Wednesday, February 24, 2016

After Rupturing His Patella Tendon .....

Nice leather seats ....
This is how Ronald Susilo came to our clinic after surgery to re-attach his patella tendon - his wife drove him while he sat in the back seat. Besides rupturing his patella tendon, he also tore his ACL and his meniscus.

With the Floss band
Last Saturday (20/02/16)  you saw him struggling to turn the pedals a full round while on the stationary bike. Only with the Floss band he managed to go one full round albeit with lots of shouting (in pain of course)!

On Monday (22/2/16), we went to the pool for hydrotherapy

And yesterday he saw his surgeon for a review. His surgeon told him "good progress". Little did the surgeon know he couldn't bend his knee more than 60 degrees last Saturday!

Today we got him on the Bongo board. Yes, both side to side and front and back. A board developed to challenge even professional athletes.

Check this out!
Holding on for dear life
What I'm trying to say is we didn't achieved this progress just because of the Floss band. Yes maybe the Floss band did kick start his rehab last Saturday by allowing him to turn the stationary bike pedals a full round. He began to believe in himself after that.

We did lots of other things along the way too, (I've left out the other rehab details of course, come talk to me if you wanna know). 

Use your Floss band as part of the treatment strategies you have to treat your patients. It's not a magic bullet. It's certainly not the only treatment aid/ tool you should be using.

To Jane Fong, Danny Ho, Sven Kruse and Sanctband, thank you for introducing to me the Floss band. It's definitely a tool I use in my bag of tools to treat my patients.
Ronald Susilo going down stairs

Saturday, February 20, 2016

More On The Floss Bands

Floss band and fascia
I have been trying out the Floss bands on my patients when there is an indication for it's use since attending the Flossing course.

Here are a few suggestions on how the Floss bands work. A common hypothesis is that it works through our fascial system.We have more fascia (or connective tissue) than anything else in our body. Fascia is a spider web like structure that wraps our muscles, blood vessels and nerves. Tom Myers say that fascia is the biological fabric we have inside our bodies.

I often tell my patients that fascia is similar to the glad wrap (or cling wrap) that wraps the meat or fruit tightly that we see in supermarkets.

When our fascia is adhered to itself, dehydrated or has unhealthy tension, movement can be restricted and blood may not be able to flow freely. For example, those knots you feel in your upper back, they may not be muscle tightness but probably fascia that has adhered to itself.

When you release tight fascia and allow for space in the connective tissue, blood can flow freely, movement becomes fluid and pain stops as a result.

Flossing helps create motion between the fascial layers which then releases the unhealthy adhesions.

Those of you who've attended the Kinesio taping courses must be thinking that this sounds similar. Yes, similar to the fascia taping techniques covered in the Day 2 of the Kinesio Taping course.

There is also the occlusion effect, The compression from the Floss band will prevent blood flow to the area the band is wrapped around. When the band is released, a rush of blood hydrates that area and can have a healing effect.

No Floss band, not enough range ....
With the Floss band
This is probably how joint mechanics improved too since joints that are painful and/ or have decreased range of motion after flossing often change remarkably.

Joints that are swollen benefit as compression (from the Floss bands) moves the swelling or drain the swollen area to other parts just like how our own lymphatic (or drainage) system works.

My patient in the picture above (no prizes for guessing who) ruptured his patella tendon last month and after surgery to attach it back didn't have enough range to ride the stationary bike. After flossing, kaboom! He's got enough range to pedal a full revolution. He yelled really loudly though!

Personally, I feel the Floss bands seem to work best in aiding recovery. Flossing the thigh muscles after a hard run  makes the legs feel a lot lighter and looser in two minutes. Yes you read correctly, two minutes or less.

 I've had a Team Singapore swimmer, cyclist and a netball player come in to our clinic today with acute muscle soreness and responded favourably to flossing and all three were impressed with how quickly the results came. You've got to try it to believe it.

My CrossFit patients tell me after a heavy squatting session when the legs feel really "dead" and heavy, the Floss bands definitely help with muscle recovery.

So, I'm not saying you have to run out and grab one straight away. I'm still trying to understand how it works and how to get consistent results with the Floss band, But like I wrote earlier, you've got to try it to believe it.

Wednesday, February 17, 2016

Learning To Use The Floss Band

Floss Bands made bySanctband
I was invited by Jane Fong and Danny Ho from Sanctband to attend the Flossing workshop in Ipoh, Malaysia taught by a German physiotherapist, Sven Kruse.

Prior to this I've never heard of Floss Bands before. But Jane and Danny from Sanctband got me interested after telling me what the bands can do. Used correctly, they can decrease pain and increase joint range of motion, especially by altering the fascia. (Sounds like Kinesio Taping to me)!

In fact in the USA, they are also known as Voodoo bands and are extremely popular among CrossFitters. Other than being a good marketing ploy by enticing people into trying them out by calling it Voodoo bands, Danny told me it was also because no one seemed to understand how they work so well - almost like "Black Magic".

The Floss bands are supposed to be able to help decrease pain and increase mobility/ range of motion in your joints. Now, that will definitely help our patients.

It is also suggested that it can be helpful in breaking up adhesions in our fascia (connective tissue) by re-perfusing tissues and by compressing the swelling out of joints to restore joint mechanics.

With Sven Kruse
Let me practise what I've learnt and I'll write another post shortly. Stay tuned.

Saturday, February 13, 2016

Overuse Injuries? Or Is It Related To Your Training Load?

