Thursday, December 24, 2020

Not On The Surgeon's Birthday

Picture from Pinterest

It's Christmas Eve and I've just finished my day at the clinic when I happened to see this article.

The authors of this study analyzed 9,800,876 surgical procedures performed by 47,489 surgeons over four years. The surgeries were all emergency procedures to prevent selection bias (patients choosing their preferred surgeons and surgeons choosing patients based on illness severity).

Four common heart surgeries, hip, thigh fractures, lung resection, appendectomy, amputation of lower extremity were among the 17 surgeries performed by these surgeons.

0.2% (2064 surgeries) were performed by the surgeons on their birthdays. These surgeons who worked on their birthdays were on average older and more likely to be men. 

Here's the shocking news. Patients had a higher chance of dying (7%) within 30 days after surgery while operated by a surgeon on the surgeon's birthday compared to other days (5.6%).

This was after adjusting for patient characteristics and surgeon fixed effects (i.e. comparing outcomes of patients treated by the same surgeon on different days).

The authors suggest that surgeons may be distracted by other life events unrelated to work when they operated on their birthdays!

Perhaps from 2021 onwards we too should give our staff the day off on their birthdays so that they will not be distracted.

Here's hoping this post finds you resting and/ or enjoying time with your loved ones after one long, unprecedented year. Merry Christmas and happy holidays from all of us at Physio Solutions ad Sports Solutions.


Kato H, Gena AB et al (2020). Patient Mortality After Surgery On The Surgeon's Birthday. BMJ: 371: m4381. DOI : 10.1136/bmj.m4381.

Friday, December 18, 2020

Patient Waited 5 Hours For Appointment

Has this happened to you before? The patient above, mentioned that there was a waiting time of about three and five hours respectively during the last two visits to see the eye doctor.

I've had many of my friends and family tell me about the same thing happening to them. Attending a medical appointment would often take up a whole day. 

On a personal note, I remember having to accompany my mother for a doctor's visit and we had to wait for over two hours as well. Such a waste of time.

At our clinics, we promise you will never have to wait more than five minutes. We will try our utmost to see you on time. We never ever book two patients or more for the same slot. 

You will not be attended by a therapy assistant if you're seeing the physiotherapist. We do not employ any therapy assistants in our clinics. If you're seeing us for an hour, you will have our undivided attention. We will not put you on a machine and attend to another patient. 

The first session with us is longer as we take the time to ask questions and assess you thoroughly to find the cause of your problem. We treat the cause of the problem and not just treat your pain. If you get better after one session, we will not ask you to come for another session.  

Rest assured, you would never have to put aside a day to see us for physiotherapy. We respect your time.

Sunday, December 13, 2020

Be Patient So You Don't Become A Patient

Maybe the best thing to do now is nothing. To not change anything. My friend, whom I shall not name is always drawn to bright, new and shiny things. He is always after the latest fads. Especially when it comes to health and fitness.

Consider his diet. He is always following the latest 'flavour of the month'. Whether it's low carb, high fat, Atkins, South Beach, intermittent fasting etc, he's tried them all. I often tell him that his quickness in switching diets (due to not seeing results quickly enough) is probably detrimental to him losing weight.

I quoted him a study done by researchers comparing low fat and low carb diets. Participants were randomly tracked for a year. Those who lost the most weight were those who adhered to that diet. Being on either diet didn't matter as much. Slow and steady wins all the time in the long haul.

I would say this is exactly the same for fitness too. A paper published in the British Journal of Sports Medicine found that the best way to avoid getting injured is to slowly increase your training volume over time. Excessive and rapid increases in training loads are responsible for a large proportion of non-contact soft tissue injuries.

I travelled extensively with our Singapore badminton players and went to two Olympic Games with Team Singapore. The players had training camps and competitions all over the world and I've had the privilege of seeing world class badminton players like Lin Dan, Lee Chong Wei, Taufik Hidayat, Peter Gade and Singapore's own Ronald Susilo  train. (Below is a picture of him beating Lin Dan at the Athens Olympics).

I'm more excited than Ronald!
They all employ different strategies to build fitness and hone their court skills. Different coaches have different coaching styles. But all lead to the same objective, to be able on put the shuttlecock where they want to on court, be it with a smash or drop shot to win the point. To win the badminton match.

Sitting on court in Beijing 2008
And the key to success is that the players stick to the plan. There are many roads leading to Rome, and they get there only if they stick to their path.

If the training you did this week was twice as much as what you average over the past four weeks, you're 5 to 10 times more prone to getting injured compared to 10 percent increases in training volume and intensity.

This is especially true when my patients are returning from injury. I always tell them to err on the side of caution. Doing too much too soon may get them injured again. Our bodies need time to adapt to training loads after injury.

So as this strange, unprecedented year draws to a close, hang in there if your diet or fitness routine hasn't gone exactly to plan. Be patient, keep at it, remember it's slow and steady that always wins in the end. Patience is really a virtue.


Gabbett TJ (2016). The Training - Injury Prevention Paradox: Should Athletes Be Training Smarter And Harder? BJSM. 50(5): 273-280. DOI: 10.1136/bjsports-2015-095788.

Gardner CD, Trepanowski JF et al (2018). Effect Of Low-fat Vs Low-carbohydrate Diet On 12-month Weight Loss In Overweight Adults And the Association With Genotype Pattern Or Insulin Secretion. JAMA. 319(7): 667-679. DOI: 10.1001/jama.2018.0245.

