Sunday, December 31, 2017

Weather Change Make Your Bones and Joints Ache?

Raining cats and dogs 
In the past when I was still a very junior physiotherapist, I'll often have patients (in the hospital) who tell me when it gets cold, their joints and/ or bones will ache or hurt. Not that I don't believe them but I'll often think to myself, hmmmm really, how cold can it get in Singapore?

Later while treating patients overseas (where it can get much colder than Singapore), the patients there tell me the same thing. They say right before the weather turns cold, their previously injured or arthritic bones/ joints will hurt.

So is that true or just an old wives' tale? Can the ache in your bones and joints predict the change in weather?
Raining all the time here at Sports Solutions the past week
A recently published study looked at medical records of 11,673,392 outpatient visits, dwarfing other studies that previously looked at whether an increase in humidity, rainfall or barometric pressure can bring on pain.

The researchers matched the dates of the visits to local weather reports and found that 2,095,761 of the cases occurred on rainy days. After controls applied for age, sex, race, various chronic medical conditions including rheumatic arthritis, they found more visits for bone and joint pain during dry days than wet days.

The authors concluded that the weather does not cause joint pain but that patients attribute joint pain to the weather when it's raining.

I can hear those of you reading this protesting already. Yes, I personally agree there are flaws in the way this study is conducted. In the real world, many patients complain that they can't get a same day appointment with the doctor when they feel pain in their joints. Even if they did get a same day appointment, the doctor will tell them it's the "weather causing their pain".

Personally I don't get any pain in my back or skull (fortunately) after my accident, before the weather changes or in cold weather.

BUT, I've definitely noticed that if I'm coming down with a fever and especially if my stomach is feeling uncomfortable either from indigestion or feeling bloated, my previously fractured L1 lumbar spine will definitely ache. Visceral manipulation (mobilization of the organs) helps that. This is covered in another post.


Jena AB, Olenski AR et al (2017). Association Between Rainfall And Diagnoses Of Joint Or Back Pain: Retrospective Claims Analysis. BMJ. 359:j5326. DOI: 10.1136/bmj.j5326.

Friday, December 15, 2017

This Is No Bull .....

Energy drinks from Cold Storage
When I was doing my National Service in the army, some of my platoon mates who were having issues with their fitness would frequently load up with "energy drinks" such as Red Bull. Especially in the morning before physical training and/ or Standard Obstacle Course (SOC) training sessions. They definitely did before the SOC tests too.

I'll ask them why and they'll say that it gives them a "boost" to be able to finish the training strongly or pass the test. Some of them will also mix Red Bull with alcohol when they book out on Fridays so they can party the rest of the night away.

Later while studying in university, I found out some of my classmates did the same when cramming for an exam or writing a paper. A published paper found that 51 percent of college students consumed at least a bottle of energy drink a month.

So I'm sure you would have seen, heard or perhaps even tried some of the above. Well, if energy drinks such as Red Bull is your drink then you may want to read on.

Sure, the energy drinks may give you a temporary boost, but it can also give you a whole lot of other problems. Previous studies show that they can mess with your sleep, make you gain weight and increase your blood pressure. They can also lead to substance abuse, mental health problems, higher risk of developing diabetesdental problems and even kidney damage.

Energy drinks are advertised to boost/ improve energy, stamina, athletic performance and even your concentration. Similar to sports drinks (Gatorade, Powerade, 100 Plus etc), the target consumer market for energy drinks are adolescents and young adults.

Energy drinks typically contain lots of sugar, high fructose corn syrup, artificial sweeteners, caffeine, certain vitamins, minerals and non nutritive stimulants (such as guarana, ginseng, taurine, L-carnitine, inositol, yerba mate and D-glucuronolactone).

An average 500 ml can of energy drink contains about 54 grams of sugar, way above the recommended 36 grams for men. You've read here that it is through consuming excessive sugar that causes you to get diabetes.

According to the article referenced below, some energy drinks reviewed contained as much as 207 mg of caffeine (recommended daily allowance for adults is 400 mg/ day, 100 mg/day for adolescents). When you consume more, you may feel anxious, depressed or even harbor suicidal thoughts.

Excessive caffeine along with other stimulants such as taurine, guarana and ginseng can also affect your blood pressure.

The authors concluded that current evidence suggest that health risks outweigh any short term perks or benefits you may experience from energy drinks.

Now you know.


Al-Sharr L, Vercammen K et al (2017). Health Effects And Public Health Concerns Of Energy Drink Consumption In The United States: A Mini-Review. Frontiers in Public Health. 31 August 2017. DOI: 10.3389/fpubh.2017.00225.

Heckman MA, Sherry K et al (2010). Energy Drinks. An Assessment Of Their Market Size, Consumer Demographics, Ingredient Profile, Functionality, And Regulations In The United States. Comp Reviews in Food Sci Food Safety.  29 April 2010. DOI: 10.1111/j.1541-4337.2010.00111.x

Now, that's a lot of Red Bull in there
I took the picture above and below while riding to my previous clinic a few years ago thinking I may one day use the pictures. Glad I can use the pictures now.

A closer look

Saturday, December 9, 2017

Early Christmas Present From Oakley

Oakley Jawbreaker
Here's my early Christmas present from Oakley. A pair of Jawbreaker sunglasses. It does seem a little big as you can see from the picture above, but then it also means you get more protection.

