Saturday, July 21, 2018

My Patient Was Told He "Just" Tore His Lateral Meniscus

Maybe it's not so obvious from just the picture above. But when I looked at my patient's legs, they were the first clue I received that perhaps there was something more than meets the eye.

He had gone on a skiing holiday in Whistler in March earlier this year and suffered a fall. After being brought to the physiotherapy clinic on site, they just gave him a knee brace and told him that he tore his lateral meniscus and that it will recover in a month or two. He actually felt fine after a few days of resting and thought he recovered fully after returning to New York where he's studying.

Two months later, when he tried to play tennis once, his right knee "gave way" and he had a very sharp pain for a few seconds. That actually subsided quite quickly too. Similarly on another occasion when he had a kick around game of football with his friends, his knee collapsed again.

He then mentioned that he wasn't confident about running, playing sport with his knee since even it seems to him that he'd recovered.

From what he told me, I immediately suspected he'd tore his Anterior Cruciate Ligament (ACL). Not wanting to "scare" him at first, I didn't say anything to my patient I went through all the ligament and joint testing thoroughly.

After checking his patellofemoral and tibia femoral joints, I did the Lachman's test, Reverse Pivot Shift test and the Anterior Drawer Test for the knee and they were all positive. (I seldom get a positive result for the Anterior Drawer Test but for him there was pain and a big difference in laxity compared to his other leg).

My patient was very shocked when I told him that he'd torn his ACL based on my assessment findings. He wasn't very convinced at first until I explained to him what I found based on his history, the positive orthopedic tests (and the fact that the physiotherapist in Whistler didn't actually examine him). Later he added that no wonder his knee never felt quite right after the skiing trip and now he knew the reason for it.
From my patient
He later went to see his general practitioner doctor and got a referral for a MRI scan and he later messaged me the result as you can see in the picture above.

After some consideration, he decided to do his ACL reconstruction yesterday in Singapore instead doing it elsewhere. Here's the picture he sent me upon discharge from hospital today.
Picture from my patient
It's not the the first time I have a patient who tore his ACL but the previous doctor/ medical practitioner/ physiotherapist they went to first missed it.

Please make sure whoever you see for your knee pain assesses your knee thoroughly.

Saturday, July 14, 2018

They're Not Spitting, It's Carb Rinsing

Helps with penalty taking?
Last couple of days before the end of the Russia 2018 World Cup and if you've been watching the football matches, you've noticed all the rinsing and/or spitting some of the football players do nearing the end of the match. Particularly before the penalty kicks so that their performance won't decline. 
Yes, the players seem to be taking a long swig from the water bottles and then they expel all the contents instead. The players are actually "carb rinsing".

I've written about this "rinse and spit" way back in 2010. It definitely works. Yes, us runners and triathletes have done this for a long time before the footballers caught on. If  you live in Singapore, you'll know that how it feels racing in our super hot and humid climate. Not everyone can handle eating a Power bar or gel and it's worse when you drink too much because you'll end up feeling bloated. And once you feel bloated, it's gonna be real difficult to run fast.

How does it work? It involves "tricking" the brain a little. Exercise physiologists explain that receptors in our mouth send signals to our brain (reward and pleasure areas) suggesting that more energy is on the way so our muscles can push a little harder and there should not be any reason to feel tired.
Ronaldo does it too
Research suggest that carb rinsing works better when the fluids are swished around the mouth for at least five to ten seconds, the longer the better so that more oral receptors come into contact with the carbohydrates in the drink.

Please take note that there needs to be actual carbohydrates in the drink that you use and carb rinsing cannot sustain you for an indefinite period. You still need to eat or drink actual carbohydrates as your body's muscles become depleted of glycogen. 

It seems to work best for intense exercise lasting between 30 mins and and hour so perhaps rinsing your mouth and then actually swallowing some of it for best results if your races are longer.


Currell K, Conway and Jeukendrup AE (2009). Carbohydrate Ingestion Improves Performance Of A New Reliable Test Of Soccer. Int J Sp Nutr Ex Metab. 19(1): 34-46.

Phillips Sm, Sproule J and Turner AP (2011). Carbohydrate Ingestion During Team Games Exercise: Current Knowledge And Areas For Future Investigation. Sports Med. 41: 559-585.