Sunday, December 6, 2020

Patient Says She Has Sciatica

Check out her hip range
Recently, a patient came in to see me with pain down her buttocks and leg saying that she has "sciatica". The lower levels of the lumbar spine are notorious for referring pain down to the buttocks and the outside and/ or back of the leg. This is commonly known as 'sciatica' since that is the path of the sciatic nerve, the largest nerve in our bodies. 

Typically sciatica usually affects only one side of the body. She thought she must have hurt her back recently before this buttock pain started. I checked her lower back and it was fine.

Distribution of Sciatic nerve
However, I hit the jackpot when I checked her hip. It reproduced all her 'sciatica' symptoms she was complaining of. 
Femoral and Obturator nerves
How did I know to check her hip? The hip joint is also known to refer pain to the groin and to the front of the thigh, more commonly in the groin due to its nerve supply from the obturator, femoral and sciatic nerves. This is from previous anatomical studies and analysis of pain patterns in patients waiting for hip replacements.

I recall reading an article where researchers did a fluoroscopic guided injection to map out pain referral patterns from the hip. A fluoroscopic injection allows exact locations in the body to be located (under x-ray imaging). Fluoroscopy injections can be used to alleviate pain or in this study's case to identify the origin of pain.  

The researchers had 51 patients (28 female, 23 male) for their study. These patients had hip pathology as evidenced by x-ray or MRI. Pre injection, these patients marked out on a body chart where their pain was (see picture below).

Pain referred from the hip 
The patients were then given a fluoroscopically guided intra-articular (FGIA) injection. There was only local anesthesia and no oral or intravenous sedation for the patients to avoid confounding of results. Only when their pain was reduced by 90% before the FGIA injection was deemed effective. 

Long needle to reach the hip
The researchers found that referred pain to the buttock was the most common (71%). Traditionally accepted referral to the thigh (57%) and groin (55%) were less common. 22% of patients had referred pain to the legs (below the knee).

The referred pain areas in this study (from the hip joint) were similar to previously reported pain patterns observed from the lumbar spine and sacro iliac joints.

This is a very useful study for knowing referral patterns of the hip joint. When a patient complains of pain in their buttocks, groin, thigh or even in the foot, one must not rule out the hip. It is important to note that there is no lumbar spine referral in this study.

Note to self (and other physiotherapists reading this), not all radiating leg pain is 'sciatica'.


Lesher JM, Dreyfuss P, Hager N et al (2008). Hip Joint Pain Referral Patterns: A Descriptive Study. Pain Med. 9(1): 22-25. DOI: 10.1111/j.1526-4637.2006.00153.x

Sunday, November 29, 2020

Arch Supports And Iliotibial Band (ITB) Pain

A patient came in this week after being diagnosed with Iliotibial band (ITB) syndrome. The outer part of his right knee would hurt badly after running about 1.5 km. After stopping to walk, he would be able to run for a few minutes before having to stop again. 

He had been running 4-5x each week, clocking about 50 km weekly. He had just seen a sports doctor who first referred him to a podiatrist to get orthotics as he 'pronated' badly.

After getting his orthotics, he 'pronated' less according to the prodiatrist who filmed him while running on a treadmill. But, alas, his ITB/ knee pain didn't change. Since I'd treated a fellow runner he knew, he came to see me, hoping I could help him run pain free.

The ITB starts from the TFL
I've written previously about the ITB and you can read more about it here (anatomy) and here. If you look at the picture above, you can see it starts from Tensor Fascia Lata (TFL) muscle and runs down the outer thigh before finishing just at the outer part of the knee (picture below). This is usually where runners experience a sharp pain.

Also know as iliotibial tract (bottom R of pic)

Studies show that when the hip rotates medially or drop inwards, a strain is placed on the ITB . This also causes the tibia (or shin bone) to rotate inwards causing the foot to pronate (or ankle eversion). 

Researchers have attempted to correct this by changing ankle pronation to see if this might relieve the strain on the ITB.

In this published paper, 30 runners (15 males, 15 females) with no ITB insertion pain were prescribed orthotic wedges to put into their own running shoes. The wedges were 7 degrees lateral, 3 degrees lateral, no wedges, 7 degrees medial and 3 degrees medial. A total of five running trials were done.

The runners were analyzed by video motion analysis while running at their self selected running pace to calculate motion forces and ITB strain.

The orthotic wedges significantly changed ankle eversion (or pronation) angles compared to no wedges. However, the strain rates did not differ between conditions. There was no change in knee joint angles and tibial rotation under all orthotic wedge conditions. 

The researchers concluded that orthotic wedges may not change forces acting on the ITB, even though they altered foot pronation while female runners had greater strain forces acting on their ITB's potentially due to increased internal hip rotation.

It is interesting to note that the female runners demonstrated significantly greater peak ITB strain and strain rates compared to the male runners, potentially due to increased hip internal rotation (because of wider hips and pelvises for child bearing purposes). I have written at length before that for female runners, their knee pain is coming from their hips. Always treat the cause of the problem. Do not treat the pain alone.

Take home message is that even though orthotic wedges can correct your foot's pronation, it may not alter forces acting on your ITB. This means that your knee pain may not get better using orthotic wedges.

Of course any one reading this may say that these off the shelf orthotic wedges are not customized and that the subjects were all wearing different running shoes. Personally I feel that the different shoes are not an issue as these orthotic wedges used in the study did significantly change ankle pronation so they did what they were supposed to do. 

Would this then be fair to say that using orthotics to change ankle pronation or eversion angles does not seem to benefit those with ITB pain at the knee? Perhaps any podiatrists reading this would like to comment.


