Time Of The Day When You Are At Your Best

Picture from Healthyplace.com

I have been out of school for decades and have not sat for any tests or exams in quite a while. But I do see new patients almost every day I am working in our clinics. I do take plenty of "tests" too, since every single patient I see will evaluate my treatment and decide if I made them better.

You must be wondering why I am writing about tests this week, Well, the Singapore primary school leaving exams (PSLE) just ended this past week.  Parents whose children just sat for the exams must heave a collective sigh of relief now that it's all over. 

The typical start times for the PSLE oral exams are at 0800 while written exams generally commence at 0815 hours. That's definitely an early start for those taking exams.

Unlike the students sitting for exams, we usually see new patients in our clinic whenever we can fit them in for an appointment. This may not necessarily be the best according to a group of researchers who analyzed the results of over 100,000 oral exams. They found a clear Gaussian distribution (also know as the Normal distribution or bell curve) in pass rates that peaked at noon. 

Passing rate by hour 

Between 11 am and 1 pm is the best time (pictured above). Any earlier or later the chances of passing significantly decreased. In fact the earlier or later in the day these students took a test, the less likely they were to pass.

The reason being our cognitive (or conscious intellectual ability) performance improves over the course of the morning and then declines in the afternoon. We also may have declining energy levels later in the afternoon. If your exam is scheduled later in the day, you may also stress about it and this usually leads to poorer performance.

According to the author's, the examiner's cognitive performance and fatigue level also matters. Both the examiner and student will be at their peak level of performance during the mid day hours.

This all means that whenever possible if you have to take a test or exam, an important meeting or a job interview, you should schedule it between 11 am and 1 pm. It can be the difference between passing and failing. 

Perhaps we should only see new patients in our clinics between 11 am and 1 pm then. 

Reference

Vicario CM, Nitsche MA, Lucifora C et al (2025). Timing Matters! Academic Assessment Changes Throughout The Day. Frontiers Psychol. 16:1605041. DOI: 10.3389/fpsyg.1605041

Training In Hot Conditions Makes You Eat More?

Just after sunrise

After all the rainy days during the first 2 weeks of September, the temperatures were nice and cool. This past week it seems like "someone turned the tap off" and it's been way hotter. 

I weighed myself yesterday morning before and after my regular Saturday ride before work and found that I had lost 2 kg (mostly water) despite eating and drinking more during the ride. These 3 hour rides, when warmer, make me feel like I'm making my body work double time. I've noticed that when the temperature is higher, I need to eat more (during the ride) or else I cannot keep up with my friends.

On Saturday rides that are cooler, I sometimes don't even eat the banana that I bring with me and can still ride well without tiring.

Turns out that training in Singapore's heat and humidity does not just make one more comfortable in hot conditions, it actually changes how our muscles use energy (Xu et al, 2025).

The authors in the study quoted above show that a month of structured heat acclimation training can help change your metabolism to race stronger when it's hot and probably in cooler temperatures too.

The researchers split 18 trained middle and long distance runners into 2 groups. Both groups completed treadmill tests and metabolic assessments at temperatures of 30-32 °C (or 86-89 °F).

The first group trained in normal temperatures (20-25 °Celsius or 68-77 °F). The other group did 20 sessions of heat acclimation over 4 weeks. They ran in tem[eratures between 30-36 °C that pushed their core temperatures to 39-40 °C (or 102-104 °F).

No prizes for guessing that the heat acclimated group made more notable adaptations compared to the control group. Their core temperature during the subsequent treadmill test was lower by 0.4 °C, a clear sign of improved thermoregulation. They were also more efficient aerobically, as oxygen uptake improved by 4 and 3.7 percent at the *first and second ventilatory thresholds.

Plasma volume improved by 4 percent, haemoglobin by 2 percent and erythropoietin by 13 percent after heat acclimation, showing better oxygen support. All signs of heat adaptation.

At submaximal intensities (75 and 85 percent VO2 max, carbohydrate oxidation dropped by 15-19 percent in the heat acclimated group. The runners used less blood glucose and muscle glycogen, using more of the body fat instead. Exactly like I wrote above when I do not need to eat as much during cooler rides. In the picture above, carbohydrate (CHO) use and energy expenditure (EE) before and after control (black bars) and heat training (red).

Upon finishing the treadmill test, the heat acclimated runners cleared lactate more efficiently demonstrating improved recovery.

However, VO2 max did not change, suggesting that having a higher VO2 max (compared to someone else) may not mean you will race faster. The efficiency gains were more beneficial.

Take home message? Those of us who live in sunny and super humid Singapore can train almost all year round in such conditions. A 4 week block of 5 days a week may give you the metabolic edge of using less carbohydrates at higher intensities. This spares your glycogen stores and delays fatigue. The thermoregulatory and blood adaptations will help you stay cooler and deliver oxygen more effectively, especially if you are going to be racing in a friendlier climate. 

You will need to monitor the above parameters and allow for adequate recovery to get the benefits. This is when your blood, sweat (lots of it) and tears will pay off if you do it correctly.

