Sunday, April 21, 2024
Shouder Keeps Clicking But No Pain
Sunday, April 14, 2024
Help! My child Is Pigeon Toed
W sitting |
Sunday, April 7, 2024
Tight Or Just Tired?
Who says my hamstrings are tight? |
I always explain that when I put both my hands on their e.g. trapezius muscles that they feel the same, one side is not 'tighter' than the other.
If I get a dollar each time my patients tell me how tight they feel when they come and see me I will have many extra dollars for sure.
A patient ran a very hard 21 km road race recently and complained of 'tightness' in his hamstrings for the past 5 days came to see me in our clinic this week. He said his hamstrings felt very hard, achy and 'tight' of course. They even threaten to cramp when he tried running or doing some strengthening exercises.
However, he can easily put his palms on the floor in a forward bend. (Note: there are other patients whose hamstrings do not feel 'tight' but they can barely get their hands past their knees while bending forward).
He tried stretching but other then feeling a little better for less than a minute the 'tightness' came back quickly. Upon assessment he definitely had some delayed onset of muscle soreness (DOMs). I told him his 'tightness' was actually fatigue from his training and racing.
I suggested resting and focusing on his recovery. Definitely decrease his intensity and mileage. My personal experience after a hard race would be doing any of the 2 aerobic exercses outlined below at reduced intensity and low volume.
These low intensity exercises will increase blood flow to the affected muscles and often reduce pain. Pedaling at low resistance on a stationary bike is ideal as you don't have to worry about traffic (if you ride on the roads). An easy swim or just walking in waist or chest high water works well too. Wearing compression garments will help reduce DOMs as well. These above mentioned strategies do have some support in the research.
After he recovers fully, I suggested testing for strength imbalances and deficits as weaker muscles do tend to fatigue more rapidly. Specific strength training will address that.
In most other cases of patients feeling 'tight', the reason is obvious. If the stay in the same position/ posture for too long, their muscles need a rest or change of position to reduce the lack of blood flow or metabolic stress that is causing the noxious stimuli. Think of the last time when you spent hours in a car, plane or behind your computer, after you move/ stretch, the symptoms of stiffness/ tightness will be alleviated.
Remember this, when you feel stiff and 'tight', it is just a feeling and not necessarily a physical shortening that needs you to structurally change it. Like other things that you feel, you may feel it more sometimes compared to others. Like other forms of sensitivity, those feelings will change if you improve your overall fitness, strength and health.
Reference
Stanton TR, Moseley GL, Wong AYL et al (2017). Feeling Stiffness In The Back: A Protective Perceptual Inference In Chronic Back Pain. Sci Rep. 791): 968. DOI: 10.1038/s41598-017-09429-1
Sunday, March 31, 2024
Even Olympic Athletes Do Not Sleep Well
Thinking of winning even while sleeping |
Whether you are an athlete or not you need to sleep. In theory, athletes need to sleep a lot, since sleep can boost performance, protect against injury and even help recovery. I have written before that a lack of sleep can lead to negative consequences. It can affect your mood, cognitive function and physical performance.
Ever wonder if champion athletes are also champion sleepers? Or they sleep just as badly as average athletes?
A recently published paper studied the sleep habits of more than 1600 Olympic and Paralympic USA athletes in the lead up to the 2021 Tokyo Olympics. The athletes filled up a Pittsburg Sleep Quality Index (PSQI) for that study.
The study compared the typical sleep pattern for male versus female athletes, summer versus winter Olympians and team versus individual sports.
You may be surprised to know that almost 40 percent of athletes were rated as having poor sleep based on their PSQI scores. The scores accounted for how long they typically sleep, how often their sleep is disturbed, how long before they fall asleep and whether sleep medications were taken.
The results were similar to that of Dutch Olympic athletes (41 percent poor sleepers) and Australian Olympic athletes (52 percent poor sleepers).
A goal of the study was to provide what was normal values for athletes training hard compared to the general population on whom the PSQI was first tested. The PSQI has a maximum score of 21, the higher the number indicating a greater number or greater severity of sleep problems. A score of 5 and above classifies you as a poor sleeper. The average among the USA Olympians was 4.3.
25 percent scored above 6 while 10 percent scored above 8 and 5 percent scored above 10. The top scorer was 16 while the lowest got zero (I am definitely envious)!
