular function in the subjects. This refers to the function of smaller arteries that branch off the big arteries and go into the muscles. The current study measured macro vascular function, this is the function of the big arteries from the heart to various parts of the body.

Both forms of vascular function are important. The responsiveness of the big arteries predict your risk of atherosclerosis, while the smaller arteries dictates how quickly and effectively oxygen rich blood goes to your muscles. This is really important for all athletes.

Possibly this may suggest that all the endurance training at a high level protects you from macro vascular function, but not micro vascular function during prolonged sitting. This is good news for your long term health.

However more specific research is needed, so train hard and at the same time try not to sit too long at work or at home watching Netflix. Hopefully with the circuit breaker ending in a few days time, you'll get out to exercise more often.


Garten RS, Hogwood AC et al (2019). Aerobic Training Status Does Not Attenuate Prolonged Sitting-induced Lower Limb Vascular Dysfunction. App J Physiol Nutr Metab. 44(4): 425-433. DOI 10.1139/apnm-2018-0420.

Morishima T, Tsuchiya Y et al (2020). Sitting-induced Endothelial Dysfunction Is Prevented In Endurance-trained Individuals. Med Sci Sp Ex. DOI: 10.1249/MSS.0000000000002302.

Great day to go cycling - Mount Faber

Friday, May 22, 2020

Physical Activities Does Not Wear Out Our Spine

I've written more than five other posts on our backspines recently, well here's another article to align with our Instagram and Facebook posts this week. You can watch the three videos here.

We've all been sitting a whole lot more, myself included during the circuit breaker. Here's what research is suggesting, that it is actually physical inactivity and not physical labor that is associated with degenerative (or wear and tear) changes in the thoracic and lumbar spine.

The researchers studied 385 subjects on the relationship between short and long term physical inactivity and degenerative changes of the thoracic and lumbar spine over a period of 14 years. They grouped the subjects into those who did no physical activity, or did so irregularly for 1 hour a week, regularly for 1 hour a week, or regularly for more than 2 hours a week.

In addition, physical labor, walking and cycling were investigated additionally.

Correlations between physical inactivity and thoracic and lumbar disc degeneration were analyzed after accounting for sex, age, Body Mass Index, hypertension, diabetes and back pain.

Subjects with disc degeneration in the thoracic and lumbar spine were more common in those with no physical activity, irregular activity < 1 hour compared than those with regularly activity > 1 hour or more a week.

You'll be happy to know that there was no obvious significant association statistically for subjects who did physical labor, walking or cycling with disc degeneration.

The researchers concluded that physical inactivity over the 14 years they studied demonstrated a strong correlation with disc degeneration of the thoracic and lumbar spine.

Just like we wrote previously that running more miles does not wear out your knees, being active, doing physical labor will not wear out your spine too.

Keep moving.


Maurer E, Klinger C et al (2020). Long-term Effect Of Physical Inactivity On Thoracic And Lumbar Disc Degeneration- An MRI-based Analysis of 385 Individuals From The General Population. Spine DOI: 10.1016/j.spinee.2020.04.016

My boys wanted the same picture as me, so here's my older boy.

And here's my younger boy below.

Saturday, May 16, 2020

Studying With Tom Myers Live Online

Looks like I've gotten myself much more screen time again during this circuit breaker period. I've signed up for a 'live' webinar taught by Tom Myers from May 15-17. Due to the unusual circumstances of the global pandemic, the course has to be taught over Zoom, of course.

This is actually the 3rd online course he's teaching since the COVID-19 started. I didn't sign up early enough for the first two and they filled up quickly. Due to high demand, they announced that Tom was teaching the same course for the third time, so I made sure I signed up straight away.

I've attended a few of the Anatomy Trains courses already, and previously one introduction course taught by Tom before. But when Tom is teaching, I just couldn't resist, even though I've learnt some of this material previously.

Tom says he misses using his hands during this pandemic
There's a slight hitch though. The course is taught from 10 pm to 12 am and from 3 to 5 am. I'll have to find a way to cope.

Picture of healthy fascia above.

Monday, May 11, 2020

What Supports The Medial Arch

I've been trying to keep myself busy during the CB and catch up on my reading and watching. Not watching Netflix, mind you. I don't have a Netflix account. At the risk of sounding like a dinosaur, I have never watched anything on Netflix.

