Sunday, July 3, 2022

Higher Cadence Cycling Slows You Down?

Stage 2 by Tim de Wale/ Getty images from The Guardian
The most important of all cycling races, the Tour De France (TDF) 2022 started on Friday night in Denmark. Cycling fans worldwide will no doubt be following the race as it unfolds. I definitely am.

Mere mortal cyclists (myself included) often like to copy what the pros do. Ever since the Lance Armstrong era, high cadence cycling or riding in excess of 90 revolutions per min (RPM) became popular. 

With his superb spinning of the pedals in the 2001 TDF he attacked and dropped Jan Ullrich in the memorable stage at Alpe d'Huez (watch from 0:27 min) on his way to victory on that stage and overall victory.

Probably from then onwards, new cyclists and recreational cyclists often believe that faster pedaling is always better. 

However, a published study concluded that amateur cyclists do not get any added benefits from high cadence cycling. In fact, it actually tires you out, especially when you ride at high intensities.

The researchers studied a group of recreationally active men and women and had them pedal hard to to ventilatory threshold (the intensity when breathing becomes laboured). Cadences between 40 to 90 RPM's were used. Heart rate, pedaling forces, thigh muscle oxygenation (amount of oxygen needed by thigh muscles to make the energy needed to keep pedaling) were all measured.

As the subjects pedaled faster, the force generated with each pedal stroke decreased. Since your muscles contract more frequently and less intensely, force generated will drop. This makes you fatigue less and helps you to recover quicker, especially while climbing. 

However in the study, the subjects' heart rate increased, meaning this required more energy, making it less efficient. At 90 RPM, their heart rate increased by 15 percent, their efficiency decreased while muscle oxygenation dropped. 

The authors concluded that this shows that pedaling at higher cadences is inefficient for recreational cyclists. This is due to wastage of energy trying to stabilize themselves while coordinating their pedaling at higher RPM's than what they are used to. 

Try it when you next get on your bike (although trying on a stationary bike may be safer) and pedal very fast at low resistance. You may be wobbling all over the saddle and your postural and stabilizing muscles will be working hard to minimize your wobbling. This leads to more work done and higher oxygen demand overall. 

Different cyclists can ride at the same speed whether they are pedaling 60, 90, 100 RPM or any other cadence. It depends on how much wattage (or work done) produced, how comfortable you are and most importantly, what you can sustain. No point pedaling at a high cadence if you cannot ride for long or far with that. You will not enjoy your ride.

I will add that the study did not consider the length of crank arms on the bicycle. Crank arm length definitely matters. A shorter crank arm will help you spin faster more efficiently. 

My experience is that if your legs feel tired quicker than your lungs, your gear is probably too heavy and you should shift to an easier gear and increase your cadence. 

If you're breathing too hard and your legs feel fine, you can use a heavier gear and pedal at a lower cadence. Try switching back and forth with the gears and take note of how you feel. This will help you find the right cadence to ride longer and stronger.


Formenti F, Dockerill C, Kankanange K et al (2019). The Effect Of Pedaling Cadence On Skeletal Muscle Oxygenation During Cycling At Moderate Exercise Intensity. Int J Sp Med. 40(5): 305-311. DOI: 10.1055/a-0835-6286

Stage 2 in Denmark last night, watch this excellent video from official TDF website.

Picure from

Sunday, June 26, 2022

Does Epsom Salt Work?

A patient came in earlier this week after an ankle sprain. She hadn't noticed that there was bruising all over the ankle joint. She told me that in order to recover quickly, she'd been told (by someone in a local running store) to soak herself in an Epsom salt bath. This reminded me of the patient who had been asked to take magnesium supplements for muscle cramps.

She was told by the very same person that once her body 'absorbs' the Epsom salt, it can reduce muscle sorenessinflammation and swelling.

So, are there any real benefits to soaking in Epsom salt baths? Or are they just old wive's tales?

You need to know that Epsom salt is also known as magnesium sulfate heptahydrate. It is made of magnesium, oxygen and sulphur. 

The proponents say that using Epsom salt in your bathwater helps your body absorb the 'much needed' magnesium to help flush away toxins and harmful heavy metals and help induce relaxation, reduce inflammation and help with muscle and nerve function. 

Getting magnesium directly into the blood intravenously or even orally is different from sitting in a bathtub and hoping the minerals get absorbed. There is only one small experiment done by researchers from the University of Birmingham in 2006 on some of their staff supporting this. 16 out of 19 of the subjects had higher levels of magnesium in their blood and urine after soaking in Epsom salt for an hour each day over 7 days.  

However Grober et al (2017) failed to find any proof of those claims. The authors also pointed out that the Birmingham study was never formally published in a peer review journal. No statistical tests were done and there wasn't a control group.

There is likewise no evidence that magnesium is absorbed through our skin (transdermal), at least not in relevant amounts scientifically.

Magnesium is an essential nutrient that's actually found in many of the foods we're already eating. It is actually abundant in our bodies. Our bodies need it to create new proteins, for energy production in cells, DNA synthesis etc. As it is essential, our bodies store it in our bones, where it can easily be accessed if needed. Since our bodies cannot produce it, we need to get it from our diet.

