Wednesday, March 22, 2023

Should A Chiropractor Manipulate Your Neck?

ST article on 220323
An article from the Straits Times today, on page C4 under the Life section. It was originally published in the New York Times  2 days earlier. There was a big uproar last year because a chiropractor there caused a patient, Caitlin Jensen to be paralyzed after he manipulated her neck.

Actually there were already many complaints against chirpractors back in 2020 during the midst of the coronavirus pandemic. The International Chiropractors Association (ICA) posted 2 reports that claimed that chiropractic care can help the immune system implying that they may be helpful in preventing Covid-19. (Cote et al, 2020). 

More than 150 researchers from 11 countries found no valid clinical scientific evidence that chiropratic care can prevent impact the immune system. They asked that appropriate action be taken against those making unsubstantiated claims that spinal adjustments can boost immunity or benefit patients with infectious diseases, especially Covid-19 infections.

This recent episode merely added fuel to the fire.


Cote PB, Bussieres A, Cassidy JD et al (2020). A United Statement Of The Global Chiropractic Research Community Against The Pseudoscientific Claim That Chiropractic Care Boost Immunity. Chiropr Man Therap. 28, 21. DOI: 10.1186/s12998-020=00312-x

There has been previous unhappiness against chiropractors in Singapore too. Here's the Straits Times article.

Sunday, March 19, 2023

How To Wake Up Alert And Refreshed

Do you go to bed early, sleep through the night and still wake up tired and groggy? - Well, it happens to me quite regularly. Turns out that I'm not alone. A study found that fewer than 1 in 3 Americans are getting enough restorative sleep (Robbins et al, 2022). 

You may say that the Americans have more distractions, but in Singapore, 41 percent of adults get between 4 to 6 hours of sleep a night only, even though they should be clocking in 7 to 8 hours.

Not only do we have insufficient sleep, the vast majority of us are not getting the right kind of sleep. So we wake up less alert, have less energy and poor moods in the morning. Low quality and/ or quantity of sleep has terrible far reaching effects, from short term ability to focus to long term risk for chronic diseases.

The good news is that there is a way to fix this. Another published study by Vallat et al (2022) listed 3 steps we can do to eliminate that groggy feeling we get when we wake up. The researchers studied 833 twins and genetically unrelated adults and demonstrated that how effectively one wakes up during the hours following sleep is not assocated with genetics. 

They found 4 independent key factors. sleep quality/ quantity the night before, physical activity the day prior, a breakfast rich in carbohydrates and a low blood sugar level following that breakfast. 

The researchers found that sleeping in for an extra 30 minutes on a morning when you need it was associated with increased alertness in that morning. Physical activity (or exercise) the day before also had a strong link to feeling alert and awake the next morning. The more exercise the better it seems.

Breakfast matters. Participants who ate a breakfast high in low glycemic carbohydrates like whole wheat bread, oats, brown rice felt more alert. However, eating breakfasts that were sugary or high glycemic carbohydrates (muffin, cereal bar, white bread, potatoes) and excessive protein had the opposite effect. 

That's the secret to waking up alert and refreshed every morning. So definitely don't skip breakfast.


Robbins R, Quan SF, Buysse DJ et al (2022). A Nationally Representative Survey Assessing Restorative Sleep In US Adults. Frontiers In Sleep. Vol 1. DOI: 10.3389/frsle.2022.935228

Vallat R, Berry SE, Tsereteli SE et al (2022). How People Wake Up Is Associated With previous Night's Sleep Together With Physical Activity And Food Intake. Nat Commun 13,7116. DOI: 10.1038/s41467-022-34503-2

Sunday, March 12, 2023

Don't Ignore The Small Stresses

Breathtaking sunset
Most of us can ignore the smaller things that irk us. Like a rude sales staff, a terse message from your manager, or even a full basket of laundry not done. We ignore the smaller micro-stresses and just focus on the big stuff since the small things do not evoke the fight or flight mechanism. Unlike getting hit with big, bad news like getting fired from your job or a serious illness.

The small things that require our attention can definitely add up. Even when we ignore them our bodies do not. Small stresses can trigger some of the same physical effects as big stresses including increasing blood pressure and lower quality sleep (Cross and Dillon, 2023).

