Sunday, June 20, 2021

Are S&C Coaches Or Physiotherapists The Real Exercise Professionals?

This week's post is on an article I read in the blog from the British Journal of Sports Medicine where the author asked whether physiotherapists or strength and conditioning (S&C) coaches are the real pros when it comes to prescribing rehabilitation exercises and getting patients/ athletes to return to sport (RTS).

The author compared physiotherapists and strength and conditioning (S&C) coaches working with athletic populations (in the UK). His view was that the physiotherapist has always been the decision maker or 'top dog' when it comes to managing the injured athlete or any patient that needed exercise to rehabilitate or improve physical function. 

He feels that the physiotherapy profession has not kept up to date with professional developments in exercise science and S&C, even falling behind and out of step in some aspects. This is despite the fact that there has been an increase in demand by physiotherapists in the UK for weekend courses in S&C training to fill in gaps in expertise and knowledge. 

The author thinks these short 2 day courses is "really an insult to those S&C professionals that have devoted time, effort and financial resources to their expertise" as they have studied exercise science, S&C at undergraduate level and gone on to postgraduate study and even advanced professional accreditation to work.

He also feels that the undergraduate training program for physiotherapists in the UK does not provide enough basic grounding in exercise prescription and training science despite claims by the physiotherapy profession that they have a firm grounding in basic clinical sciences so they can circumvent the need for extensive training in S&C.

This has then led to a deficit in rehabilitating athletic populations such that it even slows an athlete's full RTS. The athlete is usually handed to the S&C team or left to their own devices. He concludes that rehabilitation of recreational and professional athletes must be recognized as an advanced practiced skill requiring specialist training. If these gaps/ deficits in both under and post graduate training are not addressed, then physiotherapists will be relegated to technicians in the restoration of the patient/ athlete.

My thoughts? I used to work at the *Singapore Sports Council in the Sports Medicine department (the current Singapore Institute of Sport). The doctors, physiotherapists, S&C coaches and other sports science staff (nutrition, biomechanics, psychology) all have degrees and/ or postgraduate qualifications and definitely had a good working relationship. We had a weekly case discussion where the athletes who were not progressing well after injury were brought up and analyzed.

Other than that sort of setting and perhaps in the Singapore Sports School and Football Association of Singapore, I think that physiotherapists in  hospitals and private practices that treat sporting populations may differ in their ability to enable these patients to RTS. It boils down to the interest and exposure of each physiotherapist. Whether they had any previous sports/ athletic background, how interested they are in sports, and most importantly, their tenacity to want to better themselves. 

There will be S&C coaches, sports and functional trainers, CrossFit coaches and personal trainers who, with their interests and commitment to improve themselves, will be superior to some physiotherapists with regard to rehabilitation and returning patients to sport. Likewise, there will be physiotherapists who can more than hold their own. 

It is, ultimately, up to each individual in their respective line of work to keep themselves up to date, to keep improving to help athletes recover better and faster. And also to recognize when they aren't the best person to return an athlete to sport and refer them out to someone who is.


Blog article from British Journal of Sports Medicine, published on May 2, 2021.

* Thanks to my former colleagues and former S&C coaches Todd Vladich and James Wong (also multiple SEA Games gold medalist and discus throw record holder), whom guided my S&C program when I was still competing. James, a few other colleagues and I used to train at the old KATC gym at the old National Stadium 3 mornings a week at 7:30 am before we started work when we were not traveling or competing. We did this year round, especially in the off season. Those sessions and attending a Level 1 Australian Weightlifting Federation course while working there definitely made me competent at getting patients to return to sport quickly and most importantly, safely.

Sunday, June 13, 2021

Evidence For Using Floss Bands

showing Byron, Thiviyan and Megan
Remember the floss band courses we used to teach? We often had participants asking what is the evidence behind increasing joint range of motion (ROM), sporting performances, helping with recovery and decreasing pain. In short, they all wanted to know how it works

I wrote previously that you've got to try it to believe it, well there is now a published *scoping review article for floss bands (Konrad et al, 2021), referenced below.

The review paper summarizes the existing evidence for the effect of floss band treatment on range of motion (ROM), sporting performance (strength or jump performance), recovery (due to DOMS) and pain (due to disease or injuries).

In all, 24 studies met the inclusion criteria with a total of 513 subjects. 15 of the 24 studies investigated the effects of a single floss band application on the ROM of several joints. On the ankle joint, flossing was found to have a significant change of 11.17% in the dorsiflexion ROM.  

4 studies investigated the effects of calf flossing on the ankle, showing a very large increase of 19.95% in dorsiflexion of the ankle.

Similarly 4 studies measured thigh flossing and found a significant increase in knee bending (3.61%), and knee straightening (7.38%). However, another study showed no improvement in hip ROM after flossing the thigh. None of studies showed any decrease in range after flossing.

Of the two studies that investigated the effects of flossing on DOMS, one study reported significantly reduced DOMS 24 and 48 hours post exercise in the study group (in the upper arms) compared to the control group. The other study (on leg muscles) found no difference in the intervention versus control group following 12, 24, 36, 48 60 and 72 hours post exercise.

When comparing flossing to other treatment like dynamic stretching, flossing had a more noticeable effect in increasing hip range of motion and maximal eccentric knee extension (Kaneda et al, 2020b). With regards to static stretching and flossing, rate of force development was more pronounced in the flossing group compared to the static stretching group (Kaneda et al 2020a). Kaneda and colleagues concluded in both studies that flossing should be applied as a warm up rather than as a stretching exercise. This is exactly what my patients who do CrossFit tell me. They normally use a floss band for warm up before they start their easier routines, before the heavy lifting.

I know all athletes are after improved performances. Results from the individual studies showed that 11 of of the 44 performance measures showed a significant improvement (comparing pre and post floss band application, Table 3 in article). There is some evidence that joint flossing (ankle and knee) can increase jump height, although sprint performance (5 to 20 m sprints) seems to be unaffected after ankle flossing. (Personally, I would floss the quads and hamstrings and calf muscles if I wanted to improve sprint times rather than the ankle). 

One study showed improvement in maximal voluntary contraction (strength) in the quadriceps muscle and hamstrings after thigh flossing.

The researchers suggest this is possibly due to hormonal responses related to the flossing. Similar to other occlusion (or blood flow restriction methods), enhanced growth hormone and norepinephrine levels increase may be responsible for increase in performance reported. More importantly, the review concluded that from the involved studies there was no detrimental effects on performance from a single floss band treatment.