Day EM and Gillette JC (2019). Acute Effects Of Wedge Orthoses And Sex On Illotibial Band Strain During Overground Running In Nonfatiguing Conditions. JOSPT. 49(10): 743-750/ DOI: 10.2519/jospt.2019.8837

Saturday, November 21, 2020

Abnormal Knee MRI, But No Pain

Knee MRI by Becky Stern from Flickr
Here's a piece of surprising news for everyone. In this recently published paper I read, nearly all patients who had abnormalities on their knee 
MRI were asymptomatic, meaning no pain despite having an "abnormal" MRI.

The main inclusion criteria for this study were sedentary adults. They did not do at least 30 minutes of moderate intensity physical activity 5 days a week or 20 minutes of more intense activities 3 days a week. They did not have any knee pain, no current or previous history of knee injury and surgery.

The authors reviewed 230 knees of 115 uninjured inactive adults (51 males and 64 females). Median age was 44 years (range was 25-73 years) and all the subjects had bilateral MRI's (3.0 Tesla, high resolution) done.

Here's what they found. Brace yourself as you read on. MRI showed abnormalities in a whopping 97% of knees. 30% of knees showed tears in the meniscus. Horizontal tears were most common, while bucket handle tears least common.

Articular cartilage (57%) and bone marrow abnormalities (48%) were common in the patellofemoral (knee) joint. Moderate (19%) intensity articular cartilage lesions and severe (31%) were observed.

Grade 4 means bone rubbing on bone

Articular cartilage injuries is my area of interest since I did my postgraduate research in that area. It is interesting to note that a quarter (or 25%) of the subjects had Grade 4 changes (see picture above) visible on MRI but did not complain of pain. Perhaps this is important to remember when imaging the knee since there seems to be more visible findings here compared to the rest of the knee (articular cartilage wise).

Moderate intensity lesions were found in 21% of knee tendons while there were high grade tendonitis found in 6% of knees reviewed. The patella and quadriceps tendons being the most affected.

3% partial ligament ruptures were found, of which 2% were of the Anterior Cruciate Ligament (ACL).

The authors concluded that nearly all knees of asymptomatic adults they studied show abnormalities in at least one knee structure on MRIMeniscal tears, articular cartilage and bone marrow lesions in the patellofemoral joint were the most common pathological findings. 

They also reported finding bucket handle and complex meniscal tears (both of which commonly operated on) in asymptomatic knees. This interesting to note as bucket handle tears (as well as complex tears) would often cause 'locking' in the knee and therefore require surgery.

There you have it, the subjects were sedentary adults who did no exercise so no one can say that it was running or exercise that "wore out" their joints. And some these very same adults had "terrible" or abnormal MRI's, but were asymptomatic or did not have any pain.

So don't fret if your MRI is abnormal. You may not need any surgical intervention, especially if you do not have any pain or if that pain is easily treated.

Maybe these abnormalities should be just described as "wrinkles" on the inside. 


Horga LM, Hirschman AC, Henckel J et al (2020). Prevalence Of Abnormal Findings In 230 Knees Of Asymptomatic Adults Using 3.0 T MRI. Skele Radiol 49: 1099-1107. DOI: 10.1007/s00256-020-03394-z

Sunday, November 15, 2020

Towel Scrunching Exercises For Your Feet?

Have you ever been asked to do foot strengthening exercises? A patient who saw me this week was asked to do foot strengthening exercises by another health professional who saw him recently. This included some towel scrunching exercises for his "collapsed arches" so as to strengthen the muscles supporting his arches

My patient was quickly bored and I told him just walking in minimalist footwear would be just as effective as doing strengthening exercises for the foot.

We know from published evidence that weakness in our intrinsic foot muscles can lead to a variety of load related injuries. And supportive footwear can contribute to intrinsic foot muscle weakness since these muscles tend to switch off (since they aren't absorbing forces and controlling foot movement) while walking and running.

Researches randomly assigned runners into three different groups. One group wore minimialist shoes (Vivo Barefoot), another group did foot strengthening exercises and the third was a control group. All groups maintained their running mileage throughout the study.

The minimialist footwear group increased their walking step count weekly while the foot exercise group did progressive resistance exercises at least 5 days per week.

Foot muscle strength and size were measured via ultrasound at the start of the study, week 4 and at the end of  the study (week 8). Researchers found all foot muscle sizes and strength had increased significantly in both the minimalist footwear and foot strengthening exercise group. There were no changes in the control group.

The researchers concluded that walking in minimialist shoes is just as effective as doing strengthening exercises for your feet. It is definitely way more convenient changing footwear rather than doing specific foot exercises. This may result in better compliance with patients.

So definitely don't throw away your Vibrams or barefoot styleminimialist type shoes. They are definitely still useful. Vibram ended up with a bad reputation after they were sued. 

However, I feel minimalist type shoes were unfairly criticized as the evidence for barefoot or minimalist type shoes are actually sound provided your running technique is correct. 

*Much less impact if technique is correct-see below

If you walk with barefoot style/ minimalist type shoes instead or running (to strengthen your intrinsic foot muscles) there will be a much lower risk of injury.

Definitely still useful. And much less boring than doing towel scrunches.


Ridge S, Olsen M et al (2019). Walking In Minimalist Shoes Is Effective For Strengthening Foot Muscles. 51(1): 104-113. DOI: 10.1249/MSS.0000000000001751.

Liberman DE, Venkadesan M et al (2010). Foot Strike Patterns And Collision Forces In Habitually Barefoot Versus Shod Runners. Nature. Jan 463(7280): 531-535.