Severe deficiencies are uncommon but easy to spot. Symptoms include loss of appetite, vomiting and fatigue and following that numbness, muscle cramps, seizures, personality changes and heart artery changes if the deficiency continues. 

My patient was told that Epsom salt baths can reduce muscle soreness and relieve muscle cramps, that both are very important in exercise performance and recovery.

Please note that magnesium only helps when the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Those who sell these supplements, probably choose not to mention this or perhaps they do not know the difference. The muscle cramps occur in your facial and masticatory (chewing) muscles too, not just the muscles in your feet and legs. 

Perhaps it is just the warm water (not the magnesium in the Epsom salt) with its capillary dilation which relaxes and relieves pain for those who seem to swear by it. I feel the water feels more silky after adding a big scoop of Epsom salt to it. The salt exofoliates the skin well too. Perhaps that's a better reason to use the Epsom salt?


Grober U, Werner T et al (2017). Myth Or Reality- Transdermal Magnesium? Nutrients 9(8): 813. DOI: 10.3390/nu9080813.

DiNicolantonio JJ, O'Keefe JH et al (2018). Subclinical Magnesium Deficiency : A Principal Driver Of Cardiovascular Disease And A Public Health Crisis. Open Heart. 5:e000668. DOI: 10.1136/openhrt-2017-000668.

*Epsom salt was named after a spring in Surrrey, England that was first discovered in the early 1600's. The waters at the spring were thought to have healing powers and people started to believe that bathing in the waters would relieve them of sores and infections. 

Sunday, June 19, 2022

Sip it or Gulp it?

Gulp it
If you have been exercising continuously for over an hour, you know that you have to refuel at some point. Especially if you are participating in a race. Carbohydrate refuelling during a race or a long training session can definitely enhance your exercise performance since there is a limited store of glycogen (carbohydrates) in your liver.

Sip it
The amount of carbohydrates (carbs) in the stomach is one of the main factors that would determine the speed of gastric emptying. A larger volume will empty faster than a smaller volume.*

However, a large volume of carbs in the stomach is not ideal for runners. How many of you runners reading this can drink large volumes of fluid (or eat lots of energy gels) during races and endure the fluids sloshing around in your stomach and intestines

When I was still competing in triathlons, I always took small sips while running past the feed stations. I would mostly eat/ drink on the bike leg of the triathlon as it does tend to sit better in my stomach since there is less movement while I'm cycling

However, a study I read studied whether ingesting carohydrate sports drinks during prolonged running affects exogenous carbohydrate oxidation (sparing liver glycogen, and yet maintain exercise intensity)  and gastrointestinal discomfort. This means that your glycogen stores are not being used as quickly during exercise since whatever you are drinking is being used to fuel your exercise.

The runners studied did two, 100 minutes of steady state runs at moderate intensity. In the first run, the runners consumed 200mL every 20 min while they took 50 mL every 5 min during the second run.

The researchers found that exogenous carbohydrate oxidation rates were 23 percent higher during exercise when larger volumes were ingested every 20 minutes. They concluded that ingesting larger volumes would be better than frequently sipping small amounts since large volumes will stimulate gastric emptying and makes more carbs available for intestinal absorption.

More importantly, there was no difference in gastrointestinal problems whether a larger or smaller amount was ingested while running. The authors indicated that this was also similar to what was observed in earlier studies. They suggested that runners may be able to tolerate more fluids than they think they can during exercise.

Those who are still competing should try and practice ingesting more carhohydrate gels/ drinks in training to make sure you do not get any stomach upsets. This will train your gut to absorb more carbs and help you race faster.


Mears SA, Boxer B, Sheldon D et al (2020). Sports Drink Intake Pattern Affects Exogenous Carbohydrate Oxidation During Running. Med Sci Sports Ex. 52(9): 1976-1982. DOI: 10.1249/MSS.0000000000002334

*This topic has been well studied and recommendations are to consume 30-60 g/hr for exercise/ events lasting between 1 to 2.5 hours. For exercise/ events over 2.5 hours, up to 90g/ hr should be consumed. If more than 60g/ hr needs to be ingested, a combination of carbohydrates (e.g. glucose and fructose) needs to be ingested. 

Here's how I fold the paper cup to sip while running

Saturday, June 11, 2022

Are Cold Drinks Better When You Exercise?

A question I received from one of our blog's readers is whether one can drink cold water or beverage during exercise? He said that he was advised by friends that he should drink room temperature or even warm water/ beverage after exercise as cold drinks are 'too cooling' for the body.

Well, what does research and science tell us? Exercise authorities such as American College of Sports Medicine (ACSM) and the International Society of Sports Nutrition (ISSN) both recommend water and other hydrating drinks be cold when used during exercise (Kerksick et al, 2018). 

There are a few reasons for their suggestions. Our core temperature rises when we exercise and to keep cool, we lose fluids through sweating. Remember a lot of energy is spent regulating and keeping our temperature down when we exercise. Drinking ice water or ice slushie helps keep our core temperature from rising (Hosseinlou et al, 2013). This also prevents excessive water loss through sweating while exercising.

