Friday, December 23, 2016

If Only You Know The Power Of Sleep ....

The power of sleep
While I was still working at the Singapore Sports Council or SSC (now known as the Singapore Institute of Sport or SSI) I used to travel a lot with the Singapore badminton players while they were competing or training overseas.

And no matter where the badminton players were training or competing, their normal routine would be training in the morning, break for lunch and there would always be a nap after lunch before training again. Even our national table tennis players took daily naps when they were not out buying eggs (okay I'm just kidding). No disrespect meant!

Why am I writing about sleep here? You and I know that a lack of sleep can lead to negative consequences. It can affect your mood, cognitive function and physical performance. Few studies though have looked at the opposite - the effects that sleep extension can have on performance.

The American National Sleep Foundation recommends 7-9 hours of sleep a night for adults for general health and well being. But a study on Stanford basketball players by researchers Cheri Mah and colleagues showed that with 5-7 weeks of sleep extension, i.e. going to bed earlier and waking later, subjects had improved basketball performance, reaction time and running speed.

The researchers concluded that "extended sleep beyond one's habitual nightly sleep likely contributes to improved athletic performance."

As it is, most of us will find it difficult (myself included) to find more time to sleep. Our smart phones, the iPad, Netflix etc are big distractions. Yes, I have to stay up writing this so you can read it. Well, I'm not racing anymore.

Many of you will focus on improving your performance by training harder and smarter, but those improvements become smaller and more difficult to obtain after a while. Your fellow competitors will likely swim/ bike/ run similar intervals in addition to hitting the weights room etc. It all comes to to all the fine details. Some of these small gains (like sleep extension) are found outside of aerobic and interval training.

It's probably easier to change your bedtime to get more sleep by gradually going to sleep earlier. Try to go 15 to 30 minutes earlier each night to find a good time for yourself.

Sleeping in never happens for my wife and I, our boys are up by 6 am or earlier most mornings. If you can sleep in good for you.

I remember attending a meeting prior to the 2004 Athens Olympics where the then Director of High Performance, SSC was questioning the then CEO of Singapore Badminton Association (SBA) why the Singapore badminton players needed naps when they could be working part time or studying in between training as what many of the elite athletes at the Australian Institute of Sports do.

Then CEO of SBA's reply was if it (naps) has the potential to impact performance in a positive manner, then we try to take care of it.

In the picture below you see me more excited than Ronald Susilo after he defeated Lin Dan in the 1st round at the 2004 Athens Olympics.

That's how we should help our athletes.


Mah CD, Mah KE et al (2011). The Effects Of Sleep Extension On The Athletic Performance Of Collegiate Basketball Players. Sleep. 34(7): 943-950. DOI: 10.5665/sleep.1132

I really like this picture I took from a Star Wars book - Goodnight Darth Vader which I bought for my son by Jeffrey Brown.

Sunday, December 18, 2016

Which Calf Is Bigger?

Notice any difference in the picture above? If you look closely, you'll notice that the left calf is slightly bigger than the right. Upon palpation my patient's left calf does feel more "meaty" compared to his right.

This is surprising as my patient says that his right leg is his dominant leg. Usually the dominant leg is bigger and stronger than the non dominant leg.

Now, this patient, who is an ultra marathoner came in to see me yesterday after a 35 km training run in the morning. He said that his right calf muscle often cramps after about 35 km.

Even after an easy run, his right calf and hamstrings often feel more tired and fatigued compared to his left. He also felt that it required more effort to bend his left knee compared to his right.

My patient also does not have any numbness, pins and needles down his right leg or other neurological signs. After checking his back as well, I explained to my patient that the reason for his muscle cramping in his right calf muscle is simply due to muscular fatigue.

Since his left calf is bigger, it will also be stronger than his right calf. This means that after running a certain distance his right calf will work harder than the left calf and will fatigue faster too.

I explained that muscle cramping is not due to sodium (or salt) loss, dehydration, electrolyte or fluid loss. I've explained this in a bit more detail before in another post, have a read here please if you're keen.

We then discussed how he could do some isolated (right) leg training to make his right calf stronger to avoid cramping eventually.

Here in his case, size does matter.


Schwellnus MP, Nichol J, Laubscher T and Noakes T. (2004). Serum Electrolytes Concentrations And Hydration Status Are Not Associated With Exercise Associated Muscle Cramping (EAMC) In Distance Runners. BJSM. 38: 488-492. DOI: 10.1136/bjsm.2003.007021.

Saturday, December 10, 2016

Last Floss Band Course ....

... for this year.

I was informed earlier by Jane today that this is the 6th Floss Band course I've done for the year. Wow, I haven't really been keeping count and didn't realise we've done so many thus far. This I must say though, the year has really flown by. It's 3 weeks to the end of the year!

Well, one thing remained constant. We had a full house again today. There were lots of physiotherapists (from SGH and Khoo Teck Puat Hospital) and many physiotherapy students too among those who signed up. I always enjoy having fellow physiotherapists around to share and bounce ideas.
Getting to know the participants
Asking Jensen to demo for a change
Bert having a go 
I'm the winner!
 Jacqui (Her Lift's gym) and her dislocated shoulder ....
Jane, Danny, Amy and Jerome came really early for lunch first and then got everything ready when I was still seeing patients. Really appreciate their help in setting up the place and also packing up when we were done. Please contact them at Sanctband Singapore for the next Floss Band course.

A big thank you to everyone who came too, hope everyone learnt something useful and can implement in your own area of work.

It was nice seeing Ang Hong again today too. She was my relief form teacher and taught me Biology when I was 15 years young when my form teacher went on medical leave for a few months. She was also one of the first few female triathletes I knew back then.

And yes, this is the last Floss Band course for this year, but there will be more next year. Stay tuned.

*Thanks to Jane Fong and Danny Ho for the pictures.