*Using results of Daniel Liberman's study, runners who land correctly in their running technique will have benefits as impact is a LOT less (even less than heel striking with cushioned running shoes). If you land wrongly (with barefoot style shoes), the impact is 7 times greater thus greatly increasing the chance of injury. See picture above.

Monday, November 9, 2020

Thera Gun Caused Rhabdomyolysis In A Cyclist

Picture by LLL@ Zouk

I've written in August about the effects of thera/ massage and vibration guns and whether they really work. I've also written about the scary effects of rhabdomyolysis before. 

Guess what? There has just been a published case report of a cyclist being administered thera/ massage gun treatment by her coach for recovery and ended up with rhabdomyolysis.

This 25 year old female cyclist rode in a gym for two consecutive days for only about 30 minutes each day. Her coach used a thera/ massage gun immediately over both her thighs for about ten minutes to help with her recovery. The coach did not check the medical history of the cyclist nor did he check with qualified health professionals about using the thera/ massage gun on her.

The cyclist subsequently developed significant pain/ tenderness in both thighs on that same evening and multiple hematomas (or bruises) were present. She also had urine discoloration (tea colored). She went to the hospital and her serum creatine kinase levels (> 30,000 U/L) were through the roof. This is an indication of severe muscle damage.

Normal values are usually 24-195 U/L. Not saying this with pride, but when I had hyponatremia back in 2000, my creatine kinase levels were 240,000 U/L. But that's another post.

Patients with rhabdomyolysis commonly present with muscle pain. weakness, aches and bruising. It is rare, can be life threatening and is often caused by extreme exercise. It occurs when muscles that have been overworked, dies and leak their content to the bloodstream. This ends up straining the kidneys and can cause severe pain.

Anyway, back to this cyclist. She has a medical history of mild iron deficiency which had been untreated and it's potential association to rhabdomyolysis must surely be considered. 

Her coach was unaware of her mild anemia. Cycling for two days in a row would not be considered as extreme exercise since she had previously cycled two days in a row and not developed rhabdomyolysis.

In her case, it is probably the repeated use of the thera/ massage gun after cycling that damaged her muscle fibers leading to rhabdomyolysis. The coach may also have used the thera/ massage gun incorrectly. She was in hospital for 2 weeks and thankfully recovered well.

A published study found 29 cases of exercise induced rhabdomyolysis admitted to the emergency department of a hospital between 2010-2014. The most common cause was indoor cycling classes.

A few of my patients have had rhabdomyolysis. All were active in sports and definitely not couch potatoes. They all felt that the exercise that they participated in (indoor cycling) did not seem strenuous at that time. 

Remember this when you try a new exercise. Start moderately first and and don't be pressured by the coach/ instructor if you're not comfortable.


Brogan M, Ledesma R et al (2017). Freebie Rhabdomyolysis. A Public Health Concern, Spin Class-Induced Rhabdomyolysis. AJM. 130(4):

J Chen, F Zhang et al (2020). Rhabdomyolysis After The Use Of Percussion Massage Gun: A Case Report. Phy Therapy. DOI: 10.1093/ptj/pzaa199

Thanks to my patient LLL for both the pictures. Never thought Zouk would end up hosting indoor cycling. Unprecedented times indeed!

Sunday, November 1, 2020

Dealing With Defensive Medicine During COVID

I had a patient recently who injured his knee while playing badminton. The surgeon sent him for an MRI and wanted to operate after the scan showed that he had tore his lateral meniscus.

He decided to have the operation but the procedure was postponed after he got sick. The good news was that he got so much better after the wait that he decided that surgery was not needed anymore.

This reminded me of an British Medical Journal opinion article I read this morning. The article cited examples as a direct result of the lockdown/ circuit breaker period where patients got better as fear of catching Covid-19 in hospitals prevented them from seeking help.

Of course there were also tragic cases when patients cannot receive essential care and eventually dying as a result. Depression and mental health cases come to mind too.

There was an outcry in Singapore recently when it was announced that Medishield Life plans premiums were going up. Healthcare costs are definitely rising all over the world. Patients are often referred for unnecessary tests and treatment when costs are covered by insurance. Overuse and over-diagnosis consume resources and insurance premiums subsequently increase.

This is in part due to doctors practicing defensive medicine. Previously, I had written that some doctors actually charged more for steroid injections after a court case against an orthopaedic surgeon after his patient complained to the Singapore Medical Council after she developed side effects. 

The article suggested that this may be due to multifaceted reasons with vested interests playing a crucial role. Quoting the article, "medicine is permeated by a bias towards doing something rather than doing nothing, even when it may do more harm than good to our patients. Doctors failing to diagnose are resented and sometimes punished, while doctors who cause suffering through over diagnosis and over-treatment are not".

Practicing defensive medicine may also be due to expectations from patients and a fear of being sued.

While not all my esteemed physiotherapists may not agree with me, I would suggest that physiotherapy probably has the same problem. We are often quick to diagnose a 'syndrome', 'an inflammation' or a 'knot'. Perhaps it should be "I don't know for sure" now, but I can do my best to come up with a plan to treat this. If it still doesn't settle, we will definitely investigate further.

Covid-19 has definitely made us more aware of our priorities and actions. Let us use this opportunity to understand and contribute to shift away from defensive medicine and physiotherapy.

You can read the article by Minna Johansson and Iona Heath here.

Picture above taken from Joee Denis.