Vented lenses means it won't fog up so easily. I really like the fact that peripheral vision is great too.

Many thanks to Joey from Oakley.

Here's another look
Please also see this post on the Jawbreaker.

Monday, November 27, 2017

Stretching Your Muscles? Or Stretching Your Brain?

Kids stretching before gong fu classes
We've written before that just one static stretch of 30 seconds can reduce your maximum strength. Hence, I've questioned whether it improves your sporting performance or help prevent exercise related injury.

Here's another interesting thought. Does stretching makes one more flexible because repeated stretching alters the mechanical properties of the muscles, tendons and joints you are stretching?

Or stretching causes you and your muscles to tolerate more tension when you stretch? You become more flexible or can reach further because your brain tells you that you can and not because you've altered the mechanical properties in the joint.

This was exactly what researchers were wanting to know when they pooled data from 26 studies that measured the mechanical properties of the joint, muscles and tendons after stretching programs of between three to eight weeks.

Participants in those 26 studies stretched at least twice a week, average total stretching time slightly less than 20 minutes each week.

I was surprised (and I'm sure you'll be too) when the results appear to support the second theory as only very small changes were seen in the mechanical properties measure. Participants did get more flexible and were willing to tolerate greater tensile forces while stretching.

Bear in mind that the stretching period was only eight weeks. The authors point out that weight training over similar duration show increase in neuromuscular strength gains but no change in size of the actual muscles. The same may be true for stretching, neural changes first followed by physical changes.

Some readers will undoubtedly say that don't worry about whether is the the physical muscle changing or neural changes. As long as flexibility improves.

As written earlier, we do not know for sure if stretching improves your sporting performance or helps prevent injuries, but the general consensus is that regular stretching may be beneficial in the long term.

Freitas SR, Mendes B et al (2017). Can Chronic Stretching Change The Muscle-tendon Mechanical Properties? A Review. Scan J Med Sci Sports. DOI: 10.1111/sms.12957

Monday, November 20, 2017

Strength Training Just As Important (If Not More) Than Aerobic Exercises

Lifting before running
After our two beautiful boys came along, my wife used to just run as there was not much time for any other exercise. She found big benefits from minimal running. It improved her mood and energy levels while also lowering her risk of heart disease and stroke.

After a few years of just running, she felt that her fitness level was stagnating and that she was losing strength. So earlier this year, (along with two friends), my wife has been doing twice weekly strength training sessions at the Holland Village F45  gym.

A recent study found strength training just as important (if not more than aerobic training) and can add years to your life. This is the largest study so far (over 80,000 adults) to compare mortality outcomes of different types of exercise people did.

Researchers found that strength training (both gym machines and body weight) decreased the risk of early death (23 percent) and cancer-related death (31 percent).

Earlier I wrote about how weight training can also help solve Singapore's diabetes problem as highlighted by our prime minister during the 2017 National Day Rally. This study lends more weight to my suggestions to help Singaporeans get healthier.

Moreover, the World Health Organization's (WHO) physical activity guidelines suggest 150 minutes of physical activities and two days of strength training every week.

Seems like my wife's twice weekly strength training sessions at the Holland Village F45 is spot on with WHO's guidelines.

For those intimidated by gyms, (be it costs or images of heavy weights), the researchers suggested that body weight exercises like sit-ups, push-ups, lunges and triceps dips done in your own home or local park can be just as beneficial.


Stamatakis E, Lee I, Bennie J et al (2017). Does Strength Promoting Exercise Confer Unique Health Benefits? A Pooled Analysis Of Eleven Population Cohorts With All-cause, Cancer, and Cardiovascular Mortality Endpoints. Am J Epidemiology. kwx345.

Friday, November 10, 2017

Like Father Like Daughter

With Mona
Earlier you've read about how I've treated 2 of Singapore's fastest men in our clinics previously. Well, today Mr C Kunalan's daughter Mona came to see me.

I've known Mona since our school days. She used to dominate all the sprints in the National Schools Track and Field events held at the old National Stadium.

I remember when she was running in the "B" division (17 years old and under) as a 15 year old, she clocked 12.2 seconds to break the previous record and be the fastest school girl outright. Much faster even than the all the girls running in the "A" division (20 years and under).

It wasn't a surprise when she went on to don national colors and even won medals at the SEA Games.

As you can see from the picture, Mona is still in very good shape. Other than running, she still does strength training regularly to maintain her speed. Like father, like daughter.

See the resemblance?

Wednesday, November 1, 2017

Arches And Legs

It has been a big learning week for us. Aized attended the Anatomy Trains Structure and Function course last Friday to Sunday. And Ting Jun and I went for the next part on the "Arches and Legs" for the past three days.

Some of it has been revision of earlier concepts, while incorporating more in depth details as well.

Here are some pictures from our past 3 days at the course.

Feet and arches
Let me have a look too
 Deep in thought
When it comes to learning and making ourselves better physios, we make sure we do not cut any corners. As a team, we've spent lots of time going for courses, discussing difficult cases and sharing what we've learnt with each other to improve ourselves.

Majority of our patients are by "word of mouth" referrals. A patient comes and sees us in our clinic, they get better really quickly and they then refer their families and friends to our clinic.