Anyway, I've been trying to learn about the human body and how to best treat it when it's under duress. So here's sharing what I've learnt about the medial (or inner) arch and also by putting whatever I've learnt down, I can always refer back to this.

The human medial arch has a four muscles supporting it. Namely, Tibialis Anterior, Tibialis Posterior, Flexor Flexor Digitorum Longus  and Flexor Hallucis Longus (the last 3 are also known as Tom, Dick and Harry).
Back of R leg
Tom, Dick and Harry start from the back of the leg as seen in the picture above. Flexor Hallucis Longus (FHL), or Harry goes under the talus to the bottom of the big toe. This muscle carries the whole weight of the body while we push off while walking. This is also the same muscle that can cause bunions, as it puts undue pressure between the sesamoid bones under the big toe. But that will have to be another much longer post.
FHL goes in between the sesamoid bones under the big toe
I'm especially fascinated with the Tibialis Posterior muscle, especially how it attaches at the bottom of the foot in the picture below. See how wide and diverse the attachments are. It attaches to the calcaneus, the navicular bone, the 2nd - 4th metatarsals and also the cuboid.
Bottom of R foot
Other than the muscles, there is also the plantar fascia, helping to support the medial arch. Much more important than the muscles are the deeper arch support consisting of the Long Plantar Ligament (which attaches to the base of metatarsals and cuneiforms) and especially the Spring Ligament.

a = plantar fascia, b = long plantar ligament
The spring ligament is also known as the calcaneonavicular ligament (c in the picture above). It goes from the sustentaculum tali to the talus. It really acts like a trampoline to prevent your talus from flattening when you weight bear. This is most important for lifting or supporting our arches.

Typically, when we talk about arch support, we would think of taping the arch, changing our shoes, putting arch supports or orthotics into our shoes. But as you can see from the picture above that none of them can really help the spring ligament in supporting our arches.

We can really only affect/ or treat the muscles and the plantar fascia. Remember this. You may not need to buy anything fancy to support the spring ligament.

Another look at the dissected medial arch. 9 is the Long plantar ligament, 10 is the plantar fascia and 11 is the spring ligament.

Now you know.

Tuesday, May 5, 2020

Tiger Woods Blames Running For "Destroying" His Body

I came across this article from Runner's World and the video here recently saying that Tiger Woods blamed running for his decline in golf.

Tiger Woods turned pro at age 20 (in 1996) and revolutionized how golf was played. He trained really hard physically and many others copied his physical training regimen (after seeing his success) in order to catch up. He made golf really, really popular. Lots of young local golfers I treated wanted to be like him.

Many courses had to "Tiger-proof" their course by adding yardage to their tees because of his long hitting ability.

Well, with all due respect to Tiger, I don't think it's fair at all that he attributed all his injuries to running over 30 miles (or > 48 km) a week over six years.

Yes, Tiger had numerous knee surgeries after tearing his Anterior Cruciate Ligament (ACL) and at least four back operations.

I would say that his injuries were definitely partly due to his ability to hit the ball so far. The fact that he generated so much forces with his hard hitting that it affected his left knee and back.

Stand up and try this now. If you are right hand dominant, when you rotate your body to hit the ball, you can feel the rotational forces though your left knee and back. For Tiger fans, here is another possibility.

I've written before that running more miles does not wear out your knees. Plenty of published evidence support those findings. Done correctly, running is actually good for your back.

And the stress from his "personal affairs" definitely did not help either.

So don't worry, if you do not have any pre- existing injuries, running more than 30 miles (48 km) a week will not "destroy" your body or knees.

Saturday, May 2, 2020

Can Exercise Give You Headaches Or Migraines?

My patient rings up complaining of having a terrible migraine after going out for a run. She suffers frequently from migraines and usually exercise and/or seeing us in the clinic would help. She was hoping to come and see us since Physiotherapy has been reclassified as "essential services".

Despite Physiotherapy being reclassified as an "essential service" recently on 29/4/20, the criteria to see patients in the clinic are very strict.

The Ministry of Health (MOH) have told us that face to face sessions are only for "patients whose condition would deteriorate significantly or rapidly if treatment is not provided or performed and would potentially threaten their health and well being".

We can only open once a week seeing a maximum of 6 patients and we're told to "leverage on tele-consult/ tele-rehab as far as possible".
Many of our patients have called or messaged us asking to be seen and we've explained that we can only treat them if they meet the above criteria.