Sunday, December 4, 2016

How Quickly Do You Lose Fitness When You Stop Training?

Picture of Singapore Stan Chart marathon by RunSociety from Flickr
Well, many of you've just done your last race of the season. Yes, after the Standard Chartered Singapore Marathon 2016 this morning it's off season time at last.

Now it's time to take some much needed rest, both physically and mentally and not worry about training for a while.

The most common question and worst fear among my patients who run (or race triathlons) is how quickly do they go out of shape if they stop running (or training).

Ever wondered how long before detraining kicks in? Well, just as you don't become a fast runner overnight, you don't lose your fitness that quickly too. Nothing goes up in a straight line, there'll be some peaks and valleys. Likewise you don't lose your fitness overnight too.

Okay, first the good news. Research on detraining or how quickly you go out of shape shows that those who are less well-trained have less to lose. This make sense considering the elite athletes have further to fall.

Elite athletes can lose up to half of their aerobic fitness within the first 12-21 days of not training. They can then lose half of their remaining fitness in the next 12-21 days and so on. The bad news, those who've trained for a few months have a slower decline, but lost all fitness within 4 weeks.

Most studies suggest that an elite athlete's VO2 max levels drop 7 percent if they stop training for 12-21 days. They can lose another 9 percent from days 21-84.

One major reason for the quick fitness decline is the loss of blood volume. In the first 12-21 days that you stop training, you can lose up to 500 milliliters of blood. It's a simple supply and demand situation. When you stop training, you take away the demand.

The body loses the ability to bring oxygen to the muscles and you also have less fluid available for sweating (which cools the body).

The good news is with retraining, you can regain blood volume in a week although it takes a while for your red blood cells to grow again.

Other than blood volume, your mitochondria cell density, lactate threshold and your ability to oxidize fat stores all deteriorate.

Researchers have found it difficult however to measure time to regain your fitness. A common suggestion is that for every week lost, it takes two weeks to regain that previous level. The reason for this all those functional capabilities mentioned above.

When I was still racing, I used to take two weeks off at the end of the season. Yes, two weeks of no swimming, running, cycling and weight training. This allowed me to recuperate both physically, recharge mentally and also to spend time with my family, loved ones and friends. And when its time to train again, I'd be raring to go.

Do bear in mind that not all systems in your body detrain or retrain equally. Do consider your age. Runners in their 20's can resume training as though they never took time off. Older runners will take longer. 

Strength gains (from weight training) are not lost as quickly as aerobic (or cardiovascular fitness) and it usually takes 4 weeks before you start to lose peak muscle strength and maybe that will be another article later on.

So congrats and well done to those of you who ran this morning and make sure you take that well deserved time off.


Coyle EF, Hemmert MK et al (1986). Effects Of Detraining On Cardiovascular Responses To Exercise: Role Of Blood Volume. JAP. 60(1): 95-99.

Joyner MJ and Coyle EF (2008). Endurance Exercise Performances: The Physiology Of Champions. J Physiol. 586(1): 35-44. DOI: 10.1113/j.physiol.2007.143834.

Sunday, November 27, 2016

Are There Any Benefits In Running With Zero Drop Shoes?

My wife's zero drop running shoes
Although you don't see it as much now, the minimalist type running shoes were the rage all few seasons ago. These minimalist type (and not the barefoot type) usually have a relatively low heel to toe drop. Meaning the height in the midsole and the outsole at the back of the shoe is almost level and/or no difference in height.

One proposed benefit of zero drop running shoes is that it may reduce injury. Shoes with a large drop encourage severe heel striking which can contribute to knee injuries. With zero drop shoes, it may also allow your feet to land as if you were not wearing shoes which helps to distribute impact forces.

Shoes with a high drop may also tilt you forward too much and contribute to alignment and compensatory discrepancies.

If you visit the running section of most running stores now, most midsoles of current running shoes are almost back to before when they were much thicker. But many manufacturers have retained the zero drop while offering plenty of cushioning like the Hokas and Altras.

A recent study however found that a shoe's heel to toe drop may not have have anything to do with running injuries.

The researchers studied 533 non elite runners wearing running shoes with 0, 6 or 10 millimetres (mm) drop for six months. The running shoes were 2l mm in the heel and forefoot, 21 mm in heel and 15 mm in forefoot and 24 mm in heel and 14 mm in forefoot respectively. The shoes were otherwise similar.

25 percent of the runners reported being injured during the six month study period. An injury was defined as leg or lower back pain that resulted from running and prevented planned running for at least one day.

The main finding of the study was that injury rates among the three groups were similar, regardless whether their shoes had a heel to toe drop of 0, 6 or 10 mm.

However, among the runners who ran more frequently, those in the 0 or 6 mm drop shoes had a higher injury rate than the frequent runners with a 10 mm drop.

The researchers suggested that that this may be due to the runners transitioning to fast from their regular running shoes to zero drop shoes leading to increased injury rates as 78 percent of the runners recruited in the study hadn't run in zero drop shoes before.

I remember when I was racing cross country races as a kid we used to train in heavier cushioning shoes and then switched to racing flats for the race. It was very common to have sore calves after the first few races of the season as I've not done enough running in the racing shoes (which had lower drop than the training shoes). Yes, racing flats back then were very similar to the zero drop shoes now.

It was more apparent (sore calves) switching to racing spikes for the track training and track meets when cross country season ended and I raced in track events.

As I always tell my patients, their running technique is much more important than their running shoes. Be sure to rotate your running shoes to minimise injuries too.


Malisoux L, Chambon N et al (2016). Influence Of The Heel-to-Toe Drop Of Standard Cushioned Running Shoes On Injury Risk In Leisure-time Runners. A Randomized Controlled Trial With 6-month Follow-up. AJSM. 44(11): 2933-2940. DOI: 10.1177/0363546516654690.

