Give Him A Treadmill

Mauri after his debut marathon in Toledo

I had a patient who told me that while training the marathon segment of the Ironman triathlon event, she would often go to the old Kallang Practice Track and and run 50 rounds (20 km). She could focus on running and not have to worry about traffic lights, pedestrians or spraining her ankle on an uneven pavement.

Meet Vinny Mauri, who ran a 2:05:54 hrs in his marathon debut in April this year at the unheralded Glass City marathon in Toledo. The race had less than 1,300 finishers, no pacers and a previous course record of 2:19:31 hrs. 

He also does most of his training on a Planet Fitness treadmill. 6 months ago, 25 year old Mauri was largely unknown. However, at the Chicago marathon next week (11/10/26), he has a good chance of breaking the American record of 2:04:43 hrs set by Connor Mantz at the same race last year.

Mauri has what many consider an abnormal training routine. He runs the majority of his miles on treadmills at one of two Planet Fitness gyms near his hometown of Warren in Northeast Ohio.

He rarely runs slower than 6:00 min /mile (or 3:44 min/km) for any of his runs. He regularly reaches 30 miles (48 km) at under 5:00 min/mile (or 3:06 min/km) pace.

He runs very little in carbon plated shoes. In fact he only just signed a shoe contract with Asics last week. He does all that while working more than 15 hours a week at a running store. 

On June 28th this year, he earned 611 kudos after his effort on Strava post went viral for running 26.39 miles (42.7 km) on a Planet Fitness treadmill in 2:20 hrs. Impressed?

Only a week later, he ran 29.16 miles (46.66 km) even faster at 2:15 hrs marathon pace again on a treadmill. Or 5:09 min per mile (3:20 min/km).

He clocked a total of 1,223 miles (1957 km) in his last 10 weeks of training. All at an average pace of 5:38 per mile (3:30 min/km).

If you look at Conner Mantz's same 10 week training block leading up to his American record of 2:04:43 hrs set in Chicago last year, Mantz ran 1,182 miles (1891 km). His average pace of 6:35 min/mile (4:05 min/km) was almost a minute a mile slower than Mauri's.

For 4 straight Tuesdays from 25th August to September 15th, Mauri ran 4 godzilla sets of double workouts. On each of those Tuesdays, he ran 36 miles, with at least 27 of those miles at 4:56 min/mile (3:04 min/km) pace or faster. 

On 8th Septemeber, he ran 36 miles at an average pace of 4:56 min/mile (3:04 min/km). 2x50 minutes in the morning, 4x20 mins in the afternoon. That's 36 miles at 2:09:09 marathon pace. If you include his warm up and cool down runs, he logged 45 miles (72 km) that day (pictured below). 

If you include his 28 miles long run and a 13 miles "easy" run at 6:00 min/ mile (3:44 min/km) pace across the previous days from 6th-8th September, Mauri ran 86 miles in 3 days at an average of 5:27 min/mile (3:23 min/km).

He ran the fastest debut marathon in American history on a day the marathon world was watching Sabastian Sawe break 2 hours in London. In one race, he went from being a virtual unknown to 4th fastest of all time on the US marathon list.

Why does he run so much on a treadmill? Perfect weather, no need to worry about wind, snow or ice in winter or heat/ humidity in summer. He likes the convenience, gels and drinks always at hand and the bathroom is nearby if needed.

He also runs on a treadmill to protect himself as he has a natural tendency to pick up the pace during runs outside. In a 60 min recovery run outdoors recently, he wanted to run a 6:10 mile/min (or 3:55min/km), he averaged 5:25 min/mile (3:22 min/km) and was running sub-5:00 min/mile (3:00 min/km) at the end.

The Planet Fitness treadmills stop automatically after an hour, and Mauri has to stop and start the machine again once or twice per session, usually during his rest periods. The treadmills also max out at 12.4 miles/hour (20km/hr) or 4:50 min/ mile (3:00 min/km), meaning he cannot go faster than that, thus holding him back to prevent going too fast. That's slower than his marathon race in Toledo 2:05:54 hrs which is 4:48min/ mile (2:59 min/km).

