Sunday, October 24, 2021

Running Faster May Not Cause Shin Splints

Frequent site of shin pain/ stress fracture

We runners have always been told to train and don't strain. Running too fast, too often, can be a sure recipe for injury. That's why we always have an easy day for recovery after a hard session, to reduce our risk of injury. No runner wants to hear that they have a stress fracture or a small crack in their bones caused by overuse.

We think that when we run faster, we put more strain and load through our muscles and bones. So chances of a muscular or bone stress injury should be higher when we run faster.  We all assume that running slower (or slowly) causes less strain on our legs than running fast.

According to newly published research, fast paced running does not put any more pressure on your tibial (shin bone) which is a common area for shin splints and stress fractures than slow easy runs.

Runners in that study were asked to run at their own selected pace of slow, moderate and fast (but not all out). Reflective sensors were attached to their hips, knees and feet while they ran over force plates that measured impact (load) with each step.

I was really surprised to read that the slow paced runs (and not the fast runs) resulted in the most strain. Running at 'normal' or moderate pace for these runners caused less cumulative load than running the same distance at fast and slower speed.

The authors concluded that running fast does not necessarily cause more load on your tibial (shin bone) than slow running. Well, no excuse not run intervals once a week then if you're training for a race.

However, it may be too early to use this information to change our training habits as fatigue definitely does affect load when we run. Personally, I do feel I need an easy day of training to recover after a hard bike, run or weights session. Even when I was competing, it's usually 2 hard days of training back to back with a easy day (or total rest day) after. That way you won't have to worry about getting injured. Until an an accident strikes ......


Hunter J, Garcia GK, Shim JK et al (2019). Fast Running Does Not Contribute More Cumulative Load Than Slow Running. Med Sci Sp Ex. 51(6): 1178-1185. DOI: 10.1249/MSS.0000000000001888

Thursday, October 21, 2021

Sports Solutions Turns 12

The picture above was taken just outside the clinic when we started at Amoy Street in 2009. So that means our clinic turns 12 today!

We moved to Holland Village in 2014 after my bike accident in 2013 so I didn't have to cycle to the clinic. That was the main reason we moved (now you know).

We are most grateful to everyone on our team and patients that have stood by and supported us all this while. We will continue to do our best to update, improve and progress for our patients. Thank you from the bottom of our hearts.

Sunday, October 17, 2021

Ultrasound Or Ultra Bullshit?

When I was doing postgraduate studies in Adelaide back in 2003, I was fortunate to have David Butler as one of our tutors teaching Pain Sciences. He also introduced us to the term 'ultra bullshit' when it came to what he thought about the effectiveness of using ultrasound to treat patients. Especially those patients with chronic pain.

For those of you using therapeutic ultrasound, please do not be offended. I'm not suggesting that you cannot, should not or better not be using it, I'm just saying that we almost never use ultrasound in our clinics to treat patients.

However, I've been receiving therapeutic ultrasound almost daily since my T4 spine fracture last month. Why the sudden change? There have been studies showing that pulsed ultrasound can accelerate bone union by up to a week. I'm up for anything that helps my fracture heal better and faster!

Therapeutic ultrasound appears to effectively heat tissues (muscles, connective tissues etc) but research has not established the ideal temperatures for tissue benefit or tissue damage. Current research also suggests that therapeutic ultrasound will not help pain reduction, delayed onset of muscle soreness (DOMS) or iontophoresis (deliver medicine under the skin), BUT it does appear to facilitate fracture healing. That previous sentence you read was 'a sight for my sore eyes'!

So my beloved wife has been helping daily with my ultrasound regime, although she does delegate the tasks occasionally to my boys as she says it's terribly boring holding on to the ultrasound device.

Looking forward to my next MRI to see how my fracture has healed.


Eberman L, Schumacher H, Niemann AJ et al (2013). Research Evidence For Therapeutic Ultrasound Effectiveness. Int J Ath Trg. 18(4): 20-22. DOI: 10.1123/ijatt.18.4.20. * Thanks to Byron who got me the article.

Sunday, October 10, 2021

The Intricacies Of Our Thoracic Spine

Vertebral body of thoracic spine
Since my accident, I've been researching and reading so I know how to best treat the thoracic spine when it's someone else who's hurt their thoracic spine and ribcage. So this week's post is to share what I've been reading up on the anatomy, structure and function of our thoracic spine.  Also by writing it here, I can always send this link to patients who want to know more. 
Cancellous bone
The vertebral body is not a solid block of bone. In fact, it is just a shell of dense cortical bone (outer surface of bone) surrounding cancellous bone (pictured above). This shell is not strong enough for lengthwise compression and it collapses like a cardboard box with too heavy loads (see picture below).

It is reinforced by vertical struts between the top and bottom surfaces. A strut acts like a solid, but narrow block of bone. As long as it is kept straight, it can sustain immense longitudinal loads.

Vertical struts straining under load (b)

However, struts tend to bend or bow when longitudinal forces are too strong, although a box with vertical struts is still stronger than an empty box.

Stronger with horizontal cross-beams
When cross-beams that are connected are introduced to the struts, the strength of that box is further enhanced. So, when a load is applied, this cross-beams hold the struts in place to prevent them from deforming and preventing the box from collapsing. 

Our vertebral bodies follow this internal architecture described above. The struts and cross-beams are formed by thin rods of bone called vertical (VT) and transverse trabeculae (TT). This trabeculae provides weight bearing strength and resilience to the vertebral body.

