Friday, November 29, 2019

Lunch With The Team

Sham is right behind
Staff from our clinics came together for lunch today at Real Food at Orchard Central today. It was great to be able to see everybody at the same time, catch up, share stories and of course talk in front of the bosses (rather than just talking behind their backs). Just kidding!

Some were late, others got lost finding their way while some others weren't sure what to order at this vegan/ vegetarian restaurant. But somehow we all managed. Since my accidentAized has been super careful about what we eat. So no surprises that she chose this place.

While waiting for everyone, we took some pictures first of course.
Romaiza early for once ....
We're always early
Incidentally, this lunch doubles up to celebrate Sports Solutions turning 10 earlier in October this year as well.

Thanks to everyone who came and for those who couldn't make it, hope you can make it the next time. Have a great remaining rest of the year.
No meat!

Wednesday, November 27, 2019

Herlene's Going To The SEA Games

Unlike Herlene, I'm not going to the SEA Games in Philippines this time. Not as an athlete nor as a physiotherapist for Team Singapore. The last time I went to the Philippines I competed in the triathlon event in 2005.

But one of my patient's, Herlene is going to the SEA Games as a member of the triathlon and duathlon relay teams. I've treated Herlene since she was in Primary school. She came to see me today for a final tune up session.

So I took the opportunity to get a picture with her first before she leaves for the games on Friday.
Herlene was featured in the Straits Times on Monday 251119.

All the best at the games Herlene! We will be rooting for you.

Monday, November 25, 2019

The Correct Touch Is Really Important

My patient said to me that she will never see that doctor again. She was annoyed that despite her complaining of pain in her knees, he did not even bother to examine her. There was no eye contact from him at all too. He told her brusquely that she had runner's knee and should not be running. The Sports Doctor then prescribed her some pain medication and referred her for physiotherapy.

She had gone to the physiotherapist referred but did not get better. Her friend suggested that she come to our clinic since the referred physiotherapist was not a runner as well. So here she was in our clinic.

Like I've written previously, I can never be totally sure of a patient's condition if I don't assess them properly. All patients need and deserve gentle and thoughtful treatment. However, healthcare is evolving and become more businesslike. However, that human touch is still really important.

We should never take for granted that our patients give us consent to touch them to be able to assess them. Especially now in an era of electronic medical records, doctors and other health care practitioners may spend most of the allocated appointment time staring at a computer screen, tablet or looking at MRI reports.

I'm so glad that Dr Abraham Verghese, a professor at Stanford University's School of Medicine still prefers "the bedside chat, the old fashioned physical exam and the power of informed observation".

In his 2011 TED Talk, he said that by shortening the physical examination, doctors will lose a ritual that is transformative, transcendent and at the heart of the physician patient relationship.

Of course there are instances when patients are in pain and/or anxious, they will be much more guarded. Definitely patients of sexual abuse or assault may cringe at the lightest touch.

I have on many different occasions seen a patient come in for say neck pain but had a worried look that seems disconnected from their physical problem. After assessing and/or treating them and asking them if they are alright they become tearful and mention a family death, possible relationship problems or financial difficulties. That placing of hands, that human touch was the catalyst that allowed the patient to open up and release the pent up emotions.

With that human touch, we can comfort, diagnose and bring about treatment.

Be careful with your touch. It can show gentleness, compassion and heal someone. Or it can show roughness, carelessness or even incompetence.

Sunday, November 17, 2019

Help! I Have A Snapping Hip

Yesterday, I saw a 13 year old boy who was brought to our clinic by his parents as he had knee pain as well as a "snapping" hip on the same side. After joining the school's softball team earlier this year, he had trained a fair bit more than in primary school.

He recently developed right knee pain and had a year's history of pain and "snapping" in his right hip. He had previously seen a chiropractor for the last few months. Treatment consisted of  stretching the hip flexors, the Iliotibial band (ITB) and manipulating his hip and spine. He did not get any better after all the treatment with the chiropractor.

I assessed him and confirmed that his knee pain was coming from his tibial tuberosity and indicative of doing too much too soon. That's not too difficult to manage. He definitely had a case of Osgood Schlatter's in his right knee.

