Sunday, September 20, 2020

Are You Choosing Running Shoes Based On Comfort?

Don't we all love shoes that are comfortable? Especially when it comes to our 
running shoes. As runners, we all love that ahhhh sensation of our first steps in an exceptionally soft and comfy shoe. I couldn't believe how soft an Adidas NMD (not really running shoe though) felt when I first slipped it on. 

A more comfortable (or cushioned) shoe is usually preferred by new runners or for runners who are prone to injury and want extra protection and support.

The shoe companies know that subjective comfort is an essential factor in sport shoe development since this definitely helps them sell shoes. This comfort paradigm is based on an assumption that perceived comfort will lead to a path of least resistance (while running) and potentially reduce injury and improve running economy. (Luo et al 2009; Mundermann et al, 2001).

We've definitely been sold on advertisements selling us the softest, bounciest and energy return shoes that propel us forward and saves us energy and prevent injuries.

One study showed reduced oxygen consumption levels during running at submaximal speed while running in shoes that were rated subjectively as most comfortable (Luo et al, 2009). This may support the fact that running economy improves due to reduction of muscle activation (which decreases oxygen consumption or metabolic demand). 

Another study on military personnel showed some evidence supporting the use of comfortable shoe inserts (or orthotics) reduced injury rates of the foot, ankle, hip, knee and lower back compared to a vontrol group.  However, two studies are not credible enough to know what actually helps and what are the mechanisms of reduction in oxygen consumption and preventing injuries. (Both studies count Professor of Biomechanics Benno Nigg, known for his work of running shoes as one of the authors).

In this latest paper I read, the authors aimed to investigate how shoes of differing comfort affects differences in oxygen demand along with potential mechanisms associated with injury risk

Fifteen male runners who ran at least 20 km per week with treadmill experience were recruited for the study. Testing includes an incremental lactate threshold test, a comfort assessment and treadmill running trials for biomechanical and physiological assessments. 

The researchers did not find any decrease in oxygen consumption in the most preferred shoe. Potential biomechanical contributors to changes in oxygen consumption (or metabolic demand) showed some differences in stride rate between the most preferred and least preferred shoe. Personally, it was interesting for me to note that stride frequency was actually lower in the most preferred (or comfortable) shoe compared to the least preferred (or least comfortable).

Based on the findings of this study, previous suggestions (derived from two other studies) regarding positive effects of enhanced footwear comfort during running cannot be supported. Neither on running economy nor on preventing injuries.

Should we then choose our running shoes based on comfort alone? This study suggest maybe not since the most comfortable shoes were not better or worse off with regards to oxygen consumption and not enough data to show any real change on injury risk.

Comfort is just one of many factors when we choose running shoes (compared to the more common foot type option like overpronators, supinators etc). Of course I definitely would not suggest running in shoes that are uncomfortable. 

I'm also feeling appalled that only 15 male runners (and no female  runners) were selected for the study. Remember I write previously how difficult it is to recruit runners to participate in a running research.

Athletes will want shoes that give them absolute efficiency that helps that run faster while your average runner would want the least discomfort while running to get fit.  

Of course there are some runners that will choose based on colour! *facepalm*


Lindorfer J, Kroll J and Schwameder H (2019). Does Enhanced Footwear Comfort Affect Oxygen And Running Biomechanics? Eur J Sport Sci. 20(4): 468-476. DOI : 10.1080/17461391.2019.164028

Luo, G, Stergiou P et al (2009). Improved Footwear Comfort Reduces Oxygen Consumption During Running. Footwear Sci. 1(1): 25-29. DOI: 10.1080/194242809002993001

Mundermann A, Stefanyshyn DJ and Nigg BM et al (2001). Relationship Between Footwear Comfort of Shoe Inserts and Anthropometric And Sensory Factors. Med Sci Sport Ex. 33(11): 1939-1945. DOI: 10.1097/00005768-200111000-00021.

Notes on the shoes in this study provided by Adidas

Five different shoes based on criteria previously reported in another study (Luo et al, 2009) were provided for this study. The shoe conditions showed variations in total mass (80 grams), heel lift (3.7mm), forefoot cushioning, rearfoot cushioning forefoot bending and rearfoot bending. The shoes in this study includes a standard neutral running shoe, shoes equipped with non standardized features like carbon fiber plates for increased longitudinal bending stiffness, exaggerated arch support and a cross training shoe.