Moreover, cold drinks are definitely more palatable compared to a warm drink and one tends to drink more when cold drinks are available. A meta-analysis found that subjects consumed 50% more cold (0-10 degrees Celsius) or cool (<22 degrees) beverages than a control group (>22 degrees) during exercise (Burdun et al, 2012).

Researchers also found that drinking cold water improved performances in 49% of participants in the broad jump and 51% of participants in a cycling to exhaustion test (LaFata el, 2012).

I don't know about you, I definitely prefer an ice cold drink during and after exercise. However, if you prefer room temperature or even warm water, don't fret. Drinking whatever appeals to you during and after exercise to get adequate hydration is most important.


Burdon CA, Johnson NA, Chapman PG et al (2012). Influence Of Beverage Temperature On Palatability And Fluid Ingestion During Endurance Exercise: A Systematic Review. Int J Sp Nutr Ex Metab. 22(3): 199-211. DOI: 10.1123/ijsnem.22.3.199

Kerksick CM, Wilborn CD, Roberts MD et al (2018). ISSN Exercise & Sports Nutrition Review update: Research & Recommendations. J Int Soc Sp Nutr. 15(1): 38. DOI: 10.1186/s12970-018-0242-y

LaFata D, Carlson- Phillips A, Sims ST et al (2012). The Effect Of A Cold Beverage During An Exercise Session Combining Both Strength And Energy Systems Development Training On Core Temperature And Markers Of Performance. J Int Soc Sp Nutr. 9: 44. DOI: 10.1186/1150-2783-9-44

Sunday, June 5, 2022

Post Competition Blues

Picture by Getty images from Express
I was reading an online newspaper article in the Guardian (it's also in today's Sunday Times) about how Rafael Nadal was asked whether he would sign up for a magical new foot if it meant losing this year's French Open final. 

"I would prefer to lose the final without a doubt, a new foot would allow me to be more happy in my day-to-day life" he added. 

Injury ravaged Nadal fractured his rib about two months ago, so making this final at Roland Garros already seemed like a miracle. He also has chronic left foot ailment, Mueller-Weiss syndrome (osteonecrosis of the navicular bone), but has consistently dug deep to raise his game and win when it mattered.

Nadal knows that winning is lovely and it gives you a real high, but right after that high there is a big low. Life goes on and life is much more important than whatever title, personal record or victory. The term for this is "arrival fallacy", coined by Tal Ben-Shahar (Harvard Psychology lecturer) which refers to the false belief that once you accomplished a particular goal you will attain a sense of lasting gratification.

I was treating national cyclist Luo Yiwei (above) earlier this week, after she won a silver medal at the recent SEA Games in Hanoi. We discussed about how, once the race day euphoria wears off and our hard earned medals begin to collect dust in our display cupboards, we may be wondering if that was all?

This creeping sense of anti climax that you feel after a race that you've spent months preparing for, is often referred to as post race blues. (I recall feeling like this as well after my GCE 'A' levels. I told myself I'll be out celebrating once the exams were done but it instead felt like a big let down).

Post competition blues is not even tied to race performance. If anything, one can be more prone to post race blues after running the race of your life. When you perform badly, it's easier to ask yourself what went wrong and why and how you can train and race better next time. You can console yourself that next time you will do better.

It is generally more common in amateur athletes than in professional athletes. The pros have to decide when they should retire or whether they should continue to try and make a living as an athlete. This answers the 'is that all?' question as to why they keep going since they are still making a living. 

Not true for the competitive amateur runner who may have to put in 100 km training weeks and utimately has little to show for it other than bragging rights, a medal and a higher chance of a running injury.

Some of my patients who are competitive amateurs say the best 'cure' for post race blues is to simply sign up for another event and set new goals and targets. 

I have felt all that before, when training loses its appeal. For those feeling the post competition blues, I will say that you can definitely indulge in some brooding. Even when I've raced well after a big race, there's always a question of what am I going to do (that's definitely before having kids) in the days after without any concern about getting any training done.

It's a strange feeling not having to train since I've set up, planned, prepared and trained for months and years leading to the big race. It has been my entire life, outside my family and friends.

However, I always say to the athletes that I treat that post race glory is fleeting. I have definitely experienced getting slower in my Saturday rides as I age. It's like there is this invisible hand pulling me backwards when I ride with the younger riders.

That's when I realize that I have to shift my focus. I tell myself to become the best physiotherapist I can be, since I can't be the best athlete I can be anymore. 

Find a way to incorporate what you have learned from your marathon, cycling or football training into your daily life. Apply the same organization, focus, structure and goal setting to your everyday tasks. Then you will find that life and running (or other sporting goals you once had) will be just as exciting and fulfilling.

A younger Rafael Nadal and I at the 2008 Beijing Olympics

Sunday, May 29, 2022

This Is Not How You Treat Frozen Shoulder

My first thoughts (only my opinion) on seeing the picture above was, this is certainly not how you should be treating a patient with frozen shoulder or any problem for that matter. 

The photos above and below taken from  Twitter made me cringe. I am apalled at the amount of damage that had been done to the person's tissues. Manual treatment, at least at our clinics and most that I know, do not look at all like that. Now that patient has to also heal from the damage his therapist did on him!