Reasons for the poor sleep? An early training session at 6 am will definitely affect sleep. Those athletes traveling across time zones to get to training camps/ races/ competitions will also be affected. If your legs or arms are aching from hard training ( I can testify to that), or if your heart/ mind is racing before a competition , you will not sleep well. That's my personal experience too.
The results do not specify what is happening exactly, but they do suggest that a serious athlete typically scores 5 or 6 on the PSQI, so they are classified as a 'poor sleeper'.
This study by Anderson et al (2024) has more subjects compared to previous similar studies which allows the data to be cetegorized into sub categories. Here is what else was reported. Female athletes had poorer sleep quality (4.7 versus 3.9) than men even though they went to bed earlier.
The female athletes were also less likely to report falling asleep straight away after going to bed. They were also more likely to report using sleep medication. A possibility is the variation in sex hormones across the menstrual cycle which may interfere with sleep, although no mechanism was found in this study.
Team sports athletes got up earlier and had poorer sleep than individual sport athletes although this was not what previous studies found.. Perhaps a team mate who got up earlier caused the rest of the team to get up earlier as well?
May I boldly suggest that all the sub patterns were confounded by a huge variety of sports in this study. A runner is not equal to a tennis player or swimmer. Competition timings will play a part as well since most marathons are held in the early mornings compared to the later starts in some other sports. Especially those held in the late evenings.
Defintely sleep is a great untapped frontier. Since 40 percent of Olympic athletes are poor sleepers, imagine one's advantage if you can improve or even master sleep.
Is good sleep "nice to have" rather than "need to have" for achieving sporting excellence? Or you may even argue that sleep may not be that important if all these Olympians are not sleeping well and are good enough still to compete at those lofty levels.
Personally I do think sleep is important for sporting performance as well as keeping you sane during the day.
On a side note, I will add that the cost to mental health is significant too, especially for the general population. Sleep problems may increase risk for developing certain mental illnesses like depression and anxiety disorders, as well as result from them. In this age of poor mental health among the young, are they getting enough sleep to begin with?
If you're an athlete, take your sleep habits seriously, but remember that if you still have problems, you are in Olympic level company.
Reference
Anderson T, Galan-Lopez N, Taylor L et al (2024).Sleep Quality In Team USA Olympic And Paralympic Athletes. Int J Sp Physiol Perform. 19(4): 383-392. DOI: 10.1123/ijspp.2023-0317
Sunday, March 24, 2024
Just One Set Of Exercises Can Make You Stronger
Leg extension exercise |
This concept of non-responders were first described in studies done in the 1980s and 1990s. These studies explored the role of genetics in exercise response.
When a bunch of people were given the same training program, their genes can explain about half the variance in how their fitness improves. Some people did not get fitter at all even after months of training. Note that later studies took the non-responders from a study and had them train harder or a higher volumes, they did get fitter. The studies above focused on aerobic exercise, but this study (Lixandrao et al, 2024) was on strength training.
The authors had a total of 85 subjects (41 men, 44 women) above the age of 60 and not currently doing any strength training (Lixandrao et al, 2024). The study was designed to see if adding extra sets would turn the non-responder into responders. The subjects were assigned to different strengthening routines with each leg. That eliminates variations that can cloud results of strength training studies.
Note that older adults are usually less responsive to size and strength stimulus of strength training, making non-response more likely.
The exercse program consisted of 2 workouts a week for 10 weeks, Each set consisted between 10-15 reps of single leg knee extension with the weight selected to reach failure in each set. Each subject did 1 set per workout with one leg and 4 sets per workout with the other leg.
Muscle size of the subjects was measured by MRI. As expected, there were many non-responders who did the 1 set routine. 60 percent of the subjects did not gain more than 3.3 percent in the cross section of their quadriceps (this is the minimum threshold for a statisically significant improvement).
The proportion of non-responders for those who did 4 sets decreased to 19 percent. Yes, you read this correctly, those who responded to only 1 set of training had bigger responses than those who did 4 sets!
Conclusion: Doing more sets lead to greater muscle gain, even among those who do not seem to repond initially.
Note that doing 4 sets of exercises did not produce bigger strength gains than 1 set, which was both surprising and unfair. Previous studies have also shown this in experienced lifters. Doing 5 sets was better than 3 sets, which in turn was better than 1 set for muscle size. However all 3 options were basically the same for muscle strength.