Can he beat the US record next week? You can get good training on a treadmill, but it does not quite equal to racing outdoors. The race in Chicago next week will require one to know which moves to respond to when the pack goes out too fast or slow and how to adjust to the temperature and wind etc.

Mauri says he feel's fitter than before his race in Toledo. His entire buildup is documented on Strava (pictured above), yet so unorthodox, and does not include tune up races.

I don't know how it will translate to the streets of Chicago. Everything about Mauri's build up to Chicago is superior to Toledo. Longer buildup, significantly more miles at a much faster pace. He will also be racing against a stacked field.

I will definitely be cheering him on. The treadmill companies should give him a faster treadmill (than his race pace) to train at home.

Improve Your Running Economy Durability

Remember my post for runners who want to log long distances so that they can race well? Here's another benefit for running longer.

Runners with regular long runs tend to hold their form and keep their running economy better late in a run. Running economy durability becomes better.

If you have high running economy, your body uses less oxygen and burns less carbohydrates when running at 6 minutes per kilometer pace. If you have low running economy, your body is less efficient and has to work harder and burn through more carbs to maintain that same 6 min / km pace. 

When you start running, your body is fresh and highly efficient. As the minutes and miles go by, your muscles fatigue, your running form deteriorates and your systems have to work harder. Running economy durability is your resistance to this degradation over time.

Consider the following study by Zanini et al (2026). Two groups of 13 male runners were recruited as long distance training (LDT) or short distance training (SDT) runners. The LDT group of runners had regular long runs ≥ 90 mins while the SDT group had all their runs under 70 mins.

Both groups of runners were first assessed to determine their lactate threshold and maximal oxygen uptake. On another day, they then did a 90 minute run at lactate threshold. Lactate threshold here is the running pace (or exercise intensity) where lactate begins to accumulate in your bloodstream faster than your body can clear. It represents a boundary line between sustainable effort and unsustainable exhaustion.

Respiratory gases were collected and assessed every 15 minutes. Isometric squat peak force and counter movement jump values were assessed before and after the run.

When matched for 10 km performance, the LDT was faster (39:00 versus 39:10 min), had higher maximal oxygen uptake (58.9 versus 56.6 mL kg⁻¹ · min⁻¹). The LDT runners lost 3.1 percent running economy over 90 minutes versus 6.0 percent for the SDT runners. 

Results show that SDT runners had greater losses in running economy, isometric squat force and jump power compared to the LDT running group of runners. Running economy durability also correlates significantly with weekly training volume and length of the weekly longest run rather than muscular fatigue.

This study shows that long runs and higher training volumes positively affect running economy durability and protects a runner's aerobic efficiency over time. So even if there are 2 runners who can run a fast 10 km at the exact same pace, the runner who skips or does not do as many long runs will burn through significantly more energy and experience drastically higher muscle fatigue as the duration of an event stretches past the one hour mark.

Want to run a personal best in a marathon (or any long event), make sure you do your long runs regularly and race pace training.

Reference

Zanini M, Folland JP, Blagrove RC. (2026). Regular Long Runs And Higher Training Volumes Are Associated With Better Running Economy Durability In Performance Matched well-Trained Male Runners. Med Sci Sp Ex. 58(1): 162-173. DOI: 10.1249/MSS0000000000003840.

Why We Ask If You Drink Alcohol?

One of the questions we always ask our patients when they see us for the first time is whether they smoke or drink. This past week, I had a patient who gave me a 'none of your business' kind of look when I asked that question. 

I told him actually it is none of my business whether he smoked or drank. The only reason we ask that in our clinic is that both can affect tissue healing. Smoking dries and dehydrates our interstitial spaces and connective tissues. Alcohol has an inflammatory effect and damages articular cartilage.

