Sunday, July 20, 2025

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

Sunday, July 13, 2025

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.

Sunday, July 6, 2025

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

Saturday, June 28, 2025

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

Sunday, June 22, 2025

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.

Saturday, June 21, 2025

Day 1 Of Kinesio Foundations Course

Sports Solutions hosted Day 1 of the Kinesio Foundations Course today. It's been quite a few years since we have had this course. During that course, we had 2 participants from Saudi Arabia

This time it's all local with 15 participants. We have 4 medical doctors, 1 dentist, 1 occupational therapist with physiotherapists rounding out the rest.

The course is now a two day in person course with a 4 hour online pre course. Compared to the 2 previous versions of the course, there is now a much bigger emphasis on the Kinesio Medical Taping section instead of just the Kinesio Taping Methods where muscles, joint and tendons were the main focus. 

Here are some of the pictures from today.


Stay tuned for Day 2 tomorrow.

Sunday, June 15, 2025

Zone 2 or HIIT? Or Neither?

My 58 year old patient walked in yesterday to the treatment room and the first question she asked was if she should start HIIT training. Woah! Hang on, I said to her do you really know what HIIT is? (*See end of article for what HIIT is please).

She said her friends, children and all the fitness influencers she sees extols the benefits of HIIT. Then without batting an eyelid, she said, "What about Zone 2 training?"

That is basically what is happening online. One group says train at Zone 2 while the other says go hard or go home, HIIT is the way to go.  

What do the best in the world actually do? A new study by Sandbakk et al (published in April 2025) investigated elite endurance coaches and their training were not what you expected. These coaches had athletes winning more than 380 international medals in long distance running, biathlon, rowing, cross country skiing, road cycling, swimmingtriathlon and speed skating.

All the coaches stick to a traditional periodization model, including a gradual shift towards overall lower training volume and more competition-specific (race pace) training as the competitive period approaches.

Another common emerging feature was an emphasis on high volume low intensity training. Look at the picture above, MOST (80-90 percent) of the weekly training was easy. Here is the key insight, majority of the easy work was not in Zone 2. It was in Zone 1. Slower than what the internet experts are obsessed with. Slower means more sustainable and more adaptation over time. That's how you get stronger. 

True aerobic development is only possible from accumulating volume. It also allows one to recover and handle key sessions. 

This Zone 1 low intensity sessions along with combined with 2-3 weekly "key workout" days consisting of 3-5 intensive training sessions. The sessions are purposeful and focused, with recovery all planned. 

Finally, coaches across all sports focused on getting high training quality by optimizing training sessions by controlling the load-recovery balance to ensure optimal preparations for major competitions.

The athletes go through all the zones (see the above picture), not just high intensity (Zone 5), but also in between. Short, fast intervals and controlled thresholds. The exact proportion is dependent on their competition demands. There were not a lot of really hard anaerobic sessions. 

Why the big difference between these elite coaches and what we see online with all the fitness influencers? Firstly the fitness influencers usually do not compete in races or competitions. They won't be posting so many videos if they do. Train easy, adapt, get stronger does not sell as well as "unlocking this magic Zone of HIIT". High performance is not about shortcuts. It's about accumulating consistency over time. Not as attention catching, but it definitely works.

To sum up, it's mostly sessions of low intensity, with occasionally high sessions adjusted to the individual. Balance stress and recovery and consistency over all else. Now you know.

* Many gyms, fitness influencers and trainers get patients to do what is traditionally circuit training but call it HIIT. Circuit training is like 30 seconds doing push ups, rest a minute, go to another station and perform 30 seconds of high knee lifts, rest a min, 30 seconds of lifting dumbbells etc

HIIT stands for high intensity interval training. Or interval training for short.  Example, you run 15 intervals or repetitions of 400m with a one minute rest in between or the coach will say run 6 x 1km going every 5 minutes (meaning if you run your kilometer in 3:50 min, you get 1:10 min rest before starting again). You can also cycle intervals outdoors or on a trainer with your bicycle attached.

Circuit training does not sound sexy, but HIIT certainly does!

Reference

Sandbakk O, Tonnessen E, Sandbakk SB et al (2025). Best-practice Training Characteristics Within Olympic Endurance SpoRts As Described By Norwegian World-Class Coaches. Sports Med 11:45. DOI: 10.1186/s40978-025000848-3