Sunday, September 30, 2018

First She Wins 100 Km Race, Now PS Summits Cho Oyu (8201 Meters)

Remember PS, winner of the Cameron Ultra-Trail 100 km race who saw me for her plantar fasciitis three days before her race on 25th July 2018?

Here's another feather to her already impressive list of achievements. She recently climbed to the top of Cho Oyu, a 8201 m high mountain!

She sent me this message last night. Still pain free after seeing just two times for her plantar fasciitis. Once before Cameron Ultra-Trail 100 km race and once after she came home from the race.

Well done PS!!! Come home safely soon.

Sunday, September 23, 2018

Popping Vitamins Or Other Dietary Supplements?

I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.

PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.

Sunday, September 16, 2018

Mid Life Crisis In The Older Athlete?

Singapore National Games 2012 by RS from Flickr
I had a patient who recently turned 50 years young and decided that she would like to finish running a marathon. She had never ran much before (unless you count physical education classes in school) and she would consider herself pretty much inactive previously. She started training with a local running group, and within 6 weeks of training got injured and ended up seeing me in our clinic.

Here's a trend I've been noticing, a fair bit of participants in local races are above the ages of 40. I just looked up the results of the 2017 Singapore Triathlon and the 2018 Singapore OCBC National Road Race Cycling championships. The 40-49 age group has the largest number of participants and among the most competitive. I didn't look up the statistics, but with the number of participants we've treated in our clinic, I'm sure this is similar for the Spartan races too.

If you look up the 2018 Boston marathon results in April this year and last year's New York marathon the statistics are similar.

Research backs this up too. A research paper by Hoffman and Fogard (2012) found that the average age of participants in a 100 mile trail race was 44 years.

My 50 year old patient calls this urge to run her her first marathon her "mid-life crisis". I looked up "mid-life crisis". This concept was first presented in 1957 by Canadian psychologist Elliot Jacques to the British Psychoanalytical Society and later published as "Death and the Mid-life Crisis" in the International Journal of Psychoanalysis in 1965.

His theory was that as we approach middle age, we begin to realize our own mortality (or death) and we begin to freak out. As we grow older, we start to focus on how much time has passed, how much is left and what to do with whatever time is left. That can create anxiety and that anxiety can be multiplied by anxiety, depression and stress.

My 50 year old female patient says that unlike what you usually read or see in movies (where the older white guy buys a sports car and dates a younger girl in a desperate bid to feel young again), her "mid-life crisis" is to take on physical challenges.

Her goal is not to cling on to whatever is left of her "youth" or be young again. It is more about building up for the years ahead. Sounds like a good mid-life crisis to me.

Whether you are a young and older athlete, and starting a new game or beginning to exercise, pace yourself and start gently. There are big benefits from minimal running. However, if you do get injured, come and see us in our clinics.


Hoffman MD and Fogard K (2012). Demographic Characteristics Of 161-km Ultramarathon Runners. Research in Sp Med. 20(1): 59-69. DOI: 10.1080/15438627.2012.634707.

Sunday, September 9, 2018

Heat Acclimatization Can help Exercise Performance

Other than the heavy rain the last two days, it's been very hot recently. I used to love training and racing in the heat. Living in sunny and super humid Singapore meant that we're used to such conditions.

I'll often train in the hottest part of the day so that when race day came, whatever sweltering conditions encountered (on race morning) will seem like a breeze. There was a year (2001) when the Osim Singapore Triathlon was held in Sentosa and it was 38 degrees Celsius on race day and I used that advantage to finish 3rd overall behind Dimitry Gagg (former World Triathlon Champion in 1999).
On the podium with Dimitry Gagg in 2001
Turns out I may have been right in getting an edge over my competitors. And you can use that to your advantage too.

Heat is now hot! This shift towards heat training has been trending for the past few years. From running marathons to even climbing mountains, athletes around the world have been trying to get potential performance benefits of heat training.

Many of these heat studies started because of the 2008 Beijing Olympics. Many runners were preparing for the sweltering conditions and that lead to a whole lot more research done on heat acclimatization.

There are even studies of using heat therapy to fight heart disease and repair muscles.