There was no pain with clicking in his hip. Nor was locking observed at end of range hip flexion with added internal or external rotation (this rules out hip labral tear). Range of movement in his back, hips, knees and ankles was normal and symmetrical.

There was weakness in his right Gluteus Medius muscle, also his painful knee and snapping hip side, despite that being his dominant side. This greater contralateral pelvic drop was confirmed while watching him run.

The "snapping hip" sound was reproduced over his right greater trochanter when he was in left side lying when I straightened and bent his right hip. It was a fairly loud "clicking" and/or "snapping" sound each time I bent and straightened his hip. There was some local tenderness over his Gluteus Medius, Gluteus Maximus and Tensor Fascia Lata muscles and over the greater trochanter itself.

Snapping hip on outside part of R hip
This explained his "snapping hip" on the outer part of his hip. While my young patient did have pain over his outer hip, I've treated other cases where patients did not complain of pain there with the exact same condition.

Following treatment, my patient was pain free and I taught him and his parents what to do to maintain that.

This "snapping hip"condition is also known as Coxa Saltans, can also happen in adults. My young patient described above has a extra articular or outside the hip joint condition.  It can also be intra articular or inside the hip joint.
It's Psoas Major/ Iliacus if inner part of R hip
If the condition occurs on the inner part of the hip, extra articularly, it is usually due to the Psoas Major or Iliacus muscle. A snapping hip inside the hip is usually confirmed by an MRI. Those who have intra articular hip snapping will usually complain of hip catching, painful clicking or locking. And that will probably have to be another post.


Winston P, Awan R et al (2007). Clinical Examination And Ultrasound Of Self-Reported Snapping Hip Syndrome In Elite Ballet Dancers. AJSM. 35(1): 118-126. DOI: 10.1177/0363546506293703.

Saturday, November 9, 2019

Still Getting Messages While I Am Away On Holiday

Even when I'm not in Singapore, I still get messages from patients asking about their pain or condition. After a patient sees me in our clinics, I normally give my personal number to them to let them know that they can reach me if they have a question. 

Of course I tell them I will not answer the phone if I'm treating patients, but I will always reply or call back after if the need arises. Except for once, I don't remember patients abusing that privilege. Don't get me wrong, I'm definitely not complaining, I do think it's great the patients trust me enough to ask me when they feel something is not right.

If I'm travelling, I will normally divert my phone to our clinic, but patients can still reach me with their messages or WhatsApp etc.

Of course after a particular posting that is popular, I get readers from overseas asking about the condition as well. Especially after this post on shin splints which is still our most popular article. I've politely declined offers to try and diagnose them. Even though some of them write and say that they'll be happy to pay me to describe what I did for treatment or chat to them via Skype or Facetime.

Accessory navicular bone?
There are currently a few telemedicine apps available in Singapore, MaNaDr, White CoatDr Anywhere, MyDoc and HiDoc. Majority are for patients to consult a  doctor through video-conferencing or messaging. Common health issues that come through these apps include upper respiratory tract infection, headache/fever, gastroenteritis and skin conditions. It also means you can stay at home when you're sick to get a medical certificate from the doctor.

I remember discussing with Aized quite a few years ago if we need to go this way as well after reading about about Dr Jay Parkinson and how he writes and talks about the future of primary care, healthcare delivery, healthcare entrepreneurship and healthcare business model transformation.

But then again, Dr Jay Parkinson writes about the United States healthcare system where patients may have to travel far and /or wait for days before getting an appointment. In Singapore, we have a different healthcare system altogether.

Convenient these apps may be for the patient, especially when it comes to the common cold/ cough and fever etc. However, I can definitely assess a patient much better in person when they tell me their neck or knee hurts. On the phone or email, it depends on how well the patient describes their condition. Of course I listen to my patients, but I definitely trust my hands more.

For those of you reading this, yes I'm away on holiday. But I will still try to answer your questions if I can get access to an internet connection. Thank you for putting your trust in us and our clinics.
My younger boy enjoying the sunset with 2 furry friends