There are already many physiotherapists worldwide saying there is no evidence supporting 'manual therapy' and that manual therapy does not work and is a waste of time and money

There are growing calls that physiotherapists should not be doing 'hands on' treatment. This will lend further support to what they believe. 

Everyone has a right to their beliefs and I always say that they just don't know what they don't know. For every physiotherapist that wants to be 'hands off' when treating their patients, there will be a physiotherapist (or more) wanting to do only 'hands on' treatment. 

If you really want to be pedantic, that's not the spiral line. I have attached a picture of the spiral line as intepreted by Tom Myers above. 


Kerry R (2019). "Hands-on, Hands Off: Is That Even A Thing?" Physio First

*The 'hands off ' approach usually means not doing manual therapy like mobilising (pressing, pushing) on joints, muscles, fascia etc on patients. It does not mean the physiotherapist does not touch the patient, assess or palpate the patient. They still do, it's just that after their assessment, they usually prefer to educate their patients (by talking) or teaching exercises to oversee a care management program that addresses thee patient's long term goals and needs.

Sunday, May 22, 2022

Do Softer Running Shoes Cause More Injuries?

Vaporfly from Nike
Let's say you have been chosen as a volunteer in a running shoe study. The researcher assigns you a pair of running shoes with very thick midsoles to run with. Your expectations may be affected by how you run compared to being assigned an ultra thin and ultra light shoe.

It will also affect how you perceive aches and pain received from running during the study. It will probably not be possible to tell whether it was the softer midsoles, heel droplightness or other differences that gave you grief.

To avoid this, researchers in this study collaborated with Decathlon to make custom running shoes that cannot be visually distinguished and only has one single technical detail different for each experiment. Both researcher and subject were not aware (double blind) which type of shoe was used.

I have written before that runners, new to wearing shoes with thicker midsoles, tend to land more heavily and with greater force. This is even after running with the shoe for more than 6 weeks. This has become what is known as the shoe cushioning paradox, where more cushioning leads to runners landing more heavily, with a lesser chance of getting injured.

Decathlon made 2 prototypes, each with an inch thick of midsole. Half the soles had soft cushioning while the other half had firmer midsoles, which were randomly assigned to 848 runners. These runners completed a treadmill test to assess stride characteristics and were then monitored for 6 months.

Stride analyses showed that runners land more heavily when wearing the shoes with the softer midsoles.This is similar to other studies, which may cause more injuries (not less).

However, the runners wearing the shoes with firmer midsoles were 52 percent more likely to get injured during the follow up period (perhaps to suggest injury protection offered by the softer cushioning). This is similar to the shoe cushioning paradox. How is this so?

What the researchers found was the timing of impact matters. When your foot strikes the ground, there are 2 distinct impacts. The first impact occurs when your lower leg slows down suddenly after striking the ground. The second impact which occurs a few milliseconds later is the larger force caused by the rest of your body. The first impact is the one researchers suspect is linked to injuries. 

This force is greater in runners with the softer midsoles, but the softer midsoles slow down that first jolt and spreads it out over a longer period of time causing it to overlap with the second impact. This combined impact makes the total force appear greater thus giving the impression that softer midsoles cause runners to land harder.

After separating the first and second impacts into 2 differerent values, the authors found that the first impact (the one linked to injuries) was actually smaller with the softer midsoles.

Does this mean we should now run with shoes with the thickest and softest midsoles? Afterall, they do lighten the load on your joints and reduce injury risk. At least that's what the study by Malisoux et al (2022) suggest.

Do note that these Decathlon made shoes for the study are different from the ones available in stores. Morever, with each different brand, they have different technologies and use different materials. 

Just like the newest generation of Vaporfly (with its super thick soles and carbon plate), it still remains questionable whether it reduces injury risk, with the carbon fiber plate(s) still untested.

The midsole thickness definitely makes your foot more unstable especially when going around sharp corners or while making a u-turn in an out and back route. Only time and another specifically designed study can tell us more.

Even the authors concede that very little is known about the complex links between running shoes and injuries. I do like their suggestions, that is to stick with whatever you're running with, if you are happy with them. If you do switch shoes, consider carefully why you're switching, do try several designs  and take you time making the switch. Also consider alternating types of running shoes to vary the stress on your body. 

Just like what I've been telling my patients.


Malisoux L, Gette P, Backes A et al (2022). Lower Impact Forces But Greater Burden For The Musculoskeletal System In Running Shoes With Greater Cushioning Stiffness. Eur J Sp Sci 19: 1-11. DOI: 1080/17461391.2021.2023655

Sunday, May 15, 2022

Need To Poop Mid Race?

Our Singapore cycling champion Donaben Goh came to see me yesterday for one last tune up before he leaves for the Vietnam SEA Games tomorrow morning. We were discussing his fuelling needs in the cycling road race event (167 km long) and talking about stomach upsets while racing.

Familiar sight at races
If you're an endurance athlete, you would definitely have experienced gastrointestinal (or stomach) issues (GI). That includes nausea, bloating, abdominal pain, reflux, flatulence and diarrhoea during your longer traning sessions or races.

How and why does this happen? 