Now, this is what I'll call a racing flat

Sunday, November 20, 2016

Patient With "Shoulder Tendinitis" Not Better After Medication

Can you guess what's wrong with my patient's shoulder?
Just by looking at the picture above, can you guess which shoulder was giving my patient problems? I also showed the picture to some of my staff and asked them "what can you see from this picture?"

Alright, for those who can't tell, here are some more clues. My patient came in with some neck pain and a very uncomfortable shoulder. He had seen his family doctor who told him he had tendinitis in his shoulder and gave him some NSAIDS (non steroidal anti inflammatory drugs).

However he did not get much better with the medication. He still had some neck discomfort and couldn't raise his arm above shoulder height. Lying on his affected side made his shoulder worse and he could only sleep supine.

At first I too thought the shoulder pain was referred from his neck. He mentioned that there was slight tingling sensation in his fingers occasionally too (which was why I thought the problem was coming from his neck). However I changed my mind after seeing he had trouble even lifting his arm sideways above shoulder height.

I told him that he probably had a tear in his L Supraspinatus muscle. If you look at the picture above carefully, you will see a hollowing above his left shoulder blade. There is also wasting in the muscle (or muscle atrophy) around the part where his neck on the left connects to his shoulder.

I was told later after an ultrasound scan that he had a full thickness tear in his left Supraspinatus muscle with retraction of the tendon! The doctor referred him for an MRI and said he may need surgery to repair the retracted tendon.

By the way, scientists have assessed biopsies from both people and animals with supposed tendinitis and found very few signs of inflammation in the tendons.

NSAIDs are commonly prescribed to reduce pain and inflammation of tendinitis. So if there is no inflammation, the medication is not going to help.

So the word tendinitis with the suffix "itis" means inflammation is misnamed since the condition has little or no inflammation. Researchers prefer the term "tendinopathy" meaning damaged or degenerating tendon.


Warden SJ (2009). Prophylactic Misuse And Recommended Use Of Non-steroidal Anti-inflammatory Drugs By Athletes. BJSM. 43(8): 548-549. DOI: 10.1136/bjsm.2008.056697.

Sunday, November 13, 2016

Physio And Sports Solutions Lunch 2016

Both our clinics came together to have lunch today at the Straits Kitchen restaurant in Hyatt hotel today.

This is our biggest turn out ever and a big thank you to all our staff and their familes/ loved ones who came. For those who were not feeling well or were travelling, well, here's what you missed.

Waiting for the start
We had quite a few tables
Guess who ate this for first round?
Guess who's the best eater?
Trying to fit everyone in the picture

Sunday, November 6, 2016

Hands-free Mobile Phone Drivers Roughly The Same As Drunk Drivers

Posed picture of me using mobile phone while driving
I'm sure you've seen lots of drivers driving and using their phone at the same time. I saw three drivers using their phones while standing at the back door of our clinic this morning, According to Singapore Traffic Police figures, at least eight drivers were caught using their mobile devices behind the wheel last year. Hopefully, you're not one of them.

Here's an article I found by a group of researchers comparing the effects of a variety of mobile phone usage conditions to different levels of alcohol intoxication on driving performance and vigilance.

Each participant had to complete a simulated driving task on two days, separated by a week's break. Driving performance was assessed by variables including time spent speeding, braking reaction time, time driving in target speed range, lateral lane position and speed deviation etc

On the mobile phone day, the participants performed the simulated driving task under the following four conditions. No phone usage, a hands free conversation, a hands free but cognitively demanding conversation and texting.

On the alcohol day, the participants performed the simulated driving task at four different blood alcohol concentration levels (BAC), 0.00. 0.04, 0.07 and 0.1.

Here's what they found. Under BAC 0.7 and 0.1 alcohol conditions, the participants spent less time in the target speed range, more time speeding and took longer to brake than in the 0.00 condition.

While using their mobile phones, participants took longer to brake in the hands free conversation, cognitively demanding hands free conversation and while texting. They also spent less time in the target speed range and more time speeding in the cognitively demanding hands free conversation and while texting.

When comparing both conditions, the hands free conversation was comparable to the legally permissible BAC level (0.04). The cognitively demanding and texting conversations were similar to the BAC 0.07 to 0.1 results.

According to the conclusion by the authors, simple hands free conversations while driving may not represent a significant driving risk (comparable to legally permissible BAC levels). Cognitively demanding hands free conversation and especially texting while driving represent significant risks to driving i.e. similar to when they were drunk!

In Singapore, it is currently illegal for drivers to hold any type of mobile device while driving. As long as you're holding it while the vehicle is moving you can be charged. Previously, you could not call or text on a mobile phone.

However, it is not illegal to use a mobile device if it is mounted on a holder or a dashboard. Wearable technology such as Google Glass or the Apple watch is not mentioned though.

So be safe while you're out on the roads (especially if you're cycling).


Leung S, Croft RJ et al (2012). A Comparison Of The Effect Of Mobile Phone Use And Alcohol Consumption On Drving Simulation Performance. Traffic Inj Prev. 13(6): 566-574. DOI: 10.1080/15389588.2012.683118.

Riding with one finger and giving cyclists a bad name
*Picture by Comrade King from Flickr.

Monday, October 24, 2016

Arches And Orthotics

Picture from article Scientific Reports
I've often been asked by my patients about whether they need orthotics. The following article I read will explain some of the research behind orthotics on how they can affect your running rather than just my opinion.

Each time we land on our arches when we run, energy is stored in our arches. This is free energy that doesn't require anything to activate. The researchers wanted to measure wanted to find out specifically how much energy is lost if they restricted the arch with orthotics.
Orthotic that was used
The researchers made two types of custom orthotics. One completely blocked the arch from collapsing while the other allowed the arch to compress (or collapse) halfway. Only runners who did not use orthotics were recruited for their study. The runners ran on a force plate treadmill. The shoes had sensors inside which measured energy expenditure.