One interesting point was that the researchers glued lead to the heel counters of the shoes that were lighter (since shoe mass influences oxygen consumption by about 1% per 100 grams of additional mass).

Sunday, September 13, 2020

Physical Activity Decreases Your Risk Of Colorectal Cancer

Group ride on 090219 - definitely miss those rides
I was very active in primary school. Other than swimming occasionally and playing police and thief (running), I also played football, basketball, table tennis and badminton. It was only in secondary school that I started to be more serious with cross country running and athletics.

How about you? Try to recall what you were doing as a teenager. A recent study suggest that how active you were back then and and how you've maintained it till now is important when gauging your risk of colorectal cancer.

Physical activity during adolescence helps lower risk of colorectal cancer. If you have been able to continue daily moderate physical exercise well into adulthood, the results are even better.

The study showed that those who did at least an hour of physical activity daily from 12 to 22 years had a reduced risk of adenoma (polyps or a benign tumor formed from glandular tissue) by 7 percent compared to those who were less active. (Polys are considered a precursor of colorectal cancer).

Those who started physical activity as adults reduced risk by 9 percent. However, those are were active as teens and continued being active for at least an hour as adults reduced their adenoma risk by 24 percent!

The researchers analysed the data of 28,250 female subjects aged 25 to 42. Physical activity, nutrition, hormones were among some of the data studied.

The researchers suggest that being physically active reduces the risk of colorectal cancer since it helps weight management and control and thereby affects insulin resistance and inflammation as they are involved in promotion and progression of cancer.

I would be very interested if the researchers measured how intense or hard the physical activities were. And how often were these higher intensity sessions and whether they made any difference.

However, this study did not analyse that. The authors did mentioned that previous studies have shown that moderate to vigorous activities were associated with lower bowel, breast and endometrium cancers.

Take home message is that there is a cumulative effect of physical activity as we grow older. Even if you have been inactive as a child, it is not too late to start now. And the longer you maintain that physical activity, the better off you'll be.


Rezande L, Lee DH, Keum N et al, (2019). Physical Activity During Adolescence And Risk Of Colorectal Adenoma Later In Life: Results From The Nurses' Health Study II. Br J Cancer. 121: 86-94. DOI: 10.1038/s41416-019-0454-1.

Picture above taken yesterday by Dennis. I still try to be as active as possible daily with at least one complete rest day a week.

You should too.

Sunday, September 6, 2020

What is More Helpful Than Electrolytes In Preventing Muscle Cramps?

I don't believe this. Many athletes still do not know what causes muscle cramps. In a survey of 344 endurance athletes published last year, 75 percent believed that taking extra sodium would help prevent their muscles cramping (McCubbin et al, 2019).

The usual and common theories for muscle cramps are loss of electrolytes (sodium, potassium and magnesium) and dehydration (fluid). Suggestions to combat cramps are to eat more bananas, take more salt/ sodiummagnesium supplementation, drink Gatorade etc. None of which will really help.

Having written on muscle cramps a few times, I'm most interested when new research suggests alternative ways to beat muscle cramping.

The researchers (Martinez-Navarro et al, 2020) recruited 98 runners running the Valencia marathon of which 84 (72 males, 12 females) completed the study (all pre and post race testing). 

20 runners suffered muscle cramps during or immediately after the race. Blood and urine tests showed no differences in dehydration and electrolyte levels before, during and after the race for the runners that cramped versus those that did not.

What the researchers found was a big difference in creatine kinase and lactate dehydrogenase which are both markers of muscle damage. These markers were significantly elevated immediately post race and 24 hours in those runners who had cramps.

There was also no difference when the runners did their last training run prior to the race nor any sign of elevated muscle damage in pre race tests. Hence, the runners who cramped did not have any muscle damage (from not tapering/ resting or backing off from training). 

Almost all the training variables between the two groups were similar. Weekly mileage, previous marathons ran, etc were all similar save one variable. 48 percent of those who did not suffer from cramps did regular lower body strength training compared to 25 percent of those who cramped.