Reference

Xu Y, Ye C, Ma S et al (2025). Four-Week Heat Acclimation Lowers Carbohydrate Oxidation Of Trained Runners During Submaximal Exercise In The Heat. Frontal Physiol. DOI: 10.3389/fphys.2025.1581594/full

*First ventilatory threshold (VT1) is when your breathing becomes noticeably deeper and lactate starts to accumulate in the blood. This indicates a shift from using mostly fat to carbohydrate during exercise.

VT2 or second ventilatory threshold occurs later, this is often when breathing is rapid, more labored leading to a sharp increase in carbon dioxide production. This is when a significant shift to anaerobic metabolism.

Still not too hot

How to Run Faster At The Boston Marathon

Picture from Runnersworld.com

I came across a recently published article detailing the training of 917 runners (495 women, 422 men) who qualified and ran in the 2022 Boston marathon (Lempke et al, 2025). The majority of them finishing in mid-3 hour marathon times. So definitely relevant insights for most serious recreational runners if you want faster marathon timings.

This interesting new study tracked running duration, volume, cross training and changes in training frequency between the last 12 months to 4 months before the race day. Yes, you read correctly, the runners were training 12 months in advance before racing. In addition, training intensity distribution like steady state runs, quality sessions and interval sessions were also analyzed.

Let me highlight the relevant findings. The study found that those who had longer running durations, higher quality ('hard') sessions, running distance and/or volume from 12 months to 4 months before the race was consistently linked to faster timings.

From 12 months to 4 months before the race, those who ran more than 10 hours weekly predicted significantly better performance than 5-7.5 hours, 2.5-5 hours and less than 2.5 hours per week of training (pictured above). For reference, the weekly mileage for the 495 women studied ran 64.4 ± 24 each week while the 422 men studied ran 67.6 ± 26.2 km on average.

Each extra run shaved 3-4 minutes off race time, while each extra quality session was worth 16-17 minutes better timing on average. Running an extra 1 km a week was worth about 3-4 minutes off marathon time.

In the final 4 months to race day, all of the above variables predicted better performance. Runners who included cross training in the final 4 months ran significantly better. Each extra session per week translated to being faster by 6 minutes of finishing time.

Reducing running frequency in the final 4 months improved performance. The runners who decreased their total weekly running sessions averaged 3 minutes faster than those who maintained or increased the frequency of their running sessions.

Just in case you got confused reading the above (I did at first) where the study said adding an extra run each week helps in the final 4 months, but also said a reduction in frequency was associated with better performance (pictured above). 

This means that between 2 runners, the runner running 5 times a week would be faster than another runner running 3 times a week. However, a runner who reduced their runs by 2 runs a week would run faster than another runner who only reduced their runs by 1.

Note that this study was survey based and depended on what the runners recorded in their training logs. Most runners tend to be meticulous about this, I know I was. There was also no mention of what the runners did for cross training. In addition to cycling or deep water running, I also did strength training.

Reference

DeJong Lempke AF, Ackerman KE, Stellingwerrff T et al (2025). Training Volume And Training Frequency Changes Associated With Boston Marathon Race Performance. Sports Med. DOI: 10.1007/s4027-025-02304-4

Rivals Or Brotherly Love

CL and I were rivals (actually more of a team mate as we were friends too) on the track when I was competing in my secondary school's track and field meet. We competed in the 800m, 1500m, 3000m and the 2000m steeplechase events. Though I won all 4 events, knowing CL was also training hard was a powerful motivator and it pushed us both to be better runners.

Yes, having a rivalry with a colleague, friend, or even your sibling can be stressful, but the right kind of competition will elevate each other's performance.

Carlos Alcaraz and Jannick Sinner are currently the top 2 tennis players in the world. They faced each other in 3 of the 4 Grand Slam finals this year including the recently concluded US Open where Alcaraz won. They currently have a super rivalry and their duels definitely push each one to higher heights. Just like Rafael Nadal and Roger Federer (pictured above) before them.

Research has shown that rivalries can have perks. One study showed that runners ran almost 5 seconds faster per kilometre in a race when a runner whom they considered a rival was also racing.

Another study showed that when different NCAA, NFL, NBA, and MLB team performances were analyzed, when a team's rival beat them in the post season one year, that same team does better the next year.

Of course there are occasions when rivalries can hurt us. One study showed that people can be unethical or even ruthless when competing against a rival because they really want to win.

A big difference between rivalries that boost us versus those that hurt us is whether they are viewed as long term relationships. Nadal and Federer are real friends after they step off the court after trying their hardest to beat each other on court. Federer wrote a moving tribute to Nadal just before his last tournament. Nadal did the same for Federer just before the latter retired too in 2022. 

It appears that Alcaraz and Sinner too have an underlying friendship besides their rivalry.

Picture from Cyclinguptodate.com

This is very much like what currently happens in cycling too. Current world cycling champion and 4 times Tour De France winner Tadej Pogacar is very friendly with his rivals, even driving to a race (Milan San Remo) together. 

Pogacar and Vingegaard

This was highlighted in a viral podcast by Lance Armstrong. Some cyclists may agree with Lance, but it's probably the character of Pogacar, Mathieu van der Poel and Jonas Vingegaard etc to be friendly and get along. That is definitely acceptable and touching even.