Any load applied to the vertebral body is first borne by the vertical trabeculae. When the load is too much, the horizontal trabeculae picks up the slack. Hence the load is sustained by a combination of vertical pressure and transverse tension in the trabeculae.

The advantage of this design (when it is not a solid block of bone) is that a strong but lightweight load bearing structure is constructed with minimal use of bone.

Another benefit is that the space between the trabeculae is used as channels for the blood supply and venous drainage for the vertebral body. Under some conditions, it allows for haemopoiesis (making new red blood cells) and this helps with transmitting load and absorbing force.

So how did my T4 fracture when it is supposed to be strong and resilient? Well, it wasn't just a simple fall, I was rear ended by a motorbike.


Bogduk N and Twomey LT (1987). Clinical Anatomy Of The Lumbar Spine. Longman Group UK.

Oliver J and Middleditch A (1991). Functional Anatomy Of The Spine. Butterworth-Heinemann Ltd.

Sunday, October 3, 2021

Running With Ankle Weights

Picture by Megan
This week's post is requested by one of our blog's readers who asked about the benefits of running with ankle weights. This reader started using ankle weights when Covid-19 caused gyms to close last year and thought that by strapping on ankle weights, it would be like adding strength training while out walking or running.

Strangely enough, I've noticed a couple of ladies who run pass my home (now that I'm stuck at home mostly after my accident) with ankle or wrist weights too. I suppose once you're aware of them, you start looking out or noticing them.

Let's get into it. We shall start with the benefits first. Running with the ankle weight makes (some of) your leg muscles work harder since the extra weight makes it heavier to walk or run.  Over time, (some of) your muscles get stronger. For instance, if you were running with the ankle weights, it would work your hip flexors more than your hip extensors as the former have to work harder to lift your leg off the ground to prepare for the next foot strike. 

When you take the extra weight off, it makes it easier to run, you can run faster or you may find it easier to run longer distances. The heart and lungs work harder too and over time, your cardiovascular endurance improves. I found a study in 2016 which supports this (Yaacob et al, 2016).

Now for the not so good part of running with ankle weights. Your gait definitely changes when you run with them. There is now added load on your joints, especially your knees, hips, ankles and lower back. This can lead to improper or faulty technique, which may create muscle imbalances and cause injury.

What's worse is if your muscles cannot handle the extra weight, this added load gets transferred to your bones, joints and the articular cartilage. So the risk of carrying a heavier load may outweigh the potential improved performance for runners.

My take? If you have been using them and have no issues or injuries, you can probably carry on. However, if you're a new runner then I will suggest other ways to add training load to improve so as to minimize your chance of getting injured.

Would I run with ankle weights? Most probably not. The closest I came to using something similar was a weight vest. I did this way back in 2000 and 2001 when I was training for the Oxfam 100 km Trailwalker event and I used to walk (not run) up and down the steps in the spectator stands at the old National Stadium to get stronger. 


Yaacob NM, Yaacob NA, Ismail AA et al (2016). Dumbbells And Ankle-wrist Weight Training Leads To Changes In Body Composition And Anthropometric Parameters With Potential Cardiovascular Disease Risk Reduction. J Taibah Uni Med Sci. 11(5): 439-447. DOI: 10.1016/j.jtumed.2016.06.005

Sunday, September 26, 2021

Eat More And Triumph

Picture from
I remember a fellow cross country runner who was on the stockier side, was really strong and fast (of course now I know he had what we call a mesomorph body type). The teacher in charge back then suggested that he '"needed to weigh a certain amount so he could run even faster".

This teacher had good intentions no doubt, but he was a Math teacher 'assigned' to be in charge of cross country running and not a 'real' running coach. Looking back, I'm not even sure if that teacher himself ran at all.

Anyway, my friend took his 'advice' and tried to lose weight mostly by not eating or eating a lot less. Not only did he lose weight, he lost a lot of his natural strength and his confidence to boot as he fared poorly in races thereafter. He quit running soon after. 

We now know that being a good athlete is all about finding what works for you. It's about finding YOUR 'strong'. We need to fuel our bodies adequately if we want long term growth and success.

For some runners, that means following that advice my cross country teacher gave to lose weight. For others, it means having a body that looks different (to the norm) and weighing more or less. All body types can work given our different and unique genes and backgrounds.

The problem with that advice is that it is often interpreted from elsewhere, an outlier perhaps, a person that won an Olympic medal. Interpreting data from outliers may be great if you're an exercise scientist writing up research to publish in a scientific journal. Definitely not great for giving advice to other athletes.

Athletes that go against their unique genes and background will not fare well with this training stimulus. They will be like a ticking time bomb and will almost always get slower with time, just like my former team mate.

Consider the *New Zealand rowing team, A survey they did found that all but one rower was at risk of having low energy because of their beliefs and eating habits. Coaches and Rowing NZ officials worked with their rowers to take up a challenge and eat more, thus changing their approach and culture to fueling. The rowers became faster, stronger and happier. Rowing was New Zealand's most successful sport at the Tokyo Olympics and four female boats won medals.

Here's what rower Brooke Donahue, who won a silver medal at the Tokyo Olympics recently said, "Now I understand being lean isn't a priority, being strong is," and "It doesn't matter what I sit on the scales. It's opened us up to understand it's not about a number but more about a good feeling, knowing we're fueling well." 

Eating well and eating enough can fuel your performance and recovery for long term growth and adaptation. Food can be your legal and natural performance enhancing 'drug'.