So please come and see us in our clinics and we'll do our best to help you.

Looking forward to using what we've learnt at work tomorrow. Yes, back to work tomorrow.

Wednesday, October 25, 2017

Older Men And Calf/ Hamstring Injuries

Both the calf and hamstrings
After last week's post, I was just talking to my colleague and she noticed that (just like me), she has also seen a few cases of patients tearing the calf muscles too. All happened to be male patients on the older side of 40 years old.

I thought of my own patients with calf muscle strains/ tears and realized that they too tended to be the older male patients too.

I was pleasantly surprised that our observations was spot on. A recently published article in the British Journal of Sports Medicine investigated over a thousand articles on the risk factors of calf muscle strains. Ten articles satisfied their inclusion criteria of which more than 5000 athletes in football, rugby union, Australian rules football, basketball and triathlon were involved.

As you get older, your aging athletic body has a few things going against you. You have a higher incidence of disc degeneration and the potential of L5 nerve root compression as mentioned in last week's post.

Older athletes lose some muscle power output and rate of force production. (Trust me on this, I have definitely experienced this).

Moreover, as the athlete gets older, your testosterone levels and production start to decline and this may limit your muscles' rate of recovery, which can lead to accumulative fatigue.

The most predictive risk factors were down to age and previous injury of calf strain. Having previous hamstring or groin strain was also a contributing factor. A possible proposed mechanism for this is a change in the change in the muscle architecture following a muscle strain.

When your muscle heals after a previous injury, the damaged muscle is usually replaced by a fibrotic scar tissue. It is often common to get future damage in the areas adjacent to this scarring.

Another factor that may play a role is due to a change in the length and shape of your damaged calf muscle. Shorter muscle fascicle length has been noted as a risk factor for repeat hamstring strains too.

We can't help you when it comes to your age and previous injuries to the calf and/ or hamstrings. But what we can do along with treating you is to ensure you have a sound rehabilitation process with some definite focus on eccentric exercises.

Here's a tip for those who you who haven't seen us in our clinics. Do your eccentric training at the end of the day when you have no training scheduled or only light training the next day. This minimizes the risk of DOMs or delayed onset of muscle soreness.


Green B and Pizzari T (2017). Calf Muscle Strain Injuries In Sport: A Systematic Review Of Risk Factors For Injury. BJSM. 51: 1189-1194.

Sunday, October 22, 2017

SS Turns 8!

Our clinic celebrated our 8th anniversary yesterday. A big thank you to all our families, staff, friends and patients for all your support all this while. We wouldn't have done it without all of you.

Our goal has remained the same all this while. To make our patients better quicker. "As long as we're happy and enjoy treating our patients, it's not really work."

Here's to many more years to come!

Monday, October 16, 2017

Hamstring/ Calf Pain? Treat Your Back

Now here's a nasty hamstring injury
I was looking through some of our past articles in our Physio Solutions blog and came across this article on how treating the lower back helps with hamstring injuries.

Here's a good reason why this is so. This article written way back in 2004 addressed the issue of hamstring and calf strains in older footballers in particular (but can also be in runners, triathletes etc).

I came across many of Dr John Orchard's articles back when I was doing my post graduate physiotherapy studies in 2003. This particular article suggested that a possible mechanism of higher occurrences of hamstring/ calf strains in older athletes may be due to your lumbar spine (or lower back) issues.
See where L5 nerve root is, (disc is next to it in white)
He suggested that the L5/ S1 neve root segment may be more prone to irritation and compression under the lumbosacral ligament due to disc degenerative changes. Dr Orchard notes that the L5 nerve root has the "most tortured path through the lumbosacral canal" before going over the sacrum to join the sacral plexus (or nerve roots).
The lumbosacral ligament further lessens the L5 space 

It may be likely that the location of a larger lumbosacral ligament is clinically more significant in older athletes due to degenerative disc changes (or slipped discs).

Due to possible L5 nerve root entrapment, some older athletes may have regular hamstring/ calf  and nerve muscle and tendon injuries. This happens when the L5/ S1 segment loses disc height (due to a slipped disc).

Space for the L5 nerve root is thus reduced (under the lumbosacral ligament) and may cause back pain and/ or hamstring and calf muscle/ tendon injuries.

So now you know why we treat your lower back when you have a hamstring or calf injury, especially when treating just the hamstring or calf doesn't improve your condition.

This is especially so when you saw from last week's post on how the hamstrings are closely related to the thoracolumbar fascia.


Orchard JW, Farhart P et al (2004). Lumbar Spine Region Pathology And Hamstring And Calf Injuries In Athletes: Is There A Connection? BJSM. 38(4): 502-504.

Sunday, October 8, 2017

How Your Hips Are Connected To Your Shoulders

Yes, our shoulders are connected to our hips! Definitely if you refer to work done by Tom Myers in his Anatomy Trains book.
If you look at the picture above, you can see that the right Vastus Lateralis (outer thigh muscles) through its fascial attachments are linked to the buttocks then through the thoracolumbar fascia across to the opposite (left) rib cage, shoulder and arm.