It all starts at the lining of our gut (or alimentary canal from the stomach to the anus, consisting of the small and large intestine), which has 2 jobs. First, it allows food to pass from the gut to our bloodstream and it also prevents nasty bacteria and toxins from entering the same route.

When we exercise, blood from our digestive organs (up to a quarter of our blood) are diverted to our muscles to supply more oxygen to them. Moderate exercise can reduce the blood supply to the gut by up to 70 percent. 

During prolonged endurance exercise (usually longer than 2 hours at 60 percent VO2 max or more), the gut lining starts to malfunction since it is now lacking oxygen and energy. Food that the gut is trying to absorb gets blocked while toxins start to leak into our bloodstream.

In addition, the bouncing and jostling from exercise can cause direct mechanical damage to the lining of the gut. This is why GI issues happen more with running compared to cycling.

Heat and dehydration will divert more blood away from the gut, allowing more gases and/ or toxins to pass through. 

What's worse with GI distress is, it often gets worse when you're anxious or stressed, for example before your big race. Anxiety and psychological stress trigger adrenaline which further diverts blood away from the digestive system while increasing leakage in the gut lining.

How do we prevent it? In a perfect world the obvious approach would be to find out the food that triggers our GI distress and avoid them prior to our races and long training sessions.

Studies show that a class of poorly digested carbohydrates known as FODMAPs (fermentable oliosaccharide, disaccharide, monosaccharides and polyols) may cause GI distress for many of us as they are not well absorbed in the small intestine. This causes fermentation and produce gas in the colon.

This include food containing wheat, milk, onions, garlic, legumes (beans, peas and lentils) and stone fruit (apricots, peaches, plums, mangoes, lychees etc).

Timing matters too, as eating too much fat, protein or fiber 90 minutes before exercise may increase the risk of GI problems. 

Please note that people who keep to low FODMAP diets tend to have less healthy and diverse gut microbiomes.

Personally I've found that 'training your gut' works well. Many other athletes I've spoken to and treated say that eating and drinking energy gels/ bars and sports drinks that are palatable over time makes them less susceptible to GI issues. 

You have to try them out during your long training sessions or less important races. A gel or bar may taste fine at room temperature, but may taste terrible and be difficult to swollow in hot, humid conditions. Research suggests that 2 weks of training the gut can make a difference (Miall et al, 2018).

All the best to Donaben and the rest of Team Singapore at the Hanoi SEA Games.


Miall A, Khoo A, Rauch C et al (2018). Two Weeks Of Repetitive Gut Challenge Reduce Exercise-associated Gastrointestinal Symptoms And Malabsorption. Scand J Med Sci Sports. 28: 630-640. DOI: 10.1111/sms.12912 

Smith KA, Pugh JN, Duca FA et al (2021). Gastrointestinal Pathophysiology During Endurance Exercise: Endocrine, Microbiome And Nutritional Influences. Eur J Appl Physiol. 122(10): 2657-2674. DOI: 10.1007/s00421-021-04737-x

*I did not write about probiotics (supplements) as they are capable of producing a good environment in the gut but do not eliminate symptoms entirely. That's my personal experience as well. Plus 3 out 5 of this review's authors receive research funding from companies that make supplements.

Sunday, May 8, 2022

What Really Wears Out Your Joints

Picture by Dr Howard Luks
I remember treating many cases of older patients who had total hip or knee replacements due to osteoarthritis (OA) when I was a much younger physiotherapist. 

Upon asking these patients, they always wondered why they had worn out their joints despite not exercising. Some were very sedentary, while others had no time to exercise since they were more concerned with making enough to feed their families.

I've written previously that running will not wear out your knees (or your joints). So what does? There is now evidence that OA is not due to a mechanical wear and tear process. Even if you already have OA, exercise will not wear out your joints quicker. 

Of course there are mechanical causes of OA. People who are severely bow legged or have severely knocked knees can be more prone to developing OA since one side of the knee joint is over loaded. Certain fractures near a joint can lead to post traumatic OA (due to mal- alignment). 

Patients whose meniscus is torn and subsequently removed have an increased risk of developing OA. Which is why surgeons now rarely remove the whole meniscus, just the torn bit.

So, what causes arthritis in our joints? For those without any previous injuries to the joint, we have hundreds of proteins, cytokines, chemicals and other compounds that forms the articular cartilage, which lines our joints. When the joints are in good health, these chemicals support articular cartilage health and nutrition.

We do not know exactly why, whether it is due to injury, our diet, metabolism or weight that, OA develops. It may be all of the above when a 'switch' flips. Changes in the joint(s) similar to changes associated with other chronic diseases happens. That switch causes an increase the production of chemicals that harms our articular cartilage (Wang et al, 2015).

Over time, these chemicals cause injury to the articular cartilage cells. This weakens the articular cartilage and its ability to withstand load and stress.

The articular cartilage can become thinner when not functioning well. This can lead to inflammation, swelling, warmth and pain. This chronic low grade inflammation is what appears to cause OA. This is the same chronic inflammation thought to cause other chronic diseases like heart disease, fatty liver and Type II diabetes.

Researchers are still trying to understand how all these proteins and substances affect articular cartilage health and the incidences of OA. 