Surprised? Consider a prospective Osteoarthritis Initiative study that studied 2,846 participants (between 45-79 years old) and most importantly had no radiographic (or x-ray) evidence of knee osteoarthritis (OA) in at least 1 knee at baseline. These participants were followed for 96 months.

The researchers investigated for incident cases of radiographic knee OA as Kellegren-Lawrence grade changing from zero or one to ≥ two during the follow-up period. Incident symptomatic OA was defined as radiographic knee OA with knee pain worsening. 691 knees with incident radiographic OA knees were identified and 496 knees with symptomatic OA were found among the subjects.

Baseline information on alcohol consumption were obtained using the Block Brief Food Frequency Questionnaire. 

Drinking 30 grams of alcohol a day or more (about 2-3 drinks) was associated with a 93 percent higher risk of radiographic knee OA and 61 percent higher risk of symptomatic disease versus non drinkers. A similar result was observed for liquor spirit consumption (pictured above).

The underlying mechanism between between alcohol consumption and OA onset is still controversial. An animal study demonstrated that chronic alcohol consumption increased the articular cartilage breakdown enzymes (MMP-13, ADAMTS-5) in both shoulder and knee joints in mice. They also suppressed the molecules that protect articular cartilage.

The authors concluded that excessive alcohol consumption (≥30 grams/ day) was significantly associated with an increased risk of developing both knee structural changes and clinical knee joint pain. Light to moderate drinking showed no measurable negative impact on knee OA development in this study.

Light to moderate drinking data was mixed for other factors. What we know is not mixed is alcohol also disrupts sleep, triggers inflammation, adds empty calories which affects every other healthy knee arthritis habit.

Now you know why we ask about smoking and drinking. Especially if you have knee pain.

Reference

Liu T, Xu C, Driban JB et al (2022). Excessive Alcohol Consumption And The Risk Of Knee Osteoarthritis: A Prospective Study From The Osteoarthritis Initiative. Osteo Cartilage. 30(5): 697-701. DOI: 10.1016/j.joca.2022.01.011

And there is an article on drinking less alcohol in the Sunday Times today too.

Rotator Cuff Tear

A patient sent me a message yesterday regarding her shoulder. She had slept poorly and woke up with some shoulder discomfort. After seeing her doctor, he referred her for a scan. Her MRI shows a tear in the supraspinatus muscle (part of the rotator cuff) and some osteoarthritic changes in the joint. She was worried about the tear. It got scarier when her friends told her that if she did not "fix it" the tear would become worse and her shoulder would wear out.

I told her about a recently published study done where 602 participants had  scans done on both shoulders. (Ibounig et al, 2026). Median age of the participants was 59 (range from 41-76 years old) and 52 percent were female. 

Rotator cuff abnormalities were found in 98.7 percent of painful shoulders. There were 25 percent with tendinopathy, 62 percent partial thickness tears and 11 percent with full thickness tears (FTT).

More importantly, rotator cuff (RC) abnormalities were seen in 96 percent of pain free shoulders. Full thickness tears of the RC were in 7 percent of shoulders that did not hurt. 

The prevalence and severity of abnormalities increased with age, but did not differ between sexes. 

Only FTT were more prevalent in painful shoulders (14.6 percent) than in non-painful shoulders (6.5 percent). However this difference decreased after "adjustment" (absolute difference, 0.8%; 95% CI, -3.4% - 6%). This means that once the researchers accounted for age, the apparent link between having shoulder pain and a FTT vanished.

At first glance, FTT looked more common in painful shoulders (14.6%) versus non-painful shoulders (6.5%). However, older people are more likely to have shoulder pain and a FTT just from normal aging.

"Adjustment" is a statistical technique that levels the playing field as it allows reserachers to compare painful and non-painful shoulders of the exact same age. When they did this, the true difference was just 0.8 percent. This is a very tiny margin, meaning the presence of a tear does not reliably explain why a shoulder hurts.