This is often why we feel exhausted or even defeated at the end of the day, even if nothing big went wrong. They can eventually have an outsized impact on our mental and physical health.

A really interesting study by Kiecolt-Glasr et al (2015) found that even a relatively minor social stress experienced within 2 hours of a meal can affect your metabolism of that meal by adding 104 calories to that meal. If that occurs daily, it adds up to 11 pounds (or 5 kg) a year.

We can all take steps to be more aware and address the micro stresses in our lives. Communication helps. Speak to your boss if he/ she is routinely annoying you by not giving you enough time for datelines. Or call your child if he/ she does not respond to your messages. You will be surprised at how much eradicating a small but repeated stressor can boost your mood.

Cross and Dillon's research shows that people with robust personal lives, i.e. those having family, friends and hobbies that keep them occupied tend to be less affected by work related micro stresses.

Practicing meditation and mindfullness can clear your mind and clear away the big and small stresses.  Being both grateful and thankful for what you have helps too.
So I am doing just that, enjoying the rainbow and the breathtaking sunsets while on holiday with my family now. 


Cross R and Dillon K (2023). The Microstress Effect: How Little Things Pile Up And Create Big Problems - And What To Do About It. Harvard Review Press. 18 April 2023.

Kiecolt- Glaser JK, Habash DL, Fagundes CP et al (2015). Daily Stressors, Past Depression, And Metabolic Responses To  High-fat Meals: A Novel Path To Obesity. Biol Psychiatry. 77(7): 653-660. DOI: 10.1016/j.biopsych.2014.05.018

Sunday, March 5, 2023

Can Fitness Classes Help Your Next Ultra Marathon?

I was a little skeptical before I read the article which suggested that fitness classes in gyms can help prepare you for your next trail or ultra race. The article by Vincent et al (2022) found that trail runners who took a multifaceted approach to training significantly lowered injury risk through better movement and reduced fatigue during runs. 

Then I read that these gym classes (in the article) were fitness classes that bring together multiple components like strength and aerobic exercise while introducing variety and fun at the same time. I realized it's just cross training put in a fanciful way. Note that this cross training is not CrossFit

The term cross-training first became popular back during the running boom in the late 1970's and 1980's. Runners who got injured and wanted to keep their fitness would 'cross-train' by doing another kinds of workout like cyclingswimming or even weight training. Runners who were not injured and wanted to prevent injuries would cross train to correct muscular imbalances on some days. Plus the variety in training prevented burnout and boredom. It subsequently lead to an increase in popularity in triathlons the the birth of cross training shoes (*see below).

Back to the article, which found that the majority of of acute and chronic trail and ultra running injuries occurs in the lower leg usually. Especially in the knee and ankle. More than 70 percent are due to overuse (or an increase in load). Ankle sprains are the most common acute injuries. 

You need to be looking ahead to respond to to the variations in ground surfaces, make selections on which obstacles to avoid, read the weather signs etc when running a trail ultramarathon. Hence, you need to anticipate, predict and react to maintain balance while navigating trails. Especially when fatigued and hungry

The article found that trail runners who took a multifaceted approach to training significantly lowered injury risk  through better movement and reduced fatigue during runs.

Since trail running is repetitive, gym classes create movement variation that will expand your range of motion and activate different sets of muscles to reduce overuse injuries. All of which can keep you health and injury free to help you cross the finish line.

Gym classes do not just mean spinstationary cycling or treadmill running. You can choose a class that is  heart rate based interval workouts that include resistance training, rowing or bootcamp etc. You can practise specific aspects like pushing or pulling sled, using the rower to increase overall force production that you might not do on the road or trails.

Studies show that concurrent strength and endurance training help improve running performance by improving strength and running economy. Runners can then run for longer periods of time without fatigue. This is really important if you are training for ultras.

If you plan to go down this path, have a specific goal race in mind and create an objective for what you want to achieve with gym classes. It can be as simple as bouncing back quicker from your long run or running faster up a certain hill. Those who use heart rate monitors may need to find classes to monitor your heart rate zones.

Gym classes should not affect your long term goal. Start with one every week to help you get a feel for the class and to allow for ample recovery especially if you find the class challenging. 


Vincent HK, Brownstein M, Vincent KR (2022). Injury Prevention, SafetrainingTechniques, Rehabilitation, And Return To Sport In Trail Runners. Arthros Sp Med Rehab. 28;4(1): e151-e162. DOI: j.asmr.2021.09.032.