Evidence also show that a single floss band treatment is able to increase ROM of the related joint and can positively affect jumping and strength performance. Possible mechanism is suggested to be changed neuromuscular function rather than changed mechanical properties.

after surgery in 2016
After Ronald Susilo (above) ruptured his patella tendon and tore his anterior cruciate ligament at the same time, he came to see me after the surgeon reattached his patella tendon. He did not have the range to even pedal one round on the stationary bike. I definitely increased his knee ROM with a single floss band treatment. He could pedal immediately after a single floss band application. 

Yes, back then it was only one subject (or n=1), however it was a definite improvement. Those of you reading then may be critical and probably not even believe it, but I have since replicated it many times in our clinic. Hence I feel that clinical evidence (what we see in the clinic) is just as good as published evidence (like this scoping review).

There will probably be long term studies about the effects of flossing treatment on joint ROM, sporting performance, whether it helps with recovery and decreasing pain. I am sure there also will be studies that say there are no benefits to it. The question is does it work for you?


Konrad A, Mocnik R and Nakamura M (2021). Effects Of Tissue Flossing On The Healthy And Impaired Musculoskeletal System: A Scoping Review. Front. Physiol. 21 May 2021. DOI: 10.3389/fphys.2021.666129

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

Let's do the twist

Sunday, June 6, 2021

My Patient Was Told She Has Freiberg's Disease

Dr Domenico Nicoletti rID: 44376 Radiopaedia

A patient came in last week asking for a second opinion for her toe pain. She had seen a doctor at her local polyclinic, gone for an x-ray and was told she might have early signs of Freiberg's disease.

She was subsequently asked to see a foot surgeon by the doctor. Her friends also suggested she see a podiatrist.

Freiberg's infarction or Freiberg's disease as it is commonly known is actually not a disease but microtrauma causing pain in usually the second toe of the foot at the metatarsal head. It can occur in other toes too. 

It is most common among teenage girls during puberty and more common in the second toe. This is especially if the second toe is longer than the big toe as this increases stress on the 2nd metatarsal head while walking, running and during sports. 

The physical stress causes multiple tiny small fractures where the metatarsal meets the growth plate. Pain is commonly felt in the forefoot while pushing off. The affected joint may sometimes be swollen and range of motion is limited there. Due to avascular necrosis (bone tissue dying due to lack of blood supply), the metatarsal head flattens (see picture below). This is usually confirmed by x-ray. 

There is no definitive treatment for Freiberg's, as it is also thought to be related to a stress fracture. Doctors will often get the patient to be non weight bearing to immobilize the foot. Corticosteroid injections may sometimes be given. In less severe cases, a rocker boot may be prescribed. Podiatrists may also prescribe orthotics with metatarsal pads and/ or low heel footwear. Severe cases may require surgery.

As you can see from the x-ray report above, my patient is clearly not an adolescent (although people of all ages can be affected by it). Even the reporting radiologist said it could be a normal variant. She also had been inactive for the past 3 years. 

What did I do? I treated her foot and plantar fascia along her Superficial Back Line and taught her to modify her gait for the time being. She was happy to be pain free after that and even asked if she could run. If she really had Freiberg's disease/ infarction, I would not, in my humble opinion, be able to change her symptoms that much in just one session.


Carter KR, Chambers AR and Dryer MA. Freiberg Infarction. (updated Mar 17, 2021). In: StatPearls (Interbet). Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Lin H and Liu AL (2013). Freiberg's Infarction. BMJ. Case Reports: 2013010121. DOI: 10.1136/bcr-2013-010121.

Sunday, May 30, 2021

Growing Taller With The Ilizarov Fixator?

Picture from Quora

A friend fractured his arm after falling asleep while driving in the army. He had a huge circular contraption on his arm upon discharge from the hospital. This was when I first came across the Ilizarov fixator back in the 1990's. Of course I did not know what it was or what it was supposed to do back then.

It was only in my second year of physiotherapy school that I studied about it and saw it in the hospital orthopaedic wards, that I remembered my friend had the same thing on his arm. I never imagined that knowledge learnt all those years ago would help me write today's post.

The surgery was first invented by Russian doctor Gavriil Ilizarov to treat bone fractures that did not heal well. Especially those with fractures that did not grow back (non-union), those that had leg length discrepancies after breaking their legs and complex factures. The method and first prototype he designed was actually inspired by a shaft bow harness on a horse carriage using parts of a bicycle.

Picture by Troika Akron

The Ilizarov fixator is a ring-like brace that has a frame applied to the outside of the limb and connected through the unbroken part of the bone inside the limb via Kirschner or K wires. This provides more structural support than other external fixators and allows for early weight bearing.

Pic by Ahmad Zamani 

Many people around the world, obsessed with growing taller, are now resorting to using the Ilizarov fixator to extend their legs in a bid to make themselves taller. These people want to get ahead since they assume that by being taller they may get better chances in job interviews, modelling assignments, showbiz, colleges and even spouses.

You can get the procedure done in the USA, UK, Germany, Pain, Turkey, Italy, South Korea, India and China. Prices range from $USD 75,000-280,000 in the USA, 50,000-56,000 pounds in the UK to $USD 25,000 in India.

For the procedure, the leg bones are first broken in two, holes are then drilled into the bone.  A metal rod is fitted inside and held in place by a number of screws and wires. This rod is slowly and gradually lengthened by up to 1 mm a day. This continues until the patient reaches their desired height and their bones are then allowed to heal.

Several months of daily physiotherapy/ rehabilitation are then required to regain mobility. Yes, the patient has to learn how to walk again. If not done carefully, there are many complications like nerve injuries (since nerves have to stretch to match the lengthened limbs), blood clots and even the possibility of the bones not fusing back together. 

At times, the bones fuse but are not strong enough to bear the patient's body weight. Limbs can also end up being of different lengths, and shape, deforming knee and ankle joints.

Having surgery to grow taller is seen as cosmetic surgery, but there's no doubt it's also done for their self confidence and mental health. My main concern is the patients that prioritize cost over their own welfare. In my opinion, it is important to find a surgeon with a good track record no matter what surgery you may be considering.


Borzunov DY, KolChin S and Malkova TA (2020). Role Of The Non-free Bone Plasty In The Management Of Long Bone Defects And Non-union: Problems solved and Unsolved. World J Ortho. 11(6): 304-318. DOI: 10.5312/wjo.v11.i6.304.