McFadden S (2021). Tokyo Olympics: How Our Female Rowers Ate More And Triumphed. Published on 17 Aug 2021. *Article on the New Zealand rowing team is taken from Stuff.

Sunday, September 19, 2021

Minimum Dose Of Training To Stay Fit

2 months after accident in 2013
I've written about how quickly you can lose your running fitness in the past. With my recent accident, I'm definitely losing fitness as the days pass. 

However, I'm probably not the only person who worries about losing fitness. Many people have lost their fitness during this Covid pandemic. I remember a few of my patients who are security officers for ministers/ VIP's whose ability to train while on duty is severely restricted. Similarly for military personnel on certain postings. Others with personal conflict, family commitments, caring for an ill family member and injury may face the same situation.

Since I'm in the same boat, I'm reading up to find out exactly how or what I need to do so I don't lose too much, or better still maintain whatever fitness I have left 2 weeks post accident.

Let me share what I found out from researchers from the US Army Research Institute of Environmental Medicine. They looked at three key training variables, frequency (how many days a week), volume (how long the session, how many sets or reps to lift) and intensity (how hard or how heavy the weight). 

Only studies on athletic performance (not weight loss or health) in which the training was reduced for at least 4 weeks were considered. This is to distinguish them from research on tapering before a big competition (usually a 3 week taper).

Most of the studies reviewed were based on work done by Robert Hickson in the early 1980's (Hickson and Rosenkoetter, 1981). Hickson's subjects were put through 10 weeks of brutal training. They involved 6 days of cycling or running for 40 minutes at 90-100 percent maximum heart rate (HR) at the end. Then for the next 15 weeks, they reduced the number of weekly sessions to twice or four times a week. Duration was reduced to 13 or 26 minutes and intensities of the sessions were reduced to 61-67 or 82-87 percent of max HR.

Picture from Med Sci Sp Ex article

In Hickson's original study , VO2 max is shown on the Y (or vertical axis) on the left of the picture above. You can see that after the 10 weeks (albeit brutal) training block on the X axis, VO2 max have improved by a impressive 20-25 percent. For the next 15 weeks, their VO2 max stayed at their improved values, despite training dropping down to 2-4 days a week. The subjects were recreationally active but untrained. 

Overall conclusion of this review is that you can get away with just 2 sessions a week as long as you maintain volume and intensity of your workouts. This is similar to what Hickson found with further confirmation in some areas. 

However, please bear in mind that maintaining your VO2 max is not the same as your ability to perform long duration activities (oops for me then since my Saturday bike rides go up to 3 hours). Similarly, don't expect to run your best marathon time after a few months of 2 times a week training. Your leg muscles will definitely not be able to handle it.

When duration of training was reduced by one (13 minutes) or two thirds (26 minutes), VO2 max gains were preserved for 15 weeks. The study included short (5 minutes) and long (2 hours) endurance. No prizes for guessing that short endurance was preserved when comparing the 13 and 26 minutes group, but those who reduced their training to 13 minutes fared worse in the 2 hour test.

When training intensities were dropped by a third (from 90-100 percent to 82-87 percent), VO2 max and long endurance declined. When training intensities were dropped by two-thirds (61-67 percent), most of the training gains were wiped out. Takeaway message is you can get away with training less often, or for a shorter duration but not with going easy.

A few other points to note. These conclusions were based on what I'll say is an "unsustainable training protocol" of hammering 6 days a week with one rest day! Most of us would surely have a more balanced training program of hard and easy days. 

The subjects used were not trained athletes nor military personnel. If you've been  training for years, you would have some structural changes like a bigger heart and a more extensive network of blood vessels that would hopefully take longer to take away (yay for yours truly).

Of course elite athletes would probably have a higher level of absolute fitness which may fade away quicker initially.

All you gym rats will be happy to know that the overall pattern is fairly similar when it comes to strength training too. Both frequency and volume of workouts can be reduced as long as intensity is maintained. Several studies found that even once a week training is enough to preserve maximum strength and muscle size for several months.

However, for adults above 60, evidence suggests that twice a week strength sessions are better at preserving muscle. Same for training volume, older people will need two sets while one set per exercise for young populations will suffice.

Now you (and I) definitely know what it takes. 


Hickson RC and Rosenkoetter MA (1981). Reduced Training Frequencies And Maintenance Of Increased Aerobic Power. Med Sci Sp Ex. 13(1): 13-16

Sperring BA, Mujika I, Sharp MA et al (2021). Maintaining Physical Performance: The Minimal Dose Of Exercise Needed To Preserve Endurance And Strength Over Time. J Strength Cond Research. 35(5): 1449-1458. DOI: 10.1519/JSC.0000000000003964

Sunday, September 12, 2021

Sugar Is Not Your Enemy

When can I drink Coke again?
Those of you who know me well know that I have a sweet tooth. I love eating chocolate and drinking Coca Cola. However, now that I'm not able to do much exercise over the next 6-8 weeks after my accident last week, I definitely won't be eating much sugar!

There is a huge difference between consuming too much added sugar when not exercising and fueling your exercise with sugar. This always confuses athletes, myself included previously. So let me try to explain this.

Too much sugar in our diet can definitely harm our health, but consuming carbohydrate, including simple sugars can be beneficial to your athletic performance. During intense exercise and in the latter stages of a long endurance session/ race, when our muscle glycogen gets low or depleted, bananas, Coca Cola, gels and other concentrated sources of simple sugars get into our bloodstream and muscle cells much quicker. Some of you must have experienced this while on the verge of bonking and getting a sugar boost when you consume an energy gel. 