Stength is a function of muscle size and the (complex) signaling process between brain and muscle. Both do not always go hand in hand.
Among those who responded to 1 set of exercise, only 51 percent got significantly bigger muscle size results from 4 sets. 15 percent actually did worse doing 4 sets. Note that the 1 set and 4 set parts of this study were taking place simultaneously in the same person but different legs. This may suggest that while 4 sets are better than 1 for some people, they really are worse for others.
Take away from this study (Lixandrao et al, 2024)? You can get away with a minimum of 1 set of strength training if your main goal is to get stronger. However, if your main goal is to gain or maintain muscle mass, you will benefit from more sets.
Note that the more interesting take away is this rule is not always true for everyone. Definitely a little annoying if you ask me. My suggestion? If what you have been doing is not working, even if it is suggested by the latest research, you need to try changing it.
Reference
Lixandrao ME, Bamman M, Vechin FC et al (2024). Higher Resistance Training Volume Offsets Muscle Hypertropjy Nonresponsiveness In Older Individuals. L Appl Physiol. 136(2): 421-429. DOI: 10.1152/japplphysiol.00670.2023
Sunday, March 17, 2024
Knees Out Or Knees In When You Squat?
Out (left) versus in (right) |
Sunday, March 10, 2024
The Most Efficient Way to Run (According To Science)
It's a long review paper, key findings in the pictures attached. Let me highlight some of the important points. The paper does lend some support for increasing your cadence or step rate to improve running economy as this increases leg stiffness and reduces vertical oscillation. When you watch some runners run, you can see that they tend to 'bounce' up and down while running, that is vertical oscillation.
Initial Contact |
Mid stance |
During Mid Stance phase, decreased trunk flexion and reduced vertical oscillation may be associated with improved running economy. Increased vertical and leg stiffness may also be associated with lower energy cost.
Toe off |
At the Toe Off phase, if trunk flexion and ankle plantarflexion are reduced, running economy may be improved.
Those metioned above are just he key findings which I have summarised. However, there are many more details and applications in the paper itself. You can read the free paper here.
I have previously written before on running cadence and running form if you wish to read further.
Reference
Van Hooren B, Jukic I, Cox M et al (2024). The Relationship Betwen Running Biomechanics And Runnng Economy : A Systematic Review And Meta-Analysis Of Observational Studies. Sports Med. DOI: 10.1007/s40279-024-01997-3
Summary |
Can Your Sports Bra Restrict Your Breathing?
Sunday, March 3, 2024
What Time Do You Eat Dinner?
Picture from Yahoo |
I do not know for sure what time most Singaporeans have dinner, but 3 in 5 Americans normally have dinner after 9 pm (Farsijani et al, 2023).
Our bodies are much better at digesting and processing nutrients during the day and powering down and resting at night. So eating close to bedtime can cause a whole range of issues. There are studies linking late night eating to heartburn while others demonstrate how it can affect your sleep quality. As you know, Singaporeans already do not have enough sleep.
There are also recent studies that link late night eating with increases in body weight and the risk of diabetes. When you limit your calorie intake 3 to 4 hours before bedtime, it can help with blood sugar control and weight management (Vujovic et al, 2022). This is likely linked to the circadian clock which reduces the energy we use after a meal in the evening.
Again in America, early dinners seem to gaining popularity among Americans of all ages. 5 pm is the fastest growing time slot for dinner reservations while bookings for 8 and 9 pm are falling.
Surprisingly, many Gen z-ers are embracing this early bird lifestyle. Americans between the ages of 15 to 34 are getting more sleep each night (9 hrs 12 mins) over the last decade if you look at data from the U.S. Bureau of Labor Statistics.
I am surprised to say that the youths (Americans at least) today are more well rested than I thought, possibly because these youths are ditching late night drinks in favor of . Less daily commuting in this era of remote work enables them to sleep in, while an increase in venture capital for sleep tech definitely helps too.
When you limit your calorie intake 3 to 4 hours before bedtime, it can help with blood sugar control and weight management (Vujovic et al, 2022). This is likely linked to the circadian clock which reduces the energy we use after a meal in the evening.
Eat early, sleep early that seems to be what the research is telling us to ensure good health .