Gubin AV, Borzunov DY and Malkova TA (2013). The Ilizarov Paradigm: Thirty Years With The Ilizarov Method, Current Concerns And Future Research. Int Orthop. 37(8): 1533-1539. DOI: 10.1007/s00264-013-1935-0.

Before vs after by Dr S R Rozbrusch from BBC

Sunday, May 23, 2021

Instead Of Complaining About Wearing Face Masks..

He wore a mask, I didn't - posed lah ;) 
Almost daily during the circuit breaker (CB) period last year, my older boy and I went out to ride our bikes since there were hardly any cars on the road.  Most of the time we had our cloth face masks on. Needless to say, we found riding uphill more difficult when having them on. 

Made it to the top of Mt. Faber
Newly published research backs this up. Researchers had 28 young (18 to 29 years) and healthy participants perform 2 maximal exercise tests on a treadmill. One with and one without a cloth face mask.

Each participant runs to complete exhaustion as the treadmill speed and incline is increased every 3 minutes and the time to exhaustion is recorded. This is used to estimate VO2 max levels. Heart rate, blood pressure, rate of perceived exertion and the participant's perceptions of wearing a face mask while running were also recorded.

Key findings were that cloth face masks reduced run time to exhaustion by 14 percent and VO2 max by 29 percent. With masks on, the participants felt more short of breath and claustrophobic at higher exercise intensities compared to not wearing masks. Blood oxygenation levels (Sp O2 levels) were also lower when cloth face masks were worn. The reduced levels of oxygen in the blood show a definite physiological effect. 

The more effective the mask in filtration capacity (the more protection for the wearer), the more it will affect exercise performance. Take home message is that using a mask during exercise does make it a lot harder. The researchers recommend that exercise time, frequency and especially intensity be modified when wearing a cloth face mask.

The researchers also cautioned that their findings of impaired performance with cloth face masks may be in part due to the perceived discomfort. Meaning, the participants were less motivated to keep running at higher treadmill speed and incline

My racing days are long gone, but if I were still training and competing, I'll probably don a cloth face mask while training (sometimes) to up the intensity a few notches so that when I race without a cloth face mask, I'll be hard to beat. That's just like respiratory muscle training. But that is just me. Please do not take this as training advice! 


Driver S, Reynolds M, Brown K et al (2021). Effects Of Wearing A Cloth Face Mask On Performance, Physiological And Perceptual Responses During a Graded Treadmill Running Exercise Test. BJSM. epub first 13 April 2021. DOI: 10.1136/bjsports-2020-103758.

Sunday, May 16, 2021

Does Dynamic Stretches Help Running Performance?

Our new physios doing the dynamic stretches

Previously I had written that performing any static stretches before exercise or competition can be detrimental to your athletic performance. Studies have also shown that doing static stretches before competing or exercising is more likely to cause an injury. In fact, performing just one static stretch of 30 seconds can reduce your maximum strength.

Meanwhile, fitness professionals, coaches and other studies have suggested performing dynamic stretches as an alternative warm up to static stretches instead.

Well, this published study had runners do both. An initial assessment was done to get the runners VO2 max levels. The researchers had a group of well trained university runners do a general warm up (GWU) on one day versus doing a general warmup (GWU) plus dynamic stretching (DS) before getting them to run until exhaustion on a treadmill on another day.

The GWU consisted of running on the treadmill at a speed equivalent to 70 percent of each runner's VO2 max for 15 minutes. Each runner then did a standing rest for 5 minutes. This was followed by the run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

When doing the GWU plus DS, dynamic stretches were done for all the lower limb muscle groups (10 reps each), see picture below. That took 3 min 45 seconds in all. After resting for 1 min 15 seconds, the runners started their run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

Well, this published study had runners do both. An initial assessment was done to get the runners VO2 max levels. The researchers had a group of well trained university runners do a general warm up (GWU) on one day versus doing a general warmup (GWU) plus dynamic stretching (DS) before getting them to run until exhaustion on a treadmill on another day.

The GWU consisted of running on the treadmill at a speed equivalent to 70 percent of each runner's VO2 max for 15 minutes. Each runner then did a standing rest for 5 minutes. This was followed by the run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

When doing the GWU plus DS, dynamic stretches were done for all the lower limb muscle groups (10 reps each), see picture at the top. That took 3 min 45 seconds in all. After resting for 1 min 15 seconds, the runners started their run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

The results showed that the GWU plus DS group lasted significantly shorter (10:40 min)  than the group that just did the GWU (12:40 min). Distance covered was between 2.3 to 5.4 km.

The authors of this study were hypothesizing that performing GWU plus DS may help improve endurance running performance. Unfortunately the results indicated otherwise. 

Another study by the first 3 authors (Yamaguchi et al, 2015) showed that performing the same five DS (10 reps) followed by a rest period of 1 min 23 secs actually prolonged the run time to exhaustion (an extra 18.2 percent) compared to a sit down rest. Run to exhaustion on the treadmill was also done at a speed equivalent to 90 percent of their VO2 max.

What is good about this study was that there was real attention to detail. The testing was done during the off season for the runners so no prior vigorous training was done. The runners were also asked to avoid performing intense exercises or training on each test day and the day prior. 

The runners were also instructed to have similar meals and drinks on the test days and previous day and to finish any meal 2 hours before running. Runners were also asked to avoid alcohol the day before running and caffeine on the test day. Each runner wore the same attire for the test runs and performed the test at the same time of day in consideration to circadian rhythm. The laboratory temperature was kept constant at 20-24 degrees Celsius throughout. In short, the authors tried to keep everything else constant other than the warm up. 

What wasn't as good? Bear in mind that the study only had 8 runners. They are definitely fast runners (looking at their profile), but the sample size is small. The rest period after the dynamic warmup was also extremely short (150 seconds). Fatigue after the DS was attributed by the authors as the cause for worse performance.

When I was competing in events like 1500m - 5000m on the track, I'll do a rather languid jog of 2-3 km to warm up followed by some limbering movements to loosen up. This was followed by repeating some striding (or goal pace running) 5-8 times for 150-200 meters. Then it would be resting and waiting for our event to start. Definitely longer than 1 minute 15 seconds before racing. Definitely did not do any sort of stretching then.

My advice would be to try out dynamic stretches or whatever that is new (shoes, bike, run technique etc) in your off season, not before an important competition, to see if it would be something that might work for your body. Most importantly, do what works for you. Every body is different.


