X-ray Based Diagnosis Leads To Potientially Unnecessary Surgery

Picture by Balint Botz from Radiopaedia

I've written previously that many patients had back surgery when a doctor sends them for an MRI within the first 6 weeks of an initial visit.

Well, guess what? Taking an X-ray to diagnose knee arthritis may make you more likely to consider potentially unnecessary surgery (Lawford et al, 2025) as well.

Many of my patients who go to a doctor or surgeon for their knee pain end up being sent for an X-ray or even an knee MRI. Many of these patients have osteoarthritis (OA) in their knees. Actually, routine X-rays may not be necessary to diagnose the condition. A skilled and thorough assessment based on symptoms and medical history is good enough to make the diagnosis. 

A huge and common misconception is that OA is caused by 'wear and tear'. Research clearly shows that the structural changes seen in a joint X-ray does NOT correspond with the level of pain or disability a person feels. Nor can X-rays predict how symptoms will change.

In fact, X-rays are NOT recommended in Australia to diagnose knee OA. Nearly half of new patients there with knee OA get sent for a knee X-ray and cost their health system A$104.7 million each year.

Researchers in Australia showed that using X-rays to diagnose knee OA can affect how a person thinks about their knee pain and prompt them to consider potentially unnecessary knee replacement surgery.

Many patients with 'terrible' X-rays have no pain while patients with no damage on X-ray have a lot of knee pain. Hence, X-rays are not recommended for diagnosing knee OA or guiding treatment decisions.

The Australian study had 617 subjects across Australia who were randomly assigned to watch one of three videos. Each video showed a hypothetical consultation with a general practitioner (GP) about knee pain. 

The first group received a clinical diagnosis of knee OA based on their age and symptoms and were not sent for an X-ray. The other 2 groups had X-rays done to determine their diagnoses (the doctor showed one group thier X-ray images but not the other group). After watching their assigned video, the subjects completed a survey of their beliefs about OA management.

The results showed that the group who received an X-ray based on their diagnosis and were shown their images had a 36 percent higher perceived need for knee replacement surgery compared to those who received a clinical diagnosis without X-ray.

What was worse was, they even believed that exercise and physical activity could be harmful to their joint. They were also worried about their condition worsening and were more fearful of movement.

The subjects were slightly more satisfied with a X-ray based diagnosis than a clinical diagnosis. This may reflect the common misconception that OA is caused by 'wear and tear' and the joint needs to be replaced.

The study's finding shows that it may be important to avoid unnecessary X-rays when diagnosing knee osteoarthritis. Changing this can be challenging, since many people still expect or want  X-ray imaging. If we can change this mindset, it will minimize unnecessary concern about joint damage, reduce demand for expensive and potentially unnecessary joint replacement surgery.

In my opinion, we as health professionals should not focus on joint 'wear and tear' since it can make patients more anxious about their conditions and concerned about damaging their joints. There are a range of non surgical, non invasive options that can reduce pain and improve your mobility. Exercise is one of many if you read this Cochrane review.

Our health minister says healthcare spending in Singapore could hit 30 billion a year by 2030 in a Straits Times article just 2 days ago. Perhaps this is an area where we need to be more mindful of unnecessary X-ray imaging and joint replacements to bring healthcare spending lower.

You can read about what actually causes your joints to wear out here if you are keen.

Reference

Lawford BJ, Bennell KL, Ewald D et al (2025). Effects Of X-ray-Based Diagnosis And explanation Of Knee Osteoarthritis On Patient Beliefs About Osteoarthritis management: A Randomised Clinical Trial. Plos One. DOI: 10.1371/journal.pmed.1004537 

Brain Myelin Levels Takes 2 Months To Recover After A Marathon

Picture from MSIF

I ran my first marathon when I was 16 years old, just after finishing my GCE 'O' levels. Despite not training as much as I would have liked, I finished in 4:00:16 hrs. If  I had ran just 17 seconds faster, I would have gone under 4 hours. 

I can still remember the exhaustion and agony I felt after the finishing line. I had willed myself to keep going despite hitting the proverbial wall and that led me to wonder about the brain's response to endurance exercise.

So I am not surprised that a recently published study shows that marathon running can cause a temporary reduction in brain myelin content. Full recovery only takes place after 2 months. Myelin is a fatty substance that covers and protects nerve fibers in the brain and spinal cord. It makes up 40 percent of the brain's white matter. The white matter is in charge of nerve signaling to enable learning, memory, sensory perception, motor control and cognition.

Other than allowing faster transmission of nerve impluses (which helps you move more quickly or learn with better focus), myelin helps convert glucose into energy for the brain. This is very important since so much energy is needed for all those nerve signals, especially when running a marathon.