References
Farsijani S, Mao Z, Cauley JA et al (2023). Comprehensive Assessment Of Chrononutrition Behavirs Among Nationally Representative Adults: Insights From National Health And Nutrition Examination Survey (NHANES) Data. Clin Nutri. 42(10): 1910-19-21. DOI: 10.1016:/j.clnu.2023.08.007
Vujovic N, Piron MJ, Qian J et al, (2022). Late Isocaloric Eating Increases Hunger, Decreases Energy Expenditure, And Modifies Metabolic Pathways In Adults With Overweight And Obesity. J Clin and Transl Report. 34(10): 1486-1498. DOI: 10.1016/j.cmet.2022.09.007
Sunday, February 25, 2024
Ulnar Nerve Entrapment
Left ulnar nerve |
The ulnar nerve arises from the brachial plexus at C8-T1 and travels down the inner part of the upper arm through the arcade of struthers (pictured below).
At the elbow, the ulnar nerve travels just behind the bony part on the inner part of the elbow. This is also know as the "funny bone" when you can get sensations of pins and needles after bumping the area.
Picture by Conor Jones |
The ulnar nerve supplies the sensation and muscles to the 5th and half the ring finger. Symptoms are related to degree of irritation of the nerve. They start off intermittent in nature and may only come on at night after the nerve has been stretched for a longer time.
Pins and needles, aching or tingling in the little and/ or ring finger will be the common symptoms. This is what my patient felt. If the irritation persists, the symptoms may become constant and progress to numbness in the 5th and/ or ring finger and ultimately weakness in the hand.
As the ulnar nerve exits the bony tunnel, it goes into the flexor carpi ulnaris muscle. Follwing that at the wrist, it travels superficially to the flexor retinaculum and passes into Guyon's canal.
R wrist |
Picture from Medical Art Library |
Knowing the exact site of nerve irritation during an accurate clinical examination will help decide what needs to be done for treatment. Some doctors send their patients to do a nerve conduction test, but I personally find that an upper limb tension test (with radial nerve bias) done correctly does a much better job. Others may do ultrasound imaging to help diagnosis. Do not confuse it with thoracic outlet syndrome.
Just remember not to have a steroid/ cortisone injection.
*Ulnar nerve entrapments are commonly seen in cyclists, golfers, weightlifters and construction workers.
References
Kong G, Brutus JP, Vo TT et al (2023). The Prevalence Of Double- And Multiple Crush Syndromes In Patients Surgically Treated For Peripheral Nerve Compression In The Upper Limb. Hand Surg Rehabil. 42(6): 475-481. DOI: 10.1016/j.hansur.2023.09.002
Raut P, Jones N, Raad M et al (2022). Common Peripheral Nerve Entrapments In The Upper Limb. Br J Hosp Med. 83(10): 1-11. DOI: 10.12968/hmed.2022.011
Have a look at this ulnar nerve video.
Sunday, February 18, 2024
Does Strength Training Help Runners Prevent Injuries?
Monday, February 12, 2024
Weak Core, Tight Hamstrings And Weak Glutes?
A patient came in this past week with low back pain and was told by another physiotherapist that she had a weak core, tight hamstrings and weak glutes and that was why her back hurts.
Now, I do not agree with that. Actually studies show that back extensor strength is more important than flexor (abdominal) strength when it comes to low back pain (Lee et al, 1999).
Like I wrote previously, the idea for the need of a strong core was first introduced by Paul Hodges (Hodges and Richardson, 1998) when he published his article on the Transverse Abdominis (TA) muscle. His research compared the timing of TA and Multifidus in people with low back pain (LBP) for 18 months or more against healthy subjects with no LBP.
Hodges suggested that the TA was likely to be the main cause of LBP as it is the most important and deepest muscle in the abdomen. It looks and works like a corset to stabilise the back.
This article made the allied healthcare/ fitness industry conclude that the TA was a trunk stabilising muscle that was very important to strengthen for those with LBP. Patients who had LBP had weaknesses in their TA which led to instability in the spine.
Similarly with 'tight' hamstrings (Halbertsma et al 2001) and weak glutes. This female patient of mine can deadlift 90 kg. Her glutes are not weak nor are her hamstrings tight.
You can put all those myths to rest. Your low back pain is not caused by a weak core, tight hamstrings nor weak glutes. Stengthening your back extensors will be a much better option than the previously mentioned.