This then presents a dilemma for some of you who want to fuel high performance and simultaneously reduce sugar intake.

Carbohydrates include whole grains, fruits, vegetables, processed grain, rice, noodles, pasta, table sugar (sucrose) and monosaccharides (fructose and glucose).

When a food contains extra or "added sugar", it means that sugar that was not naturally present in a food or ingredient but was added during preparation or cooking, then you have to be careful. These are mostly in packaged foods although it goes by names like high fructose corn syrup, cane juice crystals, muscovado, brown rice syrup etc.

So when doctors or dieticians warn about health risks associated with consuming large amounts of sugar, they are not referring to carbohydrates, but excessive added sugar.

Excessive consumption of added sugar, also known as 'free sugar' is the problem and it is associated with obesity, *insulin resistance, Type II diabetes, cardiovascular disease and **other health problems.

How is this different from consuming sugar while exercising? During prolonged exercise (greater than an hour at least), simple sugar is useful, effective and does not come with risks and problems mentioned above. This is also true (although to a lesser extent) immediately before and after exercise.

The problems associated with simple sugars are tied to consuming it when you are at rest (or not exercising). Since your body needs to do something with the energy in the sugar you are consuming when you're not active enough to burn it, your muscles are still full of glycogen and you cannot store it, your blood sugar levels stay elevated longer and the excess is stored as fat.

When we exercise, our bodies use carbohydrates differently. Our muscles use glucose to produce energy and the amount of glucose they transport from our bloodstream into our cells increases, without needing insulin. 

Kipchoge monitors his sugar levels

Since exercise reduces blood glucose levels, insulin secretion decreases and glucagon increases. Glucagon does the opposite of insulin, it helps free glucose from its storage form (glycogen) in muscle cells and the liver to increase blood glucose levels. All that in simple terms means that during exercise the sugar you ingest does not cause your insulin levels to spike.

After a hard, long exercise session (> 60 mins), both muscle and liver glycogen levels are low, there is an opportunity to quickly store sugar (this can be Coca Cola, banana or even prata) as glycogen. This is when you can consume simple sugar (until your glycogen stores are replenished) without the ill effects described above.

So now you know, you do not have to avoid added or simple sugar during exercise and perhaps immediately after a long intense session or race, but that does not mean you should ONLY consume added or simple sugar while exercising. Complex carbohydrates and other real food that contains fiber, fat and protein are all parts of a sound nutrition that our body needs.

So, when added sugar does not serve a useful function (like exercise), and this is usually more than hour before or after exercise, you definitely should be eating real food, without added sugar.


Burke LM (2004). The IOC Consensus On Sports Nutrition 2003: New Guidelines For Nutrition For Athletes. Int J Sp Nutr Ex Metabolism. 13(4): 549-552. DOI: 10.1123.ijsnem.13.4.549

*Since added sugar is absorbed quickly, our blood sugar levels spike up quickly which leads to insulin being release rapidly to remove sugar from our bloodstream. This can lead to insulin resistance over time where more insulin needs to be produced before sugar is being absorbed. Over time insulin resistance leads to Type II diabetes.

**Other health problems include affecting leptin levels, which affect perception of hunger. When there are lots of leptin in the bloodstream, we feel less hungry. When we have low leptin levels, our brain thinks we are running low on energy and increases our appetite. Consuming too much sugar leads to leptin resistance whereby high leptin levels in the blood does not signal satiety and we either eat more before feeling full or feel hungry soon after finishing a meal.

Sunday, September 5, 2021

Gino Was In A Cycling Accident.. Again!

ECG in progress

This was yesterday. Gino needed an echocardiogram done after his accident. Let's rewind to the start of 4th September 2021.

Gino went for his usual Saturday bike ride with the CycleWorx group. They had completed about 60km when they were cycling along Nicholl Highway towards the city. The roads were empty and they were cycling on the left most lane. So it came as a shock when a motorcyclist rear ended him. Gino recalls that it all happened so quickly. He flew backwards and landed on his back. He got up to see his bicycle on top of the motorcycle and the motorcycle on top of the motorcyclist. His friends called for the ambulance and police.

I received a call from Gino at about 8am. It was words I'm not fond of hearing, "I've been in an accident." I've since learnt from his last cycling accident in 2013 that Gino has a high pain threshold and always says he's ok. When I asked him where it hurt and he said his upper back, I thought, "Oh man! Not his spine again!" He had sustained a fracture in his skull and lower back in 2013.

My dad drove me to the scene of the accident and I was relieved that the ambulance was still there. Gino was on his right side, strapped onto the gurney. He was inhaling painkillers and complaining of upper back pain. He also asked for his muesli bar that was squashed from the impact of the accident in the pocket of his jersey, which was ripped to shreds by the accident. We had to be transported to Tan Tock Seng Hospital. 

It was not a good experience there. Most of the nurses were great but the doctor who received us at Accident & Emergency was less than impressive. To cut a long story short, even after we repeatedly told her that Gino's pain was between thoracic spinal levels 3 to 6, the X-rays were done for the lower thoracic and lumbar spine. We were elated when the doctor reported that there were no fractures, and took her word for it. In hindsight, I'm questioning myself why I did not check the films! We were discharged from A&E and told we could go home. Gino was feeling less pain as he had been given meds.