This adds more weight to my previous post that muscle cramps are more likely to occur in muscles that are tired/ fatigued to the point of damage.

I would like to add that dehydration and electrolyte depletion can hasten muscular fatigue which then causes muscle cramping.

If you're still struggling with muscle cramps, it's definitely worth giving lower limb strength training a shot and for it's other benefits as well. 

Another researcher (Del Cosco et al, 2013)who wrote about muscle damage causing one to slow down at the end of marathons suggested lower limb exercises up to 80 percent maximum weight you can lift to protect your legs from damage.


Del Cosco J,  Fernandez D, Abian-Vicen J et al (2013). Running Pace Decrease During A Marathon Is Positivively Related To Blood Markers Of Muscle Damage. PLoS One. 8(2): e57602. DOI: 10.1371/journal.pone.0057602

Martinez-Navarro I, Montoya-Vieco A et al (2020). Muscle Cramping In The Marathon: Dehydration And Electrolyte Depletion Vs Muscle Damage. J Stren Cond Res. DOI: 10.1519/JSC.0000000000003713.

McCubbin AJ, Cox GR et al (2019). Sodium Intake Beliefs, Information Sources, And Intended Practices Of Endurance Athletes Before And During Exercise. Int J Sp Nutr Ex Metab. 29(4): 371-381. DOI: 10.1123/jisnem.2018-0270.

Saturday, August 29, 2020

The Gaiter Controversy In Today's Straits Times Article

ST 290820
I read with interest earlier last week regarding the dispute between an SBS bus driver and his refusal to allow a passenger who was wearing a gaiter. The bus driver obviously felt that gaiters are not masks.
ST 240820 on page B9
A gaiter is a tube of fabric worn around the neck to keep skiers or runners warm in cold weather. They are currently popular with runners, cyclists etc in other countries because they can be pulled up to cover the nose and mouth and used as a mask.
Then in today's Straits Times (page A10, under Top of the news), the writer questioned if all masks are created equal when it comes to protection from Covid-19.

The author quoted a study (listed in my reference list) from Duke University that looked at all different kinds of face masks and measured how many droplets of saliva made it through each mask.

When the neck gaiter was tested, they found more droplets than if the person was wearing no mask or other face covering. This single layer neck gaiter was made of 92 percent polyester and 8 percent spandex.

She wrote that the researchers said the neck gaiter "seemed to disperse the largest droplets into a multitude of smaller droplets which explains the apparent increase in droplet count relative to no mask in that case".

What the Straits Times writer did not mention was that the Duke University study was done with just one person. Yes, you read correctly. N = 1. More like a case study really. Next, the way the researchers did measurements was with a phone camera and lasers. Surely, that's not a reliable way to measure particles of droplets.

I'm not sure if the Straits Times writer  even read the article. Even the authors of the Duke University study said that people are "drawing too much" from the article. The authors' intent was not to say this mask does not work or never use gaiters. That's not even the main part of the article.

If you search further, you will find that researchers from Virginia Tech did a neck gaiter study and found that gaiters "perform similarly to cloth masks and very well if doubled over." You can see the PDF document by authors Jin Pan and Linsey Marr on neck gaiters right here.


Fischer EP, Fischer MC, Grass D et al (2020). Low-cost Measurement Of Facemask Efficacy For Filtering Expelled Droplets During Speech. Sci Advances. DOIL 10.1126/sciadvabd3083. Read the article here.

Images when I googled "neck gaiter" above.

*As reported by another journalist in today's Sunday Times (page A2, Top of the news), MOH has since reiterated that makeshift face coverings such as bandanas, scarves and neck gaiters should not be used. This is under recommendations of the multi-ministry task force tackling the pandemic.

Again the Duke University case study was quoted. Again I'm wondering if the journalist even bothered to read the study itself ......
ST 300820 on page A2

Friday, August 28, 2020

Another Call For Bike Lanes In Singapore

ST 280820
After my previous article written earlier this month, it is heartening to see transport minister Ong Ye Kung suggest that certain under-used road lanes be converted to cycling and bus lanes in today's Straits Times (page A4 under Top of the news).

Well, definitely preferably cycling lanes please.