Sunday, October 25, 2020

Still Using Kinesio Tapes Even If Research Paper Says They Aren't Useful?

I saw two patients with badly sprained ankles this past week. The first patient was hobbling while shuffling on one foot. I definitely made both of them better. And I used Kinesio tape as part of my treatment to help with the swelling. So I was very surprised when a systematic review and meta-analysis found that Kinesio taping did not improve ankle function or performance in people with ankle injuries.

I definitely made both of them better. And I used Kinesio tape as part of my treatment to help with the swelling. So I was very surprised when a systematic review and meta-analysis found that Kinesio taping did not improve ankle function or performance in people with ankle injuries.

A systematic review meta analysis is a search aided by computer looking for all randomized and clinically controlled studies while meta analysis means using statistics to combine the data derived from a systematic review. So the published review is not an article to scoff at.

However, I looked through the supplementary material, and the tapes used were of course of different brands, different taping techniques were used, and it included different types of ankle injuries. Some of the taping were done on the calf muscles, some around the ankle joint, while others taped the Achilles tendon. In my opinion, that would not be fair as different brands of tape would have been compared, there were different conditions, and different techniques were implemented. Not to mention that not everyone would have learnt how to tape appropriately since there are different brands of tape. It would be similar to comparing apples to oranges.

Some of the studies
Note to self. Even if it's a systematic review or meta analysis, make sure you read everything and not just the title and the conclusion. 

As clinicians, we would never just use Kinesio tape or any tape alone just to treat a patient. For the two patients mentioned above, we would never get optimal results just using tape on them. We use our hands to assess, mobilize and/ or manipulate their ankles, while others may use needles, ice, tape or even modalities to treat their patients. Others might teach exercises to get their patients better.

Should we stop using Kinesio tapes? Definitely not. If we use them correctly, they definitely work. Have a look at another of my patient after I use the original Kinesio tapes for just five hours. Scroll down to see more evidence.

Surely you can see the outline of the Kinesio tape


Nunes GS, Feldkircher JM, Tessarin BM et al (2020). Kinesio Taping Does Not Improve Ankle Functional Or Performance In People With Or Without Ankle Injuries: Systematic Review And Meta-analysis. Clinc Rehabil. DOI: 10.1177/0269215520963846

In the picture below is a patient with a hamstring tear.

Here's how his hamstring looked like 3 days later in the picture below. I have lots more photos like these in my phone of my patients. Contact me if you're still skeptical, I'll show you all the photos from my phone if you like to see them. 

3 days later

Sunday, October 18, 2020

Do Patients Present With A Standard Textbook Pattern of Referred Pain While Having A Pinched Nerve?

Dermatomes- look at C4,5 compare below

One of the useful things I learnt while I was still in physiotherapy school, that I am still using daily, are dermatomes. A dermatome is the area of skin that sends signals to the brain through our spinal nerves. These signals help us sense temperature, pressure and pain. 

When a patient comes in to our clinic with radiculopathy, which means a range of symptoms caused by the irritation of a nerve root, we can gauge what levels of the spine are affected, knowing the dermatomes chart. 

These symptoms can include pain, numbness, tingling sensations, sensory changes, loss of strength and even a change in reflexes. These can occur in the cervical (neck), thoracic (upper back) and lumbar (low back) regions. It is often known as a 'pinched nerve'.

C4,5 check with earlier picture
For example, if a patient comes in complaining of pain in the shoulder it may mean that C4,5 may be implicated. This is especially so if treating the shoulder does not make the patient better.

So I was very interested when I read about the following study, where the researchers studied how often patients who had cervical radiculopathy presented with the standard textbook versus non standard patterns.

Only patients with single level cervical radiculopathy operated by six surgeons were included in this study. Their symptoms of radiculopathy were compared to a standard textbook pattern. 

239 patients' records met the inclusion criteria. Their age, weight, BMI, gender and symptom duration were not different between patients with a standard radicular pattern versus those with a non standard pattern.

Picture of referral pattern from article

Overall, 54% (129 patients) fit the standard textbook pattern while 46% (110 patients) differed from the standard pattern. C5-6 and C6-7 were the two most common levels operated on for radicular pain. Non standard patterns of presentation were found in 50.9% (C5-6) and 44.7% (C6-7) of the cases.

Same sided neck pain (81% of patients) was the most common presenting symptom. Shoulder pain was reported in 142 patients (59.4%). 19.2% of the subjects (46 out of 239) had pain/ symptoms at the neck level with no referred pain down the arm. 

When a non standard pattern was encountered, it differed by 1.68 dermatomal levels, either higher or lower.

The authors concluded that observed patterns of cervical radiculopathy in their study only followed the standard textbook pattern in 54% of patients studied. Non standard referral patterns were more common than thought. 

Now, that's a good reminder to doctors, surgeons and physiotherapists (note to self). Patients suspected of referred pain from the neck and back may not always have symptoms that fit the standard textbook pattern.

We need to do our due diligence to ensure each patient get treated appropriately.


McAnany SJ, Rhee JM et al (2019). Observed Patterns Of Cervical Radiculopathy: How Often Do They Differ From A standard, "Netter diagram" distribution? Spine. 19(7): 1137-1142. DOI: 10.1016/j.spinee.2018.08.002.

Sunday, October 11, 2020

Are Shoulder Stabilization Exercises Useful?

Your physiotherapist or trainer may have taught you the following exercise(s) to help with shoulder pain. You may have been asked to bring your elbows back while squeezing your shoulder blades together behind you. You were told that you should feel the muscles between your shoulder blades activate and your chest stretching or opening up. This is also to help position your scapula(e) for an improved posture.

