Sunday, August 26, 2018

Don't Turn Childhood Into A Race

Picture by RS from Flickr
I didn't expect my article on not to force your teenage athletes to be so well received. I received many requests to share the article and comments from readers and patients alike.

And in the clinic, there were patients who asked me about that article. Turns out one of those conversations became the inspiration for this week's post.

One of my patients had been deciding whether or not to go for football practice. Not her or her husband but their two boys. The commitment required though makes it seem like the whole family is involved. Even their helper helps to pitch in by making sandwiches and sports drinks (although I thought they were a little young for sports drinks).

The twice weekly practices, requiring a 30 minute drive one way ends quite late on a week day leaving just enough time for dinner and bedtime (but not homework). The Saturday or Sunday practice often conflict with family lunches, birthday parties and family time for just lazing or goofing around at home.

Their boys are only six and eight and I feel they shouldn't be on such a "rigid" supervised program for sports (but that's just my opinion).

I've read from articles in Red Sports and the Straits Times that increasingly for children in Singapore, kids start playing organized team sports younger. They are often encouraged to specialize in a single sport sooner than later. Especially those kids who are hoping to enroll in a school of their choice under the Direct School Admission (DSA) scheme.

This creates pressure for kids to be proficient and exceptional only at one sport. When I was in primary school, I played table tennis, football, basketball, badminton and also competed in the running events during my school sports day and won medals for all of them.

Now, I'm not disputing the fact that sports are very good for kids. When kids take part in sports, it teaches them teamwork, sportsmanship, improves their self esteem while letting them try risk taking (safely). And of course it makes them healthy and strong. Both physically and mentally.

I, for one have seen first hand (while treating these young athletes) that these children/ teenagers who focus too early on a single sport lose interest when the going gets tough. They're often more prone to injury, stress and burnout.They sometimes fail to develop basic movement skills. Just watch a bunch of young elite swimmers (no disrespect intended) play basketball or football.

In today's Straits Times, in an article on why we should not turn childhood into a race for results, the author wrote about how US Olympian Katie Ledecky describe swimming as "really just for her still a hobby". She has by the age of 21 won five Olympic gold medals and a silver, owns six world records and a US$7 million dollar deal with a swimwear company.

She was quoted in a New York Times article saying "I feel lucky that I could enjoy swimming," and "people need to relax ... and take a step back and realize that you don't have to be great at this young age. It's not about immediate results". Ledecky said she recalled she had not raced in events longer than 25 yards (22.9 metres) until she was eight years old.

My observations mirror those of studies published. Kids who wait until their older teenage years to specialize are better all round athletes and more likely to stick with sports and continue to be active throughout their life.

So what's the solution? Try to do everything in moderation. If your child is keen on a single sport, try mixing other activities on their off days. Make sure they have off (or total rest) days.

My own two boys do lots of outdoor free play- climbing, jumping and running around in the playground nearby. Other than football once a week for the older boy (at his request) there are no other art, music or other enrichment activities for both of them.

I suggest that your child should not be involved in more hours of organized sports than their age. Expose them to as many different options as possible while waiting as long as you can to find a sport for them to specialize. Then you can support them as much as possible.

We also value adventure in our family. My wife and I hope that our boys will be competent and enthusiastic outdoors. So we try to make sure they're climbing, hiking, going for nature walks and biking. Travelling and farm stays (which the boys love) will remain an essential time for our family and this keeps us connected and is a welcome change to our over scheduled wired and connected world.

Competitions? Do your best to keep them in perspective. Your goal as a parent is not to raise an Olympic athlete but to raise a nice child that grows into a nicer, well balanced human being who will contribute to society.

ST article 260818

Sunday, August 19, 2018

McConnell Taping Versus Kinesio Taping

Me holding court
Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques started with me reviewing material we had gone through yesterday on Day 1.

After that we went straight into material for Day 2 and some of the questions the participants asked was how Mechanical Correction taping from Kinesio Taping would fare against Jenny McConnell's McConnell taping for the knee. Yes, Jenny McConnell's taping technique was first published (and made famous) in the Physiotherapy Journal way back in 1986. I remember reading the article and using the taping technique before.

McConnell's taping (L) vs Kinesio Taping
Here's a close up of what I did for Michelle's knees.
McConnell's on the (L)
No prizes for guessing which came out tops.
Michelle's happy
We had many fruitful clinical discussions on applications for the Medial Collateral Ligament (MCL), pes anserinus area, the Achilles tendon and of course the plantar fascia.

With the physiotherapy students
The four Physiotherapy students from SIT requested taking a picture with me after the course. Thanks for coming Sara, Mark, Priscilla and Dominic. The pleasure is all mine.

Group picture
A big thank to all for coming, especially to Nada and Faisal from Saudi Arabia, Tim from Loue Bicycles, Nisa and the Physiotherapy students and teachers, hope it was useful for everyone.

Saturday, August 18, 2018

You Two Came All The Way From Saudi Arabia?

Nada from Saudi Arabia
We have 2 overseas participants this time, all the way from Saudi Arabia as Sports Solutions hosted Day 1 of the Kinesio Taping Asessments, Fundamental Concepts and Techniques course today. Thanks to Nicole Montes from Kinesio USA for putting my course details on their website.