My running patient did add that she ran a lot harder and that was when her migraine started. I told her that I just read an article on runners and their calcitonin gene-related peptide (CGRP) levels.

In that study, 46% of the enlisted running subjects reported suffering from headaches/ migraines while 54% did not.

CGRP helps with making your blood vessels larger (vasodilation), which then increases blood pressure and inflammation in your nervous system. Increased CGRP levels are known to be associated with headaches and migraines.

The researchers measured CGRP levels (by drawing blood) in  runners before and after running. They then got the runners to run 21 kilometres at 75-85 VO2 max.

 CGRP levels significantly increased by one and a half times in the entire group after the run. CGRP was significantly higher for those who had prior migraines before the run and those runners reported suffering from migraines after the run.

This led the researchers to conclude that medium to long distance endurance exercise boosted CGRP levels and that high intensity exercises can heighten the reaction further. This can potentially trigger both headaches and migraines brought on by exertion.

Previous research has shown that exercise can decrease frequency of migraines and improve symptoms and reduce migraine triggers (Aristeidou et al, 2018). With this new article I have to add that migraine sufferers need not stop exercising, but they do need to watch their exercise intensity.

Low to moderate exercise intensities does not seem to be a trigger. There are also medications that helps with blocking CGRP for those of you who don't mind ingesting medication in order to exercise hard. Check with your doctor for the prescription.

Good news for those who do not suffer from headaches or migraines as an increase in CGRP levels is good for you as it has a protective effect for cardiovascular function.


Aristeidou S, Baraldi C et al (2018). The Association Between Migraine And Physical Exercise. J Headache Pain. 19(1): 83. DOI: 10.1186/s10194-018-0902-y.

Tarperi C, Sanchis-Gomar F et al (2020). Effects Of Endurance Exercise On Serum Concentration Of Calcitonin Gene-related Peptide (CGRP): A Potential Link Between Exercise Intensity And Headache. Clin Chem Lab Med. DOI: 10.1515/cclm-2019-1337.

To all our patients reading this and asking to be treated. Yes the government has indeed allowed some businesses to open. As you can see from the MOH circular, clinics have very strict criteria regarding who we can see even though this is not published in the news. Rightfully so since we are still in the circuit breaker period.

Please bear with us, we will inform you as soon as we are given further instructions by MOH to allow us to see more patients.

Sunday, April 26, 2020

Will You Lose All Your Strength During The Circuit Breaker If You Cannot Lift Weights?

Lunging with a 10 kg bag of rice 
We are currently at the end of week 3 of the circuit breaker (or modified lock down) in Singapore. Most of my patients who strength train are not able to take part in their usual exercises and training regimes. This is true especially for my bodybuilding and avid gym going patients, since gyms and other exercise centers are closed.

Not many of them have an ideal home gym for strength training during this period. So for them, there's a real threat of detraining (loss of strength) for them and other sporting populations. Any loss in muscle strength, power, muscle atrophy may affect future performance, injury risk and self esteem.

A recently published study (Blocquiaux et al 2020) studied older male patients (58-70 years old) during a 12 week whole body resistance training program. The subjects stopped training for 12 weeks and then resumed training for another 12 weeks.

Decent strength gains were made at 8 weeks (22%), and 12 weeks (36%) in leg strength (similar for upper limb).

What was most interesting was that all the strength gains (36%) during the initial 12 weeks were not completely lost during the 12 weeks of no training. 14% was lost during this period.

When the participants resumed training for another 12 weeks, they were stronger at the end of the second 12 week period than the first. It took them 8 weeks or thereabouts to regain what they lost in 12 weeks.

So if we were to compare with our current circuit breaker period (3 weeks and counting), don't be too discouraged. You can probably gain back what you lost. Hopefully it will take less time too looking at that study (Blocquiaux et al 2020) . For those of you who bike, run, row or do other endurance sports, there is a similar pattern observed for cardiovascular fitness too.

Now, lets look at female subjects. Correa et al (2016) studied a group of older women, and this time the period of no training was a whole year. The female participants gain an increase of 75% in strength after an initial 12 week training period. Much of these gains were lost after a year, back to baseline levels. However, after another 12 weeks or training, they gained a lot of this strength back, they were just 15% off their first 12 week training period.