If I say it simply, it means your Vastus Lateralis actually attach to your arms! Or if I put it in a different way, your arms don't end at your arms. They end at your legs.
Another look at the connection
So supposing you have a rotated/ and or unstable pelvis (or hip), this can affect your shoulder and change the biomechanics in your shoulders and cause pain.

So in order to treat your shoulder pain, I'm not really crazy if I assess your hips before I look at your shoulder.

Just ask Bertrand, without really assessing his shoulder pain, I made his shoulder better just by taping his hip. 

Now when you come and see us in our clinics, you know why we look at your hips first if you have shoulder pain.

Saturday, September 30, 2017

How To Prevent Fading In Your Next Marathon

Exaggerated "float" phase of the run
You were running really well in your key marathon. You've trained very well, started conservatively despite feeling great hoping to have a strong negative split. You've hit all your target times at each 5 km split that you've written down on your hand.

To your greatest horror, you start to tire in the final miles of the race. Your dreams of a personal best begin to fade too.

What was the fade due to? Was it dehydration? High core temperature or low blood sugar? Apparently, none of the usual suspects according to a paper that studied 40 marathon runners immediately before a race and within three minutes of them finishing the race.

The best predictor of the runners fading was in fact muscle damage.

With each stride you run, your quadriceps and calf muscles contract "eccentrically" (lengthen instead of shorten). The muscles shorten when you push off, but they lengthen whilst you are in mid air in the double swing (or floating phase). See picture below.

This causes an accumulation of microscopic damage to your muscles. It's this eccentric contraction that causes delayed onset of muscle soreness (or DOMs).

The above mentioned study of the marathon runners showed that the eccentric contractions can literally hobble you during the race. Runners whose pace dropped more than 15 percent from the beginning to the end of the race had levels of creatine kinase and myoglobin (both are by products of muscle damage measured in blood tests) 53 and 112 percent higher than the runners who managed to maintain a steadier pace.

When I read the paper, my first thoughts was that the runners who faded did not train enough as those who didn't. However, the researchers suggested that age, running experience and training were not significant enough to explain the differences.

The authors suggested three ways to prevent fading in your next marathon.

Doing your long run close to your target marathon pace is crucial to get your muscles stronger. A 30 km run at or close to your target race pace three to four weeks before to simulate the effort will lessen the chance of muscle damage in the race.

Due to the "repeated bout effect", it will be harder to trigger as much muscle damage once they have recovered. You will need to run harder or faster to trigger similar damage.

The second way to increase your ability to withstand eccentric muscle damage is with weight (or resistance) training. Eccentric lunges and squats of at least 80 percent of the heaviest weight you can lift will help prevent damage to your muscles. Do the weight training twice a week during your training cycle and cut back to once a week when you are tapering for the race.

Be sure to practice downhill running if your race has downhill sections. Running downhill causes lots of eccentric contractions, a sure fire way of triggering muscle damage. Experiment with your stride to find the best way of descending as lightly as possible to minimize the muscle damage.


Del Coso J, Fernandez De Velasco D et al (2013). Running Pace Decrease During A Marathon Is Positively Related To Blood Markers Of Muscle Damage. PLoS One. 8(2): e57602. DOI: 10/1371/journal.pone.0057602.

Saturday, September 23, 2017

FFTT - Floss Band, Foam Roller, Trigger Ball And Taping

Underwrap? To explain fascia?
It's been a few months since we had our last floss band course. I was told by Jane we had eight previous courses so far.

After the last course Jane mentioned to me that many people have asked about the benefits and especially differences between using the Floss band, foam roller, trigger ball and taping.

She told me my new task was to effectively address how FFTT - floss band, foam roller, trigger ball and taping can be effective (or not depending on how you use them) in treating myofascial pain, addressing adhesion/ knots in fascia and improving range of motion.

Talking about fascia
We spent lots of time on the anatomy of fascia. After explaining how to effectively move fascia, we went on to the practical part of the course. Demonstrations using the floss band, foam roller, trigger ball were shown.
Marc helping with the foam roller demo
For the taping bit, I just showed the class pictures. You've got to come to our Kinesio Taping course if you want to learn the taping techniques.

Let me also mentioned that other than Kinesio TapingFunctional Fascial Taping (or FFT) using rigid sports tape too can influence fascia.

Functional fascial taping for the knee
Ron Alexander who used to treat the Australian Ballet dancers developed the technique while working with the ballet dancers.  If you've attended the course, you will know how much you need to "gather" or pull the tape. In Kinesio Taping, the ability of the Kinesio tape to recoil does the work for you.

Once again, chapeau to Jane, Danny and Ekina for coming to get the place ready and for helping me to pack up too. I wouldn't have gotten ready in time to teach without their help. Please contact them at Sanctband Singapore if you are keen to find out more.

Thank you also all the physiotherapy students, physiotherapists, Terrance Yap from Atlas Chiropractic, the teachers from Nanyang Junior College and the rest who attended the course today. Hope you found it useful.
Getting Tang from NYJC to march
The physiotherapy students and their discussion
Gek Han deep in thought
Gurmit comfy on the floor

Friday, September 22, 2017

Kinesio Taping For F45 Trainers

Demonstrating how it's done
By special request, our clinic organized a special "Introduction to Kinesio Taping" session for F45 trainers from Holland Village and Novena.

