Hydrotherapy/ Deep Water Running Again!

Since Covid started, we have not been able to bring our patients to the pool for hydrotherapy or aqua-based rehabilitation. 

The public pool we were using is only opened for lap swimming now. We are very grateful to The Ripple Club. It was with their help that we got access to a pool for our post-op patients today.

They are all surrendering....

This is not a typical hydrotherapy session in a shallow pool like what hospitals may have. Those are often indoor sessions in waist or chest deep, warm water. Range of motion exercises and light strengthening exercises are normally done then.

For our sessions, the pool is usually 1.8 metres deep. The patients use an aqua running belt to keep them afloat.

One patient had her hip labrum repaired recently while another (a triathlete) had an OCD bone fragment removed surgically. I often include aqua running techniques (or deep water running) to produce a training effect for them since they definitely cannot run on land yet. 

If done correctly, the arms, shoulders, lower limbs and abdominal muscles are involved. For those who cannot take too much impact, this is a very good alternative since water is 773 times more resistant than air. The harder you move your arms or legs, the more drag force or resistance you encounter.

Sculling with aqua belts off

This is a very useful session for rehabilitation work and training for athletes and patients. It allows injured athletes or post operative patients to recover quicker and allows others to undertake higher intensity (water based) training, with lower incidence of injury. 

It will not do the aqua training technique justice for me to describe how you do it in just a few short sentences, please contact us if you need more information on this.

References

Davidson, K (2000). Deep Water Running Training Improve V02 max in Untrained Women. Journal of Strength and Conditioning Research. 14 (2) 191-195

Dowzer, CN and Reilly, T (1998). Deep Water Running. Sports Exercise and Injury. 4: 56-61

A big thank you to Alicia and Yannick from The Ripple Club for letting our patients try their water bikes.

*Thanks to Edmund Miranda from The Ripple Club for taking the pictures too.

Please Help My Swollen Knee

My patient sent me the above picture recently asking for help. Her knee became swollen after a recent run. After icing her knee, she decided to use some "imitation/ copy cat" Kinesio Tapes but that didn't resolve the swelling and worse still gave her an allergic reaction.

Knee joint effusions (or swelling) are usually caused by the knee joint producing more synovial fluid due to aggravating factors causing damage to the joint.

As little as 5 ml of fluid can increase pressure within the knee joint. This can be a source of discomfort and concern for the person affected.

It takes a very small volume of fluid in the knee (20-30 mls) to result in biomechanical changes. The quadriceps will be inhibited as a result (meaning you are less willing to use that muscle) and strength decreases rapidly.

It has also been found that swelling in the knee affects joint mechanics particularly during landing tasks. If someone has effusions in the knee, they tend to land with greater ground reaction forces (or impact) and in greater knee extension (or straightening). This results in more forces transmitted to the knee joint and its ligaments. So you can't run and jump quite as well.

When we see knee joint swelling in our clinics, we try to remove the swelling pronto. Flossing the knee joint, using correct Kinesio taping techniques with genuine Kinesio tapes definitely helps.

My favorite is of course aqua based rehabilitation/ deep water running to take advantage of hydrostatic pressure to help with the swelling. This also allows for quadriceps/ hamstrings strengthening early on without additional loading.

If the patient has more severe effusions, we may suggest altering their gait temporarily (we call this pain free walking), using non-steroidal anti inflammatory medication (NSAIDs) or even suggest they get the joint aspirated (I've tried it, it hurts like crazy).

Once the swelling settles, it will quickly and significantly reduce internal pressure in the knee as well as improve quadriceps strength.

We will quickly select rehabilitation exercises to allow specific quadriceps muscle recruitment without increasing intra articular pressure with knee extension. This is usually done in positions of partial knee flexion (20-30 degrees).

Now you know. Come see us in our clinics if your knees are swollen.


References

Hart JM, Pietrosimone B et al (2010). Quadriceps Activation Following Knee Injuries: A Systematic Review. J Athl Trg. 45(1): 87-97. DOI: 10.4085/1062-6050-45.1.87.

Palmieri-Smith RM, Kreinbrink J et al (2007). Quadriceps Inhibition By An Experimental Knee Joint Effusion Affects Knee Joint Mechanics During A Single-Legged Drop Landing. AJSM. 35(8): 1269-1275. DOI://doi.org/0.1177/0363546506296417.

Stress Fractures In Teenage Female Runners

Icing the shin

The Singapore National School's competitions are usually held between March and late May every year since 2009. And it's that time of the year again where we see many patients in our clinics with shin splints. Mostly adolescent and teenage girls and the occasional boy.