So, another glimmer of hope for those of you who strength train. Though I'm hoping our circuit breaker will not be a year long!

If you make do with whatever you can find at home to strength train to failure albeit with a lighter weight, you will stave off some of the losses. That's what I try to do.

Many people are dealing with all sorts of mental and motivational issues other than physical and financial ones so exercise may be way down on their list of priorities. But if you can still exercise, it will definitely lift your mood Ludyga et al (2020).


Blocquiaux S, Gorski T et al (2020). The Effect Of Resistance Training, Detraining And Retraining On Muscle Strength And Power, Myofibre Size, Satellite Cells And Myonuclei In Older Men. Expt Gerontology. 133: 110860. DOI: 10.1016/j.exger.2020.110860

Correa CS, Cunha G et al (2016). Effects Of Strength Training, Detraining and Retraining In Muscle Strength, Hypertrophy And Functional Tasks In Older Female Adults. Clin Physiol Funct Imaging. 6(4): 306-310. DOI: 10.1111/cpf.12230.

Luduga S, Gerber M et al (2020). Systematic Review And Meta-analysis Investigating Moderators Of Long-term Effects Of Exercise On Cognition In Healthy Individuals. Nat Human Behav. DOI: 10.1038/s41562-020-0851-8

Sunday, April 19, 2020

Does Lactic Acid Affect Your Appetite?

One of our blog's more popular post was regarding lactic acid or lactate. For our new readers, that post came about after a massage therapist asked me if lactic acid in our bodies can form 'crystals' in our muscles with too much running.

A few of his patients who run had gone to this particular massage place and was told by a massage therapist there that 'crystals' left there by the lactic acid/ lactate will affect their running if the 'crystals' are not removed by sports massage.

Yes, lactic acid/ lactate is produced as a by product during intense exercise, but it starts to clear or leave your body once you slow down and especially when you stop your exercise. You do not need help to get rid of it. It certainly won't form 'crystals' in your muscles!

What lactic acid/ lactate does according to recent research is that it can blunt your appetite by altering your appetite hormones (Vanderheyden et al, 2020).

What the researchers in the study did was to have volunteers do an interval workout of 10 x 1 min really hard with 1 min recovery on an exercise bike. They repeated this protocol twice at the same intensity on separate days at least a week apart. For the first time, the participants were given a dose of baking soda and the other time a dose of salt as a placebo.

Baking soda (or sodium bicarbonate) helps to partially counteract rising acidity in your bloodstream during intense exercise (to prevent you from accumulating too much lactic acid in your bloodstream). It is often used as a legitimate and legal performance enhancing drug by some runners (especially middle distance) and track cyclists.

Please note that consuming baking soda can be associated with stomach distress although there was no apparent difference in this particular study.

This allowed the researchers to compare lactate levels in the subjects' bloodstream during and after the 10 x 1 minute intervals since baking soda will decrease lactate levels.

The researchers found that the response of the subjects' appetite hormones were lower when there was more lactic acid/ lactate in the bloodstream.

Ghrelin (which measure hunger levels were lower meaning less hunger) and two appetite suppressing hormones, *GLP-1 and PYY were higher meaning less hunger were indeed different in the two groups during and 90 minutes after the intense exercise.

Previously, when I use to compete and still did really intense training, I definitely do recall that I do not feel like eating after the workout ends. I usually only felt like drinking an ice cold Coke. Well, those were the days .....

What I'm actually wondering is whether changes in our appetite hormones can affect our eating patterns on a long term basis and thus affect weight for serious endurance athletes. If you're training reasonably hard, surely weight isn't gonna be something you worry about.

To conclude, you do not need to flush lactate (lactic acid) out from your body after intense exercise, it starts to dissipate once you stop exercising. Nor do you want to take too much baking soda in a race if you're trying to lower your lactate levels as it can give you stomach distress especially if you haven't tried it in training.


Vanderheyden LWN, McKie GL et al (2020). Greater Lactate Accumulation Following An Acute Bout Of High Intensity Exercise In Males Suppresses Acylated Ghrelin And Appetite Post Exercise. J App Physiol. DOI: 10.1152/japplphysiol.00081.2020.

*GLP -1 glucagon like peptide-1

*PYY - active peptide tyrosine-tyrosine

Monday, April 13, 2020

How Much Treadmill Incline To Use?