References
Halbertsma JP, Goeken LN, Hof AL et al (2001). Extensibility And Stiffness Of The Hamstrings in Patients With Nonspecific Low Back Pain. Arch Phys Med Reh. 82(2): 232-238. DOI: 10.1053/apmr.2001.19876
Hodges PA and Richardson CA (1998). Delayed Postural Contraction Of Transversus Abdominis In Low Back Pain Associated With Movement Of The Lower Limb. J Sp Disorders. 11(1): 46-56.
Lee JH, Hoshino Y, Nakamura K et al (1999). Trunk Muscle Weakness As A Risk Factor For Low Back Pain. A 5-year Prospective Study. Spine (Phila Pa 1976). 24(1): 54-57. DOI 10.1097/00007632-199901010-00013
Sunday, February 4, 2024
Tread Lightly To Avoid Knee Pain
Picture from Functional Path Training |
The coach then suggested to us that we run like ninjas, taking smaller and quicker steps. In fact, he made us practice that. We had to run as close to other pedestrians from behind (sharing the sidewalk) without startling them while we ran past. Turns out my running coach was correct as it helped my team mates and I avoid knee pain.
Here's the evidence. A group of researchers wanted to investigate whether 2 different 2-week partially supervised gait retraining programs were effective for runners with knee pain. They randomly allocated 30 runners to 3 groups. One group focusing on reducing impact, a group on cadence and a control group.
Visual feedback to reduce impact in the study |
Running pain (before and during the run), knee function, lower limb kinematics (contralateral pelvic drop, hip adduction, tibial, and foot inclination) were assessed before, immediately and 6 months after the intervention.
Picture A- Injured runner with CPD and right hip adduction |
So if your knee pain is stopping your from running, try landing softly and/ or taking smaller, quicker steps. Hey, my running coach was right, way ahead of his time.
Reference
De Souza Junior JR, Rabelo PHR, Lemos TV et al (2024). Effects Of Two Gait Retraining Programs On Pain, Function, And Lower Limb Kinematics In Runners With Patellofemoral Pain: A Randomozed Controlled Trial. 10(1): e0295645. DOI: 10.1371/journal pone.0295645
As Peter Larson's book from 2012 says, tread lightly .....
Sunday, January 28, 2024
Diastasis Recti
Picture from Lamaze.org |
Sunday, January 21, 2024
Intense Static Stretching Versus Strength Training For Muscle Growth
Static stretching device |
What? Just as effective as strength training? I was surprised to say the least. Well you know I am not a big fan of static stretching at all. Skeptical? I was too!
81 participants were allocated to 3 groups in this study. A static stretching group, strength training and control group. Pec stretching was done for 8 weeks, 4 days per week for 15 minutes per day. Those in the strength training group trained 3 times a week doing 5 x12 repetitions. All the subjects were instructed to maintain their regular exercise routine during the study. They exercised at least twice a week in a wide range of sports like fitness training, team sports or strength-endurance training.
Results showed significant strength increase in the static stretching and strength training group compared to the control group. There were no significant differences between the static stretching and strength training group.
There was moderate muscle thickness increases in the static stretching and strength training group compared to the control group. Muscle thickness was measured using ultrasound imaging. There was actually no difference between the static stretching and strength training group.
Range of motion test |
It has been suggested that the shared underlying physiological mechanism between stretching and strength training is the high stretching tension both produces to induce stretch mediated hypertrophy (Warneke et al, 2023). This tension translates into chemical signals that stimulate anabolic processes to generate new muscle tissue.
Wow. Increased size, strength and range in 8 weeks compared to strength training. However, note that static stretching via a stretching device like in this study needed a second person to assist and adjust the stretching device. Moreover, regular strength training can prevent osteoporosis and sarcopenia.
References
Warneke K, Wirth K, Keiner M et al (2023). Comparison Of The Effects Of Long-lasting Static Stretching And Hypertrophy Training On Maximal Strength, Muscle Thickness And Flexibility In The Plantar Flexors. Eur J Appl Physiol. 123(8): 1773-1787. DOI: 10-.1007/s00421-023-05184-6
Wohlann T, Warneke K, Kalder V et al (2024).Influence Of 8-weeks Of Supervised Static Stretching Or Resistance Training Of Pectoral Major Muscles On Maximal Strength, Muscle Thickness And Range Of Motion. Eur J Appl Physiol. DOI: 10.1007/s00421-023-05413-y