Picture by richseow from Flickr
A pair of physiotherapists from the Australian Institute Of Sport (AIS) has suggested that overuse injuries are not caused by how much you train but rather by how your training load changes.

They found that comparing your total workload in the most recent week to the rolling average of the last four weeks of training could predict how likely you were to get injured. The term they used was acute versus chronic training load ratio. They suggest that a ratio above 1.5 is a risk factor for injury.

Consider another study done on a group of elite Australian Rugby League players (St. George Illawarra Dragons) for two seasons.

The players' training load was measured using GPS to track how far they ran during training sessions and games. Interestingly, more training did not seem to correspond to greater injury risk, even with back to back matches with less than a week of recovery. They actually found that players with a high chronic (four week average) workload of running 18.9-22 kilometres were less likely to get injured compared to those who trained less.

However, when they measured acute : chronic load ratio, players with a ratio above 1.6 (increasing training load by 60 % compared to their weekly average over four weeks) were far more likely to get injured. A ratio above 1.2 also put the players at risk, but less than those above 1.6.

Let's say you run 50 km a week consistently but suddenly this week you bump it up to 75 km (acute : chronic ratio of 1.5). You have just increased the chances of injuring yourself.

Or if you normally run 50 km a week but due to illness, work or travel commitments missed some training for a month or two and then decide to run 50 km a week again. That increase in mileage also increases your acute : chronic load ratio. So that is actually a training load error and not an overuse problem.

So if you had to take some time off training and want to resume training again remember to ease back into your training otherwise your acute : chronic training load increases and so will your chances of getting injured.


Drew MK and Purdam C (2016). Time To Bin The Term 'Overuse Injury': Is 'Training Load Error' A More Accurate Term? BJSM. DOI: 10.1136/bjsports-2015-095543.

Hulin BT, Babbett TJ et al (2016). Low Chronic Workload And The Acute:Chronic Workload Ratio Are More Predictive Of Injury Than Between-match Recovery Time: A Two-season Prospective Cohort Study In Elite Rugby League Players. BJSM. DOI: 10.1136/bjsports-2015-095364.

Friday, February 5, 2016

How Effective Is Your Knee Brace?

Assortment of soft knee braces from the Holland Village Guardian
How many of you have seen runners run past with a knee sleeve/ brace on? That's what I always look out for! But that's me and that's what I always do, watching people move and see if there's anything wrong or different.

I've also seen so many of my patients walk in to our clinic with a self prescribed over the counter soft neoprene knee sleeve/ brace. Often, they are asked by the doctors they see to wear a brace.
Often prescribed by doctors
I always ask the patients why they have the sleeve/ brace on. Some will say the brace helps with their pain or it makes their knee feel less wobbly. They usually reply that they feel a little more secure with the sleeve / brace. Most, however are not sure if the sleeve/ brace works.

Let me explain what the differences are. Braces that are stiff and rigid are usually made from plastic, aluminium or carbon fibre. They usually restrict joint movement by physically pressing against the bones of the knee to provide firm external support.

My patient in his rigid knee brace 
While the rigid knee brace can help restrict or limit movement, there is a definite downside  to using them. Have a look at my patient who had a tibial plateau fracture and a partially torn anterior cruciate ligament (ACL).
Check out the rigid brace
See the difference in thigh girth?
Since knee movement is often limited and restricted, the load is often transmitted to the ankle, hip and lower back. Often I end up treating them for the back pain too.

The softer neoprene type sleeves usually will not be able to provide the same mechanical support as they are much softer and do not have any rigid structural support. Neoprene sleeves generally help the wearer by increasing proprioception (or joint position sense) much like the high cut shoes basketball players wear to give themselves more awareness of their ankles to prevent ankle sprains. It is believed that improved proprioception around a knee joint can help stability by improving balance.

However, a 2012 published study of people with knee arthritis found no significant improvements in balance with the use of a neoprene knee sleeve.

There is also very little evidence that knee supports worn prophylactically on healthy knees protect active people against knee injuries.

Granted, knee supports/ braces are usually less expensive or as invasive against knee operations to treat injuries or even arthritis so so people will try them before resorting to surgery.

Some specialized knee supports may help to take pressure off the knee joint while walking and especially during exercise. My patient (in the picture below) intends to use her brace when she goes back to wake boarding and skiing after her injury. Of course I added that proper rehabilitation is important too. Such braces may also be able to help patients with knee arthritis remain active and put off surgery at least for a while.
All ready for action
As explained above, rigid knee braces (but not sleeves) may help after some knee injuries. They are often prescribed by doctors after a patient suffers a torn medial or lateral collateral ligament (LCL). MCL's and LCL's tends to heal fairly well without surgery provided there is no further strain/ injury to the knee for the first 6-8 weeks after the initial injury.

Bracing can be effective when you know what injury you have and the structures involved as a brace can be matched effectively to your needs.
My MCL taping- "Much better than any brace" says my patient
I always prefer to tape compared to using a brace though. As I always say to my patients, I can customize the taping according to their needs and it always fits better than any brace they buy.

So don't just go and buy a sleeve/ brace.


Collins AT, Blackburn JT et al (2012). The Assessment Of Postural Control With Stochastic Resonance Electrical Stimulation And A Neoprene Knee Sleeve In The Osteoarthritic Knee. Arch Phys Med Rehab. 93(7): 1123.1128. DOI: 10.1016/j.apmr.2011.12.006.

*Big thank you's to all my patients who allowed me to take pictures or sent me pictures.