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.

Friday, July 22, 2016

Will Training When You're Tired Make You A Better Athlete?

Who says I can't lift when I'm tired? Picture from The Pit
My two boys share the same bed with my wife and I. Two nights ago at about 3 am, the younger one's diapers malfunctioned and leaked. I had to help my wife remove the soiled mattress covers while my older kid snored through it all. 

It took me a very long time before I fell asleep again, probably at about 5 am. I was soon awakened by my older boy telling me that he needed to pee ..... 

Needless to say, my wife and I were sleep deprived and tired.

Training when you're tired can be tricky. There's also some evidence to suggest that it increases your risk of injury. Especially since energy levels are depleted and you become slower in your reaction and decision making time. This will probably also impact your ability to perform.

Approached properly, training while tired may actually make you a better athlete suggested exercise physiologist Darren Paul and colleagues in their study. They found that training when you're tired can result in better maintenance of strength and improved postural control.

And not only endurance athletes can benefit from pushing past fatigue during training. 

Soccer players in their research who performed strength or balance exercises at the end of their training sessions (rather than at the beginning) were not as affected by fatigue during their matches.

When you train through fatigue and you learn to push through something difficult, it definitely gives you confidence. It's definitely empowering and shows you that you can do more than you likely thought you could.

Here are some personal suggestions as to how you can train while fatigued without getting hurt in the process and improve your performance.

Always focus on your form. Good form and technique has to always come first regardless of whether you're tired or not. If you need to push through fatigue while training, do it while maintaining proper form. If you're going too hard or too fast but not having good form and technique then you need to slow down. That will minimise your risk of injury. 

Some marathoners I've treated will often do a shorter steady paced run the day before their long run. They may run 10 km at their marathon race pace the day before their long run. They will then have some level of fatigue and glycogen depletion from the previous day's run to simulate fatigue setting in later in a race while doing their long run.

While I was still training for triathlons, brick workouts were the norm. Meaning we often stack workouts on top of each other (like stacking bricks). We often practise short but very quick running after a bike training session which forces our legs to adapt quickly. 

Training through fatigue also mean you do not do three days of interval-like running in a row. If you do that you're definitely walking down the path to injury or illness. You are training through fatigue to gain fitness and to get stronger as a result of that stress. So you definitely need to factor in appropriate or even extra recovery to help your body recover and adapt. Only then can you emerge stronger.
zzzzz ....
So my wife went for a run that morning while I was out walking and putting my son to sleep. I didn't exercise that morning but I managed to run home after I ended work at Physio Solutions that evening.


Paul D, Narciss G et al (2014). Injury Prevention In Football. Time to Consider Training Under Fatigue? Aspetar Sports Med J. p 578-581. See the article here.

Sunday, July 17, 2016

Fear Is Your Biggest Enemy When You're Injured

Now that's gotta hurt (Picture from Ang Kee Meng)
Are you recovering from an injury or recuperating from a surgery? Fear plays an enormous role when you're recovering from an injury, especially a long term injury.

Trust me I've had 3 knee surgeries on my right knee. For a few years after my 3rd knee operation I was paranoid about the slightest pain in my right knee. I made sure I only ran on grass (less impact or so I thought), read every single published article on articular cartilage injuries (my condition) and did lots of deep water running.

I remember every time if someone on the bus or MRT stood too close to me (let alone bump into my knee) I'll give the person a dirty look and move away.

So I'm pleased to share that I'm not the only paranoid athlete/ person around. Researchers suggest fear can determine whether or not an athlete makes a full recovery. Some athletes even have "post traumatic stress" back to the moment they got injured.

In a group of patients recovering from an anterior cruciate reconstruction (ACL) reconstruction, strength of muscles around the knees, functional range of movement, level of activity and intensity of pain were measured over the course of their recovery. Researchers also measure levels of kinesiophobia, pain related fear of movement,

The most common reason for not having a full recovery was the fear of getting injured again. These athletes did not have higher levels of pain than others in the study, they were just plain scared.

The researchers concluded that their results show that physical impairments may contribute to initial functional deficits whereas psychological factors (or fear) may contribute to longer term functional deficits in patients who are still fearful of re-injury. This fear and/ or lack of confidence may be a barrier to future sports participation.