I am grateful that our friend who I had called after the accident, who's a spine surgeon, called us as we were waiting for our Grab ride home. He was appalled that we had been discharged so quickly after a road traffic accident. He asked to see the X-rays again and only then did we realize that the upper thoracic spine levels had not been captured. We changed our destination to Mount Elizabeth Medical Centre.

As the effects of the meds started wearing off and after the thorough assessment done by Prof Hee, Gino stood up and exclaimed," Oh no! This feels like the same pain I had when I fractured my low back." I know Gino knows his body really well so we proceeded to get him admitted to be assessed more thoroughly with MRI and to be monitored. 

His MRI films showed a wedge compression fracture at thoracic spine level 4. Since it was at that level,  he had to have his heart assessed with an ECG and blood tests plus a CT scan to ensure that all his organs and vessels were not injured and also check that his ribs are intact.

Arrow shows the location of the fracture

CT scans of his thorax turned out to be clear. Phew! There were some abnormalities with his ECG readings so we have to follow up with a cardiologist. We are hoping that it was just the stress from the accident and that it will settle, but we will get his heart checked. 

The fracture in his spine will be treated conservatively, meaning no surgery as that particular thoracic level is well supported by his ribs and connective tissue. We will let the body heal itself. Gino cannot work and cycle for a few months. His surgeon advised him to maybe to stick to the park connectors or the gym when he can start cycling again. I don't know about that!

His ripped jersey

Happy after being told he can go home

Sunday, August 29, 2021

Locking In Your Knee May Not Mean A Meniscus Tear

Picture from ScienceDirect

A discussion with our three new physios recently revealed that they were taught that whenever a patient has a meniscal tear on MRI with mechanical symptoms it would usually mean surgery is indicated.

Mechanical symptoms are described as 'locking' or 'catching' in the knee joint that is caused by something being trapped or stuck in the knee. They were taught that it can only be removed by surgery. If the mechanical symptoms present with a tear in the meniscus, that is confirmed by MRI, it is usually attributed to the tear. Hence the rationale for surgery to remove the tear.

However, mechanical symptoms in the knee can fluctuate. Other clinicians and patients may have different variations and definitions of such 'locking' and 'catching' in the knee.

I have come across many patients with locked knees (knees that cannot fully straighten or bend), but they are seldom 'locked' all the time. We always match such symptoms in our clinic with a patient's medical or injury history and with objective orthopaedic and functional tests. 

However a study by Thorlund et al (2019) investigated whether unstable meniscal tears are more likely to cause mechanical symptoms compared to other concurrent knee pathologies like articular cartilage damage, ACL tears etc.

A wide range of meniscal tear characteristics like tear pattern, location, size of tear were included in the study. However, no important relationships were found between any of the included factors and patients reported catching or locking in the knee or inability to straighten their knees.

These results question the logic that mechanical symptoms are caused by specific joint pathologies. The authors also compared the frequency of mechanical symptoms between patients with and without a meniscal tear after knee arthroscopy. They found that half of all patients reported catching or locking. They were also unable to straighten their knee fully. However, these mechanical symptoms were equally common among patients with or without a meniscal tear.

This is consistent with my previous post where bucket handle and complex meniscal tears (both of which are commonly operated on) were found in the patient's MRI, but these patients were asymptomatic.

So if you are currently having a 'locked' knee or cannot straighten or bend your knee fully, it does not necessarily mean you need surgery. Two large scale randomized trials referenced below confirm this too. Please come and see us in our clinic for another opinion.


Khan M, Evaniew N, Bedi A et al (2014). Arthroscopic Surgery For Degenerative Tears Of The Meniscus: A Systematic Review And Meta-analysis. CMAJ. 186: 1057-1064

Thorlund JB, Juhl CB, Roos EM et al (2015). Arthroscopic Surgery For Degenerative Knee: A Systematic Review And Meta-analysis Of Benefits And Harms. BMJ. 350: h2747

Thorlund JB, Pihl K, Nissen N et al (2019). Conundrum Of Mechanical Knee Symptoms: Signifying Feature Of A Meniscal Tear? BJSM. 53(5): 299-303. DOI: 10.1136/bjsports-2018-09943

Sunday, August 22, 2021

Foot Strengthening To Prevent Running Injuries?

We had a 16 year old patient who came in with footshin and knee pain this week. She had been prescribed orthotics and had been wearing them for the last ten years. Every time she tried running, her knees and shin start to hurt during and the day after her run. Somehow, the orthotics did not seem to help with the pain.

She also mentioned that she wore her running shoes (with orthotics) everywhere she went as she was told that other footwear and slippers were 'bad' for her.

You have read from a previous post that contrary to several long held beliefs, most biomechanical and structural factors are not reliable at predicting running related injuries. Naturally, I was interested when a recent study investigated whether foot muscle strengthening reduced the incidence of injury rates over a one year follow up. Especially since I wrote that my patient (plus myself included) would be bored doing foot strengthening exercises.

Researchers had 118 runners who ran between 20-100 km a week for their study randomized into two groups. The foot muscle strengthening (FMS) group received 8 weeks of 12 foot-ankle exercises done once a week supervised by a physiotherapist and 8 foot-ankle exercises done three times a week at home with remote supervision.

A second control group (CG), did a 5 minute placebo static stretching protocol three times a week with weekly feedback from a physiotherapist. 

After the 8 week intervention, both groups were instructed to continue their respective exercises three times a week until the end of a 12 month follow up while recording their adherence.