95% CI, -3.4%-6%. When the confidence interval (CI) crosses zero (goes from a negative to positive number), it means there is no statistically significant difference. The negative side means it is statistically possible that FTT are actually less common in painful shoulders by 3.4 percent.

The positive side means it is statistically possible FTT are more common in painful shoulders by 6 percent.

The math proves that one cannot look at a FTT on an MRI an automatically assume it is the cause of someone's shoulder pain. A person with a painful shoulder is statistically no more likely to have a full thickness tear than a person of the same age with completely pain free shoulders.

I told my patient that her 'abnormalities' on the scan were actually just aging. What matters most for her (and others) is function. Is there weakness and/ or pain when she moves her shoulder?

Can she sleep without pain and can she play pickleball without pain? If all her answers are no, she most likely will NOT need an operation. Just because abnormalities are seen on MRI does not mean it can cause pain or needs to be fixed.

Reference

Iboinig T, Jarvinen TLN, Raatikainen S et al (2026). INcidental Rotator Cuff Abnormalities ON Magnetic Resonance Imaging. JAMA Intern Med. 186(4): 406-414. DOI: jamainternmed..2025.7903

Best Way To Train For Hyrox

Photo by CNA/ Marcus Mark Ramos

Yesterday I had a patient who's training for her second Hyrox competition coming up this November.  She has been going to the gym and participates in their Hyrox training program 5 times a week. The sessions are mostly strength sessions with simulated practices of lunges, farmers walk, wall balls and other strength training. There is very little running, rowing or cardio during these sessions. I mentioned 8 km of running is involved and I suggested that being able to run well when tired will allow her drop her time significantly. 

I also shared with her an article that was published last year that analyzed, in depth, the physiological responses and performance factors in Hyrox (Brandt et al, 2025).

Here are the numbers that matter and the requirements needed. On the rate of perceived exertion (RPE) on the Borg scale, participants rated it as 18 out of 20 difficulty. Average time the study participants took was 1 hour 26 and half minutes. 

Average heart rate during the event was 171 beats per minute. That's very high, easily above the 90 percent of maximum heart rate for probably everyone. In fact during 79 percent of the whole event, participants are competing at intensities of 90-100 percent of their maximum heart rate.

What set apart the better performers? VO2 max showed a strong relationship with finishing time. Spearman's rank coefficient was p = -0.71. It explains how critical an athlete's aerobic fitness is to their race success. Yes you read correctly, it's aerobic fitness, not strength. In exercise science, a correlation of 0.71 is considered strong. It proves that aerobic capacity (or fitness) is not just a minor factor, but a primary driver of performance.

In contrast, neither hand grip strength (a good predictor of work efficiency and fatigue management during sled pull, farmers carry and sandbag lunges) nor muscle mass percentage were good predictors. Hand grip strength also correlates with strength in other muscle groups and is used as a predictor for total muscle strength.

While variables like strength, pacing and transition speed matter, your raw capacity to absorb and utilize oxygen (VO2 max) is one the most reliable predictors of how fast you will finish the Hyrox event.

The negative sign indicates an inverse (or opposite) relationship, as an athlete's VO2 max increases, their race time decreases. This means they finish faster.

Recommendations for training?

According to the authors, endurance training should be emphasized at moderate intensities as well as forms of HIIT (high intensity interval training) to improve both aerobic and anaerobic capacity. Since 8 km of running is involved, a substantial amount of training volume needs to be dedicated to running based sessions. 

Since excessive running mileage can increase injury risk, a strategy would be to replace or combine running with Hyrox specific endurance activities like rowing or skiing. Combining running with other Hyrox requirements should be an integral part of Hyrox training to improve running economy in a pre-fatigued state and will help with ability to transition between different metabolic demands.