Researchers used advanced MRI with multicomponent relaxometry to assess the myelin water fraction (MWF) to measure the amount of myelin in the brain. This was done on 10 runners ages 45 to 73,  both before and 48 hours after completing a marathon. 

They found substantial reduction in MWF in 12 areas of white matter after the race. The most significant reductions were observed in the pontine crossing (28%) and corticospinal tracts (26%). The affected areas are crucial for motor function and integrating sensory and emotional inputs, suggesting impact on movement and emotional regulation.

Since this was a small study, they did follow up scans 2 weeks after the marathon and 2 months after to track recovery.

MWF levels begin to rebound within 2 weeks and recovered fully to pre-race levels by 2 months. These findings suggest that brain myelin content is temporarily and reversibly diminished by severe exercise. Analyses of brain volume and hydration status showed that dehydration was not responsible for the changes in MWF. 

Since the brain and your legs are both competing for glucose while running a marathon, the brain turns to myelin lipids for energy. Previous studies have shown that lower brain myelin content is linked to cognitive decline - in areas related to verbal fluency and excutive function.

Should those of us who participate in endurance sports be concerned about myelin depletion in our brains? The authors say the breakdown of myelin from endurance exercise is actually beneficial, especially since it generates between 2 weeks to 2 months as it 'exercises' the brain's metabolic machinery.

Reduction in myelin levels can be similar to how muscles react to strength training. Your muscles break down as glycogen levels get depleted during weight training and endurance exercise before building back stronger with adequate rest. 

Better fueling with carbohydrates help sustain effort during training and races and may possibly reduce the amount of myelin used. Some runners in the research took carbohydrates during the marathon while others none, but there were no differences in this research. 

The authors did not investigate running speed. Perhaps running faster if underfueled may exacerbate brain myelin reduction.

So I was drawing on my myelin lipids to support my brain function in my maiden marathon and many times subsequently while exercising and competing for all those years. 

Can repeated depletion and restoration of myelin have long term consequences for people who frequently engage in prolonged, strenuous exercises and competitions?

The reversible nature of MWF is definitely reassuring (to me at least) and as I am still able to write an article for you readers weekly, I think all those hammer sessions and races definitely helped improve my brain function. 

I don't do those long, intense sessions much compared to before, but  I will make sure to have enough rest after. Make sure you do too.

Reference

Ramos-Cabrer P, Cabrera-Zubizarreta A, Padro D et al (2025).Reversible Reduction In Brain Myelin Content UponMarathon Running. Nat Metab. DOI: 10.1038/s42255-025-01244-7

Kinesio Foundations Course

I will be teaching the Kinesio Foundations course at Sports Solutions on the 21st and 22nd of June this year. This replaces the Kinesio Taping Assessments, Fundamental Concepts and Techniques (or Kinesio Taping Level 1-2) course previously.

The course is now a two day (16 hours) in person course with a 4 hour online pre course. Most if not all other taping courses takes place over just 2-4 hours. 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. 

Unlike other tapes, Kinesio Medical Taping utilizes much lower tensions (no pulling/ stretching of the tape) and thinly cut applications. There is a much bigger focus on skin and fascia stimulation to improve superficial, lymph and interstitial circulation. Hospitals in Singapore only use Kinesio tapes (and not other brands) when they have to treat patients with lymphedema.

Personally, I have great results using the EDF (epidermis, dermis and fascia), jellyfish and the Space Correction webcut applications with bruising and swelling. A patient with a partially torn calf muscle yesterday immediately felt better and could walk with less limping after the jellyfish application (pictured below.

Attendees will learn multiple taping techniques and be able to treat clinical cases using Kinesio tape alone or in conjunction with other strategies. There will be ample time to practice assessments, screenings and taping techniques to a variety of upper and lower body conditions.

Past participants have said that they were able to "immediately use the taping on the patients with good results" when they resumed work the day after attending the course.

Interested to attend the course? I have attached the link to sign up here. You can also email us if you need more details.

Muscle Damage Affects Your Running Gait

Picture from Aspetar

I was away for my Kinesio Taping recertification for Instructors last week and had to exercise in a new environment. As the gym was much bigger and had equipment that I do not normally have access to, I chose to use mostly those. 

As a result I ended with muscle soreness almost all over. I went for a run a day after I came home and my running stride felt 'off.' Turns out I was not imagining it. That is how our bodies try to protect itself. So is that good or is that a problem?

Turns out it may be both (Markus et al, 2025). The muscle soreness indicate that adaptations are beginning. However, that soreness can also change our running form, increasing injury risk.

To assess how exercise induced muscle damage (EIMD in this study) or delayed onset of muscle soreness (DOMS) affects running biomechanics and recovery, researchers got their subjects to run downhill for 60 minutes. This was done on a treadmill at -10 percent gradient. The runners ran at 65 percent of their max heart rate.