In order to have a baseline measurement, the runners ran in just the shoes (that were similar for all runners, pictured below) first followed by the same shoes at the same speed while testing the home made orthotics.

Picture from Scientific Reports

The runners tested the orthotics while walking as well as running.While walking, there was virtually no difference in energy expenditure. However, while running significant energy loss occurred.

In the orthotics that blocked all compression, researchers measured an energy cost of six percent (or less efficient by six percent) while the orthotics that allowed for 50 percent compression lost four percent.

Before you throw away your orthotics (if you're wearing them) the authors suggested don't throw them out yet as many runners get custom made insoles to prevent injury. They felt this is more important than saving energy without the orthotics. In fact the authors were very diplomatic and said that "We don't want to say orthotics are good or bad."

Likewise, if you are considering wearing orthotics (but may not need them), then maybe you shouldn't especially if you wanna run faster.


Stearne SM, McDonald KA et al (2016). The Foot's Arch And The Energetics Of Human Locomotion. Scientic Reports 6, Article number: 19403. DOI: 10.1038/srep1940.

Thursday, October 13, 2016

2 Pairs Of Under Armour Running Shoes

UA Charged Bandit 2 (L) and UA Speedform Slingshot (R)
My patient Marie came to our clinic last week to see me on how she was going with her training for the New York City marathon she was going to participate.

She had also brought along a few pairs of her running shoes to show me and we talked about running shoes for her race. The pair she'd chosen seemed rather heavy and clunky so I suggested the pair she was wearing then looked more suitable. She said that the UA Speedform Slingot she was wearing was more suitable for 5 km and below runs. She seemed a little hesitant about wearing them for the marathon as she thought she'll require more cushioning for the race.

She took them off and showed me and I actually tried them on and said that these are the kind of shoes I'd run with usually. I explained  why and then suggested she try them for a longer run. She then said she would try and get me a pair as she was sponsored by Under Armour.

So today Marie and Wilfred Mong, Brand Communications Manager from Under Armour came to our clinic and passed me 2 pairs of Under Armour shoes to try. The same pair Marie is now going to use for her New York City marathon the Speedform Slingshot and the Charged Bandit 2.

A big thank you to Marie and Wilfred.

Here's a closer look

Sunday, October 9, 2016

Can Exercise Be Good For Your Back Pain?

I never really had low back pain before, not before my accident anyway. It's a different story after my accident, although thankfully it's more of an ache occasionally than back pain now actually.

I seem to get back ache when I see too many patients in a row now. I used to be able to go through an entire day without needing a break. Now on a long day I often give myself two half hour breaks. In fact when I was started working again after my accident, my wife would schedule a 30 min break for me after I see four patients and made sure I rested. I started working two hours a day, three, then four and and so on. Now I usually won't see patients for longer than seven hours at a time.

I see patients 2 times a week at Physio Solutions now and often go without a break. I always take a bus there and run home when I'm done. Every single time my back is sore/ achy I still run because my back always feels better during and after the run.

You must be thinking, how can this be? Can exercise alleviate back pain?

Here's the strange thing, I was worried too when I first had back ache after seeing patients at Physio Solutions and was wondering if I should still run home. I ran anyway and within the first three minutes, my back started feeling better. Each time I had back ache and ran I had same result, my back always felt much better.

But I can't just tell my patients with low back ache/ pain to just go running, I have to be able to justify and explain why running (or other exercise) helps.

So I was rather pleased when I came across the following article (Belavy et al, 2016).

The authors wanted to understand what kinds if sports and exercise could be beneficial for the intervertebral disc (IVD) and they did a review on IVD adaptation with loading and exercise. They also examined the impact of specific sports on IVD degeneration in humans and acute exercise on disc size.

2 levels of the vertebrae and disc
Here's a summary of what the authors found.

Our human spine likes dynamic, axial loading at slow to moderate speeds. This means that loading forces that are performed regularly for longer time periods that are dynamic (not static) but not rapid and of a magnitude up to approximately those seen in jogging/ running are likely to result in positive adaptations to the IVDs.

High impact loads, explosive movements, extreme ranges of movement as well as sedentary behaviour, disuse and immobilisation are likely detrimental to the IVD.

Static or very rapid loads, magnitudes that are too low (e.g. lying) or too high (lifting in flexion) are not beneficial to your IVDs. Yes sitting is bad for you as I've written before and also too much bed rest.

The authors also mentioned that running and upright endurance sports are either beneficial or at least not detrimental to the IVD. However, sports like elite swimming, baseball, weightlifting, rowing and equestrian riding are more likely to lead to IVD degeneration.

I was very surprised to see elite swimming on the not beneficial list. During the tumble turns, loading direction and speed of loading will be in torsion and/ or extremes of range. Amateur swimming is more likely to be at the very least less detrimental to the IVDs, but it is unclear whether it will be beneficial for the IVDs.

Come talk to me if you need to find out more. I have a compression fracture in my L1 and a fractured skull after my bike accident.


Belavy D, Albracht K et al (2016). Can Exercise Positively Influence The Intervertebral Disc? Sports Med. 46:473-485. DOI:  10.1007/s40279-015-0444-2.

*Many thanks to Elizabeth Boey who got me the article. Email me if you want a copy of the article.

Sunday, October 2, 2016

The Benefits Of Exercising Before Breakfast

Picture by Evan Bench from Flickr
How many of you don't eat anything before you exercise first thing in the morning? While I was still actively training I never went training first thing in the morning on an empty stomach. Definitely wouldn't be able to finish the session.

I still try to ride close to three hours most Saturday mornings and still cannot imagine not eating anything before the ride too.

So I was pretty surprised when I read that the benefits of exercising in a fasted state (up to 90 mins in the study) will significantly reduce the chance of you putting on weight if you've been eating like there's no tomorrow.

A group of healthy young men were recruited by researchers for their six week study. They were fed a diet of 50 percent fat and 30 percent more calories than what they had been consuming overall. What's more, some of the men agreed not to exercise during the six weeks (this is the control group).