Tensegrity model
We began our day with some lessons on anatomy and discussions on how the tape works, the homunculus, the tensegrity model and the Pain Gate Theory amongst others. Yes, I did explain about the how that original 1965 paper by Ronald Melzack and Patrick Wall may still be very relevant in some ways presently.

After all that talking, it was of course time for the practical.

Where's his head?

Here you go
Stay tuned for Day 2 tomorrow.

Friday, August 10, 2018

Fat Pad Most Painful In The Knee?

I had a patient who came to our clinic recently complaining that his MRI showed that his patella (knee cap) cartilage had "worn out" completely but he didn't have any pain prior to that. He had actually gone to do his MRI under his doctor's insistence for investigating something else.

His  MRI results was like in his words "opening a can of worms" telling him what's wrong with his knees and perhaps that's why he started having pain after that.

After his ranting, I had to explain very thoroughly about the structures in our knees that cause the most pain. The information I gave him was derived from an article published quite a while ago in the American Journal of Sports Medicine but still very relevant today.

The doctors in that study came up with a simple method to document the various sensations felt inside a single subject's knees one week apart. Right knee first, followed by the left a week later. (Note that the subject had no prior knee pain).

They would arthroscopically poke/ palpate (using a specially built spring loaded device) different structures inside the knee while video recording the procedure and record what the subject's response was. Force used was between 0 to 500 grams. All this done without intra articular anesthesia. Ouch! That must really hurt.

The doctors only injected local anesthesia at the portal site (incision). The first author inspected both knees arthroscopically. He asked the patient when he poked at different structures and graded the sensation as follows (0) no sensation; (1) was non painful awareness; (2) slight discomfort; (3) moderate discomfort and (4) severe pain. This was done with with a modifier of either accurate spatial localization (A) or poor spatial localization (B).

Ready for the results? They were exactly the same for both knees. Even though it was done one week apart.

Palpation of the patellar articular cartilage in the three under surfaces (central ridge, medial and lateral facets) resulted in no sensation, or a 0 score, even with a strongest force of 500 grams. Palpation of the odd facets elicited a score of 1B. Asymptomatic grade II or III chondromalacia (wearing out) of the central ridge was identified on both patellas of the subject!

Palpation of the articular cartilage surfaces of the femoral condyles, trochlea, and tibial plateaus at 500 g of force universally produced a sensation of 1B to 2B.

The sensation from the meniscus ranged from 1B on the inner rim of the meniscus to to 3B near the capsular margin.

Sensation from the  cruciate liagaments (Anterior, posterior cruciate ligaments) range from 1-2B in the mid-portion of the ligaments and 3-4B at the insertion sites.

Palpation of the suprapatellar pouch, capsule, and the medial and lateral retinacula produced a score of 3A to 4A (moderate to severe localized pain) at relatively low levels of force (about 100 g).

The most painful structures were the anterior synovium of the knee, the fat pad and the joint capsule - 4A.

The human knee can be very complex, especially our patellofemoral joint (patella and the femur). The three asymnetrical surfaces on the underside of the patella (or knee cap) has to work together with the femur as it accepts, transfers and dissipates loads between the bones.

We know from previous research that various structures in the knee send neurosensory signals (or messages) to the brain. It is theses signals that result in us feeling pain.

Even though my patient's patella cartilage had worn out (just like the subject) there shouldn't be any pain there as articular cartilage doesn't have any nerve supply. No nerve endings means it is unable to detect pain.

Even the ACL and meniscus wasn't really that sensitive to the poking. This observation may provide an explanation for the often poor localization of structural damage that many patients experience with a cruciate ligament or meniscal injury.

Now you know, worn out articular cartilage doesn't cause you pain. The pain you have is likely to come from other structures. And you definitely don't need to ingest any glucosamine too.


SF Dye, GL Vaupel and CC Dye (1998). Conscious Neurosensory Mapping Of The Internal Structures Of The Human Knee Without Intraarticular Anesthesia. AM J Sp Med. 26(6): 773-777. DOI: 10.1177/03635465980260060601.
black and white version

Wednesday, August 1, 2018

PS Sim - Winner Of The Cameron Ultra-Trail 100 Km Race

Picture from PS Sim
PS kindly agreed to not remain anonymous anymore so I can finally write here that she is the runner who won the Cameron Ultra-Train 100 km race despite having plantar fasciitis (for the past six months at least). She came back to our clinic today to allow me to finish assessing her and treat the cause of her pain.

Actually, after my previous post, I've had questions from some readers already asking me what I did for PS and her plantar fasciitis.

Here's a summary of what I did for those asking. No ultrasound, no ESWT (shock wave) needed, no orthotics and no other gimmicks.

Just plain old accurate body reading and thorough assessment after the body reading pointed to clues around her hips being one of the main reasons to her pain in her plantar fascia. Other contributing factors also suggest that changing shoes and her foot type may have triggered it.

So, of course I started treating her hip first and also taught her what to do to prevent it from recurring. She needs to work at this still for the time being.

 I wrote in my last session with her that I only had time to treat parts of her foot along her Superficial Back Line (SBL) and The Spiral Line.
Superficial Back Line

I did more work on her SBL and also treated fascia along her Superficial Front Line today. After that I had to change her pelvic rotation and suggested she may want to try taping her foot (in case she was planning on starting training again).

Happy to discuss if anyone has questions.
Spiral Line
Congrats to PS once again for a race well won and to Melvin for winning PS.