Exercise has actually been proven to decrease the concentration of these proteins and substances that harm our articular cartilage.

Helmark et al (2010) showed that IL-10, a chemical that protects articular cartilage in the knee was produced in response to exercise. Similarly, COMP (a protein that is a marker of cartilage degeneration) was decreased in the knee with exercise.

Another research paper by Hyldahl et al (2016) demonstrated that running was associated with a decrease in cytokines (chemicals) in the knee related to articular cartilage wear and tear. 

Studies are suggesting that metabolic health definitely plays a bigger role in causing OA. Yes, other than Type II diabetes, dementia, high blood pressure and heart disease, metabolic issues are also thought to be involved in the development of OA. All tissues in our body, including our articular cartilage are sensitive to our dietary intake. The earlier we realize this, the better off we will be.

Too many health care professionals ask their patients to stop running (or exercise) to 'save' their joints. In actual fact, running and other knee exercises have been shown to relieve mild knee arthritis and does not harm articular cartilage.

Exercise has been unequivocally proven to be the most effective treatment for early and moderate OA in our joints. You do not have to stop exercising. 

Let your symptoms be your guide. If there is no swelling and no pain, you can still run or exercise. Be careful with the distance, intensity and frequency of exercise. You may also want to cycle or swim occasionally. Or try a different shoe, or different running surface and/ or include a weight training session to get yourself stronger. 


Helmark IC, Mikkelsen UR, Borglum J et al (2010). Exercise Increases Interleukin-10 Levels Both Intraarticularly And Peri-synovially In patients With Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Res Ther. 12, R126. DOI: 10.1186/ar3064

Hyldahl RD, Evans A, Kwon S et al (2016). Running Decreases Knee Intra-articular Cytokine And Cartilage Oligomeric Matrix Concentrations: A Pilot Study. Eur J Appl Physiol. 116 2305-2314. DOI: 10.1007/s00421-016-3474-z

Wang X, Hunter J and Xu CD (2015). Metabolic Triggered Inflammation In Osteoarthritis. OA and Cartilage. 23(1): 22-30. DOI: 10.1016/j.joca.2014.10.002

Sunday, May 1, 2022

Quads And Squats

We saw a few patients who tore their Anterior Cruciate ligament (ACL) in our clinic this past week. I have written many articles on the ACL before. Once you've torn your ACL, it usually takes 9 to 12 months before you can return to your sport, not to mention the financial cost. 

I came across an interesting article summarizing the evidence of the relationship between muscle forces acting on the ACL. This is important since muscles around the knee can increase and decrease the strain and mechanical loads on the ACL. This presents opportunities for preventive intenventions. 

Subsequently, our staff had interesting discussions regarding that article (referenced at the end of this post). The article demonstrated the forces acting on the knee joint and what can cause injuries there, specifically, what can hurt the ACL

The article reviewed muscle and and ACL loads during knee bending as well as weight bearing tasks like walking, lunging, landing, jumping and sidestep cutting.

Ready for the results? The quadriceps (thigh muscles) and gastrocnemius (calf muscles) increases load on the ACL due to anterior shearing forces at the tibial (shin bone). This is especially so when the knee is straightened.

The hamstrings and soleus (deeper calf muscles) helps to unload the ACL by generating posterior tibial shearing forces. For the hamstrings to 'protect' your ACL, your knee has to be bent at least 20 to 30 degrees.

R gluteus medius
The gluteus medius muscle was demonstated to consistently prevent the knee from collapsing inwards (knee valgus movement) and thus unloading the ACL, better than any other muscle.


Patients who have been been told to strengthen their quadriceps (especially after ACL reconstruction) were really surprised when we told them. Make sure you focus on your hamstrings and soleus muscles instead.

The muscle to rule them all is of course the gluteus medius. Our patients will now understand why we always ensure their gluteus medius muscle is strong to prevent knee painAchilles tendon and of course ACL injuries.

Now you know.


Maniar N, Cole MH, Bryant AL et al (2022). Muscle Force Contributions To Anterior Cruciate Ligament Loading Sports Med. DOI: 10.1007/s40279-022-016743

Saturday, April 23, 2022

Outrun A Tesla?

One of the books I'm currently reading is an authorized biography of Elon Musk, written by Ashlee Vance. Yes, that Elon Musk, who is CEO of Tesla, Space X and SolarCity. And perhaps Twitter if his attempt to buy the company goes through.

Previously, I wasn't a fan of Elon due to his brashness and controversial behaviour. My views have changed after I started reading this book (pictured below). Coincidently, Musk is also featured in a full page article in today's Sunday Times on page A22.
Naturally, I was curious when I read about ultra runner Robbie Balenger's attempt to run further than a fully charged Tesla Model 3. On a full battery, the Tesla Model 3 would last a little over 242 miles (or 387 km). This is a grueling man versus machine race.

On April 11, Balenger and the Tesla started together 250 miles outside Austin, Texas in USA. The car was driven at a median speed of 65 miles an hour for the duration on a full charge on a remote road. Balenger's goal was to follow the car's route and cover the distance in 72 hours. 

For three days Balenger suffered due to the heat and humidity with temperatures reaching 90 degrees Fahrenheit (or 32 degrees Celcius). However he did it! He covered the distance in 76 hours, 54 minutes and 46 seconds, running further than the depleted car by 100 feet. 