Addressing your fear, alongside the physical injury is critical for your recovery.

Oh, by the way I forgot to mention that I've also fractured my skull before and had a compression fracture in my lumbar spine as well.

Come see us in either of our clinics if you're struggling to recover from your injuries/ surgery from fear, lack of confidence or other physical reasons.


Lentz TA, Zeppieri G Jr, George, SZ et al (2015). Comparison Of Physical Impairment, Functional, And Psychosocial Measures Based On Fear Of Reinjury/ Lack of Confidence And Return-To-Sport Status After ACL Reconstruction. AJSM. 43(2): 345-353. DOI: 10.1177/0363546514559707.

Saturday, July 9, 2016

Hey, Isn't That Alfred Sim (Project SuperStar Winner) At The Floss Band Course Today?

Flossing Alfred Sim's shoulder
Yes, it is Alfred Sim (Season 3 Project SuperStar winner) at the Floss band course at Sports Solutions  today. I had treated Alfred when he was a much younger sprinter years ago when I used to work at the Singapore Sports Council (now known as Singapore Sports Institute). I never knew Alfred was into singing and acting.

Other than Alfred, I also met other old friends, ex colleagues and participants from other courses I've taught.

Telling the class I've got fewer than 3 white hairs ...
As usual, once the theory component was done and dusted, the practical was underway.

Hey Liam, look at Cedric (in white) not Maire
Flossing Maire's lumbar spine
Sharon elbowing Bijun in the face ....
A big thank you to all who came today, it was nice seeing familiar faces in the class, occupational therapist Sharon Seah, KTP hospital Principal Physiotherapist Bijun, Kit Ping my ex colleague from SSC and Alfred Sim of course.

Kudos the Jane, Danny, Amy, Carol for coming early and setting up the place while I was still treating patients. Chapeau to them. Please contact them at Sanctband Singapore if you wish to attend the course or get the Floss bands.

Saturday, July 2, 2016

More Miles Does Not Mean Bad News For Your Knees

Singapore Stan Chart Marathon picture by RunSociety from Flickr
You will know someone who has had to rest from running because of an injury. And you will probably know someone who has been told by the doctor to quit running or their knees will wear out. Hence, it's easy to understand why so many people believe that running is not good for their knees.

I've written before that running does not wear out your knees.

I also disagreed with the author who wrote in the Straits Times (on 240516) on the above topic and I pointed out that there is no sound evidence at all that glucosamine helps with cartilage regeneration.

Here's further proof from a recently published article that didn't set out to study runners. In fact the authors that investigated this "Osteoarthritis Initiative" study had hypothesised that "a history of leisure running may increase the risk for knee knee symptoms and ROA (radiographic evidence of arthritis) even at lower levels."

Runners were grouped into low, middle and high groups if they had done at least 250, 800 or 2000 running workouts in their lifetime. All 2637 subjects in the study had high quality x-rays of their knees done and other methods of assessing knee symptoms.

Only two to five percent of the subjects described themselves as competitive runners showing that the findings are potentially more applicable to the general population compared to other studies.

Eight years after the study, subjects (56 percent female, average age of 64) were given a physical activity questionnaire. 29.5 percent indicated that they had participated in some running at some point in their lives.

The results were the exact opposite to what the researchers expected. This "forced" them to conclude that "A history of leisure running is not associated with increased odds of prevalent knee pain, ROA, or SOA (symptoms of arthritis). In fact, for knee pain, there was a dose-dependent inverse association with runners."

This meant that the people who ran the most had the least knee pain. This was true across all age groups and for running at any stage in one's life. The subjects that were still running had less knee pain (21.1 percent) than those who had quit running (25.3 percent), who had less pan than those who had never ran (29.6 percent).

So, most recent medical research continues to "exonerate" running as a cause of knee osteoarthrits. You now have more "ammunition" to show the naysayers who tell you to stop running or your knees will wear out.


Lo GH, Driban JB et al (2016). History Of Running With Higher Risk Of Sympyomatic Knee Osteoarthritis: A Cross-sectional Study From The Osteoarthritis Initiative. Arthritis Care and Research. DOI: 10.1002/act.22939.