The rest of the subjects were assigned to two exercise groups. Both groups did the same identical, supervised exercise four times a week in the mornings.  They ran and cycled at a strenuous intensity. Two of the exercise sessions were 90 mins, two were 60 mins.

One of the exercise groups ate a hefty carbohydrate rich breakfast before exercise and continued to ingest carbohydrates (in the form of sports drinks) during the exercise.

The other exercise group fasted before exercising and drank only water during the exercise.The second group did make up by eating similar amounts to the first exercise group later in the morning.

After six weeks the group that did no exercise put on an average of six pounds. What was worse was they had developed insulin resistance - their muscles were no longer responding well to insulin and had difficulty getting glucose out of their bloodstream efficiently.

Extra fat was stored between their muscle cells too. This insulin resistance and muscles stored with fat are metabolically unhealthy conditions that can be precursors of diabetes.

The first exercise group also gained weight, half as much as the control (non exercise) group. They too had become more insulin- resistant and were storing fat in their muscles.

Only the second exercise group did not gain weight and showed no signs of insulin resistance. They burned fat that they ingested more efficiently too.

The authors suggested that exercise training is more effective if have haven't eaten before exercise compared to eating a carbohydrate rich breakfast to stimulate glucose tolerance if you are on a high fat, high calorie diet. They explained that exercising in a fasted state (usually possible before breakfast) encourages the body to burn a greater percentage of fat (instead of carbohydrates) for fuel during vigorous exercise. Since you are utilising fat, you will not store it in your muscles.

This fasting group also had increased levels of a muscle protein that helps with transporting glucose in the bloodstream thus helping to regulate insulin sensitivity.

Exercising in a fasted state helped fight the two bad effects of eating a high fat, high calorie diet. Plus it prevented them from gaining weight.

Before you proceed to embark on your training sessions on an empty stomach do take note of the following caveats. Fasting before your race definitely won't work. You run the risk of "hitting the wall" during your workout since carbohydrates are easier for muscles to utilise than fat while exercising. The benefits more not be similar if you exercise at a more leisurely pace and for less duration.

A good time to adopt such a practice to fast before exercise is probably during the upcoming festive season (yes, it's already October, the year has flown by) where you indulge in more fat and calories than anytime of the year. Bear in mind the researchers detected that only three days of a extremely high fat and high calorie diet can lead to increased blood sugar levels and insulin resistance, potentially increasing your risk for Type 2 diabetes.

Running on a treadmill or cycling on the stationary bike in the gym is definitely safer if you plan to ride more than the 90 minutes (done in the study). You definitely don't want to bonk and fall while riding outside.


Van Proeyen K, Szlufcik K et al (2010). Training In The Fasted State Improves Glucose Tolerance During Fat-rich Diet. J Physiol. 588(21): 4289-4301. DOI: 10.1113/jphysiol.2010.196493.

Saturday, September 24, 2016

Full Again Today For The Floss Band Course

Just about to start
After a break of over two months, Sports Solutions hosted the Floss band course again today. As you can see from the picture above we were really filled.

There were lots of physiotherapists in the class today (at least half of the whole group I was told) and I spent a bit more time explaining the rationale for using the Floss bands while not neglecting the members of the public who did not have a anatomy background.

After all the explanations it was time to start flossing.
Flossing the knee
Flossing Jialing's lumbar spine

Many thanks as usual to Amy, Danny and Jane for setting up the place again while I was still treating patients. They do such an excellent job organising the course, registering the participants, setting up the place, providing the Floss bands etc while I just show up and teach.

Please contact them at Sanctband Singapore if you wish to attend the course or get the Floss bands.

Friday, September 16, 2016

Earth Runners Huraches/ Running Sandals Review

My Earth runners huraches
More than a year ago Mike Dally, founder of Earth Runners contacted me and asked if I was keen to review a pair of his earth sandals. I wrote back and said that I would be most happy to try a pair and mentioned that I live in Singapore.

Mike simply wrote back and asked for my size and mailing address. I requested for the Alpha X-11 mm which was a bit thicker and were more moldable. Mike added he was sending me the conductive leather laces.

The sandals were "zero drop" (same thickness between heel and the forefoot). There was a strap between the big and second toe and buckle on the outside the secure the sandal.

What was interesting was that I noticed there was a copper grounding insert flushed with the Vibram outsole. I later read that they were there to offer electrical conductivity  (or earthing). This is to offer the primal experience of walking/ running grounded to the earth. You can read more about the concept of earthing here. The copper inserts did not bother me at all while walking or running.
Copper inserts
I've waited a long time to write this as I wanted to wear the sandals in a bit before commenting. Mike Dally told me to take my time as most of the reviewers feedback was the longer they'd worn the sandals the more comfy they feel.

I first wore them mostly at home for up to a couple of hours at a time. I found that the leather straps (even though they were very soft) tend to cut into my first web space between my big and second toe. Because of this, I felt slightly more discomfort over the base of the second toe. Otherwise I had no issues at all with walking. The buckle at the side tightened without any difficulty at all.

I've began to wear them more recently as my older boy has been wanting to ride his bicycle. He can ride well but is afraid to stop as his feet can't touch the ground yet.

Lending a helping hand
So almost every single morning he's been asking to ride so I just wear my earth sandals with normal ankle socks and run alongside him steadying him when the need arises.

How does the sandal feel while running? If you've run in minimalist shoes, then you'll understand when I say they have a fair ground feel. They were nice to run in after you've broken them in and gotten used to them. They offer more than ample protection for the running that I do. If you have black toenails like me, then they will be very much appreciated since there's nothing for you to jam your toes against.

For the fashion conscious, hey look real cool with its raw genuine hurache appearance and you can wear them pretty much everywhere else.

Thanks Mike for a great pair of running sandals.