The researchers suggestion that a stronger foot will better dissipate excessive and cumulative loads appears supported as foot strength gains were correlated with time to getting injured. 

Altogether, 28 runners ended up with a running related injury, 20 (32.8%) from the CG and 8 (14%) from the FMS group. The results showed that runners in the CG were 2.42 times more likely to suffer a running related injury compared to those in the FMS group. 

The researchers also found that the larger gains in foot strength over the 8 weeks of training correlated with the runners taking a longer time to get injured. They also reported that by the fourth month of follow-up, differences in cumulative running related injury risk were evident between the 2 groups and suggested that 4-8 months of the regime may already be effective.

However, each runners response to foot strength improvement and how this relates to different injury types or sites will require further investigation.

My thoughts are that this foot muscle strengthening regime is exactly the same as wearing the Vibram Five Fingers shoe. Remember them? They were really popular before the thickly cushioned or maximalist shoes became the rage.

In the study, the foot strengthening program takes 20-30 minutes to complete. This time commitment may be a consideration. As a physiotherapist, I should not be writing his, but if I had extra 30 minutes, I'd rather run outside than do foot strengthening exercises. 

I'm just being honest here. There are plenty of demands on my time being a father to 2 young boys, physiotherapist, business owner and trying to find time to exercise. Probably some of you who are also pressed for time would agree.

Back to our patient. I suggested that she remove her orthotics from her running shoes and gradually increase time walking with them first before attempting to run. The toe spring from her shoes and orthotics would lead to her having weaker intrinsic foot muscles and increase her chances of getting pain in her footshin and knees and possibly getting injured.


Taddei UT, Matias AB and Duarte M (2020). Foot Core Training To Prevent Running-related Injuries: A Survival Analysis Of A Single-blind, Randomized Controlled Trial. AJSM. 48(14): 3610-3619. DOI : 10.1177/0363546520969205.

My own minimalist version of the Vibrams that I use to walk around with and lift weights to strengthen my intrinsic foot muscles. My calfs get too sore when I run with them. My brother bought a few pairs for me when he was working in Shanghai for $RMB 30.

My own minimalist running shoe in the picture below. My brother bought it for me from Shanghai for $RMB30 (or S$6) , much cheaper than Vibrams ($149-$209 here in Singapore).

Sunday, August 15, 2021

What My Patient Has In Common With Soldiers


Picture from
I wrote last week that Byron had an interesting case. A patient with a foot condition that the doctor may have missed. This patient started having dull, aching foot pain 6 weeks ago after a game of tennis.

He had been playing tennis more frequently at a higher intensity, besides running and cycling. Since the pain started, he had stopped all exercise. He consulted a doctor a month ago and was diagnosed with 'inflammation in the tendon of the 2nd toe'.

Upon assessment, the patient could perform all functional tests like heel raises, toe raises and single leg hops with no pain. There was just a slight difference in muscle strength in the patient's painful foot. No pain at all during muscle strength testing, which is common during tendon injuries.

Picture from Merck manuals

The patient's pain was immediately reproduced upon specific palpation of his 2nd toe, along the shaft of the metatarsal, suggesting that he had an almost recovered "March" fracture.

March fractures (or metatarsal stress fractures) were first described in literature in 1855 in Prussian soldiers after they experienced pain and swelling in their feet after long marches. They are usually caused by repetitive stress and extrinsic environmental risk factors. If a patient is nutritionally deficient in Vitamin D or calcium, the risk of these fractures occurring are increased.

March fractures occur most commonly in the second or third metatarsals when they are unable to withstand the load from excessive forces/ loads. The second toe is less flexible and is prone to more torsional forces due to its attachments to the cuneiform bones.

Diagnosis is based on physical examination followed by confirmation by x-ray imaging.

We did not suggest that the patient go for an x-ray since it's been 6 weeks since the pain first occurred (stress fractures take approximately 6 weeks to heal). We advised him to gradually resume his exercise routine after treating him.


Warden SL, WB Edwards and RW Willy (2021). Optimal Loading For Managing Low-risk Tibial And Metatarsal Bone Stress Injuries in Runners: The Science Behind Clinical Reasoning. JOSPT. 51(7): 322-330. DOI: 10.2519/jospt.2021.9982

Wednesday, August 11, 2021

PS Sim Finishes 200 Miles Race

Picture from PS Sim

Yes, you read correctly, PS Sim is the first and only finisher (male or female) so far in the 2021 Singapore 200 Miles Ultramarathon held from 6-9 August by Running Guild. She finished in an amazing 76 hours and 41 minutes!!

She came to see me last Thursday (5/8/21) for one last tune up as she had some knee pain. After treating her, she asked if I could do some taping for her. Since the cause of her knee pain was coming from her hip, I taped her left hip (instead of her left knee) and she was pain free through out the run. Have a look at the whatsapp message she sent me yesterday below.

She even offered to write me a testimonial for the Kinesio taping that I did for her. For all the naysayers who do not believe  that Kinesio taping works, the proof is in the pudding - or rather in PS Sim's legs! 

Now, I have nothing against all the published articles that say Kinesio taping does not work. And there are many healthcare professionals who do not believe in it. However, if the researchers have never learnt to do the actual Kinesio taping correctly, or used different brands/ types of tape, then I would humbly suggest that their research methodology may be flawed. 

Similarly, if I never learnt for example, Alexander technique, and I try it on my patients and end up with poor results, surely it is then unfair for me to say it does not work.