The trainers from both F45 have had their fair share of injuries and have some basic knowledge of taping. They were very keen on the session and thought it would be great to get some pointers.
Explaining "recoil"
Of course the session touched on understanding concepts rather than just dishing out recipes on how to tape. That's always how we organize these sessions and the actual Kinesio Taping Level 1-2 courses.

Please contact us if you're interested to learn more.

Saturday, September 16, 2017

Today's Straits Times Article On Hydration

Straits Times article 160917 page C13 under Sport section
Every morning when I pick up the newspapers, I'll usually turn to the sports section first. Today, I happened to look at the article on the training plan for those planning to run the Singapore marathon at the end of the year. "Right hydration integral to a successful race". I thought the article was well written. Fairly straight forward and simple to understand. Also mentioned that over drinking water can lead to hyponatremia.

Wrote about sports drinks. Though you need to know that sports drinks cannot replace or even maintain your sodium levels during exercise or racing.

Just wanted to point out that the two percent loss of body weight (through sweating) during endurance exercise/ racing affecting your performance may not be totally accurate.

I wrote about it before earlier in the year that latest published research suggest that current hydration guidelines may well be wrong.

Two published studies on cyclists and elite male marathoners (including Haile Gabreselassie during 13 major city marathons) showed that weight loss up to three percent did not slow the runners down nor decreased the cyclist's power output.

In fact Gabreselassie lost 9.8 percent of his body weight during the 2009 Dubai marathon and still won the race in 2:05:29 hours! All drinking by the elite runners were ad libitm (or at their own time and pleasure).

Yes I do agree that the quoted study was done on elite runners. How does that apply to us in super humid and sunny Singapore?

My own thoughts are that the sports drink companies definitely recommend us to drink to much. I wrote before that I definitely drink less than my fellow team mates and competitors. From the time I started running cross country as a twelve year old kid to when I was racing triathlons. Even now during my weekly group bike ride. Most of the other cyclists carry two or more water bottles while I survive the three hour ride on one.

In fact I often had a side stitch after drinking while running cross country as a kid. That also deterred me from drinking too much then.

Of course this does not mean you try not to drink at all in your next long run/ ride and especially your next race. What I'm suggesting is that you at least give it a try in your next few long bike or run sessions.  Everyone is different. Try to get through those long sessions drinking as little as you can. You might be pleasantly surprised that you may not need as much fluid as you think.


Beis LY, Wright-Whyte M, et al (2012). Drinking Behaviours Of Elite Male Runners During Marathon Competition. Clin J Sport Med. 22(3): 254-261. DOI: 10.1097/JSM.0b013e31824a55d7.

Wall BA, Watson G et al (2015). Current Hydration Guidelines Are Erroneus: Dehydration Does Not Impair Performance In The Heat. BJSM. 49(16): 1077-1083.

Friday, September 8, 2017

Lumbar Spondylolisthesis But No Real Deficits So Far

Have a look at the MRI and you can see a very obvious spondylolisthesis in my 38 year old patient's lumbar spine at the L5-S1 area. The last time I saw one so obvious was when I was working at the Singapore Sports Institute in a young gymnast in 2001.

Spondylolisthelis is a condition in which one vertebra slides forward over the vertebra below it. In simple terms, it means that there is a forward slip of one vertebra relative to another.

From what my patient says, there wasn't any traumatic incidents. He complains of lumbar area aches in the past year.  Often there is discomfort over his L buttock and tightness down his L outer thigh at the end of the day. He is still able to exercise including running and playing football. Other than that he hardly has any other symptoms.

His surgeon has suggested surgical intervention to stabilize his spine at the end of next month. Looks like lots of rehab after surgery.

Saturday, September 2, 2017

How Singapore Can Solve Our Diabetes Problem

In our National Day Rally, Prime Minister Lee Hsien Loong highlighted that 1 in 9 Singaporeans has diabetes. And of these, an average of 1200 undergo amputations every year!

I was quite shocked at the sobering figures that he cited. Three in 10 Singaporeans above the age of 60 have diabetes. If you break in down by race, 2.5 in 10 Chinese over 60 have diabetes, half of Malays over 60 years old and six in 10 Indians over 60 are affected.

PM Lee then urged Singaporeans to get regular medical check ups to know if they are diabetic or are at risk and suggested solutions to counter it. He then recommended that Singaporeans exercise more, suggesting that the easiest way to do so is "just walk  a little bit more every day".

If possible, I would definitely suggest including weight training (also known as strength training or resistance training).

In case you think weight training is only for bodybuilders pumping iron for beefy biceps and bulging pecs, current evidence shows that weight training - whether with a light dumbbell or your own body weight may be the best exercise for lifelong overall function and fitness.

Here's what most important. Research has shown that weight training helps with improved insulin sensitivity among people with diabetes and pre diabetes. Twice weekly weight training sessions helped control insulin swings (and body weight) among older men with type-2 diabetes.

During weight training, our muscles are rapidly using glucose (or blood sugar). This energy consumption continues even after you finish your strength training session. This is especially beneficial for anyone at risk for metabolic conditions like Type-2 diabetes, high blood pressure, and unhealthy cholesterol levels making weight training the most effective remedy.