Sunday, September 11, 2016

Can Antihistamines Decrease Muscle Soreness?

I still shave/ wax my legs. Not as often as before, but I still try to keep them hair free.

Ever since my racing days, I've been making sure my legs are free of hair. Why is that so you should be asking?

In the event of a bike crash and the resulting abrasions, the wounds are easier to clean if there is no hair on the skin.  From time to time I need to take Clarityn (which is a relatively mild antihistamine) for my hives that result from the ingrown hair.
Easier to clean the wounds with no hair
I sometimes use Clarityn for mild allergies as well. Piriton (or chlorphenamine) is stronger, but it makes me very drowsy.

So I was surprised to read that taking a single dose of antihistamines can help lessen delayed onset of muscle soreness (or DOMs) after a hard workout.

After a hard workout, blood flow to your muscles remain elevated for a while. Histamines (part of your body's immune response) play a role in triggering this post exercise blood flow, which may be linked to inflammation and subsequent repair of muscle.

The researchers' aim was to investigate if blocking histamines with antihistamine medication would reduce post exercise blood flow, reduce inflammation and increase muscle damage and DOMs.

The subjects had to run downhill on a 10 percent grade for 45 minutes after taking the antihistamine medication (control group didn't take). Blood flow, inflammatory markers, pain sensitivity, perceived soreness and strength were measured for three days.

Results showed that blood flow to the legs was reduced by 29 percent an hour after exercise in the antihistamine group. There were however no differences in markers of inflammation.

Creatine kinase (used to determine muscle damage) levels were very different. This seems to supports the idea that blocking histamine receptors resulted in increased muscle damage.

The control group (didn't take medication) was 19.3 percent weaker the day after the hard workout compared to the group that took the antihistamines (7.8 percent weaker).

Before you rush to the nearest pharmacy to buy some Clarityn, do bear in mind that the results were a little more complex after you examine them closely.

This is very similar to what I wrote a few weeks earlier about the balance between recovery and adaptation.

The researchers themselves do not know exactly why this is so. It is possible that the antihistamine medication make you feel less pain and soreness (even if there was more damage in your muscles).

This makes antihistamines a double edged sword. They may make you more prone to muscle soreness even though you may not feel it.

If, however you want an edge to reduce next day soreness and strength loss when you have back to back races or games then taking antihistamines may help.

If you interfere with the recovery process to make yourself better soon (or recover faster), do you then risk delaying the repair or adaptation process? It is a short term versus long term trade off.


Ely MR, Romero SA et al (2016). A Single Dose Of Histamine-receptor Antagonists Prior To Downhill Alters Markers Of Muscle Damage Andd Delayed Onset Muscle Soreness. J Appl Physiol.
DOI: 10.1152/japplphysiol.00518.2016.

Friday, September 2, 2016

Michael Phelps Does Cupping For Recovery. Should You?

You've seen the tell tale signs all over his back and shoulders during the Rio Olympics. Strange, dark purplish circular marks were seen on Michael Phelp's body.

These are the marks after cupping is done. Cupping (thought to be an ancient Chinese recovery technique) is supposed to help recovery and increase mobility.

Glass cups are put on the skin to create suction (using either heat or air), pulling the skin slightly up and away from the underlying muscles. The suction usually lasts only a few minutes, it then causes the capillaries just beneath the skin's surface to rupture. This causes the obvious eye-catching bruises that you see.

The Chinese practitioners believe this can balance the flow of Qi (energy) and blood to wherever it is stagnant or deficient due to soft tissue imbalances from over training or traumatic injuries.

You can expect to feel some mild discomfort (from the tugging of the skin) but it's mostly relaxing once you get used to it. Your skin may feel a little sensitive afterwards. The cupping can be repeated again after the marks from the previous session have dissipated, which usually take a few days.

There's no doubt many athletes, coaches and trainers believe in cupping for recovery even if there isn't any clear and convincing evidence that it is better than myofascial release, massage, taping or using your pressure ball/ foam roller. 

Even my dad believes in cupping. I remember helping my dad do cupping on his back at home as a teenager. I had to put glass cups after using a lighter to set fire to a piece of cotton ball that he'd soaked with some Chinese herbs. I definitely had no knowledge of what it was back then.

If you're looking for scientific proof for cupping, a meta-analysis of 135 controlled trials suggest that more research is needed although there appears to be no negative effects.

The athletes may be feeling better because of a placebo effect. Still, a placebo effect can be beneficial at the Olympic level as Michael Phelps will attest.

My dad? He comes to our clinic for treatment when needed now.


H Cao, X Li and J Liu (2012). An Updated Review Of The Efficacy Of Cupping Therapy. PLos One. 7(2): e31793. DOI: 10.1371/journal.pone.0031793.

Rozenfeld E and Kalichman L (2016). New Is The Well-forgotten Old: The Use Of Dry Cupping In Musculoskeletal Medicine. J Bodywork Mvt Therapies. 20(1): 173-178. DOI: 10.1016/j.jbmt2015.11.009.

Friday, August 26, 2016

Can Watermelon Juice Make You A Better Athlete?

You've read from our blogs about drinking coconut water, green juices, lemon water etc. I am sure that  when it comes to our health or getting a competitive edge, we are always eager to try something new but evidence-based.

Guess what I read in a recent article? L-citrulline supplementation appears to help VO2 max levels and high intensity exercise performances. In real food form, watermelons are the best natural sources of L-citrulline.

In the published study, ten cyclists were given either L-citrulline, L-arginine or placebo tablets over a period of three seven-day cycles. On day six and seven, the subjects completed a moderate and intense cycling test.

Only the subjects taking the L-citrulline tablets had improved their VO2 max, time to exhaustion and maximum power during a 60 second all out sprint. There were no changes in performance in the L-arginine or placebo group.

Now, before you run out and eat/ drink all the watermelons you can, here are some of my personal thoughts.