Rollo I, Williams C et al (2008). The Influence Of Carbohydrate Mouth Rinse On Self-selected Speeds During A 30-minute Treadmill Run. Int J Sp Nutr Ex Metab. 18(6): 585-600.

Sunday, July 8, 2018

Influence Of Maximalist Running Shoes On Biomechanics

Hoka One One Bondi 4
I had a runner come in to our clinic today. After finishing the Boston marathon in April recently, he had been taking it easy. But since his next race is the New York marathon later on 4th November this year, he started training again just this past week.

After asking the necessary questions regarding his training, I then noticed he was wearing a new pair of maximalist  running shoes. He'd bought it after running Boston as it was a lot cheaper there than in Singapore.

My patient thought that the mega cushioned maximalist shoes would help protect him from the pounding that comes with the running (since he's in excess of 6 feet). 

It was then really fortunate that I'd recently just read an article on the influence of maximalist running shoes on running biomechanics.
Women's NB 880

In that study, researchers had 15 female runners tested by running 5 km on two occasions on a treadmill. Each time, their running biomechanics were analysed before and after running in a pair of "traditional" New Balance (NB) 880 which had a heel height of 35 millimetres and forefoot height of 34 mm versus a Hoka One One Bondi 4 (4l mm heel, 34 mm forefoot height). 

It is important to note here that the runners were more accustomed to shoes like the NB than the Hokas.

Before reading the article, it seemed logical to me to expect the plush mega cushioned shoes would be more supportive for the tested runners.

However, runners in that study had greater vertical loading rates (the speed at which impact forces affect the body) and peak impact forces (maximum amount of force incurred at one time) in the Hokas than the NB shoes. Meaning, when the runners wore the more cushioned Hokas, the bodies absorbed more of the impact forces of running and in less time. While wearing the regular NB shoes, the impact forces of each step were lower and more evenly spread over time.

The authors noted that even though all the tested runners were assessed to be heel strikers, the higher impact forces while wearing the Hokas cannot be totally attributed to a change in foot strike pattern. In other studies, running in mega cushioned shoes result in runners landing with stiffer knees, resulting in higher impact forces.

Another point to note is that the runners in this study were new to maximalist shoes. I don't know about you, for me, if I get a new shoe to run in (or new tennis racket or any new equipment), my body takes a while to get used to it and run efficiently with it. (Note: even my wife who got a new iPhone X previously took a while before she liked it).

Previously, when minimalist running shoes were more popular caution was advised when trying those shoes. This study suggest such caution if your new running shoes have significantly more cushioning than your previous.

It will be interesting to note what happens to the impact forces when you get used to the maximalist running shoes. The authors of this study are now conducting follow up research on the same runners. The runners are monitored by starting with 20 percent of the weekly mileage in the Hokas, and adding 20 percent the next week and so on.

As I've suggested before, it's probably wiser if you have a few different pair of running shoes so that you can rotate your running shoes to minimize your risk of injury. Now, which runner can resist getting another pair of running shoes to run in?


Pollard CD Ter Har JA et al (2018). Influence Of Maximal Running Shoes On Biomechanics Before And After A 5k Run. Orth J Sp Med. 6(6): 2325967118775720. DOI: 10.1177/2325967118775720.

Friday, June 29, 2018

Popliteus Is The Problem, Not Baker's Cyst

Back of L leg
I had a patient who came to our clinic this past week complaining of pain in the back of her knee. She looked at her symptoms online and thought she had a Baker's cyst. One look at it and I told her not a chance of it being a Baker's cyst.

After examining her knee carefully, I told her it was her popliteus muscle bothering her.

Here's some background information about my patient. She was about 13 months post ACL (anterior cruciate ligament) surgery, back to weight training, running and training two to three times a week for netball.

Now, as far as I remember, every single patient who've undergone an ACL reconstruction I've treated have had a problem with their popliteus muscle at some point or other.

The popliteus muscle is triangular in shape sitting at the back of the knee. It starts on the lateral femoral condyle (posterior, outer part) of the femur (thigh bone) and the lateral meniscus. It then runs down and across the back of the knee joint to finish on the posteromedial (inner) part of the tibial (shin bone).
R popliteus
The muscle limits excessive internal and external tibial rotation. It helps straighten your knee from full extension by rotating the tibial internally. It also "pulls" the lateral meniscus out of the way during knee bending to prevent too much compressive forces from the femur of the tibial so you don't tear your lateral meniscus.