In addition, weight training can strengthen our bones and improve our posture through bone remodeling. Weight training stimulates the osteoblasts (bone building cells) to build more bone. Weight training is also superior to aerobic exercise for enhancing and maintaining total body bone strength. And that's probably another post.

That's why I bought a Olympic bar, squat rack and got some free weights earlier this year as I realize I was losing muscle mass.
Showing my boy how it's done


Ibanez J, Izquierdo M et al (2005). Twice-Weekly Progressive Resistance Training Decreases Abdominal Fat And Improves Insulin Sensitivity In Older Men With Type 2 Diabetes. Diabetes Care. 28(3): 662-667. DOI: 10.2337/diacare.28.3.662.

Thursday, August 24, 2017

Kinesio Taping At Raffles Institution

A few weeks ago I received a call from the Physical Education Head at Raffles Junior College (or known as Raffles Institution now) to teach their PE teachers Kinesio Taping. They had seen an increase of self taping by their students in school especially during PE classes and/ or training sessions. They needed to know if the students were doing it correctly as most were just following instructions looking at youtube.

Just so you know, participants who have attended the Kinesio Level 1-2 courses must sign a disclaimer that they cannot post any videos of what they've learnt online. Hence, whatever videos you can find online are not the real Kinesio Taping techniques but are from other copycat or imitation tapes.

So there I was showing the PE teachers there from year 1 to 6 some pointers on how to tape. The emphasis was on understanding concepts rather then simply giving them "recipes" on how to tape.

We've had lots of people asking when Sports Solutions will be hosting the next Level 1-2 Kinesio Taping course where they even learn about what the homunculus has to do with Kinesio Taping.

Well, I was informed by Kinesio Taping International that they were tweaking the Level 1-2 course from June 2017 onward. They were making some changes to the course world wide. As of now, the Kinesio Taping Instructors recertification courses are slated to take place between October 2017 to January 2018 in USA, South America, Europe and Asia.

I need to clarify some of the content changes at the next Kinesio Taping Instructor Recertification course that I will only attend in early January 2018. I want to ensure that I'm not shortchanging the future participants that I teach. Hence, I've decided I'll only teach the next Level 1-2 course after I've attended the next Instructors Re-certification early next year.

Yes, Kinesio Taping Instructors have to re-certify themselves every three years to be able to keep teaching.

We will definitely inform those who keen to attend the next Kinesio Level 1-2 taping course on our website and Facebook page when dates are finalized.

Saturday, August 19, 2017

Can Sports Injuries Lead to Osteoarthritis In Your Joints?

Picture by Liji Jinaraj from Flickr
The first question I get always get asked when an injured athlete sees me in our clinic is "How quickly can I get back to training?"

Actually it's not just the athletes, every single weekend warrior or physically active patient that I see will ask when they can get back to their usual activity or exercise.

I'm guilty of doing the same. That's exactly what I asked my doctor after my bicycle accident.

There is now evidence to show that if you rush to get back to playing, whether as part of a team or elite sport or simply just your usual weekly recreational tennis game or jogging you may not allow the injured joint to heal fully.

Adequate recovery includes strengthening the structures the support the injured joint. This will allow joint stability to reduce risk of re-injury and stave off irreparable joint damage. If you're not careful, irreparable joint damage can eventually lead to post traumatic osteoarthritis (OA).

OA is a degenerative joint disease. It happens when the protective articular cartilage lining the surfaces of bones wear out. This causes pain, stiffness, swelling and often disability that diminishes one's quality of life.

Post traumatic OA don't just happen to older patients. It can affect adolescents or young adults too.

Researchers suggest that acute joint damage can lead to a deterioration of the surface of the bone itself and structures that cushion and stabilize bones of a joint like the knee (Anderson et al, 2012).

That same study found that OA can develop in more than 40 percent of people who seriously injure their ligaments, the meniscus in the knee or articular surface of a joint.

They also found that people with a history of knee trauma are three to six times more likely to develop knee OA.

In order to better manage post traumatic OA, a group of Athletic Trainers (ATC) has suggested a more aggressive approach to both preventing and managing post traumatic OA. Especially in younger patients who get injured playing sports.

They suggested that having less deficits (between both legs) in muscle strength, endurance, balance movement quality and stability will reduce a person's risk of getting injured. After the initial injury, it should be properly managed to prevent additional injuries to the same joint or other joints to minimize OA developing. Ideally a structured rehab program should be maintained for six to nine months.

So don't be too impatient to return to your usual physical activity especially after a joint injury. You may have to modify the activities you do in order not to place unnecessary repetitive stress on the injured joint. Remember our articular cartilage likes and needs weight bearing forces for nutrition. Inactivity will cause the articular cartilage to deteriorate.


Anderson DD, Chubinskaya S, Guilak F et al (2012). Post-traumatic Osteoarthritis: Improved Understanding And Opportunities For Early Intervention. J Ortho Res. 29(6): 802-809. DOI: 10.1002/jor.21359

Palmeri-Smith RM, Cameron KL, DiStefano LJ et al (2017). The Role Of Athletic Trainers In Preventing And Managing Post Traumatic Osteoarthritis In Physically Active Populations: A Consensus Statement Of The Athletic Trainers' Osteoarthritis Consortium. J Athl Train. 52(6): 610-623. DOI: 10.4085/1062-6050-52.2.04.