So, you do not have to be buddies with your rival, but surely you can be friends and have mutual respect for each other. Wish each other well and do your best to beat the other and this may help both of you soar to higher heights.

References

Kilduff GJ (2014). Driven To Win: Rivalry, Motivation And Performance, Soc Pysch Per Sci. 5(8): 944-952. DOI: 10.1177/1948550614539770

Kilduff, GJ,  Galinsky AD, Gallo E et al (2016). Whatever It Takes To Win: Rivalry Increases Unethical Behaviour. A Manag J. 59(5): 1508-1534. http://www.jstor.org/stable/26157371

Pike BR, Kilduff GJ & Galinsky AD (2018). The Long Shadow Of Rivalry: Rivalry Motivates Performance Today And Tomorrow. Psych Sci. 29(5): 804-813. DOI: 10.1177/0956797617744796

Girls Get A Lot More Anxious Than Boys

Picture from Motherwellmag

In a first of its kind study, Prof Setoh and colleagues from Nanyang Technological University found that girls are a lot more anxious than boys. This happens between the ages of 8.5 and 13 years when they go through a sharp spike in social anxiety. They fear being judged negatively in social situations.

By the time they turn 13, their social anxiety levels are significantly higher than boys. If untreated, this may lead to poor mental health and interpersonal relationships. Academic and work performance later in life may be affected as well.

The article was just published on 300825 in the Research On Child And Adolescent Psychopathology. The Straits Times also published an article on it on 010925.

ST 010725

You must be wondering why I chose this topic this week, or wondering about my credentials on adolescent mental health. 

Just after I came across the newspaper article, I remembered a recent study by Lundgren et al  (2025) on how physical activity during certain periods can protect children from developing depression, anxiety and addiction. Their study was based on a large group of Swedish children followed from birth until their 18th birthdays. The long time frame allowed comparison between parent-rated levels of activity to diagnoses from a national registry. This is to eliminate pre existing issues that caused low activity levels or transient dips that were interpreted as social anxiety issues.

The study involved 17,055 children, who were born between 1997-1999. The parents had to rate various aspects of their child's health at 5, 8 and 11 years. Activity levels were tracked separately for school days and non school days. Participation in organized sports were tracked at 11 years and reported in hours per week.

The authors found that physical activity (reported by parents) declined from 4.2 to 2.5 hours each day between 5 and 11 years of age. Analyses showed that boys and girls had different outcomes and patterns. 

Time outdoors showed no protective associations while participation in organized sports at 11 years of age showed significant protective effects on anxiety and addiction for both boys and girls and on depression for boys. The authors concluded that his study provides evidence that physical activity and participation in organized sports may have protective effects against several adolescent mental health diseases.

Possibly policymakers working to control vaping in Singapore could use this information?

Access to the articles at the links below.

References

Lundgren O, Tigerstrand H, Lebena A et al (2025)Impact Of Physical Activity On The Incidence Of Psychiatric Conditions During Childhood: A longitudinal Swedish Birth Cohort Study. BJSM. 1:59(14): 1001-1009. DOI: 10.1136/bjsports-2024-108148

Tng GY, Law ECChen HY et al (2025). Developmental Trajectories Of AnxietySubtypes From ChildTo Early Adolescence: The Role Of Parenting practices And Maternal Distress. Res Ch Adoles Pysch. DOI: 10.1007/s10802-025-01364-4 

Can Too Much Running Increase Colon Cancer Risk?

Just when I'm reading about Ultras

If you've read a previous post of mine you know that there is evidence showing that people who are physically active have a lower incidence of cancer. A 2016 meta-analysis of 52 prospective studies found physically active adults were 24 percent less likely to have colon cancer compared to sedentary peers.

So I was very surprised when I came across a poster presentation that suggested that those who do high volume ultra marathon and marathon running may actually have an increased risk of advanced pre-cancerous colon lesions. The New York Times wrote about this too.

Researchers had 100 long distance runners ranging from 35 to 50 years who completed at least 2 ultramarathons (> than 50 km) or 5 marathons. These runners underwent screening colonoscopies, with all polyps reviewed by a team of oncologists, pathologists and gastroenterologists. 

They were found to have polyps (> 10mm with  tubulovillous features) that were more likely to turn into cancer compared to the general population (40-49 years old). 15 percent of the 100 runners had advanced adenomas. This was greater than 10 times higher than the benchmark. 39 runners had at least 1 adenoma of any type.  Prevalence in the matched general population was just 1.2 percent.

Most cases happened in runners with very high training exposure (pictured above), multiple ultramarathons or completed more than 15 races. There were even a few cases of high grade dysplasia, just 1 step away from colorectal cancer.

The researchers' hypothesis was that due to extremely high volume distance running, this leads to repeated low blood flow to the gut leading to chronic injury and inflammation. This can repeatedly injure the stomach lining. This recurring pattern may then accelerate carcinogenic changes that lead to the development of pre-cancerous adenomas.