Even though strength appears to be less important, participants still need to be able to move external weights as per competition standards. Previous research indicated that endurance and weight training may interfere with each other if done together, affecting adaptations. To minimise interference, separating strength and endurance into distinct sessions. If both are done together, the more important aspect should be trained earlier.

It is not enough to run fast in isolation. Not enough to just be strong either. You have to be able to keep running fast after you have rowed, pushed the sled, done wall balls and lunges etc. And to repeat it over and over again.

Your aerobic (or cardiovascular) engine, running and the ability to maintain performance while fatigued is crucial.

"More running?" My patient said. Definitely I said, at least more than what you have been running so far, since you have doing lots of strength training previously.

Reference

Brandt T, Ebel C, Lebahn C et al (2025). Acute Physiological Responses And Performance Determinants In Hyrox- A New Running-Focused High Intensity Functional Fitness Trend. Front Physiol. 16:1519240. DOI: 10.3389/fphys.2025.1519240

What About Peptides?

Yesterday I had a patient, a medical doctor, who asked me about peptides. She asked whether I knew if my patients are using them. She was not the first person asking me about peptides. If you asked someone about peptides a few years ago, it would probably not ring any bells. Now, peptides is the latest buzzword in wellness and longevity.

Earlier this year, Singapore authorities warned against peptides sold online to help one grow muscles while helping with weight loss.

BPC-157 (body protection compound, or more famously known as the Wolverine) has been circulating around gyms and fitness spaces ever since fitness influencers like Joe Rogan touted its benefits. The muscle recovery effects are so popular that people have even injected their dogs to support their dog's health. Others are using a number of different peptides to improve cognition, longevity, sleep duration and revive sexual libido.

Peptides do occur naturally in our bodies. A peptide is a short chain of amino acids (which are building blocks for proteins), usually 2 to 50 amino acids linked together by chemical bonds called peptide bonds. If amino acids are individual lego bricks, and you put a few of them together, they become a peptide. If you link more than 50 of them, you build a protein. Since they are smaller, they are more easily absorbed by the body than full sized proteins.

While proteins are best known for building muscles, they have other important functions. We have millions of natural peptides in our bodies. Peptides act as messengers throughout the body. They regulate hormones, regulate inflammatory responses and boost our immunity systems. 

Since they are so versatile, artificial versions of peptides are used in medicine. These are lab grown chains of amino acids that mimic fragments of natural peptides. Insulin and GLP-1 (Ozempic and Wegovy) are 2 well known examples of FDA (food and drug administration in USA) approved synthetic peptides.

In late July 2026, the FDA voted to add 6 popular peptides to an approved list. BPC-1, KPV, TB-500, MOTs-C, Epitalon and Semax. Pharmacies in USA are allowed to use these peptides to make custom medications.

BPC-157 was approved as a treatment for ulcerative colitis, an inflammatory bowel disease. It is a synthetic peptide derived from a protein in human gastric juice. Very popular among athletes and gym rats after animal studies show that it could help heal fractures, tendon ruptures and ligament tears as well as reduce knee pain. However, these benefits are not confirmed in human studies. Almost entirely anecdoctal evidence from athletes self reporting faster recovery.

TB-500 is another trending peptide among athletes. This peptide was originally marketed for veterinary use in race horses and greyhounds. It has been marketed online for helping with tissue repair and regeneration, improving flexibility and boosting the immune system. Similar to BPC-157, TB-500 is promoted for healing muscle injuries, treating chronic diseases and inflammation. Human research is still lacking.

KPV is a peptide made of 3 amino acids, lysine (K), proline (P), and valine (V). A 2007 animal  study found that it can be a therapeutic agent for inflammatory bowel disease. Most research has been conducted in labs on mice. Another 2017 study tested a topical  KPV on human cadaveric skin  and found that it did not permeate well through skin and "could limit the systemic toxicity of KPV applied topically to the skin."

MOTS-c is created from mitochondria DNA to help with obesity and osteoporosis. Again, most findings have been limited to animal studies. 