The sample size (10 athletes) in the study was relatively small. Recreational cyclists were used in the study so the results may be different in elite athletes. So great news if you're a recreational athlete.

For elite athletes however, probably you may want to wait for more studies to be replicated to make sure the results are valid.

The subjects in the study were given L-citrulline tablets. You'll need to drink about 2.5 litres of watermelon juice to get the same dose of L-citrulline used in this study. And probably have to go the the toilet pretty soon after.


Bailey SJ, Blackwell JR et al (2015). L-citrulline Supplementation Improves O2 Uptake Kinetics And High -intensity Exercise Performance In Humans. J App Physiol. 119(4): 385-395. DOI: 10.1152/japplphysiol.00192.2014.

Sunday, August 21, 2016

Do Compression Garments Help While Exercising? Or Only With Recovery?

Picture I retook with my iPhone 6 from Alex Hassentein/ Getty Images
Allyson Felix just missed another gold medal in Rio earlier in the week, finishing second in the 400 meters after losing to a dive by Shaunae Miller of the Bahamas.

Last night, she just won her 6th gold medal at the Olympics in the Women's 4 x 400 m relay, the most ever by a woman in track and field.

Five of her gold medals have come in relays. Her individual gold came in the 200 meters in 2012.

Why am I writing about Allyson Felix? Other than being one of my favorite runners, she is also one of many athletes in the Rio Olympics wearing compression sleeves (see picture above) while competing.

You too would have seen many athletes wearing them while training or racing. I've written about compression garments before way back in 2009.

Newly published studies suggest they definitely do help muscles recover significantly after exhausting exercise. The compression garments can aid the the movement of blood through muscles after exercising, when blood flow would otherwise be slow.  This increase in circulation may help reduce inflammation and muscle aches.

To provide such benefits, the compression garments must be quite tight, which some people may find uncomfortable. They must be also be worn for several hours after exercising/ racing, even if they become unpleasantly damp and stinky.

However, they do have certain downsides that may cause some of us not to wear them. Most recent studies indicate that compression garments do not boost blood flow through muscles during exercise, most probably because the movement of blood when we are exercising is already at its peak.

Even though many athletes report that exercise feels easier when they wear compression garments, these athletes performed similarly whether they wear the compression garments or not.

The authors concluded that compression garments has small effects on short duration sprints, running at VO2 max, as well as time trial performances (Born et al, 2013).

Like I wrote before  I've never raced with compression garments, I've only worn them after hard training so I can recover and train again the next day.

Maybe Allyson Felix didn't have to wear her calf compression sleeves after all ......


Born DP, Sperlich B et al (2013). Bringing Light Into The Dark: Effects Of Compression Clothing On Performance And Recovery. Int J Sp Physiol Perf. 8(1): 4-18. DOI: 10.1123/jisppp.8.4

Engel FA, Holmberg H and Sperlich B (2016). Is There Evidence That Runners Can Benefit From wearing Compression Clothing? DOI: 10.1007/s40279-016-0546-5.

*Here's another look at Allyson Felix's compression sleeves - took the picture with my iPhone 6 from the original by Cameron Spencer/ Getty Images.

Saturday, August 13, 2016

Too Much Recovery May Slow You Down

*You did great Jo!!!
You've read that it's best to do a recovery ice bath after your training session, eat within 30 minutes of your exercise to replenish your glycogen stores, get a massage etc.

Well, you'd better stop that. Are you kidding me? Isn't that what Michael Phelps, Joseph Schooling and all the other top athletes do after training? And you're asking me not to do that?

Well, don't be recovery-obsessed, not while you're in training anyway.

Exercise and training are all about adapting to stress. However, the more time you spend "forcing" recovery, the less chance your muscles have to build up strength and endurance.

Researchers are discovering that when you try to recover quickly (from training) by removing the signals of stress (from your exercise/ training), you may be helping only short term recovery. This will also reduce the signals needed for your muscles to adapt.

While the researchers are suggesting that you still need to recover from training, but you just need to plan and periodize recovery the same way you would plan and periodize your training.

Meaning, you don't have to achieve optimal recovery after every training session. Some fatigue and soreness is acceptable and even necessary at certain times in your training program.

However, during high quality training sessions and especially during competition, an increased focus on recovery (and not adaptation) is needed.

So here are some general guidelines. Most often your recovery strategies should be targeted towards the longer term.

During base training/ pre season or easy workouts, adaptation to training stress is fine. You want some fatigue and soreness (or "inflammation") because this is part of the muscular adaptation process. Using ice immersion post training will often interfere with the adaptation process leading to less than optimal adaptations.

Ice immersion can and should be used during competitions especially if you're racing in a few events a few hours later (like Phelps and Schooling during the Olympics) or over a few days. It is also time to eat real god food to recover, get your massage sessions in etc.

You'll probably have to figure what works best for you as different recovery strategies work differently for everyone. Some prefer a massage while others prefer ice baths.


Halson SL, Bartram J et al (2014). Does Hydrotherapy Help Or Hinder Adaptation To Training In Competitive Cyclists? Med Sci Sports Ex. 46(2):1631-1639. DOI: 10.1249/MSS.0000000000000268.

Roberts LA, Raastad T et al (2015). Post-exercise Cold Water Immersion Attenuates Acute Anabolic Signaling And Long-term Adaptations In Muscle To Strength Training. J Physiol 593(18) : 4285-4301. DOI: 10.1113/JP270570.

*I used to swim with and treat Jo Schooling way back in 2004-2008 when we were both swimming at the Centre of Excellence under coach John Dempsey. He used to kick my butt in the pool even when he was ten years old. Great job on winning Singapore's first ever gold medal at the Olympics. So very happy and proud of you!

Sunday, August 7, 2016

Race Faster With Racing Flats

Used to race in the Nike Duellist PR when I was a kid
I've had a few patients ask me this past week what shoes to wear for their upcoming races especially since they want to achieve a personal best timing. Other than definitely no new gear on race day, I am happy to share what I know regarding racing flats.