Getting tested at the then Racers' Toolbox (now Coached)
My patient who had been running outside contacted me after reading that running outside was more dangerous. After checking the viral article she read, I reminded her that the Belgian engineers chose to bypass all standard publishing protocols so that article wasn't reliable (picture below showing the simulated spread droplets of breathing, coughing and sneezing from people who are walking, running or cycling).
Picture by ANSYS taken from here 
Despite my reassurance, she decided that she would run indoors for now since she had a treadmill at home. She was wondering what incline she should be using while running.

The hills we run or cycle up outdoors are measured as a percentage. The treadmill also displays incline as a percentage. So if you've set the incline on your treadmill to 1.5, it means you are running at a 1.5 percent incline (not level 1.5). Most treadmills allow you to adjust the incline from 0 to 12 percent. Some models even allow for a decline. Good if you want to practice running downhill.

I suggested to my patient that she should set her treadmill at the 1 percent incline as research shows that it will simulate outdoor running as it makes up the lack of wind resistance while running indoors (Jones and Doust, 1996). This is especially so if you're running between 12 to 17 km an hour. Under 12 km an hour no adjustment is necessary as the difference is small, but you can probably still set the incline at 1 percent for an extra challenge. This may also help you transition back to running outside.

I suggested running by effort rather than by than speed alone as this may reduce the risk of fatigue, injury and frustration. This will also help with pacing before she returns to running outside.

If you too have read that viral article, the article suggested staying at least 4-5 meters behind others when walking in a single file, 10 meters while running or cycling slowly and 20 meters while cycling quickly.

I definitely don't have a treadmill and I prefer to run and bike outside. My suggestion is to respect everyone's space. Don't run or pass too close, don't follow behind and don't cut in too quickly. Stay safe.


Jones AM and Doust JU (1996). A 1% Treadmill Grade Most Accurately Reflects The Energetic Cost Of Outdoor Running. J Sports Sci. 14(4): 321-327.

Today's Straits Times 13/4/2020 on page B21 under the Sports Section too mentioned the guidelines laid out in the viral article.

Today paper published it's commentary on that same article on 15/4/2020. You can read it here.

Sunday, April 5, 2020

Let Us Help With An Online/ Video Consultation

I remember doing an video consultation a few years ago with a former patient of mine who left Singapore and relocated to Hong Kong. I treated his shoulder previously and he tore his Anterior Cruciate ligament (ACL) and had the reconstruction done in Hong Kong.

He was frustrated as he was not improving (as you can read from his iMessage to me above) and wanted my advice. I was very hesitant as I wondered how I can assess him physically without being there. I wondered if I could really be of help.

I told him that if I hadn't treated him before I would not have agreed to the video conference. Even though he insisted on paying, I didn't charge him for that video consultation.

In this particular consultation what really helped was that my patient already had his ACL reconstruction done. He was also able to describe his symptoms in detail. So what the patient tells us can perhaps replace the assessment tests we need to do. We can then guide the patient through the session if we need them to do any active movements or tests.

Why am I writing about tele/ video consultations here? Well, these are unprecedented times. On 3rd April 2020, our Prime Minister went on national TV and announced the implementation of a "circuit breaker" to minimize the further spread of COVID-19.

In line with the new policies set out by our government, our clinics will be closed from Tuesday 7th April to 4th May 2020, both dates inclusive. We will reopen as soon as we are able to do so.

We understand and support this temporary closure as it is in the best interest of our community. We all need to do our part to make this work to overcome this pandemic.

We will be available for tele/ video consultations during this period of closure.

If you’re a patient at Physio Solutions, please contact  +65 9297 9641.
If you’re a patient at Sports Solutions, please contact +65 9112 5326. 

Despite my doubts and hesitation wondering whether online/ video consultations will help, my patient thought it was "super helpful" if I may quote him from his message above. Again, he asked me to bill him, but I did not. He actually felt much improvement from what I taught him and subsequently came back to Singapore to see me 3 times for his knee.

Friday, March 27, 2020

Boosting Your Immune System While Exercising During The Coronavirus Outbreak

My cycling group has been discussing how to do our regular Saturday group ride after new restrictions by the government to restrict groups to not more than 10 people together. Or risk a $10,000 fine and a stint in jail for six months or both.