Yamaguchi T, Takizawab K, Keisuke S. (2015). Acute Effect Of Dynamic Stretching On Endurance Running Performance In Well-trained Male Runners. J Strg Cond Resc. 29: 3045-3052. DOI:10.1519/JSC.0000000000000969

Yamaguchi T, Takizawab K, Keisuke S et al (2019). Effect Of General Warm-up plus Dynamic Stretching On Endurance Performance In Well-trained Runners. Res Quart Ex and Sport. 90(4): 527-533. DOI: 10.1080/02701367.2019.1630700.

*thanks to Thiviyan and Rashid Aziz for getting me the articles

Sunday, May 9, 2021

Am I Crazy To Feel Pain In My Knee When My Scans Are Normal?

My patient came in yesterday saying that his knee started clicking even though he didn't feel any pain with the clicking. There were occasional twinges of pain only occasionally. However, he was worried that his knee will get worse. After assessing his knee (which turned out fine) and reassuring him, I told him my own experiences.

After I had my third knee operation (within the space of a year), my right knee started feeling better. Of course I started training again as soon as the surgeon permitted. For a start, I ran almost exclusively on grass (since it was the softest surface I could find), often going multiple rounds, to ensure that I can get my mileage since I was hoping to compete again after my injuries.  

However, I was much more sensitive about my right knee, to the point of being paranoid about every sensation I felt in the knee. Each time I was on the bus or MRT and if someone came close to my right knee, I'd move away and glare at the person for coming too close to me. Does this sound like you?

Well, it turns out this action of pain sensitization is common across other painful knee disorders as well. In patients with knee osteoarthritis, pressure from placing your hands on the knees alone can trigger pain. The good news is that this sensitization for painful knees can be treated.

The following systematic review investigated 52 studies that studied pain sensitization across four different painful knee disorders. The authors found evidence of pain sensitization in people with knee osteoarthritispatellofemoral pain and post meniscectomy patients. They however found conflicting evidence in patients with patella tendinopathy.

The researchers found that the extent of structural joint damage in the observed knee disorders does not correlate to the severity of symptoms. Hence, pain is not necessarily a 'signal' from a joint or area that is damaged.  Meaning x-rays or MRI results does not correlate with pain. Some patients have no 'damage' on x-ray/ MRI but have a lot of pain, while others with lots of damage on film may have no pain.

Many factors play a role to determine if a person will perceive a stimulus as painful or not since pain can be a complex experience that is associated with memories, belief and social context. Anxiety, depression, fear of movement, viewing their condition considerably worse than it actually is may also play a part.

It is suggested that repetitive stimulation may lead to subsequent sensitization of the nervous system. This include loading of the knee joint, ongoing inflammation at the knee joint or related tissues and altered biochemical markers. These factors contribute and maintain the pain sensitization in the knees.

In patients with knee osteoarthritis and patellofemoral joint pain, pain sensitization can be treated through exercise therapy, mobilization, pharmacological (yes, painkillers) and surgical intervention. Correct exercise is recommended for treatment of painful knees. There is the incorrect belief that exercise may harm the joint cartilage in patients with osteoarthritis.

If doctors, surgeons and physiotherapists focus less on x-rays/ MRI's and more on factors (including psychosocial factors mentioned above) relating to each patient's pain and disability, there will be more opportunities for collaboration and improved treatment outcomes.


De Oliveira Silva D, Rathleff MS, Petersen K et al (2019). Manifestations Of Pain Sensitization Across Different Painful Knee Disorders: A Systematic Review Including Meta-analysis And Metaregression. Pain Med. 20(2): 335-358. DOI: 10.1093/pm/pny177.

Sunday, May 2, 2021

Stationary Cycling Just As Good As Pilates For Chronic Low Back Pain?

The Pilates instructors reading this post along with those of you who do Pilates aren't gonna like me a lot, not with a heading like the one above. But before you get upset, please let me be clear, I have nothing against anyone doing Pilates or any Pilates instructors. I'm just sharing what I read from a published study.

This study compared the effects of specific trunk exercises (or Pilates) versus stationary cycling on subjects with chronic non specific low back pain

One group was randomized to undergo specific trunk exercises (SEG) for 8 weeks while the other group did stationary cycling (CEG). The SEG group performed Pilates with attention to muscle control, posture and breathing. 

THE CEG group were informed that they were performing a style of cycling called Pilates Pedal. This is to reduce bias so that their group will not wonder why their exercise program did not include trunk specific exercises. Look at the diagram below, you will see that the CEG group just did a mixture of mixed resistance cycling and no core exercises.

Pain was reduced in both groups after exercises compared to the start of the study. Even though disability was significantly lower in the SEG group compared to the CEG group after 8 weeks, the overall data pattern suggested no long term differences between both groups 6 months later.

Fear-avoidance beliefs (FAB) or activity avoidance behavior scores were lower in the SEG group at 8 weeks only, the CEG group had lower FAB scores at 6 months.

The authors concluded that an 8-week supervised group of Pilates had only better short term but not long term clinically meaningful improvements compared to stationary bike cycling.  

If a patient with chronic non specific low back pain stick to either Pilates or stationary cycling (or any exercise program  for that matter), similar improvements will be achieved as long as a minimal level of adherence is maintained.

If you look in detail at the baseline scores for pain and disability, you will notice they were mild to moderate. Hence, results from this study may not be transferable to those with severe back pain and disability.

Pilates or stationary bike cycling (or any general exercise), your choice really, as along as you stick to it, will help with your recurrent low back pain. Find exercises you enjoy and keep at it.


Marshall PWM, Kennedy S, Brooks C et al (2013). Pilates Exercise Or Stationary Cycling For Chronic Nonspecific Low Back Pain. Does It Matter? A Randomized Controlled Trial With 6-Month Follow-up. Spine. 38(15): 952-959. DOI: 10.1097/BRS.0b013e318297c1c5.

*thanks to Byron Tan who got me the article. Email me if you like to have a look at the article

Sunday, April 25, 2021

Should Youths Run Long Distances?

Picture by Richseow from Flickr

I had a friend ask me on Thursday if his friend's kids should come in to our clinic for physiotherapy or sports massage as they were complaining of feeing 'tight' in their muscles. This year, some of the National School Games are allowed to proceed (after being called off because of Covid-19 last year), so many school athletes are competing again.

I do not recall having such privileges during my time. Perhaps we were hardier or maybe ignorant about recovery and whatever help you can get from sports medicine/ physiotherapy. Besides, I was never into running high mileage during my school days. There were other teenage runners who mentioned that they clocked 100 km a week, while I seldom got above 30 km. We did a lot of quality intervals rather than quantity. Definitely no junk miles. Preparing for the GCE 'A' levels did not leave us much time to run that much either.