Moderate exercise does lower systemic inflammation, but ultra marathon training can increase inflammation in the gut made worse with frequent high volume racing. This worsens during intense exercise in the heat. Since chronic gastrointestinal stress impairs absorption of fibre and micronutrients that normally protects the colon, their findings may be reasonable. More so if recovery isn't adequate.

The difference compared to the normal population does cause some concern. However, do note that this is a relatively small study done only in 1 location. There is no proof of causation, genetics, nutrition and other lifestyle factors that may also play a role. 

For most of us runners, running is protective against colon cancer, and does not increase our risk to it. I do not have any patients who run >2 ultra marathons or more than 5 marathons a year. If they do, then their risk profile may (emphasis on may) be higher. 

So if you do log mega mileage, race often and are concerned about your cancer risk, it may be wise to get colon cancer screening particularly if you have persistent gastrointestinal symptoms.

Do wait for the full peer review study to be published before making any final conclusions.

Reference (for the abstract)

Cannon TL, Bonomelli S, SwainWR et al 92025). Risk Of Pre-Cancerous Advanced Adenomas Of The Colon In Long Distance Runners. J Clin Oncology. 2025 ASCO Annual Meeting. 43(16) suppl. DOI: 10.1200/JC0.2025.43.16_suppl.3619

Are You A Fast Or Slow Walker?

Let's go for a walk

Walking seems like such a simple thing. We usually do not think about it until you cannot walk properly. My patient who had a recent ACL reconstruction literally had to learn how to walk again Pictured below).

Walking actually relies on quite a few body systems working together. Your eyes to help you see where you are going.  Your muscles and bones working together to get you places, your heart and lungs to circulate oxygen. Of course you need your brain and nerves to coordinate everything.

Previous studies have shown that walking speed is a significant predictor of life expectancy in older adults. Pooled results from 9 studies involving 34,000 adults aged 65 and older showed that walking speed was significantly associated with lifespan. Men with the slowest walking speeds at age 75 had a 19 percent chance of living for 10 years compared to those with the fastest walking speeds who had 87 percent chance of survival.

Another study found that even amongst healthy adults aged above 65, participants with slower walking speed were 3 times more likely to die of cardiovascular disease compared to those who walked faster.

Did you know that if you are a slow walker you may have a smaller brain compared to a faster walker? Research has shown that how fast you walk to the shops, MRT, or your local coffee shop can predict your chance of a heart attack, being hospitalised or even dying. Your walking speed can even reveal your rate of cognitive ageing.

As we age, these systems start to slow down. Studies show that walking speed is a significant predictor of life expectancy in older adults. This does not just apply to older adults as Rasmussen and colleagues (2019) found that even amongst 45 year olds, a person's walking speed can predict the rate at which their brain and body were ageing.

In that study (Rasmussen et al, 2019) had 904 subjects, all 45 years old born between 1972 and 1973 living in New Zealand. Their health and cognitive function were assessed regularly over their entire lifespans. 

There was fairly huge variation in walking speed among the subjects. You would think that these 45 year olds would have similar walking speeds but some walked as quickly as healthy 20 year olds while others walked as slowly as much older adults.

The 45 year olds with slower walking speeds showed signs of "accelerated ageing" with their lungs, teeth and immune systems were in poorer shape compared to those who walked faster. They also had 'biomarkers' associated with a faster ageing rate such as higher blood pressure, raised cholesterol and lower cardiorespiratory fitness. 

The slow walkers also had a weaker hand grip strength and found it more difficult to get up from a chair. Other signs of cognitive ageing include lower IQ test scores, worse memory test scores, processing speed, reasoning and other cognitive functions. MRI scans showed they had smaller brains and a thinner neocortex - the outermost brain layer which controls thinking and higher information processing.

Even the faces of the slow walkers were rated as ageing faster than the faster walkers!

The research suggests that the slow walkers' brains and bodies age at a faster rate compared to the quick walkers. There were already signs that these health differences were present from an early age  as researchers were able to predict the walking speed 45 year olds based on intelligence, language and motor skills test taken when the participants were just 3 years old. 

Wow, I am so surprised that there is a link between how fast people walked at 45 years old and their cognitive abilities all the way back to when they were 3 years old. Perhaps walking speed is not only a sign of ageing but a clue to lifelong brain health.

Reference

Rasmussen LJH, Caspi A, Ambler A et al (2019). Association Of Neurocognitive And Physical Function With Gait Speed In Midlife. JAMA Netw Open. 2:2(10): e1913123. DOI: 10.1001/jamanetworkopen.2019.13123.

Fit But Overweight Or Normal Weight But Unfit

Picture from Truenorthwellness

What if you were fit but overweight and even obese compared to being unfit but normal weight. Which do you think is better?

A new meta-analysis pooled results from 20 prospective cohorts thus investigating nearly 400,00 people (Weeldreyer et al, 2025). Participants were categorized by body mass index (BMI) as normal weight, overweight or obese. Their carodiorepiratory fitness (CRF) were measured by maximal exercise testing to determine if they were fit or unfit based on age adjusted VO2 max. This was to determine if BMI or CRF predicts mortality risk better.

This meta-analysis is different from earlier ones since it includes more women. It also has participants from a broader age range, geographic backgrounds and health status. Better statistics all round. Findings more generalizable and results more precise.