R shoulder
I must confess that I, too, have been guilty of teaching this in the past. Fortunately, that's a long time ago! I used to to instruct patients to do scapula (or shoulder blade) stabilization exercises when they come in to our clinic complaining of shoulder impingement. This is also known as subacromial pain syndrome. Sub acromial means all structures below the acromion that can cause problems. Please see picture above and below.

What are some common scapular stabilization exercises? Anything that emphasizes retraction (drawing back)  and depression (bringing lower) of the scapular. Like what I described in the first paragraph of the article.

Well, not all cases of subacromial pain patients will benefit from doing the above exercise. Not according to a recently published randomized controlled study (Hotta et al, 2020).

The objective of that study was to determine if adding scapular stabilization exercises especially retraction and depression of the scapular will help patients with subacromial pain. 60 subjects were randomly divided into two groups. One group did strengthening exercises for muscles around the scapular while the other did the strengthening as well as stabilization exercises for 8 weeks (3x daily).

Results at the end of their study after 8 weeks and even 8 weeks after showed no differences between the 2 groups. The researchers concluded that adding scapular stabilization exercises that emphasized scapular retraction and depression to a general strengthening exercise for muscles around the scapular did not add any benefits to pain, muscle strength or range of motion.

Now after 21 years of treating patients with shoulder pain, my approach has changed dramatically. I now look at a person's shoulder together with the ribcage, neck, spine, hips, feet. I look at how a patient's body is sitting in space and how it moves through space. All while assessing the balance of the structures around their joints. I see which structures need to be worked on by me and which the patient would need to tone and strengthen on their own with specific instructions.  


Hotta GH, De Asiss Couto AG et al (2020). Effects Of Adding Scapular Stabilization Exercises To A Periscapular Strengthening Exercise Program In Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial. Muscu Sci Pract 49: 102171. DOI: 10.1016/j.msksp.2020.102171.

Sunday, October 4, 2020

What Happens When Patients Are Sent Too Early For An MRI

Picture by Naiserie from Flickr

My patient came in to our clinic yesterday complaining of some mild low back pain. He had been referred by his family doctor to have an MRI done as the doctor was not sure what was the cause of the back pain.

I was surprised, after examining him, that he was referred for an MRI so soon. His back pain did not seem sinister. At the end of yesterday's session, his back was completely pain free.

I shared with him a really interesting article I had just come across. The researchers studied data of patients seeking treatment for non-specific low back pain without a red flag (warning or danger) condition and no low back pain in the previous six months.

More patients had back surgery if they were referred for an MRI within the first six weeks of an initial visit to the doctor (1.48 % versus 0.12 % in cases without an early MRI). 

The patients also complained of a higher pain score when they had an early MRI. In fact, overall outcomes were worse, including greater use and potential harm for prescription medication (35.1 % versus 28.6 %). There were also higher costs for other medical care ($8,802 versus $5,560).

This association was also true when patients had to pay for their treatment (compared with not having to pay at all).

Perhaps this information will help bring down costs for Singapore's Integrated Shield Plans since there was such an outcry when it was announced that premiums were going higher despite increasing coverage.


Jacobs JC, Jarvik JG et al (2020). Observational Study Of The Downstream Consequences Of Inappropriate MRI Of The Lumbar Spine. J Gen Int Med. DOI: 10.1007/s11606-020-06181-7.

Sunday, September 27, 2020

Toe Spring And Plantar Fasciitis


Ever wonder why so many people other than runners are getting plantar fasciitis? It may be because of the amount of 'toe spring' in your shoes.

You may have already noticed this in your running (or other) shoes, most of them seem to have 'toe spring'. Toe spring is how much the front of the shoe is curved upwards. This curve allows your foot to roll off the front of your foot more easily compared to wearing flatter soled shoes.

Hence, the toe spring allow your foot muscles to work less hard when you are walking or running. The more toe spring in the shoe, the less work your feet have to do.

However, this may lead to weaker foot muscles according to research (Sichting et al, 2020).Weaker intrinsic foot muscles may increase your chances of sustaining injuries like plantar fasciitis.

In the research which includes famed Harvard evolutionary biologist / barefoot running researcher, Daniel Lieberman, had subjects walk on a specially designed treadmill that had force plates and infrared cameras to measure how much power was put into each step.

The subjects walked barefoot in four different pairs of custom made sandals. The sandals had varying angles of toe spring from 10 to 40 degrees. These ranges of curvatures were designed to be similar to modern footwear.

Sandals were chosen as they allowed the researchers to see the exact motion of the subjects' feet as they walked. The different degrees of toe spring can be filmed to see how they affected their gait with special attention paid to the metatarsophalangeal (MTP) joints at the base of their toes. This is where the toe bones join to the foot bones.

The results showed that the more the shoes curved up front, the less propulsive force was generated with their MTP joints. This means that your intrinsic foot muscles are working less to maintain stability when you move making walking and running easier. However, it also decondition your foot muscles over time, making them weaker and not able to protect other structures in your foot.

Weaker intrinsic foot muscles make one more susceptible to conditions like plantar fasciitis as people rely on their plantar fascia to do what the intrinsic muscles normally do. This may also explain why people get injured if they transition too quickly minimalist type barefoot style running shoes.

Many of my patients who do not run with plantar fasciitis have been told to wear more 'supportive' and comfortable shoes while outside or even at home. This may be worse as their intrinsic foot muscles continue to weaken.

