Sunday, June 28, 2020

My Patient Had Myositis Ossificans

I had a patient who came in recently with Myositis Ossificans. Myositis Ossificans is a condition where there is formation of bone inside a muscle, other soft tissue or around a joint after an injury. It is more common in younger patients and athletes after a traumatic injury such as receiving a hard kick while playing football.

It can also happen where there is a repetitive injury to the same area, such as my left elbow joint area (more on this later).

Regardless of what caused it, Myositis Ossificans happens when there is an 'error' in the body's healing process. This occurs after fibroblasts (or muscle cells) are accidentally replaced by immature bone cells at the injury site.

This causes a hard lump to develop within the muscle. It starts off as a gradual process and begins shortly after the initial injury.

Unlike other common muscle strains or injuries, patients with Myositis Ossificans will find that their pain worsens as time goes by instead of getting better. The muscle /injured area feels warm, often has a decrease in range of motion, swelling and a obvious lump or bump.

This patient received a big knock on the thigh after an accidental collision while cycling. It was initially thought of as a deep muscle bruise. But when the pain and swelling did not subside, the patient's parents consulted me and I immediately suspected Myositis Ossificans after hearing the history and feeling the 'lump' in the patient's thigh. This was later confirmed by an ultrasound scan by a doctor.
Carrying angle on the left is altered
I, too had Myositis Ossificans in my left elbow. This occurred back in 1994 after I fell repeatedly on my left elbow while cycling.

I had exactly the same signs and symptoms described above. If you look at my left elbow now, it's still looks mildly swollen and a little 'deformed' compared to the right. My left elbow's carrying angle has also been altered.

I can't straighten my left elbow fully (lacking the last 2-3 degrees) compared to my right. Other than that it does not really bother me at all.

It's not difficult to treat once you know what it is and especially if you seek treatment early. Otherwise you may end up with a slightly 'deformed' elbow like mine. Just purely cosmetic, no real deficits.


Rossetini G, Ristori D et al (2018). Myositis Ossificans: Delayed Complicatio Of Severe Muscle Contusion. JOSPT. 48(5): 348-427. DOI: 10.2519/jospt.2018.7567

See the 'lump' near top of picture

Monday, June 22, 2020

Spinal Manipulation Helps With Hip/ Knee Weakness In Otherwise Healthy People

Wow, this article definitely caught my eye as a single manipulation on the spine in healthy subjects increased the lower limb strength, at least in the short term.

The subjects were found to have lower limb musculoskeletal dysfunction along with muscle weakness. Those with knee and hip weakness who are otherwise healthy had large strength gains.

Strength training will hypertrophy muscle and increase strength over a period of six weeks though the authors suggested that weakness can persist despite muscle hypertrophy. They suggested this occurs in the early stages of joint pathology or when there is limb or spinal joint immobility which may then inhibit muscle activation.

The authors also presented evidence of three randomized controlled trials (these are Level 1b evidence of moderate quality) that showed immediate small to large effect size muscle strength gains immediately after spinal manipulation.

The authors suggested that spinal manipulation to particular spinal segments after screening for specific muscle weakness can increase short term strength. This will present a chance for efficient intervention as patients benefit by starting an exercise program to train the new muscle function gained. This provides extra incentives and more motivation for the patients to keep training.

What remains unclear though are the neuro muscular mechanisms through which the spinal manipulations increases strength.

Hmmmm, as you can read, I'm intrigued by the possibilities of increasing strength with a simple manipulation of the spine, but not convinced yet.

I would still suggest that those with true hip and knee weakness (and no other condition) engage in a strength training program.


Wong CF, Conway L et al (2020). Immediate Effects Of A Single Spinal Manipulation On Lower-Limb Strength In Healthy Individuals: A Critically Appraised Topic. J Sp Rehabil. June 2020: 1-5. DOI: 10.1123/jsr.2019-0372.

Sunday, June 14, 2020

Phantom Limb Pain

How many of you have heard of phantom limb pain? The physiotherapists reading this definitely have, but what about my other readers?

Phantom limb pain (PLP) is the feeling of pain in a body part that does not exist (usually amputated because of an  accident or diabetes). Amputees often get phantom limb pain. After amputating a foot, arm or leg from a person, the brain still has that foot, arm or leg mapped. It is not totally clear how and why a person without the physical limb can still have sensations or pain.

Interestingly, it does not just happen in the arms and legs. Phantom breasts, penises and tongues have been reported too (Davis 1993).

Other than pain, patients say sometimes they feel 'it' tingles or itches too. Often PLP symptoms become worse when the person becomes stressed.

PLP tells us about the representation or map of the limb (the 'virtual limb' inside the brain). This is known as the homunculus. Those of you who attended my Kinesio Taping or Floss Band courses would have already heard of this.
The homunculus
It's been a while since I've treated an amputee, but I read about this very interesting case of a woman with PLP. This woman, named RN in the study was born with only three fingers on her right hand. When she was 18, she got into a car accident and several bones in that right hand was broken. Six months later, her doctors decided to amputate that hand.

After amputation, RN reported having pain as though her hand was still there. You would expect her pain to be in the hand with the three fingers she lost. However, she reported feeling five fingers on her painful phantom hand. And they were not five normal fingers. She said her thumb and index finger felt shorter than the rest, but there was definitely five fingers.