The reference group - normal weight and fit was compared to all other combinations. Compared to the reference group, those who were both overweight but fit and obese but fit, both groups had virtually the same risk of dying from any cause. About 4 percent lower and 11 percent higher respectively, which was not statistically significant. Being fit protected against being overweight and obese for all-cause mortality.

Not so good news for the unfit. Those who had normal weight but were unfit had a 92 percent higher all-cause mortality risk. The risk was similarly high for unfit and overweight (82 percent higher) and even higher for the unfit and obese (104 percent higher).

For cardiovascular disease mortality, the differences between weight categories were more pronounced. The fit but overweight had a 50 percent higher risk while those fit and obese had a 62 percent higher risk than fit individuals with normal weight. Note that neither was significant, although it meant that being fit protected one against the risk of dying from cardiovascular disease.

Now for those who were unfit for cardiovascular disease mortality, the numbers were not pretty, in fact they shyrocketed. 104 percent higher risk for normal weight, 158 percent for  overweight and 235 percent for the obese.

In short, being unfit more than doubled mortality risk for many cases, regardless of BMI, while being fit can netralize the impact of carrying extra weight.

These findings show that BMI alone is a weak predictor of health and improving cardiorespiratory fitness can cancel out much of the risks associated with a higher BMI.

Perhaps BMI is not a good indicator. One may have a high BMI and yet be muscular and fit - the Amercian football players in the NFL have high BMI values. They are classified as obese, but they are actually very fit and muscular.

Should we be more concerned with increasing fitness levels over weight loss during public health awareness? There seems to be more emphasis now on weight loss and eating less processed food rather than increasing physical activity. 

This study suggests boosting fitness levels should be at the top of the list, not just as a replacement for tackling obesity. Studies like this show that physical activity is definitely more important than diet for those who want to live to a ripe, old healthy age. Not to say that diet does not matter. But fitness is king. Perhaps our Ministry Of Health should angle some incentives?

Reference

Weeldreyer NR, De Guzman JC, Paterson C et al (2025). Cardiorespiratory Fitness, Body Mass Index And Mortality: A Systematic Review And Meta-Analysis. BJSM.59:339-346. DOI: 10.1136/bjsports-2024-108748

Aircon Mall Marathon

Picture from Arabnews

I remember meeting some Singaporeans who lived in Doha when Team Singapore went to compete in the 2006 Asian Games. They told us during the hottest months temperatures went up to over 50 degrees Celsius. How can one exercise safely I remember asking myself back then.

Well, while Singapore celebrates turning 60 on August 9th, 2025, a sprawling shopping centre in Dubai organized a "Mallathon" on the same day.

Back by the Dubai government, it aims to encourage exercise during the hottest month in United Arab Emirates (UAE). They make use of Dubai's giant malls which are otherwise empty at that time. 

Runners can take part in organized 2.5km, 5 km and 10 km races at designated malls complete with podium presenattions and prizes.

One can also wait in line to use electric bikes that powered blenders to make healthy smoothies after exercising.

Perhaps our Singapore malls can do the same. To help revive our ailing retail and food and beverage scene.

Happy National Day Singapore!

Are The Chinese Brands Surging Ahead?

My first observations about someone are always about their footwear. I have done this ever since I was a teenager, I would be curious about people's shoes. I always look at what shoes a person is wearing especially if they are a runner. Of course as a physiotherapist now, I do the same.

If you are a runner you may or may not have heard of Anta, Li-Ning, Qiaodan, Xstep. They were usually unheard of a few years ago and dismissed as inferior to Nike, Adidas, Asics and New Balance (sorry if your brand is not listed). 

However, Chinese Super running shoes with their carbon fiber plates and super foam are increasingly becoming mainstream compared to before. Selemon Barega (Tokyo Olympics 10 000 m winner) switched from Nike to Li-Ning 3 days before the race and won the 2025 Seville marathon in an impressive 2:05:15 hours.

Some Chinese running brands have already set up shops in Singapore. Li-Ning has 2 stores here while Anta now has 11 stores after opening their first in 2023.

There may still be perceptions of Chinese Super shoes as being lower quality and/ or durability. They are definitely cheaper costing between S$150-200 a pair compared to more than S$300 for Super shoes from established brands.

I have definitely noticed some of my patients using Chinese super running shoes. My patients say that they are not only cheaper than the established brands, they seem to have even more energy return and propulsion. Personally, I have not tried any of the Chinese running brands yet.

Not just with running shoes, it seems. If you happen to be a cyclist you may have heard of Winspace or X-Lab? Some cyclists still regard cycling tech from China as cheap and/or  counterfeit. Too good to be true or too dangerous to use because of high failure rate.

Cycling World Tour team XDS Astana is using a carbon fiber bike made by X-Lab. This is the last team Mark Cavendish, who has won the most stages in the Tour De France rode for albeit on a different bike before he retired last year.

Winspace wheels are much cheaper compared to Campagnolo, Enve or Lightweight wheels. Lightweight's Meilenstein Art wheels cost $8000 while Winspace's Lun Hyper go for $1500. At almost the same weight, with a deeper rim profile, it ticks all the boxes. Winspace wheels have even been rated as excellent by engineering expert Hambini. They are also UCI approved. Matter of time before they get used at a World Tour level race or even at the Tour De France.