There have been studies of youth athletes (not specific to runners) that show sport specialization makes them more prone to injury. Especially those who played their primary sports for more than eight months in a year. These youth athletes had more overuse injuries in the upper and lower limbs compared to those who spent less time in their primary sport.

Youth athletes who participated in their primary sport more hours each week than their age in years had more injuries of any type. They were also more likely to have a history of overuse injuries if time spent training exceeded recommendations for their age. Hence it is important to do different sports for youths. And not to push them.

A running specific study on track and cross country events (989 girls and 1022 boys between 12-18 years) found that youth athletes who specialized had more overuse and previous injuries of any kind compared to those who did not specialize (Post et al, 2017)

Another study (of 126 female cross country and distance track and field athletes) found an increased risk in those runners who specialized compared to those who did not (Rauh et al, 2018).

In order to reduce the risk of running related injuries in the youth runner, we must take into account the complex interaction of various factors, including growth related changes unique to this population. A summary of the risk factors are in the table below taken from Krabak et al (2021).

In addition, the following recommendations are based on expert opinions in the study by Krabak et al (2021). A musculoskeletal screening on your youth athletes for previous injuries, menstrual dysfunction (girls) biomechanical concerns and training errors.

Youth runners should take part in high impact and multidirectional activities focusing on control of the backhip and lower extremities through puberty to reduce injury and promote bone health.

Make sure your youth runners have at least one rest day a week, 1-2 weeks off every 3 months and limit participation to less than 9 months each year. Single sport specialization should be discouraged until they pass puberty.

Self motivated youths can be allowed to take part in long distance events if they follow an acceptable supervised training program, maintain normal growth in height and weight and are healthy with good nutritional intake.  

So all physical education teachers, coaches and parents, if your youth athlete has BMI < 17.5kg/m2 or body weight below 85 percent of normal for their age, bone density scores of Z > 1.0, untreated eating disorders, high risk stress fractures (in femoral neck, proximal tibial or navicular bone) and female runners without menarche by 16 years old or less than 6 menstrual cycles in the past 12 months then they will require further medical evaluation.


Krabak BJ, Roberts WO, Tenforde AS et al (2021).Youth Running Consensus Statement: Minimising Risk Of Injury And Illness In Youth. BJSM. 55: 305-318. DOI: 10.1136/bjsports-2020-102518.

Post EG, Trigsted SM, Riekena JW et al (2017). The Association Of Sport Specialization And Training Volume With Injury History In Youth Athletes. AJSM. 45: 1405-1412. DOI: 10.1177/0363546517690848.

Rauh MJ, Tenforde AS, Barrack MT et al (2018). Associations Between Sport Specialization, Running-Related Injury, And Menstrual Dysfunction Among High School Distance Runners. Athl Trg Sp Health care. 10: 260-269. DOI: 10.3928/19425864-20180918.

Sunday, April 18, 2021

Does Your Growing Child Have Knee Pain?

Recently, we have seen some young athletes in our clinics, complaining about pain after playing sport. I've written about growing pain in young children/ athletes before. When these children/ athletes are having a growth spurt during adolescence, the long bones grow faster than muscles. The muscles take a while to lengthen so the muscles tend to pull on the attachments on the bone.

This is especially so when a child is active, the muscles will pull on the bony attachments where the muscles attach causing pain (also known as apophysitis).

An area of pain at the knee which is common in children is known as Osgood Schlatters disease (OSD). The pain is located where the patella tendon finishes at the tibia, known as the tibial tuberosity.

Researchers from Denmark studied 51 youth athletes (51 percent female) between the ages to 10 to 14 with OSD. The youths already had pain for an average of 21 months.  Intervention consisted of four visits with a physiotherapist with both child and parent. The first block of treatment focused on decreasing load through decreased activity, education and static hold exercises.

The next block the subjects progressed to exercises which led to a return to their sport. Follow up was done at 4,8,12, 26 and 52 weeks. 

All subjects showed improvement at 12 weeks (study endpoint) with less kids complaining of pain and increased function and quality of life. 31 percent of subjects still suffered from discomfort at 12 weeks, discomfort that they would be not happy to live with, while 80 percent were very satisfied with their treatment results.

Only 16 percent of the subjects managed to return to their sport (RTS) at 12 weeks, compared to 69 percent at 52 weeks follow up. Thigh and hip abduction strength which was the focus of the exercise interventions improved significantly by 12 weeks as did vertical and horizontal single leg jumps.

At one year follow up, only 5 percent of subjects were very unsatisfied with their progress and unable to return to sport.

The study called for significant restrictions (guided by pain/ symptoms response) at the start of sporting activity to decrease load on the tibial tuberosity. Data from the tracking device the subjects wore prior to start of the study to the first block of treatment showed a decrease of 15 minutes per day of moderate to vigorous activity. This may suggest that getting active kids to slow down is difficult. 

Parents may need to explain to the child that activity modification is key to reducing symptoms. Reining in the kids in the short term will help return to sport sooner.

Surprisingly, the tracking devices showed that activity levels decreased by 37 minutes per day by week 12, suggesting that although many reported feeling better and can do more, they were actually less active.

We usually do not encourage stretching the affected muscle as static stretching can place more traction forces on the tendon insertion on the bone. Correct strength training that is pain free often helps to take the load off the tendon attachment. Meaning the weight does not have to be heavy. Elastic bands are very useful too when the young patients cannot handle the weight.

Please come and see us in our clinics if your young and teenage athletes need help.


Rathleff MS, Winiarski L, Krommes K et al 92020). Activity Modification And Knee Strengthening For Osgood-Schlatter Disease: A Prospective Cohort Study. Ortho J Sp Med.6(4): 2325967120911106. DOI: 10.1177/2325967120911106

*note that OSD or Osgood Schlatter's disease is not a disease. It is named after Robert Osgood (1873-1956) and Carl Schlatter (1864-1934), an American and Swiss surgeon respectively that described the condition concurrently.

Wednesday, April 14, 2021

Where The Streets Have Allyson Felix

I've written about Allyson Felix before previously and I hope she will still be a force to reckon with at the Tokyo Olympics. Being Nike's poster girl previously, I admired how she spoke up when Nike were unfair to their sponsored pregnant athletes.

As you can see from the article above, she still found a way to train when stadiums were closed during the lockdown after getting her coach to use a measuring wheel to mark out distances "on literally the street in front of her door". 