Remember Prime Minister Lee Hsien Loong's 2017 National Day Rally speech on the number of Singapore citizens with diabetes?  I suggested weight training as evidence suggests it helps with improved insulin sensitivity among people with diabetes and pre diabetes. If more Singaporeans start to cycle to run errands or work instead of taking the car, that definitely adds up too.

By riding to work, you get a workforce that gets fitter as they lose weight, save money and help the environment. Our mental health improves and we feel less stress and feel happier. In addition to having a cleaner and greener Singapore, we reduce our carbon footprint as well.

I have a particular favorite, when you ride bikes, you get the sheer joy of feeling the wind in your face - a better and greener version than driving a convertible.

Over to you Minister Ong Ye Kung and the Ministry of Transport.

Sunday, August 23, 2020

How Are Restaurants And Physiotherapy Clinics Similar?

ST 230820
The inspiration for this weeks post came from a few unlikely sources. First was a patient telling me yesterday of how a friend on Facebook shared that a physiotherapy practice was in the red and that they needed patients to ensure the practice's survival. So if anyone needed physiotherapy to please go support that particular clinic.

Then in today's Sunday Times article, the author wrote about diners who make and confirmed bookings at restaurants but do not show up. A restaurant founder (of six restaurants/ nightspots) who was interviewed said that irresponsible behavior by diners have always existed and is now becoming social norm. To quote her, "diners feel more entitled now by the fact that the restaurants need them more than they need us".

That we definitely understand. We have our fair share of patients who make appointments and after confirming, and reminders by our staff, fail to turn up.

Some jobs need us to show up in person. For the time being, restaurant staff, surgeons and physiotherapists are definitely in that category. With artificial intelligence and robot controlled arms who knows how long our jobs as physiotherapists are safe .....

Many other jobs or services are currently done with a combination of asynchronous work, video calls and others. A big thank you to all our patients who still despite a long and/ or a risky commute, come to see us.

We will strive to be totally switched on 100% and do our best all the time when treating you.
This is our promise.

*Keeping rogue diners in check. This Sunday Times article is on page C17 under the Life section today.

Sunday, August 16, 2020

Spraino Patches For Preventing Ankle Sprains?

We see lots of patients with ankle sprains in our clinic. Recently there was a patient who sprained her ankle while playing badminton with her friends.

The lack of match play and practice as all indoor courts were closed during the circuit breaker/lockdown period probably contributed to her getting hurt.

Most ankle sprains happen on the outside of the ankle. Badminton, which is a popular sport in Singapore is mostly played indoors.

The majority of ankle sprains that occur in badminton are 'non-contact'. This means players often sprain their ankles without contact with another player.

A contributing factor is due to the shoe traction-playing surface friction mechanism since only the player's shoe is in contact with the floor when the sprain occurs. This is true across various sports played indoors like floorball, basketball, handball and badminton.

Interestingly, I came across a research paper on a low friction shoe patch called Spraino that can help prevent lateral ankle sprains in indoor sports players.
Spraino patches on outer side of shoe
The researchers studied the 480 participants (that played handball, basketball and badminton) who completed the trial. The participants were above 18 and were playing at sub elite level They trained at least twice weekly, had a previous lateral ankle sprain in the last 24 months and had returned to sport prior to commencement of the research.

The participants were randomized into two groups, with one group getting the Spaino patches to mitigate the risk of lateral ankle sprains. The other group played as usual with no Spraino patches.

The adhesive Spraino patches (meant for indoor use only) were attached along the outside edge of the shoe. The front patch covers 2-4 mm of the shoe sole while the rear patch does not. The patches had a durability of 20-40 hours of activity.

The intervention group received Spraino patches and application instructions as well as instructions on how to order new patches and report adverse events. They were encouraged to use Spraino patches during all indoor sport activities. Both groups were allowed to tape or keep using any other injury preventive measure of their choice.

The researches found that Spraino was just as effective as other preventive measures (like exercise and prophylactic bracing and taping) when compared to not using Spraino. The participants using Spraino had a 53% lower incidence rate of severe ankle sprains compared to the control group.

The Spraino group was also less fearful of getting an ankle sprain and this is important since fear can be a major hindrance to sports activity.