This is why shoes with more toe spring are popular because they are more comfortable and prevent your feet from tiring. This is great in a race and it may be why most racing shoes have a lot of toe spring (see picture below).

More research needs to be done with toe spring and foot injuries as other elements of footwear like stiffer soles and amount of cushioning can impact how our intrinsic foot muscles work.

So what should a runner do? Some physiotherapists and podiatrists often suggest doing intrinsic foot exercises like towel scrunching or pulling your toes toward your heel.

I suggest going barefoot more often. Either at the beach, or when you're at the playground with your kids. In Singapore we are generally barefoot while we're at home. That's better than wearing shoes with lots of toe spring at home. 

While training, look for running shoes with little or no toe spring when you train. 

For my patients who have plantar fasciitis, I tell them to wear flat slippers like Havaianas to minimize the effect of toe spring and for their intrinsic foot muscles to get stronger. 

That is totally different from what some other physiotherapists or podiatrists may suggest. Of course, I also treat plantar fasciitis differently from them.


Sichting F, Holowka NB, Hansen OB and Lieberman DE (2020). Effect Of The Upward Curvature Of Toe Springs On Walking Humans. Sci Reports 10, 14643. DOI: 10.1038/s441598-020-71247-9.

Asics Metaracer Tokyo - a racing shoe with lots of toe spring

Sunday, September 20, 2020

Are You Choosing Running Shoes Based On Comfort?

Picture by Oyvind Solstad from Flickr
Don't we all love shoes that are comfortable? Especially when it comes to our running shoes. As runners, we all love that ahhhh sensation of our first steps in an exceptionally soft and comfy shoe. I couldn't believe how soft an Adidas NMD (not really running shoe though) felt when I first slipped it on. 

A more comfortable (or cushioned) shoe is usually preferred by new runners or for runners who are prone to injury and want extra protection and support.

The shoe companies know that subjective comfort is an essential factor in sport shoe development since this definitely helps them sell shoes. This comfort paradigm is based on an assumption that perceived comfort will lead to a path of least resistance (while running) and potentially reduce injury and improve running economy. (Luo et al 2009; Mundermann et al, 2001).

We've definitely been sold on advertisements selling us the softest, bounciest and energy return shoes that propel us forward and saves us energy and prevent injuries.

One study showed reduced oxygen consumption levels during running at submaximal speed while running in shoes that were rated subjectively as most comfortable (Luo et al, 2009). This may support the fact that running economy improves due to reduction of muscle activation (which decreases oxygen consumption or metabolic demand). 

Another study on military personnel showed some evidence supporting the use of comfortable shoe inserts (or orthotics) reduced injury rates of the foot, ankle, hip, knee and lower back compared to a control group.  However, two studies are not credible enough to know what actually helps and what are the mechanisms of reduction in oxygen consumption and preventing injuries. (Both studies count Professor of Biomechanics Benno Nigg, known for his work of running shoes as one of the authors).

In this latest paper I read, the authors aimed to investigate how shoes of differing comfort affects differences in oxygen demand along with potential mechanisms associated with injury risk

Fifteen male runners who ran at least 20 km per week with treadmill experience were recruited for the study. Testing includes an incremental lactate threshold test, a comfort assessment and treadmill running trials for biomechanical and physiological assessments. 

The researchers did not find any decrease in oxygen consumption in the most preferred shoe. Potential biomechanical contributors to changes in oxygen consumption (or metabolic demand) showed some differences in stride rate between the most preferred and least preferred shoe. Personally, it was interesting for me to note that stride frequency was actually lower in the most preferred (or comfortable) shoe compared to the least preferred (or least comfortable).

Based on the findings of this study, previous suggestions (derived from two other studies) regarding positive effects of enhanced footwear comfort during running cannot be supported. Neither on running economy nor on preventing injuries.

Should we then choose our running shoes based on comfort alone? This study suggest maybe not since the most comfortable shoes were not better or worse off with regards to oxygen consumption and not enough data to show any real change on injury risk.

Comfort is just one of many factors when we choose running shoes (compared to the more common foot type option like overpronators, supinators etc). Of course I definitely would not suggest running in shoes that are uncomfortable. 

I'm also feeling appalled that only 15 male runners (and no female  runners) were selected for the study. Remember I write previously how difficult it is to recruit runners to participate in a running research.

Athletes will want shoes that give them absolute efficiency that helps that run faster while your average runner would want the least discomfort while running to get fit.  

Of course there are some runners that will choose based on colour! *facepalm*


Lindorfer J, Kroll J and Schwameder H (2019). Does Enhanced Footwear Comfort Affect Oxygen And Running Biomechanics? Eur J Sport Sci. 20(4): 468-476. DOI : 10.1080/17461391.2019.164028

Luo, G, Stergiou P et al (2009). Improved Footwear Comfort Reduces Oxygen Consumption During Running. Footwear Sci. 1(1): 25-29. DOI: 10.1080/194242809002993001

Mundermann A, Stefanyshyn DJ and Nigg BM et al (2001). Relationship Between Footwear Comfort of Shoe Inserts and Anthropometric And Sensory Factors. Med Sci Sport Ex. 33(11): 1939-1945. DOI: 10.1097/00005768-200111000-00021.

Notes on the shoes in this study provided by Adidas

Five different shoes based on criteria previously reported in another study (Luo et al, 2009) were provided for this study. The shoe conditions showed variations in total mass (80 grams), heel lift (3.7mm), forefoot cushioning, rearfoot cushioning forefoot bending and rearfoot bending. The shoes in this study includes a standard neutral running shoe, shoes equipped with non standardized features like carbon fiber plates for increased longitudinal bending stiffness, exaggerated arch support and a cross training shoe.