What a sight it must have been for her neighbors to behold when a six-time Olympic Olympic gold medalist, 13 times World Champion comes sprinting down the road at full speed. Along with her coach yelling encouragement at the top of his voice. 

Instead of complaining about what she can't do, I love the way she and other athletes resorted to unorthodox ways to train so they can be ready to compete when they can. 

I know too, that our Team Singapore athletes have resorted to ingenious ways to train too, chapeau to them. 

Let's see how she fares if the Olympics does go on.

Sunday, April 11, 2021

Can Your Menstrual Cycle Make You More Prone To Injury?

Photo by Jeffrey F Lin from Unsplash

Ladies, it's true that sometimes men don't get it, but not the way you think. Not when it comes to injury risk anyway. 

I've written way back in 2009 that women are more prone to ACL injuries compared to men during the time of the month because changing hormone levels affect ligament strength. The bad news is it's not just ligaments. Researchers found evidence that muscles, tendons, joint and ligaments were more affected across the menstrual cycle.

The English women's national football team (from under-15's to the senior squad) were studied over a four-year period for this study. Injuries during training camps and competitions were tracked. Only players with regular menstrual cycles and not on hormonal contraceptives were included in the analysis. 156 injuries from 113 players were recorded.

The key finding seems to be that estrogen has broad effects on decreasing stiffness of ligaments and tendons. While this is may be helpful during childbirth, it also make your knees, ankles and other joints less stable when estrogen levels are higher.

My wife explains that at the start of menstruation (which is the follicular phase), estrogen is lowest.  Estrogen levels begin to rise to a peak shortly before ovulation (luteal phase). It then drops sharply, before rising again to a gentler peak during the luteal phase.

Bearing the above in mind, ACL injuries tends to be more likely during the late follicular phase where estrogen levels tend to be highest and ligaments tend to be loosest. During this phase, knee joints get one to five millimeters looser (Chidi-Ogbolu and Baar, 2018). 

It can be that tendons that have became looser or more lax may actually decrease injuries to the muscles since they may be able to absorb some of the impact from forces that may strain or tear a muscle (Chidi-Ogbolu and Baar, 2018). 

The analysis showed that muscle and tendon injuries were about twice as likely during the late follicular phase (higher estrogen levels leading to lax muscles and tendons) compared to other phases.

Joint and ligament injuries were significantly less during the late follicular phase (24 in total). Quite the opposite of the study's hypothesis (lax ligaments bad, lax tendons good).

An interesting note was that 20 percent of the injuries happened when a player's menstrual cycle was late or overdue (based on when the players expected their next period to start). This may be due to the "female athlete triad", which involves persistent calorie deficits and can lead to missed or irregular periods, lower bone density and increased overall injury risk.

Some of you reading this may be planning to avoid contraceptives during training and then using them during during the competition season since hormonal contraceptives can be protective of ligaments (since they suppress the higher peaks in estrogen). Beware of the trade-offs though, higher estrogen levels help promote muscle building and repair muscles and tendons in response to training.

It is clear that hormonal fluctuations matter although clearer guidelines on the menstrual cycle may be needed since knowing estrogen can affect injury risk may not pan out totally in the real world. 

My suggestion would be to track and record your periods so you are aware of what factors can and may be at training/ competition. Knowledge is certainly power in this case.

More research is definitely needed and you'll be the first to know the latest information when you read it in our blogs.


Chidi-Ogbolu N and Barr K (2019). Effect Of Estrogen On Musculoskeletal Performance And Injury Risk. Frontiers Physiol. 9: 1834. DOI: 10.3390/fphys.2018.01834.

Martin D, Timmins K, Cowie C et al (2021). Injury Incidence Across The Menstrual Cycle In International Footballers. Frontiers in Sp Active Living. DOI: 10.3389/fspo.2021.616999.

Sunday, April 4, 2021

Scoff Not At Elastic Resistance Bands

Tan Howe Liang(pictured below) is still the strongest man I know. Yes, the same Tan Howe Liang that won Singapore's first ever medal at the 1960 Rome Olympics. He was a senior gym instructor at the gym at the old National Stadium and we often bumped into each other when I was still working there. I was always amazed when he told stories about his training days. Mind you, he could still squat with very heavy weights whenever I saw him train then. 

Silver at the Rome Olympics, SNOC picture

But don't fret if you don't have easy access to a gym or other fancy, expensive gym equipment. Other than your bodyweight, elastic resistance bands can be great for strengthening muscles too.

Not many of you may believe me if I said that training with elastic bands can be just as effective as training with weights for strengthening muscles.

The following systematic review and meta-analysis is possibly the first to compare the effects of strength training for strength gains with elastic tubes and bands versus conventional devices (dumbbells and weight machines).

The search identified 365 articles, of which eight studies were within the inclusion criteria comprising of 224 individuals between 15 to 88 years old. All subjects were performing regular strength training. In these groups were physically active individuals, athletes, individuals with coronary heart disease and moderate chronic obstructive pulmonary diseases.

Results of the meta-analysis showed that there is no superiority for both upper and lower limbs between training performed with elastic bands and training with free weights on strength gains. This was consistent across groups mentioned above and also when compared with a control group in the elderly, individuals with osteoarthritis and even fibromyalgia. 

The authors conclude that training with elastic bands is just as good as conventional resistance for promoting strength gains in different populations using diverse protocols. 

Having elastic bands at home to train with eliminates the need to travel to the gym and this may be more practical and a lot cheaper for certain people who may find it difficult to go to a gym. patients will have greater adherence to strengthening programs too. 

Personally I feel elastic bands are great for strengthening and correcting muscular imbalances. I still use them on a very regular basis. Especially after my accident.

Exercising with bands in my back brace in 2013

Do not let anyone tell you that you are wasting time if you are not using heavy weights and expensive equipment. Effective strength training can be achieved with body weight, free weights and especially elastic bands too.

We have managed to rehabilitate many national athletes back from injury and even avoid surgery in many cases using elastic bands to strengthen the injured areas. Especially in cases when a weight plate/ bar is initially too heavy and risk further injury and load to the person's joints.


Lopes JSS, Machado AF, Micheletti JK et al (2019). Effects Of Training With Elastic Resistance Versus Conventional Resistance On Muscular Strength: A Systematic Review and Meta-analysis. Sage Open Med. DOI: 10.1177/2050312119831116.

Don't neglect the legs

Sunday, March 28, 2021

Overdoing HIIT Sessions Can Affect Your Health

Picture by Ving Henson from The Pit

Many of my patients tell me they are doing HIIT classes now. If you interested about your fitness and have been exercising regularly, you will definitely know what HIIT stands for. High intensity, interval training.