Anyway this post is not about Kinesio taping, this post is to congratulate PS Sim on a run super well done on Singapore's 56th National day! 

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

Sunday, August 8, 2021

Don't Give Up On Physiotherapy

MeganThiviyan and Byron
This past week, we saw a few new patients in our clinics who had almost given up on physiotherapy. They felt this way because the physiotherapy treatment that they had received, consisted of brief sessions of exercises or the use of machines like ultrasound, interferential currents and shock wave (ESWT).

There is no wonder why many people who have had such experiences with physiotherapy conclude that physiotherapy does not work.

We are grateful that those patients gave us the chance to show them that physiotherapy does indeed help!

This is what we do in our clinics. We start by doing a thorough assessment of a person's lifestyle and goals. Then we observe how their body is when they are static and when they are doing functional activities. We do not chase the pain. Treatment plans are drawn out based on how each patient presents him/herself at that moment and where a patient wants to get to in the near future. We mainly use our hands, not machines or modalities.

We had 3 newly graduated physiotherapists join our team 12 weeks ago. Megan, Thiviyan and Byron.

Megan saw the gentleman below last week. He complained of some neck and shoulder pain and discomfort possibly due to working from home last year. 

Left picture before treatment

He sits for long hours and does not exercise. After assessing him, Megan decided to treat his feet. Yes, you read correctly, she did not treat his neckshoulders or lower back, not yet anyway. She was able to significantly change his pain and his posture in less than hour.

From the side view (picture above on right), his feet are not pointing outwards as much. His knees are not as hyperextended, he seems to have 'lost' his tummy since he is standing more upright. His neck is also not poking forward as much with respect to his body.

Left picture before treatment

From the back view, the space between his left arm and body and right arm and body is more equal. His right hip is not tilting down as much as before. Well done Megan!

Thiviyan recently received an email of commendation from one of his patients. She had gone to a surgeon before seeing him and he got her better quickly using the approach that we use in our clinics. 

Bravo Thiviyan!

Lastly, there is Byron . He saw a patient with an interesting foot condition that the doctor the patient saw missed. That will probably be another post.

We're really pleased with how ByronMegan and Thiviyan are progressing. 

As experienced physios, we are grateful that we get to teach our young physios and we are learning from them too. They see the world through different lenses. When we consider all the different perspectives in the assessment and treatment of our patients, we become stronger as a team and more skilled at helping our patients. 

As we previously wrote, we do not aim to be the biggest physiotherapy clinic, we just want to be the best at helping our patients reach their goals.

Sunday, August 1, 2021

Choose A Pink Drink For Your Next Run

Megan getting ready for her run
If you're lacking some motivation prior to your next run, it may help to consume or even just rinse and spit out a pink drink rather than just clear regular water.

Skeptical? I was. Until I read the article (Brown et al, 2021) where researchers got runners to run at their own desired speed on a treadmill for 30 minutes. Throughout the run, they rinse their mouths with an artificially sweetened drink that was either pink or clear. Yes, just rinse and spitting the drink out, not even drinking. Actually both the drinks were the same, save for a few drops of food dye in the pink drink to get the colour. 

During another treadmill run, the runners had the other drink (pink if they got clear in the first run and vice versa).

When the runners rinsed with the pink drink, they showed more endurance and intensity compared to when they rinsed with the clear drink. When rinsing with the pink drink, the runners ran 212 meters further and ran faster by 4.4 percent. Here's what was even better. The runners reported higher levels of enjoyment while running when rinsing with the pink drink. This result is similar to what previous similar studies reported.

The authors commented that in another taste study, participants reported that the pink drink was sweeter compared to the clear drink even though they were the same except for the colour. There is definitely a relationship between colour and our mental and physical response. This powerful placebo effect can definitely be harnessed for better running experiences.

This effect of colour in sports is not new, with red in particular thought to provide a performance advantage. Remember Tiger Woods always used to wear red when he was so dominant in golf. Well, what we also teach during the Kinesio Taping courses uses similar concepts in the colours available when it comes to taping.

Pink was used in this study because of its perceived sweetness. And we usually tend to associate sweet tastes before exercise in anticipation of using glucose to fuel our exercise.

The authors wrote that this effect is mainly cognitively (acquiring knowledge/ understanding through thought, experience and senses) driven. Once receptors in the mouth detect the sweet taste, this activates the areas in the brain associated with reward and motivation. Once these areas are activated during exercise, it leads to exercise feeling more enjoyable and easier. One can then run faster and harder based on this feeling.

Drinking or even just rinsing like what the participants did will work just as well. This will help for exercise up to an hour. For any exercise of longer duration, there needs to be actual carbohydrates in the drink that you use (unlike this study where the pink drink is artificially sweetened and has no calories). I've written previously on carbohydrate rinsing in 2018 and way back in 2010.

This no calorie pink drink rinsing cannot sustain you for an indefinite period, especially if you are doing a really long training session or race. 

This is especially useful and will work when you're bloated from drinking too much in a long distance race. If you're doing this in a race, there needs to be actual carbohydrates in the drink that you use, unlike this study where the pink drink is artificially sweetened and has no calories.


Brown DR, Cappozzo F, Roeck DD et al (2021). Mouth Rinsing With A Pink Non-caloric, Artificially-sweetened Solution Improves Self-paced Running Performance And Feelings Of Pleasure In Habitually Active Individuals. Frontiers Nutr. 12 May 2021. DOI: 10.3389/fnut.2021.678105

Sunday, July 25, 2021

4 Exercises To Avoid If You Have Shoulder Pain

We've seen quite a few patients in our clinic recently with shoulder injuries after exercising at gyms. Often, the patients will ask how soon they can get back to their regular gym exercise routine. 