Why racing flats? You can definitely turn your feet over much faster if your footwear is lighter. Think about this or try it out if you want. If you had to, would you prefer to run 5 km wearing a 10 kg weight vest or run with a 5 kg dumbbell in each hand (or 5 kg ankle weights strapped to each ankle)?

Hence, I would definitely suggest investing in a good pair of racing flats, as light as possible without sacrificing support of course.

Racing flats aren't minimalist shoes like the Vibram Five Fingers, they are ultralight running shoes designed to give runners an additional edge in competition. No fancy cushioning or support, just the bare basics.

I also recall the most famous published article on the topic. Subjects ran in the exact same pair of shoes in that research with lead weights inserted into a sleeve sewed onto the sides of the shoe so both toe and heel drop remained the same. So only weight adjustment was tested in the study, with no variables like midsole height difference.

The researchers found that the "effect of carrying extra weight on the foot during running has been measured at 1 percent (increased aerobic demand) per 100 grams per foot".

100 grams is about 3.5274 ounces. Each extra ounce will cost 0.2835% more (1 divided by 3.5724). So if you're running a t 5:40 min per mile pace, every mile will save you 0.83 seconds per ounce less weight.

Although that Nike funded study was done a long time ago that message has always stayed with me. Ever since I started racing track and cross country in my teenage years I would warm up in my normal training (usually a lot heavier) shoes and then switch to race in the lightest racing flats.

Before you run out and get the lightest racing flat you can find, please bear in mind that cutting down shoe weight usually means sacrificing on cushioning. That's the reason why you never see elite marathoners competing in Vibrams. They may train with it, but never race with it.

Here's the reason. "As shoe weight went lighter, the cost (energy of the runner) also dropped some, but when the weight went too light, then the cost went up because there was getting to be less midsole cushioning and the runner's muscles had to start absorbing more landing shock and that costs more energy."

The surface you run on is also important. A nice soft artificial track will absorb some landing shock (so you can get away with minimalist spikes) but on the road, you'll definitely need some cushioning and that adds a little weight to the shoe.

So, your ideal racing flat will differ from another runner and vary according to speed and race distance. More time spent on your feet generally requires more support. You can probably get away with a lighter shoe for a 5 or 10 km race.

The lighter your footwear, the faster you can turn over your feet ......  Now you know.


Frederick EC (1984). Physiological And Ergonomics Factors In Running Shoe Design. Applied Ergonomics. 15(4): 281-287/ DOI: 10.1016/003-6870(84)90199-6.

Another racing flat, my Air Streak from 1997


Sunday, July 31, 2016

Do You Really Need An MRI?

Picture by Cory Doctorow from Flickr
My patient had severe low back pain with some referred sensation of numbness, pins and needles down to the left buttock and hamstring area after her weight training in the gym recently. She went to see her doctor who referred her to a spine surgeon who then ordered a spine magnetic resonance imaging (MRI) to investigate further.

Results show she had a prolapsed disc (PID) or what is commonly as a slipped disc. The surgeon suggested surgical intervention to remove the disc but my patient refused and sought a second opinion.

Subsequently she came to our clinic after her friend with similar findings on MRI (but didn't have surgery) got better after seeing me.

I've encountered some patients who showed up in our clinics with "many problems" on their MRI but no pain while other patients showed no abnormality on their MRI but complain of severe pain. If you "believe" the MRI you may end up treating the MRI and not treating the patient (or trying to fix the problem on the MRI rather than addressing the actual issue causing your patients' symptoms/ pain).

Personally, I believe that nine times out of ten, a competent health care provider (doctor, physiotherapist etc) can pinpoint the cause of your pain/ injury without ordering an expensive MRI.

In our clinics, we ask many questions about the patients' symptoms, training regime (for a sports injury), much like a detective looking for clues. We then do a thorough physical assessment - comparing limbs, palpating the area that hurts, moving your limbs/ joints through different positions or have the patient perform the aggravating movement, checking alignment etc.

Done correctly and accurately, we can often pinpoint the root cause of the problem from the physical assessment and treat it.

It's also interesting to note that everyone is built a little differently and our structures change with age. As MRI's are very sensitive, they can reveal abnormalities that aren't the actual cause of your problems.

A recent review article found 37 percent of 20 year old subjects and 96 percent of 80 year old subjects have evidence of disc degeneration on MRI. The authors concluded imaging findings of spine degeneration are present in high proportions of individuals with no pain. These changes in the spine may be a sign of normal ageing rather than medical conditions/ acute injuries that require treatment.

Here's a common running related example. Another of my patients came to our clinic after seeing a Traditional Chinese Physician, physiotherapist and even saw a surgeon for medial (inside) heel pain and didn't get better. She had been walking more than normal and woke up having to hobble with pain upon setting her foot on the ground. That clearly to me would lead me to check her plantar fascia.

In fact, her surgeon did order an MRI and confirmed what I suspected. He proceeded to give her a cortisone injection (steroid injection) which didn't help. My patient endured the cost and hassle of doing the scan for no good reason.

I treated her twice and am happy to report she's well on her way to recovery.

Don't get me wrong. There are definitely times when a MRI scan is needed. If you've had a Physiotherapist /doctor etc assess you thoroughly, rested, had treatment and still not gotten better then it might be a good time to get an ultrasound scan, x-ray or MRI to investigate further.

What about the first patient who had a PID whom I wrote about at the start of this post? Well, she's back running, weight training like normal. Her doctor was surprised to say the least ......


Brinjkii W, Luetmer PH et al (2015). Systematic Literature Review Of Imaging Features Of Spinal Degeneration In Asymptomatic Populations. J Am Neuroradiol. 36(4): 811-816. DOI: 10.3174/ajnr.A4173.