Why are girls more susceptible to shin splints and stress fractures? Well, some new data shows that if teenage female athletes don't eat enough to support their training, there will be complications regarding their subsequent training and health.

The study tracked 323 female athletes at Stanford University in 16 different sports including cross country running. Bone scans and questionnaires were used to assess the runners based on the components of the "female athlete triad" consisting of "low energy availability, with or without disordered eating, menstrual dysfunction and low bone mineral density. "

Risk status were calculated based on an article published in the British Journal of Sports Medicine  in 2014. Have a look at Figure 4 in the article if you're keen to know more about the calculations.

Looking only at the cross country runners (47 runners) data, half the runners were classified as low risk, and three of those later developed stress fractures.

Sixteen of the runners had moderate risk and 50 percent of these developed stress fractures within a year. These girls were about four times as likely to get injured compared to the low risk group.

Seven runners were in the high risk group and five of them developed stress fractures. They were nearly six times as likely as the low risk group to get injured.

Well, if you're thinking like me, not so good news for the girls if you're a runner and in the moderate to high risk group.

The researchers suggested the following guidelines for female athletes in the moderate to high risk group. The athletes need to ensure they're getting enough calories to support their training along with calcium and Vitamin D. Their menstrual function, bone health and nutrition needs to be monitored on an ongoing basis.

Higher risk athletes may have to consider using low impact cross training more often in their weekly routine. Good sleep and recovery are important too.

Stress fractures occurred mostly in the foot for the low risk athletes, probably as a consequence of biomechanics and jumping sports (due to higher forces).

In the higher risk categories, many of the stress fractures were in the sacrum, pelvis and femoral neck (where the bones tend to be softer). These areas may be due to weakened bone rather than biomechanical forces.

So all the doctors, physiotherapists, physical education teachers, coaches, heads of departments and administrators in charge of female teenage athletes reading this post, please take note.

Reference

Tenforde AS, Carlson Jl et al (2017). Association Of The Female Athlete Triad Risk Assessment Stratification To The Development Of Bone Stress Injuries In Collegiate Athletes. AJSM. 45(2): 302-310. DOI: 10.1177/0363546516676262.

Shin Splints Most Common In New Runners

Picture by Anne Sophie from Flickr

Latest published  research indicates that shin pain is the most common complaint among new runners. Shin splints or stress fractures is also our most popular article in this blog with over 200 comments and counting.

The researchers studied 933 new runners for a year to see how many were injured, what injuries they had and how long it took before they resumed running. They were considered new runners if they haven't run more than 10 kilometres the previous year. The runners were considered injured if they had running induced pain in their legs or lower back that prevented them from training (distance, duration, pace or frequency) for at least a week.

254 runners were injured during their first year of running. 15% of this injured runners had medial tibial stress syndrome (or shin splints), 10% had knee pain, 7% injured their Achilles tendons while 5% hurt their plantar fascia or soleus (deep calf muscle).

Stress fractures were relatively rare, probably because the new runners' mileage in their first year were not high enough. 75% of the injuries happened during the runner's first 201 kilometres.

Time to heal varied widely amongst the injured runners.Those who hurt their calf resumed training after 30 to 40 days, while those with shin pain took an average of 72 days to fully recover. The worst were those who had plantar fasciitis, it took an average of 159 days to recover.

Majority of the 254 injured runners recovered fully (220) by the end of the year long study. Only 34 remained injured.

The researchers concluded that their findings emphasized the importance of the need for new runners to be mindful of shin splints as it is most common injury in their study. Even among recreational and elite runners, shin splints was the most common injury with an incidence of 13-20% (Lopes et al 2012).

Wanna run pain free? Have a read here.

References

Lopes AD, Hespanhol Junior LC et al (2012). What Are The Main Running-related Musculoskeletal Injuries? A Systematic Review. Sports Med 42: 891-905.

Nielsen RO et al (2014). A Prosepective Study On Time To Recovery In 254 Injured Novice Runners. PLOS One. DOI: 10.1371/journal.pone.099877.

Even Kobe has shin pain. (Picture from Flickr)

One Last Farewell Swim

One last swim for charity

This was the pool where I learnt how to swim in the 1970's. I've been teaching my son how to swim there too this past few years. When my wife was pregnant, she did hydrotherapy there for her low back pain and to get some exercise as well.

When I started training seriously for triathlon, this was the pool that I started training at. When I broke my head and back last year (and my previous knee surgeries) this was the the very place I came to do my rehabilitation.