With non stop news regarding the coronavirus alerts, we definitely still need to exercise as we need a break from all the stress and anxieties that have come up daily. Don't know about you, I do definitely.
Beautiful morning
Personally, I feel that running or cycling outside is great for clearing my mind and releasing all that pent up energy. Getting out early in the morning, seeing the sun come up, hearing the birds and smelling the morning air is really nice for me. Both our minds and bodies need that.

So how do we stay safe and ensure that our exercise/ workouts now helps rather than suppress our immune system?

For those of you who are like me and need to keep on exercising, here are some basic guidelines. Do watch your intensity and duration of your exercise. Evidence suggests that being physically active makes you less vulnerable to falling sick. Data by researchers show that physically active people are 40-50 percent less likely to have days ill with acute respiratory infections.

Evidence suggests limiting sustained efforts greater than 60 percent heart rate max to not more than 60 minutes at a time. To get more bang for your buck, you can mix some high intensity efforts with rest or periods of lower intensity. That happens during our group bike rides. After riding hard for a while, we do slow down to recover. I guess stopping at the traffic lights counts too.

However, before you go out and train/ exercise harder with all the time you have now, take note that more is not always better. If you train too hard (a hard long run or a few hours of training), it actually leads to an increase in stress hormones, inflammatory changes and an increase in free radicals that will be harmful to your body.

Though this is a temporary effect, if you are under mental or emotional stress, not sleeping enough and eating poorly, it can make you more susceptible to falling sick.

In their laboratory, the researchers found that the stress starts when your intense efforts exceeds 60 minutes. It gets really bad after 90 minutes.

This is not the time to push your limits. Even for elite athletes, it's more about your health than your fitness levels.

There is plenty of data supporting regular, moderate exercise being protective of your health. You will get the most out of your exercise when you allow time for sufficient recovery. If you're tired, take a rest day, especially if you feel a slight hint of an illness coming. Do get enough sleep, eat well and manage your stress.

In this time of fear, danger and uncertainty, please take care of yourself and stay safe.



Nieman DC and Wentz LM (2019). The Compelling Link Between Physical Activity And The body's Defense System. J Sp Health Sci. 8(3): 201-217 DOI: 10.106/j.jshs.2018.09.009.

Nieman DC, Lila MA and Gillitt ND (2019). Immunometabolism: A Multi-omics Approach To Interpreting The Influence Of Exercise And Diet On The Immune System. Ann Rev Food Sci Tech. 10: 341-363. DOI: 10.1146/annurev-food-032818-121316.

Sunday, March 22, 2020

Her Coach Asked Her to Skip Breakfast

I wrote about the ketogenic diet the week before and a runner I treated two days ago was advised to skip breakfast before her runs to get into the "ketogenic zone" so that she can burn more fat.

I was fairly skeptical as I doubt you can be ketogenic and start burning ketones just by skipping breakfast despite not eating from dinner time the night before.

Anyway, I told her an article I'd just read on a similar topic while doing research writing the earlier ketogenic diet article.

British researchers studied elite cyclists who were habitual breakfast eaters on two occasions. One one occasion, they arrived at the laboratory in an overnight fasted state and ate breakfast. On the other occasion the did not eat breakfast (like my patient).

Researchers found that elite cyclists had a 4.5% drop in a 30 minutes time trial race in the evening after skipping breakfast. This is even after allowing the cyclists to eat as much as they want for lunch.

Due to our busy schedules, we may not be able to exercise in the mornings. While rushing to work, we may even skip breakfast.

The results showed that skipping breakfast may only be effective in reducing calories for people who eat breakfast regularly (and this helps to lose weight) in the short term.

However exercise performance may be compromised through out the whole day if you skip breakfast. Not great at all if you're exercising or training again later in the day. This will be worse if you're competing later in the day.

Don't skip breakfast.


Clayton DJ, Barutcu A et al (2015). Effect Of Breakfast Omission On Energy Intake And Evening Exercise Performance. Med Sci Sp Ex. 47(12): 2645-2652. DOI: 10-1249/MSS.0000000000000702.

Have a look at this article where a high-carb diet trounces low-carb one for endurance athletes.

Sunday, March 15, 2020

Coronavirus And Running

My patient who saw me yesterday was complaining that the Boston Marathon originally scheduled on 20th April next month has been postponed to 19th September. She had also planned to run Berlin originally, but with the change in dates that may not pan out.