Most heat acclimatization protocols help athletes perform better in the heat. This includes lowering core body temperatures, increasing perspiration rates and increasing volume of blood.

And what if after all that training in the heat race day wasn't hot? What if race day turns out to be as cold as the 2018 Boston marathon?

Fret not, results of a study (Lorenzo et al, 2010) on whether being well adapted to heat might affect your performance in cool conditions put that worry to rest. Scientists had cyclists train for ten days in 41 degrees Celsius (105.8 degrees Fahrenheit). Their VO2 max improved by 5 percent while their one-hour time trialing performance improved by 6 percent! This was when they were tested at 12.8 degrees Celsius (55 degrees Fahrenheit). Just in case you were wondering, they improved by 8 percent in hot conditions for both VO2 max and the one hour time-trial.

Control group cyclists had no improvements in V02 max, one-hour time trial performance, lactate threshold and other physiological parameters.

Suddenly, hot rooms, saunas and even non breathable training suits were the latest must haves and even suggested to be a cheaper and more convenient alternative to altitude training.

When it is too hot, it is a shock to our system. This is similar to what happens to our system when we exercise or train in altitude.

When we exercise in altitude, the decrease in oxygen triggers the body to produce more red blood cells. Heat training increases the volume of blood plasma in our bodies and this help send more oxygen to our muscles.

However, it is not totally certain that increasing blood plasma volume may lead to improved athletic performance. What may happen from the resulting dilution of blood is that it may trigger a natural response for the body to produce new red blood cells - just like altitude training.

Training in hot conditions does not only change blood plasma. Other benefits include psychological resilience (or the ability to endure) and altered perception of high temperature. Just like what I intended for by training in the hottest part of the day.

Before you head out and train yourself silly in the heat, make sure you gradually increase your intensity and heat exposure. Drink enough but do not overdrink.


Lorenzo S, Halliwill JR et al (2010). Heat Acclimation Improves Exercise Performance. J App Physiology. 109(4): 1140-1147. DOI: 10.1152/japplphysiol.00495.2010.

Saturday, September 1, 2018

Can Your Calf Muscle Cause Your Knee To Hurt?

Now that's some very defined soleus muscles
Really? You must be wondering how and why after looking at the title of this week's post. Well, my last patient today had knee pain caused by her soleus (or calf) muscle. She had recently been doing a lot of step ups in her gym classes and her knee pain started soon after.

Runners' knee or patellofemoral joint pain (pain under the kneecap) is very common in runners. I've written before about how this may be due to heel striking, heavy landing and hip dysfunction.

There is also some evidence where the length of the soleus muscle can influence patellofemoral joint pain (PFP). It has been suggested that in runners with PFP, there is a greater activation in the muscle compared to runners without knee pain (Piva et al, 2005).
See soleus after you cut away gastrocnemius
Your calf muscles consist of the more superficial gastrocnemius muscles and the deeper soleus muscle. If you peel off the gastrocnemius muscles, the soleus muscle lies underneath. Together they end as the Achilles tendon finishing at the heel bone (picture above).

The soleus muscle is largely thought to help with our posture as it is mostly made up of Type I slow twitch muscle fibres. The gastrocnemius muscle is made up of mainly Type II fast twitch fibres.

The fast twitch muscles of the gastrocnemius allows you to sprint. However, the gastrocnemius muscles tire easily.

The slow twitch soleus muscle is very important for your walking and running. Since they're more fatigue resistant, you use them a lot chalking up mileage whenever you run.

One of the main functions of the calf muscles is to absorb shock. If they're overused, they can't absorb shock well, your knee takes more of the load and you get knee pain.

A very simple way to take load off your soleus muscle is to take smaller steps when walking or running. Increasing your step rate, especially while running will ensure you're not over striding and heel striking. This reduces impact loading and lessens your chances of knee pain.


Piva SR, Goodnite EA et al (2005). Strength Around The Hip And Flexibility Of Soft Tissues In Individuals With And Without Patellofemoral Pain Syndrome. JOSPT. 35(2): 793-801. DOI: 10.2519/jospt.2005.35.12.793.