Will I consider Winspace's wheels? I currently use Campagnolo's WTO 45mm Bora wheels on rim brakes. I am not a fan of disc brakes on road bikes. Personally, I think bicycles have gotten more expensive and more complicated with disc brakes. I am sure bike manufacturers like the higher margins that come along with them too. When it becomes impossible to find a rim brake wheelset from a mainstream brand I may have to switch to them since Winspaceare committed to supporting both disc and rim brakes.

See how cheap they are

I still look at cheap carbon wheels, shoes, ceramic pulleys on AliExpress and Shopee (above). For reference, my Ceramic Speed pulley wheels alone cost $500 a pair. I'm not telling you the price to brag, but to make a point. I'm tempted to use them, but horror stories that show up online have steered me away so far.

2 Pirelli tubes on the left

Except for my inner tubes. Previously I used the very expensive Pirelli TPU inner tubes for my bike. I am now using TPU inner tubes made from China. They are so many different brands now. China has created many cheaper alternatives to the popular TPU-based inner tubes from Pirelli or Tubolito that cost $30 compared to $8 ones from China. Well, far so good, they have not let me down yet.

What do you readers think? Are Chinese brands taking the world by storm? BYD cars are now most popular in Singapore while mainland Chinese food and beverage brands are also growing their brands here.

What Helps Prevent Muscle Atrophy During Immobilization

Which leg was immobilized?

We see many patients with muscle atrophy on their affected limb. This definitely happens after surgery where whole body or single limb immobilization may be necessary. This leads to decreased muscle size and strength.

What strategies are there to mitigate this? You may be very surpised.

20 male participants (average age 33) took part in this study (Labidi et al, 2024). All were former competitive athletes, primarily in athletics, now working as fitness coaches. 

The participants were split into 2 groups. They had 2 weeks of single lower leg immobilization with a orthopaedic walking boot . They were taught to use crutches and instructed not to weight bear on that leg. This was followed by 2 weeks of supervised rehabilitation before return to sport (RTS). 

The participants underwent 4 weeks of a standardized training program to ensure a common training base before the immobilization procedure. There were 5 sessions (3 resistance, 2 endurance) of training each week. They also received 4 nutritional sessions inclusive of face-to-face consults with a nutritionist and educational videos to standardized daily energy and protein intake throughout training, immobilization and rehabilitation phases.

Picture from SIU Med

The participants then underwent 4 weeks of supervised training. The 1st group had whole body heat therapy (HEAT) while the 2nd group had sham treatment (SHAM) throughout the immobilization and rehabilitation periods.

During the immobilization period, the participants received 11 passive interventions of 60 minutes. The HEAT group sat in a heat chamber at 48 to 50 degree celcius at 50% relative humidity (at 0 m altitude). 

During the rehabilitation period, the participants received 5 active interventions (conditioning) of 60 minutes. The HEAT group performed the sessions in the heat chamber at 35 degrees Celcius and 60 degress relative humidity at 0 m altitude. 

The SHAM group sat in an altitude chamber, set at only 200 m (to create a placebo effect while avoiding any effect of altitude). The temperature was at 24 degree celcius and 40% relative humidity.

Ready for the results? All of the following were measured pre-immobilization, post-immobilization and at RTS. Muscle strength (isometric and isokinetic) were measured. Muscle volume was measured by MRI and ultrasound while muscle biopsies were also obtained. Maximal isometric strength for the calf muscles (plantarflexion) was lower at RTS compared to pre-immobilization in SHAM. 

Isokinetic strength during a fatigue test was higher at RTS compared with pre-immobilization in HEAT but not SHAM. 

Shape of muscle and muscle thickness were lower at post-immobilization compared with pre-immobilization only in SHAM. Cross sectional area of the soleus and the medial, lateral gastrocnemius were decreased in SHAM. Only the medial gastrocnemius was smaller in cross sectional area in HEAT.

The results indicate that using heat therapy during immobilization and rehabilitation reduces muscle atrophy and maintains calf strength in healthy humans. Repeated heat exposures should be considered to counteract muscle atrophy during immobilization.

I'm not sure that it's practical to get in a sauna with a cast on but maybe with a boot or back slab that can be removed temporarily? I would do it if I wanted to return to sport badly enough or maybe if I'm old and wanted to prevent muscle bulk and strength while awaiting healing to happen. For those with with an aversion to heat, definitely no go.

Reference

Labidi M, AlhammoudM, Mtibaa K et al (2024). The Effects Of Heat Therapy During Immobilization And Rehabilitation On Muscle Atrophy And Strength Loss At Return To Sports In Healthy Humans. Orth J Sp Med. 12(10). DOI: 10.1177/23259671241281727

Our Words Affect Pain

Picture from Coregymball

It may be just words you think. Perhaps not. Recently published fascinating research suggest that how healthcare providers describe an injury can have a direct impact on a patient's pain. 

Not only were the patients blinded (a technique used to minimise bias), the patients also did not know they were part of a study.