This is the first time in the race's 124 year history that the race will not take place in April. Other than the Boston marathon, new reports of other international race cancellations are coming in on a regular basis.

In sunny Singapore, The Sunday Times today reported that the Sundown Marathon on May 23rd has been cancelled. This race had 23,000 runners last year. Other local postponed races this year includes next month's JP Morgan Corporate Challenge and the 2XU Compression Run (picture above).

I can understand how runners are disappointed that all their training may have come to waste. After all the sacrifices, preparation and training done, it must be terrible not to be able to race.

The Singapore government has rolled out "social distancing" guidelines to further limit the spread of COVID-19. As many of my patients who run have commented, running is the optimal sport now since everyone is encouraged to avoid crowded, enclosed spaces whenever possible. All of us who run or cycle alone sometimes are already practicing a form of "social distancing" unprompted.

Of course we are not running away from others when we go running alone. We run or cycle alone to preserve our sanity, to analyze and solve problems that crop up.

With so many races in limbo, some of you may question why you train hard when there seems to be nothing to train for. To run hard means to subject yourself voluntarily to varying degrees of discomfort. And pushing yourself hard in a workout means you're resisting the urge to stop.

Yes, because of the coronavirus, many races have been and will be cancelled. But we have other reasons to run, we can run for the satisfaction that comes from confirming our resilience to no one else but ourselves, our ability to endure, to not stop.

I don't race anymore, but I'm definitely still running to get my adrenaline rush.

If you have to self quarantine and cannot go out for a run, maybe you can try emulating Pan Shancu who ran 6,250 laps around two large tables set up inside his apartment. One lap around the tables measured about 8 meters and he ran 50 km in 4:48:44 hours!!

Sunday, March 8, 2020

Can The Ketogenic Diet Help With Weight Loss And Sporting Performance?

Picture from The Star
I couldn't believe my eyes when I saw two of my patients two days ago (both husband and wife are in their 50's). Both had lost 12-15 kg while on a ketogenic diet supplemented by going to the gym occasionally in less than three months. The husband even showed me a six-pack for his abdominal muscles. He said that he hadn't had them since his teenage years. I was shocked to say the least.

It seems like the ketogenic diet (eliminating carbohydrates) is all the rage in the fitness world nowadays. The ketogenic diet is similar to the caveman diet I've written about way back in 2009. It is probably time for me to revisit that low carb, high fat diet since I get questions on whether it is a good to be on a keto diet? Whether it helps to lose weight and most importantly whether it makes you stronger or faster as an athlete?

Those on the ketogenic diet follow a strict guideline to consume 80 percent of their calories from fat, 15 percent from protein and just 5 percent from carbohydrates.

After you eliminate carbs from your diet, your body goes into a state of ketosis where it uses fat for fuel. It uses the available fatty acids to produce ketones such that when your body is in ketosis, eating more fat will enable you to burn more fat.

While it is clear that you can definitely lose weight (or fat) while on the ketogenic diet, I am more interested if it helps sporting performance.

Previously I had questioned if carbohydrate loading was still relevant. The 1983 article quoted in that post is frequently quoted in the ketogenic community. The cyclists in that study underwent a 4 week ketogenic diet showed they used significantly more fat compared to a high carbohydrate diet.

Yes, fat burning was significantly ramped up (since they had 4 weeks to get used to the diet), time trialing ability remained unchanged but high intensity power was affected. There was a severe restriction on the ability of the cyclists to do anaerobic work.

Sports scientists around the world subsequently experimented with various fat adaptation protocols and kept coming up with same problem. The ability to sustain race pace was not a problem but sprint ability was always compromised.

Louise Burke, head of Sports Nutrition at the Australian Institute of Sport got together 19 elite 50 km race walkers preparing for the 2016 Rio Olympics over two training camps. They spent 3 weeks adapting to a low carb, high fat diet as the 1983 Phinney study had prescribed. Results confirmed that these elite walkers became super efficient at fat burning. The bad news was these fat adapted walkers became less efficient, requiring more oxygen to sustain their pace. This is a big liability while racing.