The poplitues muscle is very seldom the main cause of the problem. There is usually a problem with other stabilizing strutcures in that posterior lateral corner of the knee. It is often hurt because of compensating mechanisms related to that. Such has hip rotator weakness that transmits excessive forces towards the knee. Also, hamstring weakness with hip, knee pivoting movements, which are extremely common in netball.

Consider that most ACL reconstructions for patients now are done usually using the hamstring grafts so the hamstring is consistently weaker thus causing the injury/ strain to the popilteus muscle.

Treating the poplitues muscle for my patient was the easy part. I got her pain free at the end of the session. Ensuring the pain does not come back is trickier.

She needed to address the weakness in her hip stabilizers and hamstrings to prevent the problem from coming back. And that will take some effort on her part.

Saturday, June 23, 2018

11th Floss Band Course

What a coincidence. Physio Solutions turned eleven earlier this week and at the end of the same week I'm teaching the 11th Floss Band course. Good things come in pairs I suppose.

My Saturday usually starts with an early bike ride. I'm usually out of the house before six in the morning and get back in time to start work in our clinic by 1030 am. I see patients til 1:30 pm so I have about 30 mins to get ready.

Drenched this morning
Thanks to Danny and Amy who have already set up the chairs, projector etc I hook up my laptop to get my presentation ready before I try to eat and drink a little before I start teaching at 2 pm.

Fortunately, the course got up fine today. Despite my early start, I wasn't too tired and was still able to answer the questions that came my way. We had a mix of trainers, physiotherapy students, massage therapists, cross fitters and a couple of physiotherapists attending today.
3D image of skin, fascia and muscle from my slides
We went through the anatomy and function of fascia, Pain Gate Theory etc so the participants can explain how the Floss Bands work.
Too tight says Si Rui
A big thank you to Danny, Amy and Jane who came later for helping to get the clinic ready for the course and also for helping tidy up after. Please contact them at Sanctband Singapore for the next Floss Band course and if you need to get the Floss bands.

Thank you to the participants who came too. Hope everyone found the course useful.

Sunday, June 17, 2018

Don't Force The Teenage Athletes

I read with interest a recent New York Times article about Katelyn Tuohy. A female teenage track phenom with the headline "America's Next Great Running Hope, and One of the Cruelest Twist in Youth Sports."

Although Katelyn had already won titles and set records at sophomore (15-16 years old) level, the article made the point that many previous high school phenoms fail to live up to their early promise because of changes to their physique. The article pointed out that this seems to be a cruel twist in youth sports as girls turn into women.

The article mentioned that it was nearly impossible to predict an elite girl's future success in distance running because the female body changes so much as they continue to grow. Other than a good lung capacity, long distance races require great body weight to strength ratio. The teenage girls are skinny in their early years. Then as they mature and and grow, they may not develop the strength to move their bigger bodies  as quickly.

It's not surprising then that many girls end up with eating disorders, body related issues and end up getting injured. Off the top of my head, I can think of so many teenage athletes I've treated over the years that ended up going down that same path.

Many of the young athletes couldn't understand that it was perfectly normal to have the ups and downs (in their performances) they experience as their bodies change. Girls tend to put on more fat to prepare the body for reproduction. Good if we want to maintain our population, but not good if you're an elite athlete looking to improve your performance.

I had a former classmate PTL in primary school. He won the "Individual Champion" title in our school's track and field meet after winning 100, 200 m and the shot putt (plus the 4 x 100 relay too). That streak started in Primary Four (while he was ten) til Primary 6 (there was no meet from Primary One to Three).

We went to the same Secondary school and he won the 100, 200, 400 m and 110 m hurdles to emerge "Individual Champion" again in Secondary One and Two.

While in Secondary Three (they finally had longer events in track and field), PTL won the first 3 events and finished runners up for the 110 m hurdles event. We shared the "Individual Champion"  title after I won the 1500, 3000 m, 2000 m steeplechase and was 2nd for the 800 m. (Luckily for me, they gave out 2 trophies).

By the time we were in Secondary Four, I won all my four events while PTL didn't win any of his individual events. I ended winning our school's only individual medal at the National School's meet later that year while PTL ran the relays and never competed again after that.

