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 (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

Megan, Thiviyan 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. 


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 the three of them 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