RN lived with this phantom hand for many years before seeking help. She was 57 before she saw Dr Ramachandran (a pioneer for phantom limb research). Like what we learnt from David Butler, Dr Ramachandran treated her with the mirror box. After the mirror training, RN reported that her two smaller fingers had grown to normal size. She now feels that she had a normal right hand, that happened not to exist.
David Butler and the mirror box
Super interesting right? RN never had a normal right hand. You would think that her brain wouldn't have the map (or homunculus) to tell her how it may feel like.

To quote Dr Ramachandran : "The amputation of her hand appears to have disinhibited these suppressed finger representations in her sensory cortex and allowed the emergence of phantom fingers that had never existed in her actual hand."

In other words, the brain has a ready-made map (or homunculus) for a normal hand, that was tweaked to accomodate RN's condition. Once the physical hand was amputated, that map was restored.

*pictures taken with my iPhone XS from David Butler's Explain Pain book.


Davis RW (1993). Phantom Sensation, Phantom Pain And Stump Pain. Archives Phy Med Rehab. 120: 1603-1620.

McGeoch PD and Ramachandran VS (2012). The Appearance Of New Phantom Fingers Post-amputation In A Phocomelus. Neurocase. 18(2): 95-97. DOI: 10.1080/13554794.2011.556128.

Saturday, June 6, 2020

This Is What Our Physiotherapists Can Do

2:08 pm - wearing socks
Here's a patient I saw this past Thursday in our clinic. He was complaining of right sided low back pain after sitting at home all day long during the circuit breaker working on his laptop. You can see from the picture above that the picture was time stamped at 2:08 pm this past Thursday.

After a quick assessment, I treated his feet. Yes, you read correctly. I didn't go anywhere near his back. Have a look at the picture at 2:31 pm. Since he wasn't a new patient, my receptionist only book a 30 minute follow up session for him. New patients get 60 minutes in our clinics.
2:31 pm - took off socks
You can see he's wearing blue socks in the first picture while I was assessing him. He took off his socks as I was treating his feet. You think his socks caused all the difference? Nah, I was pulling your leg.

Have a closer look when I put the two pictures side by side below. Click on the pictures for a bigger version.
Before and after
How's that after just 23 minutes of treatment (including assessment)? Notice his feet are not pointing outwards as much. His knees are also not as hyper extended. His pelvis is level and and not tilted forward like before. His upper body is more upright with respect to his hip as compared to earlier. And his neck is not poking forward as much with respect to his upper body.

My patient was shocked when I showed him the pictures I posted here. And by the way, his back wasn't hurting anymore when I was done treating his feet.

This is what our physiotherapists in our clinics can do with our hands when we treat patients. Not a chance that video/ tele consults can do this.

Monday, June 1, 2020

Exercise As A Remedy For COVID Stress

Today is the last day of the circuit breaker (CB) or lockdown period in Singapore. Finally, light at the end of the tunnel.

During the CB, I've noticed a lot more people in my neighborhood running than before, and many you can tell, never really exercised regularly previously. But good for them, at least they are exercising now. I guess with all the free time, gyms closed and not wanting to lose their sanity, many people go walking and running.

You can probably guess that quarantines and lockdowns or similar measures to combat plagues are associated with poor mental health. Past quarantines resulted in lingering stress levels, confusion and mounting anger (Brooks et al, 2020).

A recently published study (though not peer reviewed) done in the early stages of the lockdown (in USA) suggested that benefits of exercising extended beyond just physical benefits and help us mentally too (McDowell et al, 2020).

The study found that people who managed to keep exercising during the lockdown were less depressed and more mentally resilient compared to those whose activity levels declined.

Data from manufacturers of activity trackers showed that most people's daily step count decreased from March since most countries were under lockdown during that period.

In that study, researchers asked about 3000 non smoking subjects probing questions about their personal lives. Multiple questionnaires about how often they exercised and how many hours were spent sitting before the pandemic began.

This was compared to the lockdown period in April. Subjects were asked if they were fully self quarantined at home or did they get a chance to go outside while following social distancing rules.

They were also asked about their current mental health, whether they had symptoms of depression, anxiety, loneliness or if they were generally happy.

After collating the replies, the researches split the subjects into groups based on whether they previously had or had not met the standard exercise guidelines of 150 minutes per week of moderate exercise now compared to before the lockdown. The researchers then compared exercise routines and moods.

No surprises that the researchers found that those who managed to exercise were more cheerful and vice versa. The people  who previously had been active but because of the lockdown rarely exercised were more likely to be depressed, anxious, lonely and worried compared those who still managed get in 150 minutes of exercise a week.

Those subjects in full quarantine were the most affected as few managed to maintain any exercise routine and they reported feeling sad, depressed and solitary.

After looking at the study in detail, I noticed that most of the respondents were middle class well educated whites. Not many of other races were represented.

Because this study relied on their memories of the exercise routines, the findings may not be totally reliable as it covers separate but temporary parts of their lives during the lockdown. We can perhaps infer that exercise and their moods were linked.

I can definitely testify that exercise can improve moods and well being. If you haven't been able to exercise and get out much during the CB, bear in mind that we still have to exit the CB in stages.

Stay safe.


Brooks SK, Webster RK et al (20120). The Psychological Impact Of Quarantine And How To Reduce It: Rapid Review Of The Evidence. 395: 912-920. DOI: 10.1016/S0140-6736(20)30460.

McDowell C, Lansing J et al (2020). Changes In Physical Activity And Sedentary Behaviour Due To COVID-19 Outbreak And Associations With Mental Health in 3,052 Adults. Cambridge Open Engage. DOI:10.33774/coe-2020-h0b8g.

See if you can guess where I took the following pictures during my solo CB rides.
Guess where this tank is?
Abandoned guard tower
Not in use water tank?