Now, how do I get some Spraino patches for my patient. Perhaps I should email the authors. They should have named it something else though, in my opinion ;)


Lysdal FG, Bandholm T et al (2020). Does The Spraino Low-friction Shoe Patch Prevent Lateral Ankle Sprain Injury In Indoor Sports? A Pilot Randomozed Controlled Trial with 510 participants With Previous Ankle Injuries. BJSM. DOI: 10.1136/bjsports-2019-101767.

Monday, August 10, 2020

Thera/ Massage And Vibration Guns. Do They Work?

Picture taken by iPhone 11 Pro from Shopee
Earlier in the week, I read an article on the same topic written by CNA Lifestyle. Actually, I already wrote half of the article on that exact same topic last week but decided to publish the article on bicycle lanes in Sigapore since bicycles are much closer to my heart.

The author did a good introduction on what massage or thera guns are and what they do in that article. She also interviewed other health professionals for their thoughts. So my article will be different. It will explain the science behind why thera or massage guns feel so good when you use them. And of course the evidence available.

Thera or massage guns are being advertised with all kinds of benefits like helping with aches, pain and stimulating "muscle recovery". They can certainly vibrate your muscles/ tissues but almost all the medical claims are not totally true.

Vibration therapy definitely is relaxing for most people especially if it's not too strong or sudden or in an uncomfortable location. Sitting in a warm pool with bubble jets (like a jacuzzi) come to mind and I'm sure all of you who tried will agree that it's a pleasant sensation.

And vibration, waves and frequencies are what some physiotherapists already use for treatment. These include ultrasound, electrical (TENs) and magnetic stimulation, infrared radiation and even lasers. The above are mainly microscopic vibrations aimed at cells at the cellular level and a wider range of frequencies and smaller amplitudes.

Even ESWT (or shock wave) uses high intensity waves to smash kidney stones, (used by doctors) and/ or stimulate bone healing. Many other physiotherapists also uses ESWT to treat plantar fasciitis.

An article published in the British Journal of Sports Medicine showed that runners who receive daily sessions of vibration therapy on the legs were less sore  and had fewer blood markers associated with soreness compared to runners who did not (Broadbent et al, 2010).

Coarse vibrations have interesting neurological effects too. Vibrations added to really flexible gymnasts appears to increase their flexibility further (Kinser et al, 2008).

One reason why vibrations help is a change in our proprioceptive state. Proprioception is how we sense or judge our position. When the body is being vibrated or shaken, plenty of input goes to our cerebellum in the brain. When there is no danger perceived by the cerebellum, the nervous system send signals for the body to relax. That's why the body calms down and you feel good.

Another reason is the strong and distinctive vibratory sensations are quite the opposite of feeling stiff and tight. Just like splashing cold water on your face when you're hot, vibration feels like a natural remedy to your stiffness.

So patients with conditions like muscle strains, neck pain and especially low back pain with fear being a big part of it may feel better after using massage guns or other vibration therapy.

However, if you have shin splints (will hurt more actually), plantar fasciitis and nerve entrapment issues then they probably will not help.

So, still thinking about splashing your your earned cash on this? Save your money. Or better still come see us in our clinic to treat the cause of your problem.


Broadbent S, Rousseau JJ et al (2010). Vibration Therapy reduces Plasma IL6 And Muscle Soreness After Downhill Running. BJSM. 44(12): 888-894. DOI: 10.1136/bjsm.2008.052100

Kinser AM, Ramsey MW et al (2008). Vibration And Stretching Effects On Flexibility And Explosive Strength In Young Gmynasts. Med Sci Sp Exer. 40(1): 133-140. DOI: 10.1249/mss.0b013e3181586b13.

Saturday, August 1, 2020

Bike Lanes In Singapore?

Singapore's only bike lane@ Coastal road
I last wrote about having bicycle lanes on the road way back in 2010 and 2011. No one really paid attention then. Then earlier this week, British Prime Minister Boris Johnson came out promising to build thousands of miles of new bike lanes to get the Brits moving and healthy after months of coronavirus lockdown.