Friday, August 11, 2017

Don't Drink The Pool Water!

During the last couple of days over National Day, we took a family staycation at the Goodwoodpark Hotel. I ended up spending lots of time in the pool with my two boys as you can see in the picture above. Probably ended up drinking some too.

Not the greatest thing to do if you read what Canadian researchers found when they tracked two public pools for three weeks. Olympic swimmers have admitted doing it and now evidence shows that the rest of the general public are doing it too.

Doing what? Peeing in the swimming pool that's what!

The researchers tracked the concentration of an artificial sweetener, acesulfame potassium (ACE), which is found commonly in processed food and passes through our bodies unaltered. Great for the researchers if you happen to eat processed food and pee in public pools.

By tracking ACE levels, the researchers calculated that swimmers released 75 litres of urine (enough to fill a medium sized dustbin) in the first public pool (830,000 litres, about one-third the size of an Olympic pool).

There was 30 litres of urine in the second public pool, which was around half the size of the first pool over this two week period.

The research team sampled a total 31 different swimming pools and eight hotel jacuzzi hot tubs in two Canadian cities. ACE was present in 100% of the pools and hot tubs!

Number of pool visitors were not monitored, but the results also suggested that urine content in the pool was added several times each day.

If you thought that the pool readings were bad, measurement in the eight jacuzzi hot tubs were much higher. One particular hotel jacuzzi had more than three times ACE levels than the worst swimming pool.

Just so you know, urine is sterile, but the compounds in urine (urea, ammonia and creatinine) can react with pool disinfectants cause eye and respiratory irritation. Long term exposure to these compounds has been linked to asthma.

The results were not surprising as another anonymous survey showed that 19% of adults polled admitted to having urinated in a swimming pool at least once. Professional swimmers have confessed to being among the worst offenders.

Have you ever peed in a swimming pool? Hmmm, let me ask Jo Schooling when he next comes and sees me in the clinic.


Blackstock LKJ, Wang W et al (2017). Sweetened Swimming Pools And Hot Tubs. Environ Sci Technol. 4(4): 149-153. DOI: 10.1021/acs.estlett.7b0043.

Wiant C (2012). New Public Survey Reveals Swimmer Hygiene Attitudes And Practices. Int J Aquatic Research Edu. 6(3): Article 4.

Researchers Lindsay Blackstock and Xing Fang Li testing for ACE

Saturday, August 5, 2017

Joseph Schooling At Sports Solutions

Jo at Sports Solutions
For the past few days, our staff were already talking about taking pictures with him when they saw his name booked in for an appointment in our clinic today.

I was treating another patient when Jo arrived, so Jo went to see Aized for his appointment. My next patient was running late so I went to say hello to Jo. Aized said the first question he asked was "Where's Uncle Gino?"

Yes "Uncle Gino" is what Jo still calls me. We used to swim together from 2004 until early 2008 when we were both swimming at the Center of Excellence (COE) under coaches John Dempsey,  Au Yong Kim Moon and Herbert Yu. I used to treat all the swimmers there including Jo.

That was my agreement with head coach John Dempsey. He would allow me to swim with the COE swimmers (while I was still training for triathlons) on the condition that I treat all the swimmers who needed help.

In fact I first treated him at a swim meet in Kuala Lumpur, Malaysia in 2004. Jo used to kick my behind in the pool even when he was nine years young!

Great seeing you today Jo! As Aized said, our pleasure and honor to be treating you when you're home.

Saturday, July 29, 2017

Rhabdomyolysis - The Scary Side Effects Of Exercise

My patient just attended her first spin class with her colleagues. Prior to this, she's been running and wakeboarding for exercise.

The doors to the studio were shut, while the air conditioning was turned off. Other than that, she didn't find pedaling fast on the stationary bike to rhythms of popular music while an instructor shouted motivation too difficult. Neither did she feel she pushed herself too hard. Her legs at the end of the hour long class weren't too sore or wobbly afterwards.

Over the next two days, her legs started throbbing and she came into the clinic to see me. I noticed bruises on her thighs and asked if she knocked them against the stationary bike. She said she didn't recall that happening.

The next day she noticed blood in her urine and checked herself into a hospital where she was warded and after blood and urine tests and was told her she had rhabdomyolysis.

Rhabdomyolysis is rare but can be a life threatening condition often caused by extreme exercise. It occurs when muscles that have been overworked dies and leak their contents into the bloodstream. This strains the kidneys and can cause severe pain.

My patient ended up staying in hospital for a few days before being discharged and has since recovered.

Subsequently I saw an article that documented three unusual cases of rhabdomyolysis, each occurring after a first spin class all treated by the same doctors (Brogan et al, 2017).

The article also described 46 other cases of people developing rhabdomyolysis after a spin class (42 of them in people taking their first spin class). The authors wrote that the condition was rare and not a reason to avoid high intensity exercise.

Another published study found 29 cases admitted to the emergency department between 2010-2014 for exercise induced rhabdomyolysis. Weight lifting, running, cross fit were some of the causes, but the most common cause was spinning classes!

The patients were not unfit, they were in fact being pushed too hard. Since they were not used to the new exercise, they ended up getting really bad muscle trauma.