Picture from article

50 recreational runners with Achilles tedinopathy took part in the radomized trial (pictured above). They ran 3 times a week. Runners in the experimental group received diagnostic information of tendon pain that highlighted reversible changes in muscle function as their primary problem. They did not hear any reference to tendon pathology.

The control group received an explanation of tendon pain that prioritised irreversible structural tendon pathology as the cause of pain.

The primary outcome measure was how much pain the runners had during a standardised hopping task measured on a scale of 0-100. Secondary outcomes were how stiff the lower limbs were hopping and time in seconds for pain to ease after completing the hopping task.

The diagnostic information immediately affected pain intensity during the hopping task. The average pain score was 25.4 in the experimental group versus 36.7 in the control group.

Time to ease (no pain) after hopping was near identical in both groups. Lower limb stiffness was higher in the experimental group. Note that higher leg stiffness is better for leg hopping because increased leg stiffness allows for greater force production and more efficient energy transfer. This leads to higher jump heights and faster movement.

This is a really intriguing area of research. We now have data showing that information from healthcare providers during the first visit has an immediate effect on pain. The language we use during clinical interactions can be powerful, shaping our perceptions and pain responses. This knowledge should change how we interact with our patients. 

However, we need to also be able to do this in our clinics without compromising the accuracy and necessary medical information.

Reference

Travers NJ, Travers MJ, Gibson W et al (2025). The Content Of Diagnostic Information Has An Immediate Effect On Pain With Loading In People With Morportion Achilles Tendinopathy: A Randomized Clinical Experiment. Bra J PT. 29(5). DOI: 10.1016/j.bjbt.2025.101244

Quadrilateral Space Syndrome

R posterior arm picture by Mickeymed.com

I treated an 11year old girl recently with pain in her quadrilateral space. What space you may ask? The quadrilateral (or quadrangular) space is a tiny window or space that the axillary nerve and other blood vessels (posterior circumflex humeral artery) exit from the shoulder to the back of the arm. It's boundaries are teres minor on top, the humerus (arm bone) on the right, teres major below and the long head of triceps on the left. The axillary nerve supplies the deltoids and the teres minor muscles. 

Picture from Clinical Anatomy & Op Surgery

This young patient plays softball for her school and is her team's first choice pitcher. Softball pitching is different as the ball is thrown to the batter using an underhand motion. The goal while pitching is similar to baseball, to get the batters out by strikes or preventing them from reaching base. 

Injury or compression in the quadrilateral space often leads to pain, numbness in the posterior shoulder/ arm and/ or weakness in those areas.

This condition is much more common in young athletes participating in arm over head sports like swimming, throwing and volleyball in their dominant hand. But she did do many overhead throws prior to having this pain in her posterior shoulder and arm. In addition, her coach also started her on a weight training program in the upper body and arms.

Injury or compression in the quadrilateral space often leads to pain, numbness in the posterior shoulder/ arm and/ or weakness in those areas. There is often tenderness in the quadrilateral space on palpation. 

My patient also had some paresthesia (numbness, tingling sensations) on the outer shoulder and elbow when I checked her upper limb tension test. Her shoulder external rotation strength was also noticeably weaker on her thowing arm, which should not be the case.

Once we determined the cause, treatment was easy as we simply had to 'widen' the quadrilateral space while also addressing the overhead throwing overuse and the sudden increase in weight training. A simple phone call to her coach,who happened to be a previous national pitcher and patient of mine solved that.

Reference

Pocellini G, Brigo A, Novi M et al (2025). Different Patterns Of Neurogenic Quadrilateral Space Syndrome: A Case Series Of Undefinied Posterior Shoulder Pain. J Orthop Trauma. 26(1). DOI: 10.1186/s10195-024-00813-y.

3 Common Sites Of Musculotendinous Junction Injuries

I recently had a patient with a musculotendinous junction injury. Also known as the muscle-tendon junction (MTJ), it acts like a bridge to transfer forces from the muscle via the tendon to the connecting bone the muscle attaches to. This allows for movement to take place. 

It is a special area where the muscle's fascia connects and inersects with tendon tissue. Structurally, the MTJ is seamlessly integrated into the tendon, with finger-like folds increasing the surface area for a stronger connection and to distribute stress (pictured above).

It's a common site for injury as the MTJ undergoes some stress during daily activities and substanstial stress while playing sports. MTJ injury is often accompanied with both muscle and tendon injuries leading to restricted force trasmission.

Due to it's highly specialized structure, it does not often heal well after injury. Conservative treatment are mostly effective for minor MTJ sprains while partial tears and complete ruptures will require surgical intervention.

It can happen during a fall leading to trauma to the area. It often occurs due to repeated overload, usually from high intensity training in young athletes or overuse in middle age or older adults. My observations are MTJ injuries usually happen after a period of rest/ decreased muscle use followed by a period of intense muscle activity. 

An example who be my patient mentioned above. He went on holiday for 3 weeks with no exercise and resumed his weekly basketball game on returrn and promptly tore his hamstrings at the MTJ. These tears occur frequently during eccentric muscle loading. 