So definitely on this last day that Buona Vista Pool is opening its doors for the last time I had to come and bid a very fond farewell to the pool.

In fact, I went to the pool twice today. Brought patients there for hydrotherapy this morning and later in the afternoon went with my wife and son to take some pictures and for one last swim with my son. We went earlier in the afternoon before the crowd came, hence it look really empty.

Big splash coming up

Look mama, I can swim

We'll definitely miss you dear Buona Vista Pool.

The Good And "Bad" Of Swimming

Picture by RichSeow @ flickr.com

In many ways, swimming has the benefits of most land based aerobic exercises like running, walking, cycling etc. Swimming has been also found to effectively improve cardiovascular fitness and muscle mass while also effectively reducing blood pressure.

Since swimming is done in water, it cools you down and there is a lot less impact compared to land-based exercises and heat related illnesses. Chances of  injuries are also much lower. This is the main reason why our athletes/ patients can do rehab almost straight after surgery while maintaining their fitness levels.

Despite all its advantages, here's one real drawback regarding swimming. It seems to make you eat more! At least that's what the researchers found.

Researchers found that swimming (whilst beneficial in improving cardiovascular fitness) is not particularly effective at promoting weight loss. In fact, those who swam (compared to those who brisk walked, jogged or cycled) tended to put on weight. (There were more than 15 000 adults studied over a decade).

I'm always starving after I swim. Now I know why I feel like I can eat a horse after swimming. Please share your views.

References

Tanaka H (2009). Swimming Exercise: Impact Of Aquatic Exercise On Cardiovascular Health. Sports Med. 39(5): 377-387.

Littman AJ et al (2005) Effects Of Physical Activity Intensity, Frequency, And Activity Type On 10-year Weight Change In Middle-aged Men and Women. Int J of Obesity. 29: 524-533.

It's Never Late To

...... start exercising that is.

Picture by Brian Dees from flickr.com

After my bike accident, I went to the pool 4-5 times a week for rehab rehab. There was this older gentlemen (I think he's at least 70) that I saw frequently. He would cycle to the pool and swim lots of laps. He looked really strong and I remember saying to myself that I would like to be strong and healthy like him when I get to his age.

Well I guess research is good at confirming what I believe this older gentleman is.

British researchers studied 3454 adults over 8 years who were healthy and disease free at the start of the study. Their average age at the start of the study was 63.7 years young.

The adults were considered healthy if they did not develop any major chronic diseases, depressive symptoms or any physical or cognitive impairment during the 8 years of the study.

19.3% (or almost a fifth) made it to the final follow-up healthy. Those who exercised moderately or vigorously at least once a week were on average 2.67 and 3,53 times more likely to experience healthy ageing compared t those who were inactive.

What's more amazing was that those who had only become physically active during the study had a higher likelihood of experiencing healthy ageing than those who did not.

The researchers concluded that significant health benefits were even seen among participants who became physically active relatively late in life.

Today's the last day of the year and tomorrow is a brand new year. It's a good time for you to start exercising regardless of whether you are young or old.

Reference

Hamer M, Laviole KL et al (2013). Taking Up Physical Activity In Later Life And Healthy Ageing: The English Longitudinal Study Of Ageing. BJSM. doi:10.1126/bjsports-2013-092993.

Who Came For Hydrotherapy Today?

Who's that jumping?

I've been going to the pool fairly regularly (especially since that's the safest exercise/ rehabilitation I can do after my bike accident and often alone too.

Occasionally I get Ronald Susilo (former Olympian, Sportsman of the Year) joining me. Recently he was actually planning to play in the current ongoing Li Ning Singapore Super Series Badminton Open and he requested joining me at hydrotherapy to do some conditioning. (Alas, he did not get his chance, but that's a different story).

Now, Ronald and I go back a long way, I've been treating Ronald since the late 1990's, way before he became a household name in badminton. We've done hydrotherapy previously while he and the rest of the Singapore Badminton team were preparing for the Olympics.

And, surprise surprise, he showed up with 2 of his young charges today at the pool for some conditioning with him, with me taking charge - just like the old days.

Ronald taking a rest

Now, it was with dismay that I read in the papers today that all 3 of our male local shuttlers were knocked in the qualifiers yesterday and so Singapore will not have any representation in the main draw of the Men Singles today.

So hopefully, with today's session and more, Ronald's young players will do well enough to do us proud at subsequent Singapore Open's and more.

All the best at the tournament, Team Singapore.