*The Nike Air Trainer 1 (in chlorophyll, above) was originially created as a multi purpose performance shoe back in 1986. Nike's goal was to have one shoe so that you can run, weight train, do other sports and exercises with it so you don't have to carry a few pairs of shoes with you around. 

John McEnroe used it when he was still playing professionally. Click on the link to see the picture (Getty images copyright, so I can't use it here).

Sunday, February 26, 2023

Is It Easy To Return To Pivoting Sports After Articular Cartilage Surgery?

Picture from Upswinghealth
My receptionist has been complaining of left ankle pain, especially after her netball training. While treating her, I found out that her ankle injury was sustained a year ago while playing competitive netball. She's been training very hard as she's hoping to represent Singapore one day. 

She saw 3 physiotherapists concurrently last year, but none really treated her. They all just gave her exercises to do. 

After assessing her, I told her she may have an osteochondral injury (or articular cartilage injury) in her ankle. I also shared with her a recent article (Toyooka et al, 2023) on how successful athletes are, at returning to pivoting sports after articular cartilage surgeries.

The scoping review evaluated the following articular cartilage procedures: microfractureosteochondral autograft transplanation (OAT, or mosaicplasty,  harvested from one's own joint), osteochondral allograft (OCT, using a cadaveric graft) and autologous chondrocyte implantation (ACI, or autologous chondrocyte transplantation, ACT ). All of which have been written here previously.

16 studies fulfilled the ine inclusion criteria, of which 7 studies evaluated the microfracture technique alone. 44 to 83 percent managed to return to sport (RTS) after 6.2 to 10 months. 25-75 percent managed to return to their preinjury level. Average defect size was between 1.9-4.9 cm2

87-100 percent of athletes managed to RTS after their OAT or mosaicplasty surgery after 11.8 weeks to 6.5 months.. 67-93 percent managed to get back to their preinjury levels. Mean defect size varied from 1.34 to 2.9 cm2 (this is smaller than most OAT procedures that I've read previously).

For ACI, 33-96 percent managed to RTS 10.2 months after their surgery. 26-67 percent managed to return to their preinjury levels. Mean defect size ranged from 2.1 to 6.4 cm2. These athletes had also previously undergone an average up to 2.7 other surgeries.

The rate of RTS with the microfracture technique was not higher compared to other techniques in this review. This technique is usually the first-line treatment for articular cartilage injuries since it is relatively low cost and technical ease. Patients usually RTS within 9 months. The main disadvantage is that there is no restoration of hyaline cartilage. Fibrocartilage is formed after the procedure which may not tolerate pivoting sports. It is also not suitable for those with larger defect injuries. Defect sizes larger than 2 cm2 may not have good postoperative oucomes. 

Microfracture awls to puncture holes in the bone
The OAT or mosaicplasty techniques involve harvesting a bone plug with intact cartilage from the patient's joint in a non weight bearing area and transplanting that into the defect area. The main advantage of this technique is that it has high healing potential as a patient's own bone plug is used allowing the bone to integrate immediately. There may be some risk to donor site morbidity if too big bone plugs are taken (pictured below).

Harvesting the bone plugs in the knee
87-100 percent of athletes managed to return to pivoting sports after their OAT or mosaicplasty surgery after 11.8 weeks to 6.5 months in this review. 67-93 percent managed to get back to their preinjury levels. This suggest that the OAT  procedure may offer a good acceptable result for high demand athletes. Mean defect size varied from 1.34 to 2.9 cm2 (this is smaller than most OAT procedures that I've read previously) and smallest in this review.

ACI requires 2 surgeries to restore the damages done to the hyaline cartilage lining the joint, described in more detail in a previous post. For this review, 33-96 percent managed to RTS 10.2 months after their surgery. 26-67 percent managed to return to their preinjury levels in high demand pivoting athletes. Pivoting sports may have a lower RTS ate compared with other sports.

Mean defect size ranged from 2.1 to 6.4 cm2. These athletes had also previously undergone an average up to 2.7 other surgeries. This technique is used primarily with larger defects. However, it's limitations are requring 2 surgeries, high cost, open surgery and a very prolonged rehabilitation. 