His pledge came after plans to force restaurants to display calories on menus as part of a bigger battle to help the British lose weight. This is after an analysis by the Organization for Economic Development released in 2019 found that Britain was the second fattest nation in Europe, with almost a third of the population classified as overweight.
ST 1/8/2020 on page A23
Being obese makes one more vulnerable to many diseases including the coronavirus.This is especially true for Johnson himself after his own experience with Covid-19. His life was in danger and he had to be treated in intensive care largely because he was overweight. He had previously dismissed the idea of government intervention over what the public should eat, but changed his mind after being hospitalized.

When Minister Mentor Lee Kuan Yew was still alive, he did consider special bike lanes for cyclists in Singapore. He had in his younger days cycled to university in Cambridge and had to also cycle about five miles uphill to visit his girlfriend and later wife as she lived in a different hostel.

From -Hard truths to keep Singapore going
"It's better for everybody's health, it's better for the environment and it's certainly better than having the place or having the roads overcrowded with cars, taxis, buses."
From -Hard truths to keep Singapore going
During the circuit breaker/ lockdown in Singapore, it was a dream come true for cyclists, as there was so much less traffic on the roads. My sons and I went cycling almost daily as we did not have to worry about sharing the roads with the cars and buses. Throughout the world, bicycles were selling like hotcakesincluding Singapore, as many people rode bikes for both transport and exercise.

Some of you reading this may say that it's too hot to ride bicycles to the office or to run errands. Yes, in our climate you will will definitely need a shower after riding to work. But it will also not to be too cold when it rains. So we will need to have toilets and parking spaces for bicycles. A small price to pay for a cleaner and greener environment.

Many drivers will not like this idea (there are many drivers who hate cyclists if you look at the online forums) of bike lanes on our roads. Well, you can't please everyone.

Newly appointed transport minister Ong Ye Kung, are you reading this?

*A big thank you to Jeffrey Keng. The very first picture right at the top and the one just above was taken from a video by Jeffrey Keng on 22/9/18 while we were cycling along Coastal road.

Sunday, July 26, 2020

Do You Need To Treat Your Trigger Points?

A common comment I get from patients is that they have "trigger points" in their muscles. Either they have been told by someone else treating them or they have read somewhere that "trigger points" are sore, painful areas in their muscles.

Trigger points are often assumed to be specific areas of tenderness in a muscle which can cause generalized musculoskeletal pain when over stimulated. It is believed that most of this occurs because of muscle overuse, muscle trauma (or injury) or even psychological stress.

Trigger points are also thought to arise from sustained repetitive activities like working on a computer/ phone all day or lifting heavy objects at home or work.

Trigger points feel like a lump or knots just under the skin. When pressing on trigger points, most people don't feel any pain or discomfort although there are others may feel pain.

If you google "trigger point therapy" the following shows up (see picture above). Many physiotherapy clinics and other healthcare professionals advertise and make money by claiming to be able to treat your trigger points.

I have also had some of my patients that me that some health practitioners they see say that trigger points are distinct areas of localized inflammation. However published evidence suggest otherwise.

Patients with chronic tension-typed headaches were matched with a healthy control group that had no such trigger points in the trapezius muscle.

Samples after needles were inserted into the patients at rest, 15 and 30 minutes after static exercise (10% of maximal force). All samples were coded and analyzed blindly.

The researchers found no difference in resting concentration of inflammatory mediators or metabolites between patients with tender trigger points and non tender controls. There was also no change after exercise.

The researchers suggest that the trigger points are not sites on ongoing inflammation.

Now you know. Trigger points are not sites of inflammation. You do not have to treat it. Getting rid of trigger points may not solve the problem.


Ashina M, Stallknecht B et al (2003). Tender Points Are Not Sites Of Ongoing Inflammation- In Vivo Evidence In Patients With Chronic Tension-type Headache. Cephalalgia. 23(2): 109-116. DOI: 10.1046/j.1468-2982.2003.00520.x

Sunday, July 19, 2020

Lots Of Recreational Runners Take Drugs To Run

Not the kind of drugs that that elite athletes use like growth hormone or erythropoietin, but common off the counter ones like Ibuprofen. 

Don't believe what I'm writing? Consider the following patients I treated recently. I had a runner who runs ultras and another newbie runner who just started running during the circuit breaker/ lockdown because he couldn't go to the gym. Both had a combination of mild injuries and muscle soreness and instead of taking a break they both gulped down a couple of Ibuprofen tablets and occasionally stronger non steroidal anti-inflammatory drugs (NSAIDs) so they can keep running and training.