The challenge was sponsored by activewear brand, Ten Thousand, as part of the company's Feat of Strength series.

Balenger , a plant-based (or vegan) endurance athlete also holds the former record for running the most laps around New York's Central Park in one day. He ran 16 loops of the 6.1 mile (9.76 km) course, covering 97.5 miles (156.16 km) in March 2021.

He also ran 3,175 miles across the USA in just 75 days in 2019. Amazing! 

Below is a picture of today's Sunday Times article on Elon Musk.

Sunday Times page A22

Sunday, April 17, 2022

Can A Bit Of Tape Rotate Leg Bones?

Unlike others in the picture above who are skeptical and think that leg bones cannot be rotated with "a bit of tape" in 2022,  I remain open to finding out how to treat our patients with knee pain

Just because I cannot ride a unicycle does not mean others cannot. Similarly if the author above cannot rotate his / her patient's leg with "a bit of tape" does not mean others can't.

We do see many patients in our clinics presenting with knee pain. Even though we have very good results treating these cases, I am always on the look out on how to get these patients with knee pain better quicker. Especially those who run.

In our clinics, we almost never tape the patient's knee, especially if the cause of their knee pain is coming from elsewhere. In fact, we do not even use rigid sports tape when we do tape the patient's knee.

Using Kinesio tape compared to using rigid sports tapes to do McConnell taping, (first published in 'Physiotherapy' journal in 1986 by Australian physiotherapist Jenny McConnell) definitely produces a superior result.  

So I was really intrigued when I saw a paper that investigated the effects of using rigid sports tape for tibial internal rotation taping (IRT) and external rotation taping (ERT) done on subjects with patellofemoral pain syndrome (knee pain) during three functional tests. During double leg squat, single leg squat and maximum isometric thigh muscle contraction.
Internal rotation taping
The researchers found that compared to no taping, both IRT and ERT significantly reduced pain during the three tests, especially for those with higher pain levels initially.
External rotation taping
ERT was found to be more effective than IRT. Why? The authors did not provide any suggestions. My thoughts are that when you externally rotate your tibial (shin bone), you can activate your gluteus medius better. Remember, one of our most popular posts shows that the cause of patients' knee pain is usually coming from the hip.

To see if the two taping techniques work, let me try the ERT and IRT techniques on my colleagues in our clinics first before I unleash them on our patients. Bear in mind we still want to treat the cause of the problem and not just the pain itself.

Deng F, Adams R, Pranata A et al (2022). Tibial Internal And External Rotation Taping For Improving Pain In Patients With Patellofemoral Pain Syndrome. J Sci Med Sp. DOI: 10/1016/jsams.202204.003

*thanks to Byron and Megan for helping me with the photos

Sunday, April 10, 2022

We Don't Just Treat Sports Injuries

Many new patients who call our clinic often tell us that they don't play any sports and wonder if they can still see us. To which we reply, "Most definitely!"

As all our physiotherapists are trained to read your body to ascertain how it's positioned in various postures and during movement. We work like detectives, finding the main cause of your problem. We know exactly what we can change to make a difference to your problem and when we might need to refer a patient out to a specialist e.g. neurosurgeon etc.

We specialize in spinal pain and problems, joint pain, muscle strains, joint sprains, nerve related problems (where you might experience pins and needles, numbness or reduced sensation or strength), headaches, and of course injuries that you sustain during sports.

So exactly how different is a sports physiotherapist and a musculoskeletal (meaning muscle and bones) physiotherapist? Having worked in a professional sports setting, treating elite athletes for 10 years, traveling with Team Singapore athletes to the Olympics, SEA, Commonwealth, Asian Games and others and now being in private practice for 12 years , I will attempt to explain the main differences..

The biggest difference would be the time allocated to the athletes and patients. When treating athletes at a professional level, we may sometimes see the athlete 3 times a day. 

Say we have a badminton player who has a niggle in his foot, we get to experiment with taping the player's foot with rigid or Kinesio tape. How can I change his navicular bone position? That alone may determine how well the player trains that morning. Or, if there's a match later that evening we can trial any tape, shoe, or racket earlier in the week before the actual game. 

Oftentimes, the head coach will request specific sessions with injured players to get them up to speed with recovery.

Taping with rigid tape
In an actual game, the physiotherapist has to be paying attention and watching to get clues about the mechanisms of injury. We often need to assess and treat our player ASAP usually within the minute.  I will have in my kit bag, different types of tapes ready, blister kit. splints, nail cutter, scissors, lotions, painkilling sprays etc. in case I need them. We try to be the 'magic' healer, asking questions, cleaning sweaty areas to treat, to allow them to play again.

Yes, Treating elite athletes can be very time consuming and labor intensive.

In a private practice setting (like Physio Solutions and Sports Solutions), the patients are just as eager to be pain free, to get better and to return to exercise. Unlike a competition setting, we get much more time to ask questions and assess thoroughly. Finding and treating the cause of the problem becomes easier. The hands-on, manual therapy we do has huge benefits in changing a patient's condition. However, we may only get to see patients once or twice a week. 