Based on this review, the OAT procedure had the highest RTS rate in pivoting sports. They also returned to sport faster, especially when the defect size is small. For large defects, OCA and ACI may be considered with ACI preferred since OCA (caderveric) has many limitations like being expensive, limited in supply and restricted in many countries. Harvested bone plugs also need to be implanted within 14-21 days.

Most studies in this review reported high RTS rates although return to preinjury level was lower. RTS is a very critical variable and benchmark (to me) for patients who are athletes. These data can be used as a basis for selecting treatment options. 

Not only there are very few studies that only study athletes, the sports they compete in also vary. There was a tendency for RTS to be higher when the level the athletes were competing in were higher (especially professional), perhaps due to their access and compliance with rehab protocols, adaptibility to competition and for financial reasons.

Note that there was not enough data on the lesion size to decide between ACI and OAT. There were no significant difference in short term results between the two, although ACI outperformed the OAT in 10 year outcomes (in 2 studies).

Well, to my receptionist and other athletes reading this post, I hope this helps with your decision making should you need to consider the different options to return to your sport. It is definitely a long and winding road, with treacherous falls along the way while attempting your comeback, but it can be done.

Trust me, I've had 3 knee surgeries, a skull fracture and broke my back twice. You just need to be be persistent and never give up. Our team in our clinics have been patients before too and know how it feels like to be a patient and will be able to understand and do their utmost to help you.


Bentley G, Biant LC, Vijayan S et al (2012). Minimum ten-year Results Of A Prospective Randomised Study Of Autologous Chondrocyte Implantation Versus Mosaicplasty For Symptomatic Articular Cartilage Lesions Of The Knee. JBJS Br. 94: 504-509.

Biant L, Vijayan S, Macmull S et al (2012). Autologous Chondrocyte Implantation Versus Mosaicplasty For Symptomatic Articular Cartilage Defects In The Young Adult Knee: Ten Year Results Of A Prospective Randomised Comparison Study. Orthop Proc. 94-B: 122-22

Toyooka S, Moatshe G, Persson A et al (2023). Return To Pivoting Sports After Cartilage Repair Surgery Of The Knee: A Scoping Review. Cartilage. Pub online. DOI: 10.1177/194760352211414

Sunday, February 19, 2023

Steroid/ Cortisone Injections Significantly Increase Risk Of Tendon Tears

Picture from BuzzRx
I was asked to do a home visit for a patient who was having some pain in his hip 2 days ago. The patient hurt his knee last year while playing golf and the doctor he consulted did a steroid/ cortisone injection for him. His knee was better for a while but some of the pain came back a short while later. 

Perhaps my patient was not able to weight bear well on that right knee since then and subsequently that caused his right hip to act up. After assessing him, I found that his sore knee was not the main cause of his hip pain, but definitely a contributing factor. 

I shared an article (referenced below) that I just read just a few days ago with my patient and his family regarding steroid/ cortisone injections. There were 1025 patients with shoulder pain in that hospital study. 205 patients received a steroid/ cortisone while 820 did not (they acted as the control group).

Patients in that study who received a steroid/ cortisone injection (for their shoulder pain) significantly increased the risk of having a shoulder tendon tear by 7.44 times compared to those who did not receive a steroid/ cortisone injection! 

Those who had concurrent chronic liver disease were 3.25 times more likely to have a torn tendon while those who smoked by 2.4 times. Another reason to stop drinking and smoking too.

Since my patient is an avid golfer and still very active, I told him he definitely does not need to have any more steroid/ cortisone injections anywhere else on his body. There are high chances of degenerative changes in the surrounding areas where the steroid/ cortisone is injected.

Remember my true story when I used to work at the Singapore Sports Institute (formerly Singapore Sports Council). Back then, I used to treat the badminton players frequently and traveled with them on most of their training trips and competitions. (Ronald Susilo and I pictured below after he beat world number one Lin Dan at the Athens 2004 Olympics).
I'm more excited than Ronald
In 2006-2007, Ronald Susilo had on and off right elbow pain, in his playing arm. He was subsequently injected with steroids (cortisone) a few times to help with the pain so he could train and compete.

Tragedy struck at the 2007 SEA Games in Thailand. He tore a forearm muscle while playing at the Games. I was tasked with accompanying him back to Singapore for a visit to the surgeon to repair it.