The researchers tracked running gait changes, muscle soreness, blood markers for muscle damage and also did MRI scans of thigh muscles immediately post run, 24, and 48 hours after.

The runners took shorter steps 24 and up to 48 hours after that run, likely as a compensating mechanism since taking a smaller stride is the body's way of reducing impact when muscles are fatigued or damaged. Damaged muscles were verified (significantly elevated) using blood markers (creatine kinase and lactate dehydrogenase) and MRI scans showed thigh muscles damage. 

Take home message? If you just had a hard training session or especially a race, you have to expect some biomechanical changes for at least 48 hours after that if you still want to run. Since you have a reduced stride length, your pace will be slower and you will be running less eficiently. 

Anything else that will help? My personal experience suggests that performing reduced intensity and low volume exercise will increase blood flow to the affected muscles and often reduce pain. Pedaling at low resistance on a stationary bike is ideal as you don't have to worry about traffic (if you ride on the roads). An easy swim or just walking in waist or chest height water works well too.

 Wearing compression garments will help reduce it as well. These above mentioned strategies do have some support in the research.

Or better still, give yourself a few days of well earned rest (especially after a race) before going hard again. 

Reference

Markus I, Arutiunian A, Ohayon E et al (2025). Kinetics Of Recovery And Normalization Of Running Biomechanics Following Aerobic-Based Induced Muscle Damage In Recreational Male Runners. J Sci Med Sport. DOI: 10.1016/j.sams.2025.01.002

Kinesio Taping Instructor Recertification (CKTI) In Bangkok

I have not taught any Kinesio taping courses since 2019 in Malaysia, just before Covid-19 struck. In fact, the last course I taught in Singapore was in August 2018.

Kinesio Taping Association International needs our licence as a CKTI (certified Kinesio Taping Instructor) to be renewed  every 3 years to be able to teach again. There was an online recertification during the Covid years in 2021 which I attended, but due to the many rules in place I did not teach since then.

So I chose to come to the recertification in Bangkok since Alburqurque (held in October 2024) and Barcelona (January 2025) were much further away.

There was a memorial for Dr Kenso Kase (who passed away in August 2024) and Jim Wallis (December 2024) (a very senior instructor) at the event to honour them.

The course has definitely evolved. It is now called the Kinesio Foundations course (over 2 days) and we spent a lot of time (pictured below) over the last 2 days learning how to teach the new syllabus.

Sports Solutions will definitely be teaching the new Kinesio Foundations course. They will be held on 21st to 22nd June. Here's the link to sign up.

With Elisa Kase

Race Pace Versus Heart Rate Variability Guided Training

Picture taken from Flowly

A patient came in this week after he raced the Tokyo marathon last weekend. He was not happy as he started cramping in his hamstrings after 'only' 5 km.

I asked about how his training went. He told me he did 4 runs a week, all on a treadmill, mostly easy runs. His longest run was by time, 2:55 hrs (which he thought was equivalent to about 20 km).

He did all his runs with a heart rate monitor, training at "Zone 2" mostly and followed recovery metrics like heart rate variability *(HRV). Zone 2 training is low intensity exercise that involves training at 60-70 percent of maximum heart rate. He did not do any interval training nor any race pace training.

I discussed with him how he can do better since he will be running the Chicago marathon on October 12th this year. He really wants a improvement after his self described disastrous Tokyo race. I shared with him a study that tested 3 different approaches of training (Ranieri et al, 2025).The researchers split the runners into 3 different groups for 6 weeks. 

First, a heart rate based training group where training is prescribed by heart rate zones. Next a race pace training group in which training is prescribed running at percentages of race pace. Lastly a HRV guided training group. The HRV training group did training prescribed by heart rate zones but this was adjusted daily based on HRV readings. Hence their intensity was based on how well they recovered. 

All the runners did lab tests before and after the study. V02 max, running economy, ventilatory thresholds and other key endurance metrics. Participants were assessed by a 7 km time trial after the training period.

Results? Race pace training was the most reliable for improving race performance. Every single runner in that group went faster in the 7 km time trial with an average improvement of 3.8 percent. The runners also had gains in fat loss and maximal aerobic speed. The heart rate training group improved their ventilatory threshold readings but this did not lead to V02 max or time trial improvement. It did not deliver clear performance advantages over race pace training.

The HRV training group led to bigger physiological improvements. They had significant increases in ventilatory thresholds and V02 max, but this did not translate as well to race performance. Some participants also put on weight (fat mass) perhaps due to more frequent easy training days.

The authors concluded that race pace training had the least variablilty in response, meaning it worked reliably across runners. HRV based training showed individual differences, some saw gains, others did not. This is not surprising since HRV itself is highly variable.