They are usually complete muscle tears. In hamstring injuries this account for 14.4% of all bicep femoris injuries. The supraspinatus muscle has the highest incidence of the tendon midsubstance injuries (11.4%). Complete tendon avulsions are more frequent in the triceps brachii and pectoralis major.

Conservative treatmant options like rest, ice and compression etc helps in the initial stages if the tear is small. Several studies have indicated that surgical treatment yields better results in terms of function, strength, patient ratings and recovery to pre-injury performance for the more serious tears.

Continous development of tissue engineering that focuses on regenerating new tissue from cells are now helpful to MTJ injuries by utilizing biological and synthetic scaffold-based tissue. This helps in the repair and healing of MTJ tears. However it is not easy to fully mimic the unique characteristics of our muscles, tendons and the MTJ itself.

Hopefully, newer polymers and scaffolds will help with healing of MTJ injuries in the future. For now, please be vigilant in your exercise after a period of rest. Avoid exercising at higher intensities initially while allowing for your muscles to adapt again. Note that the calf, pectoralis major (chest) and hamstrings are the most vulnearble areas.

Reference

Tong Sm Sun Y, Kuang B et al (2024). A Comprehensive Review Of Muscle-Tendon Junction: Structure, Function, Injury And Repair. Biomedicines 12, 243. DOI: 10.3390/biomedicines12020423

The Old Do Not Need Gentle Movement

Picture from NRI Nation

I was very surprised to read that older adults need more than gentle movement. They need strength. Yes, a lot of stength if you read the following review by Toien et al (2025). This is in contrast to current guidelines which recommend low to moderate intensity (60-70 percent of 1 RM) and slow to moderate concentric velocity.

The review showed convincing benefits of maximal strength training (MST) in healthy and 'diseased' older adults including frail and post stroke patients. Training performed with heavy (80-84 percent) of 1 RM and very heavy loads (>85% of 1 RM).

Key benefits were increased strength gains (2.5 percent per session). 4.5 percent increases in muscle power per session. Increase in Type II muscle fiber size, decrease in oxygen cost of walking and stair climbing. It also helps with balance.

MST uses loads of about 90% of 1 RM, which can only be performed a maximum of 3-5 reps, 3-5 sets and maximum intentional concentric velocity.

Here are the guidelines. Do 4 sets of 4 reps at about 90% of 1 RM or 4 RM. Do this 2 to 3 times a week. Single set options are also effective twice  a week. Prioritize lower body compound lifts e.g. leg press, squats, step ups since strength reduction is more effective in lower compared to upper limbs with increasing age. Moreover the lower limbs are crucial for walking during everyday activities. 

Picture from article

For this, a horizontal leg press (pictured above) may be ideal over a free weight squat since technique and safety will minimally limit the intensity of the load. The health care provider needs to consider the main challenges of the specific disease or individual. Those with osteopenia or osteoporosis will benefit from axial loading through the spine to stimulate bone density enhancement. The hack squat or horizontal leg press where the back can be reclined to ensure loading through the spine is recommended to attain this axial loading of the spine while also protecting the impact of the heavy load. 

Some diseases or injuries may require other exercises to target an affected or impaired muscle or muscle group. Examples may include the bench press for wheelchair users, dorsiflexion for foot drop patients or hip abduction following hip surgery. Also note that very heavy unilateral (or single leg) strength training induces adaptations in the untrained, opposite injured limb. This is useful during acute or chronic periods of immobilization to limit the loss of function in the immobilized limb.

Supervised training are encouraged since it improves safety and confidence.

It is a very interesting read since it is good to have evidence that it is safe to use the heavier strength training lifts compared to the current guidelines. I am wondering if the 4 sets of 4 repetitions at 90 percent of 1 RM for older patients is a recipe for injury. Is the volume and frequency of the MST sustainable for the long term?

Reference

Toein T, Berg OK, Modena R et al (2025). Heavy Strength Training In Older Adults: Implications For Health, Disease And Physical Performance. J Cachexia Sar Muscle. 16(2): e13804. DOI: 10.002/jcsm.13804

Day 2 Of Kinesio Foundations Course

Ligament correction with Dr Frank Liew (dentist)

Most of the participants already took the Kinesio tapes off after the the first day. For the few who still haves them on, we started with some questions on how tape left overnight felt. The participants discussed why there were good or adverse reactions.

What's up Dr Kong (on the right)?

Day 2 Of Kinesio Foundations Course started with corrective techniques. Mechanical correction, fascia correction, ligament/ tendon correction and spring assist etc

Surprisingly, the 2nd day of the course zipped by much quicker than usual as we went through more the corrective techniques. There were practical applications such the association of MCL (medial collateral ligament) and your pes anserinus, how a rotated pelvis would affect the shoulder. How the hip affects the knee and also strategies on how to treat a foot drop. We covered all that and more.

Cutting the tape for EDF, jelly fish - not easy

The coup de grace were the EDF and jelly fish taping affecting the epidermis, dermis and fascia. The participants realized it's much easier to have a good pair of scissors for the EDF techniques.

A big thank you to the participants, my family and colleagues for helping out. Would not have done it without all of you. Looking forward to the next course.