I've accompanied Ronald for all his sporting surgeries. His shoulder in 2004, Achilles in 2005 and right forearm in 2007. These were his words to the operating surgeon, "Gino knows my body better than I, he's been around for all my operations."

As usual I was waiting outside the operating theater for Ronald when they operated on his forearm. The first words the surgeon said to me when he came out of the operating theatre was, "We found cortisone still in his arm." My interpretation was that he meant too much steroid/ cortisone had been injected into Ronald's forearm. That probably caused the muscle to tear. Just like what the study by Lin et al (2022) had found.

Yes, there would definitely be occasions where a steroid/ cortisone injection is needed.  However, speaking from personal experience, if you're an athlete or participating in sports regularly like my patient, please reconsider if your doctor suggests a steroid/ cortisone injection. There are definitely other ways to treat your pain/injury besides getting a steroid/ cortisone injection. You definitely do not want to risk tearing any muscle or tendon after that.


Lin CY, Huang SC, Tzou SJ et al (2022). A Positive Correlation Between Steroid Injections And Cuff Tendon Tears: A Cohort Study Using A Clinical Database. Int J Environ Res Pub Health. 19(8): 4520. DOI: 10.3390/ijerph19084520.

Sunday, February 12, 2023

New Evidence That Collagen May Help Your Tendons

Collagen liquid used in the study
I recently had quite a bit of pain in my right Achilles tendon. Besides getting Aized to treat me and wearing my Strassburg sock to sleep, I had to do some rehab as well. Running didn't hurt much, going down stairs was more painful.

Naturally my curiousity was piqued when a newly published study (Lee et al, 2023) on a group of elite female football players found a big improvement in tendon stiffness after taking collagen supplements 3 times a week. The study measured the properties of the patella tendon which connects the patella (kneecap) to the shin bone as this is a common injury site for female soccer players. Ultrasound and strength tests were measured before and after training.

Training consisted of on-field soccer practice, leg strengthening exercises and plyometrics.

The participants took 30 grams of hydrolyzed collagen (pictured above) 3 times a week immediately after training while the control group took a calorie- matched placebo drink. Both groups also took 500 milligrams of Vitamin C as it is thought to be necessary for the body to be able to use the collagen.

Results showed an increase in tendon stiffness. The stiffer tendons become, the more they stretch and the more energy they store. Stiffer tendons have shown to be associated with better running economy since they can recycle more energy from each stride.

The group taking the collagen had a significant 18 percent increase in tendon stiffness compared to the placebo's 8 percent gain. There were no differences in size or cross sectional area of the tendon, suggesting that the extra collagen ingested improved the microscopic structure of the tendon. There was also no differences in leg strength.

Remember Professor Keith Barr? I wrote about his gelatin collagen research in 2019. His research group from UC Davis published evidence suggesting that taking collagen plus Vitamin C enhances jump and squat performance but without significant change in leg stiffness (Lis et al, 2022).

Another published research (Jerger et al, 2022) found that taking collagen supplements daily boosted tendon cross sectional area, but did not improve tendon stiffness more than the placebo group.

Confused? Especially with each study mentioned above producing different results. Study protocols were different and this is actually good since it means that you do not have to follow one specific 'magic' protocol to get the benefits.

More research and details need to be worked out, as more studies are done, it will hopefully prove that tendons and ligaments can heal better than we think. So other than training your tendons and wearing your Strassburg sock when you sleep, collagen supplements may be something you want to try.


Jerger S, Centner C, Lauber B et al (2022). Effects Of Collagen Peptide Supplementation Combined With Resistance Training On Achilles Tendon Properties. Scan J Med Sci Sports. 32(7): 1131-1141. DOI: 10.1111.sms.14164

Lee J, Bridge JE, Clark DR et al (2023). Collagen Supplementation Augments Changes In Patella Tendon Properties In Female Soccer Players. Frontiers in Physiol. Vol 14. DOI: 10.3389/fphys.2023.108977

Lis DM, Jordan M, Lipuma T et al (2022). Collagen And Vitamin C Supplementation Increases Lower Limb Rate Force Development. Int J Sp Nutr Ex Metab. 32)2): 65-73. DOI: 10.1123/ijsnem.2020-0313