When I was a teenage runner, those intervals we did certainly did not have such a fancy name like HIIT. You run 15 intervals or repetitions of 400m with a one minute rest in between or the coach will say run 6 x 1km going every 5 minutes (meaning if you run your kilometer in 3:50 min, you get 1:10 min rest before starting again).

I've written how HIIT can be beneficial and how it can even reduce growth in cancer cells. Since HIIT is a super time efficient method for improving aerobic fitness and other health outcomes and metabolic conditions such as diabetes, high cholesterol or high blood pressure.

One such outcome is increasing our cell mitochondria (power generators in our cells) in our muscles. With more mitochondria in our cells, we become stronger. 

Before you think more HIIT is better, a recent small study showed that people who tried to do 5 HIIT sessions in a week ended up with sudden and severe declines in their mitochondria function, along with blood sugar dysfunction. 

When the subjects decreased their HIIT sessions, their metabolic condition started to improve but did not disappear, hinting that the benefits of extremely strenuous exercise may still depend on how much we do and how we allow ourselves to rest and recover.

The researchers first tested the subjects in their lab for the current fitness levels and metabolic health, which included blood sugar levels throughout the day. In the first week, 2 sessions of HIIT were performed, 5 reps of 4 minute long bike intervals on a stationary bike with 3 mins rest in between. The subjects pedaled as hard as they could while their power output was tracked. Their leg muscles were biopsied while a 24 hour blood sugar control was investigated.

In week 2, they did 3 HIIT sessions while increasing some of their intervals to 8 minutes. During week 3, they did 5 HIIT sessions with a mix of 4 and 8 minute intervals of all out cycling. Week 4 allowed for some recovery and they subjects and the amount and intensity of exercises were halved. All the tests were repeated weekly.

The findings showed the subjects getting stronger by week 2. They were pedaling harder and getting fitter, better daily blood sugar control and more mitochondria in the cells. These mitochondria were also more efficient, producing greater energy compared to baseline.

However, by week 3, the subjects were not able to generate more power, their muscle biopsies showed that their mitochondria were only producing 60 percent of the energy of week 2. Blood sugar control levels were spiking and dipping throughout the day.

After allowing for recovery in week 4, the following week showed the mitochondria producing more energy, but still 25 percent less than week 2. Blood sugar levels stabilized too, but again not to the same extent as week 2. The subjects could however ride with the same or even greater vigor as with week 2.

The researchers did not find out what exactly caused the decline in results (glucose intolerance and insulin secretion)  that occurred after week 3. It may be the combination of total biochemical changes that weakened the mitochondria which in turn disrupted the blood sugar control levels. 

This study was done on normal healthy subjects and not athletes nor people with metabolic conditions such as diabetes, high cholesterol or high blood pressure. The latter group attempting such training must get the go ahead from your medical professional. For those of us who just want to be healthier, don't do HIIT sessions excessively since previous studies and formal recommendations suggest 3 intense sessions in a week as maximum. Otherwise, injuries may come knocking on your doors too. 

The researchers managed to assess blood glucose profiles in world class endurance athletes and found that they, too had impaired glucose control when compared with a matched control group. So for athletes who want to be stronger, faster quicker, do allow ample time for recovery between training sessions.


Flockhart M, Nilsson LC, Tais S et al (2021). Excessive Exercise Training Causes Mitochondrial Functional Impairment And Decreases Glucose Tolerance In Healthy Volunteers. Cell Metab. DOI: 10.1016/jcmet.2021.02.017

Sunday, March 21, 2021

Reliable Predictors Of Running Injuries

You need a new pair of running shoes so you decide to go to a specialist running store to choose a pair that's suitable for you. The store manager at the specialist running store tells you to hop onto their in store treadmill and 'analyzes' your running gait.

He then proceeds to critique your running gait and its biomechanical implications. And suggests the most expensive running shoe (in the store) for you so you do not get injured. Is that a common scenario that happens?

Contrary to several long held beliefs, most biomechanical and structural factors are not reliable factors at predicting running injuries

Researchers studied 300 runners who have been injury-free for the past six months and found several more reliable factors (rather than biomechanical and structural factors) in predicting who would be more likely to get injured.

The runners' demographics, physiology, biomechanics, psychosocial issues and training were documented. Their hamstrings, quadriceps muscle strength, knee, ankle flexibility, arch height of their feet were tested. 

A gait analysis studied how their feet, knees and hips distribute forces while running

Any runner who reported an injury were followed up at six and twelve months later. After the first year, the researchers emailed the injured runners a biweekly questionnaire asking them what injuries they sustained in the past two weeks.

Those that were injured went to a doctor and physiotherapist who were part of the study for treatment.

Results of their study after the two year follow up indicate that female runners sustain injuries at a higher rate than male runners. Stiffness in the knee joint, which were more common in runners weighing more than 80 kg significantly increases the chances of an overuse running injury. 

The runners who were injured also reported significantly worse mental health related to their quality of life and more negative emotions compared to the non injured runners.

Most biomechanical, structural factors like arch height, overpronation, flexibility, Q-angle  (see picture above), lower limb strength, weekly mileage, footwear and previous injury are not reliable factors for overuse running injuries.

The researchers recommended that caution should be used when trying to alter what were commonly thought risk factors such as excessive pronation, poor flexibility, weekly mileage etc unless a runner has extreme values.

It appears from this study that the importance of biomechanics and anatomical structures assumed by doctors, physiotherapists, personal trainers and other clinicians are not as high risk as assumed. 

I feel that this does not mean they are not important. It is still important to consider the individual patient/ runner when assessing their condition. 

We still need to be aware of each patient's individual structural and biomechanical anomalies, but not to the point where we nitpick every discrepancy in strength, joint angle, foot position and range of motion.      


Messier SP, Martin DF, Shannon L et al (2018). A 2-Year Prospective Cohort Study Of Overuse Running Injuries: The Runners Injury Longitudinal Study (TRAILS). AJSM. 46(9): 2211-2221. DOI: 10.1177/0363546518773755

Sunday, March 14, 2021

Is It Better To Bend Your Back Or Knees When Picking Something Off The Ground?

Thanks to Tasneem and Joakim for the photo

I can't find any similar statistics in the local Singapore context, but more than 40% of employees in European countries suffer from work related musculoskeletal disorders (WMSD) yearly. This results in 3-6% absence from work, affecting 2.5% of the gross domestic product across Europe. 52% of injuries are attributed to overloading during lifting tasks, of which 65% affect the lower back.