It is, therefore, important to educate patients on what they have to do in the time between appointments. We may teach them self tests and exercises on e.g. their calf range to see how they're progressing. We are easily contactable via text, email or phone if you need to ask questions between your sessions.

In summary, when you become our patient, WE GOT YOU.

Sunday, April 3, 2022

My Patient Has Os Trigonum Syndrome

Not her legs
My 11 year old patient came in complaining of pain at the back part of her ankle. She's an avid ballet dancer and tennis player and trains up to 4 times a week.

After examining her thoroughly, I found that her pain was reproduced at a very specific location, especially when she was pointing her foot. I explained to her mum that she probably has Os Trigonum syndrome.

The Os Trigonum is a small, extra accessory bone that is sitting at the back of the ankle joint. This extra bone may be present in up to 20 percent of the general population. It forms when one area of the bone fails to fuse with the rest of the bone (the talus in this case). Often people do not know if they have an Os Trigonum if it has not caused any problems. 

This is similar to the accessory navicular bone in the foot, which usually does not cause any problems. However, it can cause pain after twisting your ankle (just like it can cause pain in the accessory navicular bone in the foot). This happens when the Os Trigonum moves or breaks leading to pinching at the back of the ankle joint, causing what is known as a posterior impingement. 

It can also be caused by repeated downward pointing of the toes, which is especially common in ballet dancers (when assuming an en pointe position) and football players (when shooting).

Sometimes it can be mistaken for pain originating from the Achilles tendon. An x-ray is usually ordered by the doctor to show the Os Trigonum at the back of the ankle. A MRI scan is used occasionally to exclude articular cartilage damage in the ankle.


Skwiot M, Sliwinski Z, Zurawski W et al (2021). Effectiveness Of Physiotherapy Interventions For Injury In Ballet Dancers. PLoS one. 24(6): eo253437. DOI: 10.1371/journal.pone.0253437.

Thanks to Byron for the picture

Wednesday, March 30, 2022

We Went Bowling For Team Building

We went to the Escape Room during our last team building session. And we were going to playing indoor games (Charade, Monopoly or card games perhaps) for our team building event this quarter.

However since restrictions were lifted for Covid-19, the younger members of our team decided we should go bowling. 

And so we did. It was nice to be able to hang out in a bigger group. You get hungry after some exercise. So of course we had to get something to eat after bowling.

Megan was not feeling well so we missed her today. But she missed a fabulous lunch too.

Mark your calenders for the next team building event on June 3rd. Stay tuned.

Sunday, March 27, 2022

What Is Ergodicity?

Ice baths for recovery
I did not know what the word 'ergodicity' meant. I had to look it up. It means when you do a test or research on a whole group, you assume the result applies to everyone. Say you get a hundred gorrillas to flip a coin 10 times. All 10 flips ends up with a head. You then conclude that all gorillas can always flip 10 heads in a row with 10 coin flips.

Can you see the error with this conclusion? Neumann and colleagues (2021), sugests that sports scientists may inadvertently be making errors like this frequently. Their research studied the relationship between training load and recovery. If you're into endurance sports, you know recovery is really crucial.

When you train more, your fitness improves, however, it also increases your chances of injury and burnout. This has led to all sorts of research to investigate how we handle different training loads and how quickly we recover so that we can train harder without breaking down.

So, is there a link between training load and recovery? Is it possible to measure training load and subsequent recovery in a large group of people and use those results to recommend or predict how you and I or any individual would respond?

Neumann and colleagues (2020) studied footballers from a top Dutch football league club, over 2 seasons. Daily training and recovery data were collected from footballers of their under-17, under-19 and under-23 teams.

The most basic question to address is if total training load in a workout affect how recovered the footballers feel before the next day's training session? This is done in 2 ways. 

For the whole group analysis, an average training load is calculated on a given day. The analysis is repeated for each workout day and you can average the results.

For each individual analysis, you monitor every pair of workout/ recovery scores for each individual over the course of the data. This data is then averaged. 

If both group and individual data produce identical results, then the training and recovery is ergodic, meaning the results of the group studies can be applied to individuals (like you and I). If results aren't identical then oops.....

Well, sure enough, the group and individual analyses produced different results. The correlations between training load and recovery did not match up. training loads varied far more for a given individual footballer over time than they did between individual footballers on a given day. How a bunch of people respond to a single workout session does not always tell how you respond to a series of workouts. 

I recall when running cross country in secondary school how all of us in the school team were given the same workout session and each of us responded differently.

You must be wondering now if all the previous research done on training and  on large groups apply to you, or whether they are invalid. Researchers use randomized placebo controlled trials to normalise the effects of individual variation. They also report individual results to group averages. 

Read and understand the recommendations from researchers to improve your personal training/ performance and recovery. But bear in mind that we are all an experiment of one (or n = 1). Age is also a confounder. What hurts now after a certain workout did not hurt when I was 28.


Neumann ND, Yperen NWV, Brauers JJ et al (2021). Nonergodicity In Load And Recovery: Group Results Do Not Generalize To Individuals. Int J Sp Physiol Perform. 17(3): 391-399. DOI: 10.1123/ijspp.2021-0126