Looking back now I know PTL reached puberty and had his growth spurt earlier than us in Primary school and was physically superior to everyone else. That's how he won all the events earlier. When the rest of us "caught up" hitting puberty later he didn't have that advantage anymore.

Perhaps PTL, having been raised on victories from young, could not comprehend or accept defeat. Early victories may have paved the way for defeat and giving up eventually.

Hence, I will never ever push my kids to excel in sports or something they don't like. I was never pushed when I was a kid. The desire all came from within. However, if they're keen, I will definitely help, support and guide them if I can.

So parents, teachers, coaches and all of you who are involved with young athletes take note of what Kara Goucher said. "Talent never goes away. Once these women/ girls (or boys) adjust to a mature body, the talent can come through again. The obsession with labeling these girls as 'the next big thing' is part of the problem  .... Katelyn is very talented. She will grow and probably slow. But once she adjusts, if she still has the love, the talent will still be there."

Don't push the kids, support, guide and help them if they themselves wish to excel.

Here's a close up of my first Individual Champion trophy. Thanks to my brother who took the pictures for me.

Thursday, June 7, 2018

Beach Running Anyone?

I have patients who get impact associated injuries like shin splints or stress fractures all the time. it's probably the most common running injury we see in our clinics along with knee pain.

Other than deep water running which has no impact, I often suggest going to the beach to get them running again.

Have you tried running on the beach? Research shows that running on sand requires 1.6 times more energy expenditure than running on a firm surface. Try it to believe it. Due to the change in technique you require as well as balancing on the sand, the stabilizing muscles in your hips, knees and ankle are working much harder.

Soft sand is particularly difficult while hard or packed sand (near the edge of the water) is definitely easier to run on. It definitely works different muscles (compared to running on the road) and it requires more focus so you don't sprain your ankle due to the uneven surface and constantly shifting ground.

In fact, while combating the "slip" element, range of motion of joint angles around the hip, knee and ankle were found to similar to running during faster speeds on firm ground (Binnie et al, 2013). That translates to a much higher heart rate, increasing your oxygen debt and blood lactate levels. Meaning you get fitter, stronger and faster quicker.

So incorporating sand running into your training can definitely help improve your race times.

Another article found that soft sandy surfaces reduced muscle soreness and fatigue (Binnie et al, 2014) due to almost four times less impact versus a firmer surface. Because of the softer surface, there's also less stress on our joints which can lessen impact and helps prevent injuries.

When running on firm ground, less of the elastic energy which is stored in our tendons is absorbed, so you don't have to work as hard. When running on sand, it absorbs the forces, meaning you have to generate more forces with your muscles to run.

Researchers found that there was almost four times less impact forces on soft sand compared to firm ground with every single foot strike. This is really good if you need to reduce load through the legs but still want to get in a hard workout when you run. 

Research also suggest that runners who ran on the beach (especially on soft dry sand found farther away from the water) had less muscle damage and inflammation compared to running on grass (Brown et al, 2017).

Due to where I stay, I hardly get to run barefoot on the beach. When I do, which is often during our family's holiday trips, I always start much slower than my usual runs. I also do not worry about the time or distance that I clock. In fact, I often do some short hard sprints (because of the lower impact) to get my heart rate up even higher.

Hearing the waves crash also helps to calm and clear my mind, which is a nice bonus.


Binnie MJ, Dawson B et al (2014). Effect Of Sand Versus Grass Training Surfaces During An 8-week Pre-season Conditioning Programme In Team Sport Athletes. Eur J Sp Sci. 32(14): 1001-1012. DOI: 10.1080/02640414.2013.879333.

Binnie MJ, Peeling P et al (2013). Effect Of Surface-specific Training On 20-m Sprint Performance On Sand And Grass Surfaces. J Strength Cond Research. 27(12): 3315-3520. DOI: 10.1519/JSC.0b013e31828f043f.

Brown H, Dawson B et al (2017). Sand Training: Exercise-induced Muscle Damage And Inflammatory Responses To Matched Intensity Exercise. Eur J Sp Sci. 17(6): 741-747. DOI: 10.1080/17461391.2017.1304998

Lejeune TM et al (1998). Mechanics And Energetics Of Human Locomotion On Sand. J Expt Biol. 201: 2071-2018.