I suggested to my patient that he needed to do some race pace training if he wanted to achieve his target timing. He can take his target finishing time and calculate how fast he needs to do his 1 km, 5 km or even 400m repeats. This teaches his body to gauge the pace he needs to run and not go too fast especially at the start. It will also prepare his body for the demands of race day.

I also suggested running more outdoors rather than solely indoors on a treadmill since the treadmill is softer and will not mimic the road conditions that he races on. Specificity is key. The gym environment is temperature controlled unlike outdoors. So if the race location is hotter and more humid then he will be less able to handle it.

Takeaway message? The best approach is not to train solely on a single approach. It is best to know when to use each approach. For example, you cannot train exclusively by race pace. The body will not be able to handle the load, one would likely get injured. 

Heart rate based training can definitely be used but should not be relied on exclusively too. It will improve physiological markers and your lab based testing (V02 max, lactate threshold), but may not result in faster race timings. 

HRV is a useful tool for monitoring stress and how well your body is recovering. Many professional athletes use it. However this study raises an important question of whether better physiological markers lead to better performance.

If you're looking for a fool proof way to inprove your race times, this study suggest that training at your race pace sould be a part of your training routine.

Reference

Ranieri LE, Casada A, Martin D et al (2025). Performance And Physiological Effects Of Race Paced-Based Versus Heart Rate Variability-Guided Training Prescription In Runners. Med Sci Sp Ex. DOI: 10.1249/MSS.0000000000003671

*Heart rate variability (HRV) is a measure of how much time passes between each heart beat. It is better to have a higher than lower number. It is physiological measurement that is used to understand how your body is coping with life and environmental changes. A low HRV may suggest that your body is not rested, less resilient  and may not handle changing situations. You can measure HRV with a smart watch, fitness tracker etc. 

Most People Will Never Sprint Again After ..

Sprinting behind our clinic

... they turn 30 for the rest of their lives.

Actually, I started doing a few 200 m sprints upslope along Warna Road once a week on Wednesday mornings about a month ago. This is usually after a 5 km warm up run. I have not done any sprints like this for a long, long time.

From Twitter (or now known as X)

Coincidently, I saw this 2 days ago (above) on Twitter (or X) and the title caught my eye. 95 percent of men and women will never sprint again by the time they reach 30 years of age. 

Do you think there's any truth to that claim? 

How's my running form?

Perhaps I should address why I started sprinting again after so many years? I felt my runs were stagnating. I only run twice a week now and though I entertain no dreams of competing, I long for the moments when I feel like it is 'effortless' to run. I also want to avoid sarcopenia.

I was never a high mileage runner previously. In the past when I was still competing, track intervals really helped me improve. So I thought it was a good time to restart some sprint work.

You can definitely improve performance by swapping distance for speed (Jin et al, 2025). In the quoted study, the researchers split well trained runners into 2 groups. These runners had an average VO2 max of 67 mL/kg/min and personal best of 14:38 mins for their 5k time. 

One group did sprint interval training (SIT). They did 10x30 seconds all-out sprints with 3.5 minutes rest twice a week for 6 weeks. The traditional training group continued running long distance twice a week.

Both groups also kept up their regular endurance base training (40-60 minute runs) 4 times a week other than the above sessions.

You can probably guess the results. After 6 weeks, the SIT group outperformed the traditional group in all endurance metrics. Their time to run exhaustion (which is a key indicator of endurance) was better.

They had a 5 seconds improvement in a 3000m time trial versus no change in the traditional training group. The SIT group also had faster 100 m and 400 m times, suggesting better speed and neuromuscular efficiency.

Surprisingly, there was only slight V02 max improvement in the SIT group even though running economy improved moderately. This shows that the SIT group became more efficient runners.

Now you know that sprint intervals are not just for sprinters. This study proves that endurance runners can gain real benefits when they add speedwork 1-2 times a week. 

You definitely don't have to follow this protocol in the quoted study. I started with just faster striding upslope before even attempting to sprint. Definitely not all out sprinting. I clocked about 50 seconds each rep when I first started and it's gone down to 40 seconds during my last rep 2 days ago.

All of us should sprint from time to time to recruit muscles that we don't normally use. I would also suggest jumping as high as you can too to build your explosive power. But not both at the same time. I do the jumps on my weight training days.

For those who still race, sprint training will definitely help improve performance without adding volume. You can improve your running efficiency while also improving your kick should you need to pass other runners at the last part of the race.

Reference

Jin K, Cai M, Zhang Y et al (2025). Effects Of 6-Week Sprint Interval Training Compared To Traditional Training On The Running Performance Of Distance Runners: A Randomized Controlled Trial. Front Physio. 16: 1536287. DOI: 10.3389/fphys.2025.1536287