I haven't found any published evidence for what I'm suggesting. They are based purely on my personal observations, treating many patients with shoulder pain and of course doing the same exercises myself.

So here are a few exercises to avoid in the gym (at least until the pain ceases) if you currently have shoulder pain.

First up is the behind neck Lat (Latissimus Dorsi) pull downs. The bar behind the head position potentially creates a situation where the humerus (arm bone) can move too much in front. Majority of the time, it is due to lack of scapular retraction. This creates a scenario whereby they need more than average shoulder extension to get their elbows behind the body so the bar  can clear the back of their head. This places high loads on the front of the shoulder  and can potentially damage the anterior glenohumeral ligaments and the Biceps Brachii tendon. 

Next is behind the neck shoulder press. This is similar to the Lat pull down, but more damaging. When pressing up, the Deltoid muscles have to work, whereas during a pull, the Latissimus Dorsi works. The Deltoid abducts the shoulder and also elevates the humerus into the acromion process. So a pulling movement with the Latissimus Dorsi will pull the humerus away from the acromion and reduce shoulder impingement. However, the behind the neck shoulder press can potentially cause shoulder impingement.

The upright row. A lot of people 'cheat' by extending their lower back to get the bar up when the weight is too heavy for them. At the top of the pull, the elbows are in a higher position than the arms putting the shoulders into abduction and internal rotation. This position can cause or worsen shoulder impingement since our shoulder should naturally externally rotate with shoulder abduction. 

Dips. I used to do lots of parallel bar dips as a kid, but I hardly do them now. Try it yourself, when dipping, there are super high tensile loads on the front of the shoulder at the bottom of the dip. The Biceps tendon, anterior shoulder capsule, and Subscapularis tendon are all under huge loads. The scapula is also tilting anteriorly at the bottom of the dip. Much worse if you add weights attached to the waist.

If you do the above exercises occasionally, I'm fairly certain no harm or damage is done. But if done regularly, with high load and especially if you have a pre-existing shoulder dysfunction, they can definitely make your shoulder worse.

Don't get me wrong, the above mentioned exercises are not bad exercises to do at the gym. It's just that some of us do not have the perfect joint placement for certain exercises, due to imbalances and underlying movement restrictions, that makes those exercises damaging.

Sunday, July 18, 2021

About Intervertebral Discs

Picture from M.A. Adams et al, 2010

Having learnt in anatomy class (when I was a physiotherapy student) that our intervertebral discs (IVD) are avascular (has no blood supply), I was instantly surprised when recent research showed that it may not be totally true.

picture from springer link

A little anatomy lesson before I tell you more. Our IVD's are fibrocartilaginous joints that are thought to be the largest avascular structures in the human body. They are made up of three distinct and interdependent tissues. The outer most cartilage endplates are thin layers of hyaline cartilage that anchor the IVD to the adjacent vertebral bones. The vertebral end plates have plenty of blood supply and this allows for diffusion of nutrients into the IVD through the cartilage end plate.

The annulus fibrosus (AF) is a series of super strong well organized concentric lamellae of fibrocartilage that surround and protect the nucleus pulposus (NP) of the IVD

The NP is the innermost jelly like substance made up mainly of water and proteoglycans. The NP helps distribute pressure evenly across the IVD and prevent excessive forces loading the spine. This is what can herniate through the AF, causing what is commonly know as a 'slipped disc' or prolapsed intervertebral disc (PID).

A group of researchers performed a comprehensive *scoping review on peer-review publications on the blood supply of human IVD's excluding disc herniations. 22 out of 3122 articles found met the inclusion criteria of fetal to > 90 years old, various health status and both sexes using gross dissection, histology or medical imaging to assess if there is blood supply.

Consistent observations from this review were that there is no blood supply in the NP of the IVD throughout life. 

Both the cartilage endplates and AF have considerable blood supply during fetal development and in infants, but decreases over our lifespan. A common feature of the cartilage endplate was the presence of channels throughout the tissue, likely from the well vascularized vertebral endplate from the adjacent vertebrae. Between birth and ten years of age, there is a drastic decrease in blood vessels within these channels; which are not seen at all in adults.

However, there are blood vessels growing into the endplates and inner layers of the AF especially when there is damaged or disrupted tissue regardless of age. This is more common in older adults. Location of blood vessels are variable. 

It is thought that annular fissures or tears associated with degenerated discs are perhaps more conducive to the ingrowth of blood vessels since there is a loss of proteoglycans (a protein compound found in connective tissue) due to the healing process. Interestingly, there are also nerves found together with the blood vessels suggesting some patients may get more pain than others with such conditions.

Through this scoping review, we now know that the IVD is not entirely avascular as often thought and cited. This is great news for patients. We always knew that you can heal from a "slipped disc", but the discs having a blood supply means a better chance that it can heal from an injury.


Fournier DE, Kiser PK, Shoemaker JK et al (2020). Vascularization Of The Human Intervertebral Disc: A Scoping Review. JOR Spine. 15: 3(4): e1123. DOI: 10.1002/jsp2.1123.

*A scoping review has a broader scope compared to traditional systematic reviews with correspondingly more expansive inclusion criteria.

* you can read more about slipped discs and how slipped discs can heal here.