Here's what I read. 46% of runners recruited (total 109 runners) recruited during the 2016 London Marathon registration planned to take an NSAID during the race.  Of those 109 runners returning for data collection, 34% had already taken an NSAID on the morning of the race while more than half the runners completing the study (16 out of 28 runners) had taken an NSAID.

Only 13 of the 28 runners (13) correctly stated the risks of taking NSAIDs while only 10 runners (35%) knew the correct safe dose.

NSAIDs while helpful with masking your pain while exercising can cause stomach ulcers, acute kidney injuries and also a risk of strokes and heart attacks (depending on dosage  and how long they are taken).

Under duress of a long distance endurance event, risks may increase. Reduce blood flow and motility in the stomach make tummy problems common even without NSAID use. Muscle damage from racing may increase protein in the blood which can lead to acute kidney damage. This may be worsened by NSAID use. Hyponatremia can also be heightened by use of NSAIDs.

Researchers in UK, surveyed 806 runners in the Parkrun there to find out about usage in a diverse group of runners. A third of  these runners raced marathon distances or higher. Almost 90% of the runners surveyed used NSAIDs (most used Ibuprofen, which does not require prescription by a doctor).

More than half the Parkrun runners took NSAIDs before a run or a race.The longer the run, the more likely they were to take NSAIDs before or during the run. One in ten runners took them during a run and more than 65% took them after a run.

33% of the ultra runners compared to 17.5% of marathon runners took NSAIDs during the event. This is of concern a the longer events already put extra stress on their stomach and kidneys as it is.

Those who do not log longer distances used NSAIDS so that they can keep exercising with pre-existing pain, ongoing medical issues or current injuries. Those who ran further (>40km a week) were more interested in reducing inflammation, soreness, pain and performance enhancement/ improvement.

Almost half the surveyed runners used NSAIDs without any advice from a healthcare professional thought almost all said they would read the advice if it was provided to them.

I, too have taken NSAIDs on the night before and the day of a race. Tried it twice, although I thought they didn't make much of a difference to my performance. Hence, I didn't take them after.

If you're using NSAIDs to run through pain and injury to meet your training/ racing targets, it is counterproductive to the long term health benefits of running especially since NSAIDS can affect healing and recovery. Using NSAIDS occasionally before or after your weekly run is definitely less risky compared to frequent, regular usage during demanding training. Needless to say, they should be avoided while your body is under sustained physiological stress during races.


Rosenbloom CJ, Morley FL et al (2020). Oral Non-steroidal Anti-inflammatory Drug Use In Recreational Runners Participating In Parkrun UK: Prevalence Of Use And Awareness Of Risk. Int J Pharm Pract. DOI: 10.1111/ijpp.12646

Whatmough S, Mears S et al (2017). The Use Of Non-steroidal Anti-inflammatories (NSAIDs) At The 2016 London Marathon. BJSM. 51:409. DOI: 10.1136/bjsports-2016-097372.317

Sunday, July 12, 2020

Do Heavy School Bags Cause Back Pain In Children?

I had a nine year old girl come to our clinic to see me this week complaining of neck pain. Her grandmother who brought her thought it may be related to her very heavy school bag that caused it. That along with the extra time on screens during home based learning recently during the circuit breaker.

After examining the little girl, I explained to her grandmother that what she thought may not be true.

You would have seen plenty of advertisements on the internet suggesting you buy your child an ergonomic bag pack for your child to avoid back and neck pain. However, when I searched the literature, there were no convincing proof in the last 20 years between heavy school bags and posture/ back pain among the young.

Many of you would have seen a young child with a big school bag on their shoulders. You would have read about it in the papers. There are many articles available online regarding this topic too. Many of the articles quoted above suggest that your child should not carry more than 20 percent of their body weight. After searching, I found out that this figure is taken from an article by Dockrell et al in 2013).

The most recent evidence published was from a systematic review in 2018 conducted by a team of Australian Physiotherapy researchers. They examined 69 eligible studies with a total of more than 72,600 children.