Consider an elite runner in the Boston marathon when a fellow runner surges on Heartbreak hill and he/ she cannot follow, the race may be then be lost. Or for a cyclist (who on a low carb, high fat  diet) competing in the Tour De France on daily stages where breakaways or sprints to break up a pack is the norm and he cannot sprint to keep up then he definitely has no chance for a stage victory.

This is because high fat diets don't just ramp up fat burning, they actually decrease carbohydrate usage by decreasing the activity of a key enzyme called pyruvate dehydrogenase or PDH.

However, if you are doing ultra distance racing then the loss of sprint power isn't a big deal at all since you are more interested in completing the distance under a certain time rather than outsprinting a fellow runner. Especially when a bigger challenge for an ultra runner is refueling. Those of you who have done ultras will know what I mean when you are so sick of eating a sports gel or a banana after 12 hours without needing to go to the toilet.

It will be so much better and easier for your participation if you can rely less on external carbs while drawing on your fat reserves.

Take home message is that the low carb, high fat diet is effective for losing weight (but long term effects are not known).

If you're on the keto diet and exercising and/ or racing at 60% of your V02 max then your exercise efficiency should remain the same once you have gotten use to the diet. This mean that for moderate efforts no problemo, performance is not affected.

However if you're exercising/ racing over 70% V02 max, i.e. when you're going faster, charging uphills, it will not be the best diet plan for you.


Burke LM, Ross ML et al (2016). Low Carbohydrate, High Fat Diet Impairs Exercise Economy And Negates The Performance Benefit From Intensified Training In Elite Race Walkers. J Physiolo. DOI: 10.1113/JP273230

Phinney SD et al (1983). The Human Metabolic Response To Chronic Ketosis Without Caloric Restriction: Preservation Of Submaximal exercise Capability With Reduced Carbohydrate Oxidation. Metabolism. Aug 32(8): 768-776.

Thank you for reading this long article.

*Olympic 50 km race walkers were chosen for Louise Burke's experiment as the event is among the longest in the Olympics, with the winning time just under 4 hours. Also for the rules of sport that forbid race walkers from breaking into an all out sprint, making the loss of high end power less of a problem. Burke published a very famous article called "Fat adaptation for athletic performance: The nail in the coffin?" in 2006.

She, however softened her stance in 2015 with another article "Re-examining high-fat diets for sports performance: Did we call the nail in the coffin too soon?".

Also note that Kenyan runners get 76.5% of their calories from carbohydrates (including 23% from ugali, a sticky and stomach filling cornmeal starch) and 20% from loads of sugar in their tea and porridge.

Ethiopian runners get 64.3% of their calories from carbohydrates (biggest contribution from injera, a sourdour flat bread made from an Ethiopian grain called teff).

If there's a better alternative diet than carbs for better endurance performance, the Kenyans and Ehtopian runners certainly are not following that.

Sunday, March 1, 2020

Patient Has 'Tight' Upper Trapezius Muscles?

My patient came in to our clinic yesterday complaining of 'tightness' in his upper trapezius muscles. He saw me two weeks ago for his R knee pain and that had settled, but now it was discomfort in his upper trapezius area. He had been using the trigger ball in his upper trapezius area and there were marks all over the area.

Other than tightness, he was complaining of a deep ache and constant discomfort there. He thinks this sometimes causes him to have headaches and neck pain as well.
Upright scapula
What gave me the most clues was looking at him from the side view. While looking at him from his left side (I'm using the picture above to keep his identity anonymous), his trunk was tilting backwards with respect to his hips. However, when I got him to straighten up you can see his left scapula tilting forward (right side of the picture below).
See how his left scapula tilts forward
Having explained to him what I saw, I then proceeded to treat him. I did not do any deep tissue massages/ or release his upper trapezius muscles (the area of his complaint). Neither did I stick any needles there to relieve the 'tight' muscle tone. I did not even treat his neck.

So what did I do? I treated his Front and Back Arm Lines. Yes, you read correctly. I treated his arms. If you look at work done by Tom Myers, he's able to dissect the "arm lines" (see picture below) from a cadaver.

In the picture on the right, the Superficial Back Arm Line has been laid over a skeleton model to show the fascia connections.

My patient was amazed, fascinated and happy that I got him better just by treating his arms. He almost couldn't believe it.
Treating the Deep Front Arm Line is key to getting his condition better because of the anterior tilting scapula. Treat the cause of the problem, not the pain.
Deep Front Arm Line