Semax is a synthetic peptide developed in Russia and studied for its effects on the brain, including its effects on Alzheimer's disease. Evidence in humans remain limited. The FDA is evaluating how it can treat migraines, cerebral ischaemia and trigeminal neuralgia.

Epitalon is a pineal polypeptide extract from cattle and a 2025 study demonstrated high (or long) telomere lengths which are associated with longevity. Researchers are checking if they can improve sleep by increasing melatonin production and for insomnia treatment.

I think some people trying peptides may have exhausted conventional options and are bypassing quality checks if they buy and self administer based on information off social media. Others may want a 'short cut' to achieve their weight loss or training goals.

The world of synthetic peptides may be promising for sure, but there are dangerous side effects and some may even cause cancers. Do your research if you really want to try some of these peptides. Be aware of the side effects before you give them a go.

Reference

Mayfield CK, Bolia IK, Feingold CL et al (2026). INjectable Peptide Therapy: A Primer For Orthopaedic And Sports Medicine Physicians. AJSM. 54(1): 223-229. DOI: 1177/03635465251357593

Previous Treadmill Incline Guidelines May Be Wrong

I have written before that running on a treadmill indoors is easier than running outside and that research shows that setting your treadmill at 1 percent incline simulates outdoor running (Jones and Doust, 1996). This is especially so if you run at speeds of 12-17 km per hour. Under 12 km an hour, no need to set the incline up as the difference is small.

However a new study (Shahidi et al, 2026) found that the energy cost of running outside is still about 4 percent higher than running inside on a treadmill at 1 percent incline.

The researchers had 12 trained runners (21.3±‍2.4 years, 176±‍6.8 cm, 67.8±‍5.9 kg) first tested for their VO2 max. They subsequently ran 3 minutes at speeds between 8 to 15 km/hr both indoors on a treadmill and outdoors on a 400m track. Gas analysis was averaged over the final 60-90 seconds of each stage to determine steady-state VO2. 

The results (pictured above) show that running economy was significantly higher while running outside on a 400m track compared to running indoors on a treadmill. Especially as you run harder and closer to your limit (70-100 percent of the ventilatory threshold or VT2). Running outdoors requires much more energy than running on a treadmill.

At slower recovery paces, the physical effort between the 2 feels amost identical. Once your intensity hits the high effort zones, the treadmill becomes easier than the track.

Regardless  of how fast or slow the runners ran, running outside always used more total energy per kilometer than running on a treadmill.

The findings suggest that the commonly used 1 or 1.5 percent treadmill grade correction does not fully replicate the energetic demands of running outside. 

So, you will burn more total calories running 5 km outdoors than running 5 km on a treadmill if you go at the exact same pace. Your heart and lungs have to work slightly harder every single second you are outside to cover the same distance. Since the energy cost is higher across all speeds, an outdoor longer run will always leave you more physically spent than an identical treadmill long run.

Note that this is a small sample size study with only 12 national level trained subjects. Will the results apply to the rest of the population? Also they were made to run with the apparatus pictured above to measure exchange of gases. The runners may have to breathe harder outdoors.

In Singapore, the temperature and humidity affects us enormously when exercising outdoors, air conditioning while running indoors mitigates that.

One can run by heart rate and/ or time running on a treadmill and perhaps not worry about pace since the treadmills may not be properly calibrated as well.

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

References

Jones AM and Doust JU (1996). A 1% Treadmill Grade Most Accurately Reflects The Energetic Cost Of Outdoor Running. J Sports Sci. 14(4): 321-327.

Shahidi SH, Can R, Paca FM et al (2026). Overground Running Incurs A Higher Energetic Cost Than Treadmill Running At A 1% Grade: A Comparison Of Running Economy, Oxygen Cost Of Transport, And The Energy Cost In Endurance Athletes. PLoS One. 21(8): e0355988. DOI: 10.1371/journal.pone.0355988