Remember this next time you try a new exercise. Rhabdomyolysis occurs when you do not give your muscles time to adjust to a new aggressive exercise. When you stress your muscles too much, they tend to break down, releasing contents like myoglobin into your bloodstream which causes brown or tea colored urine, a classic symptom of rhabdomyolysis.

While any intense activity can cause rhabdomyolysis, it almost always strikes the person doing something new. So when you try a new exercise, start moderately first.

Know your limits, don't be pressured by the instructor. You can stop the exercise if you're struggling. Exercise can be dangerous when your body is not prepared for really intense levels.


Brogan M, Ledesma R et al (2017). Freebie Rhabdomyolysis: A Public Health Concern, Spin Class-Induced Rhabdomyolysis. AJM. 130(4): 484-487. DOI: 10.106/j.amjmed.2016.11.004.

Cutler TS, DeFilippis EM et al  (2016). Increasing Incidence And Unique Clinical Characteristics Of Spinning-induced Rhabdomyolysis. Clin J Sp Med. 26(5): 429-431. DOI: 10.1097/JSM.0000000000000281.

Here's a picture of a spin class.

Picture from

Friday, July 14, 2017

How Healthy Are Elite Athletes?

Taken with my iPhone off my computer from
Compared to most people in the general population yes, elite athletes are very healthy if you read the article by Lemez et al (2015). However, this is a controversial topic that has been debated for years by athletes themselves, coaches and researchers.

I'm sure you've watched the riders at the Tour De France or the athletes competing at the Olympics. At these competitions, they usually rested and focused, look lean, powerful, slick and bursting with energy.

Can you guess how much it took for them to get there? All the grueling training and obsessive dedication required to reach those levels. Is at good for them? Will that pursuit of sustained excellence damage their health?

The answer depends on how you define health and who you compare elite athletes to.The findings from the comprehensive review on mortality and longevity in elite athletes is very clear. Elite athletes fare better than everyone else when it comes to longevity and disease if you define health as "the absence of disease and the capacity to enjoy life and withstand challenges."

That article by Lemaz et al (2015) examined more than 450, 000 athletes and found that elite athletes live four to eight years longer when compared to an equally matched control group in the general population.

Athletes who competed in running, cycling, soccer and swimming (sports with high aerobic demands) had the greatest benefits. Those athletes have lower rates of heart disease, stroke and smoke related cancers. The Tour de France cyclists for example have a 40 percent lower mortality rate than non athletes.

See how skinny he is (taken from
The other element of health is psychological, the question of enjoyment in life. That is difficult to quantify and answer.

Some studies show that elite athletes have better mental health after their retirement from elite sports. This may be due to the resilience they developed while competing or that exercise itself (trumps medication when treating depression).

However, other studies show comparable rates or even potentially increased risk for mental health issues. This is actually also dependent on the support the elite athletes received during their athletic career and early retirement (Rice et al, 2016).

Similar to an overworked doctor in the emergency department, corporate lawyer or investment banker, elite athletes often put into situations that require them to sacrifice a lot for their mind and body.

The best endurance athletes will push their bodies and their minds as far as humanly possible and this may not be good for them. If not controlled, that very same drive and determination that propels the elite athlete can eventually become harmful.


Lemez S, Baker J et al (2015). DO Elite Athletes Live Longer? A Systematic Review Of Mortality And Longevity In Elite Athletes. Sports Med Open. DOI: 10.1186/s40798-015-0024-x.

Rice SM, Purcell R et al (2016). The Mental Health Of Elite Athletes: A Narrative Systematic Review. Sports Med. 46(9): 1333-1353. DOI: 10.1007/s40279-016-0492-2.

Monday, July 10, 2017

Rise In Singapore Teenagers' Use Of Steroids?

"Muscular kids" gym bound at Holland V MRT today
I was a little annoyed with myself when I saw the Channel NewsAsia (CNA) headline on their website this morning.

I actually read about a similar report in the Journal of the American Medical Association (JAMA) just two weeks ago and was going to write about it but I got sick last week and didn't write it yet. So CNA beat me to it. 

Well, my wife told me the journalist (from CNA) does this for a living, whereas I am just a Physiotherapist. So it's already good I have the ideas (but not the time to write it). Grrrrrrr, guess I have to blame it on the fact that our whole family fell sick recently. 

Next time .....

So what does an American journal finding got to do with our local youths?

Well, ever since Holland village has sprouted three gyms, I've noticed a lot more "muscular kids" walking around. Yes, we do have three gyms right here in Holland Village. First F45 set up shop, followed by Ritual gym  and then Virgin Active opened it's doors recently.

Similar to the American article, it may be a widespread misconception that anabolic steroids is only an issue in elite sports. Both the American article and the Channel NewsAsia article suggest that there may be more anabolic steroid users among our teenagers. The Jama article suggest that "most young men using these drugs are doing it to improve their appearance."

Personally, I don't think it's a new problem. I've definitely had cases of teenage bodybuilders and young adults see me in our clinics for sports injuries (and telling me in strict confidence of course) that they've been injecting themselves with anabolic steroids. And that's all I'm gonna say.


Pope HG Jr, Khalsa JH et al (2017). Body Image Disorders And Abuse Of Anabolic-Andrrogenic Steroids Among Men. JAMA. 317(1): 23-24. DOI: 10.1001/jama.2016.17441