When picking up something off the floor, we generally use two standard lifting techniques, the stoop or squat technique, which have been well described in many articles. The squatting technique is usually advised when lifting heavy objects since this technique is thought to result in lowering intervertebral disc (IVD) compression and shear forces compared to the stoop technique. 

Squat (a) versus Stoop (b)

Stoop lifting is usually restricted to lifting light objects since it is thought that stoop lifting causes higher IVD compression and shear forces compared to the squat.

However, there is no agreement or sound evidence for lifting ergonomic guidelines (or good lifting techniques). Hence the following study to investigate if squat or stoop lifting imposes more load on the person lifting.

Different weights were tested for both lifting techniques using a full body musculoskeletal model, 3D marker and ground reaction forces. They were used to calculate joint angles, forces and power. Muscle activity of nine different muscles were also measured to calculate effort.

Ready for the results? For all lifting conditions and both techniques, the highest joint forces during lifting and lowering were at the L5S1 spine levels, followed by the hip and knee. The hip joint generated the most power while lifting for both techniques.

Squat lifting was mainly executed by additional work on the knee extensors (Quadriceps), shoulder and elbow, potentially explaining similar prevalence of WMSD in the shoulder, elbow to LBP in people who do frequent lifting. 

The authors concluded that based on their findings, squat lifting is not favored over stoop lifting (this is in contrast to current recommendations) although forces were slightly higher in the L5,S1, hip and knee during the stoop technique. This is also supported by Van Dieen et al (1999) who concluded that there is no evidence to suggest squat over stoop lifting after reviewing 27 studies.

Now, many of you reading this may already not agree with what the authors concluded. There are so many variables that can change the results. How low the object is will influence the load on the back, making comparisons with other studies difficult. 

Even a small adjustment like turning the knees out (not controlled in this study) while squatting already reduces back loading. Likewise, healthy volunteers in this study will likely have different lifting dynamics compared to real blue collar/ laborers since the latter would have efficient strategies for all the lifting done over the years. Lifting in the research setting may not totally replicate real world situations.

Weight (10kg in this study) and dimensions of the load lifted will definitely affect the lifting technique as well since the box (length 36 cm, width 14 cm and height 21 cm) used in this study was relatively small. 

For those of you who do not have low back pain, this post may possibly challenge or even change the way you lift a box off the ground or while picking a pen that you've dropped. You have always been told that when you're picking up something or lifting that you should bend your knees, keep your back straight before you lift. That is supposed to be good form or good ergonomics.

Well, especially for those of you who are pain free, you can say to anyone who insist you bend your knees and not your back while lifting that it is not totally true. 


Van Der Have A, Van Rossom S and Jonkers I (2019). Squat Lifting Imposes Higher Peak Joint And Muscle Loading Compared to Stoop Lifting. Ap Sci 9(18): 3794. DOI: 10.3390/app9183794

Van Dieen JH, Hoozemans MJM and Toussaint HM (1999). Stoop Or Squat: A Review Of Biomechanical Studies On Lifting Technique. Clin Biomech. 14: 686-696

Thank you for reading this long article. If you're interested, another study by Mawston et al, (2021) pictured above and referenced below found that during a maximal lift in pain free individuals, a flexed lumbar spine (picture C) is more efficient and stronger as opposed to a straight spine! So much for having a 'good' posture while weight training. Perhaps that shall be another post.

Mawston G, Holder L, O' Sullivan P et al (2021). Flexed Lumbar Spine Postures Are Associated With Greater Strength And Efficiency Than Lordotic Postures During A Maximal Lift In Pain-free Individuals. Gait and Posture. DOI: 10.1016/j.gaitpost.2021.02.029

Sunday, March 7, 2021

No Need To Stretch Or Foam Roll Your ITB?

You are a runner and you haven't been able to run more than 2 km before a sharp pain in your outer knee reduces your run to a hobble. Resting, icing and changing your running shoes made no difference. The sports doctor you saw just diagnosed you with the dreaded Iliotibial Band Syndrome (ITBS). He tells you that you need to stretch your Iliotibial band (ITB) and use a foam roller.

Sounds familiar? Well, this latest published paper on the ITB by Paul Giesler (2020) challenges common treatment approaches of stretching and massaging the ITB. Basically, he says that you do not want to stretch or foam roll your ITB.

I've written about the ITB before in a few different posts. Except for Daniel Liberman and Carolyn Eng's study, most other articles seem to suggest that the ITB causes pain via a 'friction syndrome'. This is thought to be due to the ITB rubbing to and fro over Gerdy's tubercle on the outer shin bone while running due to hip weakness. 

Treatment is normally targeted at stretching the ITB (to reduce friction). Doctors will often suggest a steroid injection to reduce 'inflammation' (in the bursa) on the outer knee.  Giesler (2020) however,  suggested that ITB pathology is more likely to involve compression of sensitive structures beneath the ITB rather than friction.

also know as Iliotibial tract (ITT)

Since the ITB is a really broad, strong and complex structure with many attachments (picture above) along the hip, thigh and around the knee, it can provide stability for both the hip and knee. Like I wrote before, the ITB is actually thought to function like our Achilles tendon. To store and release energy like a spring. Therefore you cannot and would not want to stretch a spring. A coiled spring can release energy much better than a spring that is stretched out.

From Carolyn Eng's running simulation 

Hence the need to treat the cause of the problem rather than just treating the pain over the outer knee. Hip strength and control thus thought to be key in causing ITBS, especially weakness in hip increased hip adduction (dropping of the hip inwards) during loading. 

Runner on L has increased hip adduction

In runners/ patients with excessive hip adduction while running, progressive rehab and addressing potential causes should be adapted for individual runners, especially while running downhill and during longer runs. I've written on this topic specifically, you can read that article here.

So treatment should be to calm the symptoms (knee pain) and treat the cause. We don't get you to stretch your ITB or use the foam roller in our clinics, come see us if you want to run pain free.

The Paul Geisler (2020) article is free, click on the link under references if you want to read it.


Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Eng CM, Arnold AS, Liberman DE et al (2015). The Capacity Of The Human Iliotibal Band To Store Elastic Energy During Running. J Biomech. pii: S0021-9290 (15) 00354-1. DOI:10.1016/j.jbiomech.2015.06.017.

Geisler PR (2020). Iliotibial Band Pathology: Synthesizing The Available Evidence For Clinical Progress. J Ath Trg. DOI: 10.4085/JAT0548-19