Many of the articles were rated as either having a moderate to high risk of bias due to high attrition rates, mixed testing methods, confounding factors and poor prognosis. As a result, most of the articles did not find an association between school bag characteristics and low back pain even though there were mixed sample sizes, different school bag weight and different definitions of back pain.

The authors suggested that due to variables in school bags, measuring instruments and timing of data collection, there were no straight "yes" or "no" answers. Hence, no strong conclusions can be formed.

An older systematic review in 2008 examined 10 qualified trials with more than 17,000 children/ teens on neck, upper back and shoulder pain. The authors found that static postures, depression, stress, psychosomatic symptoms, age and gender (girls had higher reports of pain than boys, especially those who were depressed (Prins et al, 2008).

If I may digress here, even among adult research there was insufficient evidence for association between spinal curves (e.g. scoliosis) and all other health related outcomes. This includes low back pain, disc herniation, neck pain, fractures, headaches, symptomatic degenerative lumbar disc disease and thoracic pain (Christensen et al, 2008).

Perhaps many of us (including all the online articles you read) after seeing a child hunched forward with a heavy school bag while walking home assume that heavy back packs causes neck and/or low back pain.

This may have fueled further beliefs among doctors, physiotherapists, other clinicians and the general public that heavy back packs can cause neck/ back pain.

Personally, I do get concerned whenever I see a young child carrying a heavy back pack even if the evidence does not suggest that it will hurt them permanently.

As my wife says (quoting Tom Myers), children have very elastic connective tissue and they are very resilient. Unless your child is perpetually carrying a super heavy school bag, it probably will not affect their necks and backs permanently.


Dockrell S, Simms C et al (2013). Schoolbag Weight Limit: Can It Be Defined? J Sch Health 83: 368-377.

Prins Y, Crous L et al (2008). A Systematic Review Of Posture And Psychosocial Factors As Contributors To Upper Quadrant Musculoskeletal Pain In Children And Adolescents. Phy Theory Pract. 24: 221-242. DOI: 10/1080/09593980701704089

Yamato TP, Maher CG et al (2018). Do Schoolbags Cause Back Pain In Children And Adolescents? A Systematic Review. BJSM. 52: 1241-1245. DOI: 10.1136/bjsports-2017-09827.

Sunday, July 5, 2020

Iliotibial Band Pain In Runners

The ITB originates from the TFL
I had a patient this week that was suffering from Iliotibial band (ITB) pain and he was so fed up with the pain that he was considering getting a steroidcortisone injection to get rid of the pain. He sent me an article he'd found for me to ask for my opinion.

Having previously suffered from Iliotibial band or ITB syndrome myself before, I'll naturally read any article I'd come across about the ITB.
The ITB over the Vastus Lateralis muscle
The article itself wasn't so interesting even though the authors got a good result after their intervention. The authors concluded that a steroidcortisone injection was effective in reducing ITB pain in runners in the first two weeks of treatment.

I'm not a fan at all when it comes to injecting steroid (or cortisone) to treat any sporting injuries. I written previously that often the cause of the problem is from the hip. For best results, you treat the cause of the problem.

As I've written previously, if you're an athlete or exercising regularly, you definitely do not want a steroidcortisone injection since there is a very high chance of degenerative changes in the surrounding area of the steroid injection. You can read about how my patient tore his forearm flexor tendon after repeated steroid injections.

Anyway, what intrigued me about this article was the small sample size and how long it took to recruit the runners (it took two whole years). The authors managed to recruit 45 runners but only 18 fulfilled the criteria and finished the study.

There was an attempt to have a longer follow up period, but there was too much variability in the second phase treatment of the condition. Their return to running, distance ran, rehabilitation program, change in footwear and use of orthotics etc.

Most of the eligible runners did not want to stop running during the 2-week intervention period. Exactly what I said about athletes (not wanting to rest) in my interview which you can see here. This shows the challenge of recruiting runners for research.

How about you? If you were recruited for a running research and asked to stop running for 2 weeks for the sake of research, would you comply? I'd like to hear your views.


Gunther P and Schwellung MP (2004). Local Corticosteroid Injection In Iliotibial Band Friction Syndrome In Runners: A Randomised Controlled Trial. BJSM. 38(3): 269-272. DOI: 10.1136/bjsm.2003.000283.

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