One interesting point was that the researchers glued lead to the heel counters of the shoes that were lighter (since shoe mass influences oxygen consumption by about 1% per 100 grams of additional mass).

Sunday, September 13, 2020

Physical Activity Decreases Your Risk Of Colorectal Cancer

Group ride on 090219 - definitely miss those rides
I was very active in primary school. Other than swimming occasionally and playing police and thief (running), I also played football, basketball, table tennis and badminton. It was only in secondary school that I started to be more serious with cross country running and athletics.

How about you? Try to recall what you were doing as a teenager. A recent study suggest that how active you were back then and and how you've maintained it till now is important when gauging your risk of colorectal cancer.

Physical activity during adolescence helps lower risk of colorectal cancer. If you have been able to continue daily moderate physical exercise well into adulthood, the results are even better.

The study showed that those who did at least an hour of physical activity daily from 12 to 22 years had a reduced risk of adenoma (polyps or a benign tumor formed from glandular tissue) by 7 percent compared to those who were less active. (Polyps are considered a precursor of colorectal cancer).

Those who started physical activity as adults reduced risk by 9 percent. However, those are were active as teens and continued being active for at least an hour as adults reduced their adenoma risk by 24 percent!

The researchers analysed the data of 28,250 female subjects aged 25 to 42. Physical activity, nutrition, hormones were among some of the data studied.

The researchers suggest that being physically active reduces the risk of colorectal cancer since it helps weight management and control and thereby affects insulin resistance and inflammation as they are involved in promotion and progression of cancer.

I would be very interested if the researchers measured how intense or hard the physical activities were. And how often were these higher intensity sessions and whether they made any difference.

However, this study did not analyse that. The authors did mentioned that previous studies have shown that moderate to vigorous activities were associated with lower bowel, breast and endometrium cancers.

Take home message is that there is a cumulative effect of physical activity as we grow older. Even if you have been inactive as a child, it is not too late to start now. And the longer you maintain that physical activity, the better off you'll be.


Rezande L, Lee DH, Keum N et al, (2019). Physical Activity During Adolescence And Risk Of Colorectal Adenoma Later In Life: Results From The Nurses' Health Study II. Br J Cancer. 121: 86-94. DOI: 10.1038/s41416-019-0454-1.

Picture above taken yesterday by Dennis Thong. I still try to be as active as possible daily with at least one complete rest day a week.

You should too.

Sunday, September 6, 2020

What is More Helpful Than Electrolytes In Preventing Muscle Cramps?

I don't believe this. Many athletes still do not know what causes muscle cramps. In a survey of 344 endurance athletes published last year, 75 percent believed that taking extra sodium would help prevent their muscles cramping (McCubbin et al, 2019).

The usual and common theories for muscle cramps are loss of electrolytes (sodium, potassium and magnesium) and dehydration (fluid). Suggestions to combat cramps are to eat more bananas, take more salt/ sodiummagnesium supplementation, drink Gatorade etc. None of which will really help.

Having written on muscle cramps a few times, I'm most interested when new research suggests alternative ways to beat muscle cramping.

The researchers (Martinez-Navarro et al, 2020) recruited 98 runners running the Valencia marathon of which 84 (72 males, 12 females) completed the study (all pre and post race testing). 

20 runners suffered muscle cramps during or immediately after the race. Blood and urine tests showed no differences in dehydration and electrolyte levels before, during and after the race for the runners that cramped versus those that did not.

What the researchers found was a big difference in creatine kinase and lactate dehydrogenase which are both markers of muscle damage. These markers were significantly elevated immediately post race and 24 hours in those runners who had cramps.

There was also no difference when the runners did their last training run prior to the race nor any sign of elevated muscle damage in pre race tests. Hence, the runners who cramped did not have any muscle damage (from not tapering/ resting or backing off from training). 

Almost all the training variables between the two groups were similar. Weekly mileage, previous marathons ran, etc were all similar save one variable. 48 percent of those who did not suffer from cramps did regular lower body strength training compared to 25 percent of those who cramped.

This adds more weight to my previous post that muscle cramps are more likely to occur in muscles that are tired/ fatigued to the point of damage.

I would like to add that dehydration and electrolyte depletion can hasten muscular fatigue which then causes muscle cramping.

If you're still struggling with muscle cramps, it's definitely worth giving lower limb strength training a shot and for it's other benefits as well. 

Another researcher (Del Cosco et al, 2013)who wrote about muscle damage causing one to slow down at the end of marathons suggested lower limb exercises up to 80 percent maximum weight you can lift to protect your legs from damage.


Del Cosco J,  Fernandez D, Abian-Vicen J et al (2013). Running Pace Decrease During A Marathon Is Positivively Related To Blood Markers Of Muscle Damage. PLoS One. 8(2): e57602. DOI: 10.1371/journal.pone.0057602

Martinez-Navarro I, Montoya-Vieco A et al (2020). Muscle Cramping In The Marathon: Dehydration And Electrolyte Depletion Vs Muscle Damage. J Stren Cond Res. DOI: 10.1519/JSC.0000000000003713.

McCubbin AJ, Cox GR et al (2019). Sodium Intake Beliefs, Information Sources, And Intended Practices Of Endurance Athletes Before And During Exercise. Int J Sp Nutr Ex Metab. 29(4): 371-381. DOI: 10.1123/jisnem.2018-0270.