Sunday, December 31, 2023

Farewell 2023

Sunset at Cowrie beach, Melbourne
Time really has flown by. It's the last day of the year as I type this final post for 2023 in Melbourne, Australia.

As the sun sets on 2023 and we welcome 2024 on the horizon, here are some of my thoughts before we ring in the new year. 

I sustained a paper cut on my finger last week while leafing through some books and magazines. The cut is super tiny, almost invisible but still hurts a fair bit. 

This is always an analogy that I give my patients about the many injuries and the subsequent pain they feel. The pain is not always proportional to the actual tissue damage . Remember this the next time you hurt your neck , backknee or roll your ankle. Or other body parts.

For those of you who have eaten too much (like me) over the festive season and not kept up with your regular exercise routines,  here are some suggestions for getting in some activity no matter where you are: 

Find and do any exercise you enjoy. Some (or even a tiny bit) is better than none. More is almost always better. Walking and climbing stairs count too. 

Both weight (or strength) training and aerobic training are important but the best exercise is the one that gets done.

Whatever amount of exercise you are capable of today, that will be enough. Do that amount. Just start.

At Ripples N Tonic farmstay
Have a great 2024! 

Friday, December 22, 2023

Still Walking With Crutches After One Month?

Picture from
Neymar Junior is definitely a world class footballer who just had an ACL reconstruction after tearing his anterior cruciate ligament (ACL) on 181023. However, his rehabilitation does not seem world class at all. 

You can hear him yelling when his knee is being forced to bend (knee flexion) with 3 people involved. I am not sure if the video was put up just to garner more views, but that is not what to do if you want to improve knee bending range. Getting full extension (knee straightening) is more important early on to avoid any chance of getting a cyclops lesion

And still walking with crutches after one month? Our patients are sometimes discharged and walking with no crutches from the hopsital or our clinic after a few days.

Come see us in our clinics if you need rehabilitation after your your ACL reconstruction.

Saturday, December 16, 2023

Iliopsoas Related Groin Pain

Previously I have written about hip adductor related groin pain (ARGP), which is the most common area for groin pain. There is also iliopsoas related groin pain (IRGP). Patients who have IRGP usually have iliopsoas tenderness/ pain while stretching the area  and have pain with resisted hip flexion (or bending). 

There is not enough evidence to suggest which exercise protocol or treatment technique is superior for treating IRGP. However, there is evidence to suggest a quicker return to sports (and to running) using a multi-modal program (manual therapy, stretching, heat and exercise therapy) compared to exercise therapy alone (Weir et al, 2010).

Strengthening the iliopsoas via isometric, concentric and eccentric contractions using elastic bands for 6 weeks have been found to substantially improve iliopsoas (hip flexor) strength (Thorborg et al, 2016). King et al (2018) found that athletes had high rates of pain free return to sports participation and had improved cutting performance when rehabilitation focused on inter-segmental (lateral hip, legs and abdominals) control.

Neutral spine, anterior or posterior tilt
There you have it, no magic stretches, protocol, nor any therapeutic machine to really treat groin pain on its own. Some physios teach core or stabilization exercises with a neutral spine (pictured above).

3 planes of motion
Like I wrote before, we do see many patients with groin pain in our clinics. Our approach to treatment is very different. It depends on what our assessments show. The patients do not do any strengthening exercises when they are in the clinic. We prefer to treat them using mostly our hands instead. Since the pelvis (or hip) has 3 planes of motion, we treat them with our hands with respect to he 3 planes of motion (pictured above).

For example, for a patient with groin pain, they may also have a hip rotated to the right side (pictured below). 
Hip rotated to right side
We can treat the hip with respect to the shorter side. Short in terms of length. So the right side is shorter in front (pectineus) in the picture above, while the left hip is shorter behind. 

The patients can then do the strengthening exercises they need on their own. We treat what they cannot do themselves in the time they have with us. Come see us in our clinics if you have groin pain.


King E, Franklyn-Miller A, Richter C et al (2018). Clinical And Biomechanical Outcomes Of Rehabilitation Targeting Intersegmental Control In The Athletic Groin Pain: Prospective Cohort Of 205 Patients. BJSM. 52(16):1054-1062. DOI: 10.1136/bjsports-2016-097089

Thorborg K, Holmich P, Christensen R et al (2011). The Copenhaen Hip And Groin Outcome Score (HAGOS): Development And Validation According To The COSMIN Checklist. BJSM. 45(6): 478-491. DOI: 10.1136/bjsm.2010.080937

Weir A, Jansen JA, vande Port IG et al (2011). Manual Or Exercise Therapy For Long-Standing Adductor-Related Groin Pain: A Randomised Controlled Clinical Trial. Manual Therapy. 16(2): 148-54. DOI: 10.1016/j.math.2010.09.001

Sunday, December 10, 2023

Does Having Different Leg Lengths Cause Injuries?

A runner came to our clinic this past week with a brand new pair of orthotics as he was found to have a leg length discrepancy of half a centimetre (cm). He ran the Singapore Stan Chart marathon last week with them and ended up with a slight injury. 

I had previously written about how it is very common to have a leg length discrepancy (LLD) and that most of the time it did not matter for most people. I had not provide any references to justify my post then so please allow me to do so now.  

Actually, 90 percent of people have a LLD of up to 1 cm (Gordon and Davis, 2019). Knutson et al (2005) also reported that that the most people have an average leg length difference was 0.52 cm and for majority of people this difference does not matter unless there is a difference of 2 cm or more.

What about runners? Would having different limb lengths cause an injury for runners? Many healthcare professionals insist LLD can cause injuries and will often prescribe orthotics to correct this discrepancy.

While running, there is only single leg stance phase (where one foot contacts the ground) and some flight time (where both feet are off the ground) before the other foot contacts the round. At no point is both feet on the ground at the same time when we run (running does not have double leg stance phase unlike walking).

LLD actually has a greater effect on double leg stance (both feet contacting the ground) activities. During single leg stance activities, the effect is lessened as the gluteal (or buttock) muscles, especially gluteus medius work to stabilize the pelvis. 

Hence, running is less likely to be affected by leg length differences and studies have shown that LLD was not associated with the development of a running injury (Hespanol et al, 2016). 

Rauh et al (2018) did find that male runners with a LLD greater than 1.5 cm had a greater chance of developing a lower leg (shin/ calf) injury.

Now you know that LLD of up to 1 cm are very common and unlikely to cause pain in many cases, especially runners. There is also insufficient strong evidence when to start treatment and it should not be based solely on the length of the LLD. 

If the gluteus muscle is weaker on the left (pictured), it can cause a functional leg leg difference and cause that side of the pelvis to drop lower. If the difference is above 2 cm, there is a higher chance that biomechanics are affected and can cause problems. Majority of people do not have this.

What about differences of 1 to 2 cm? Personally I believe if it ain't broken, don't fix it. Meaning only if a patient or runner's condition is causing pain then we it may be worth exploring if changing hip or leg strength helps.


Gordon J, Eric MD, Davis DE (2019). Leg-Length Discrepancy : The Natural History (And What We Really Know). J Ped Ortho. 39():p S10-S13. DOI: 10.1097/BPO.0000000000001396

Kuntson GA (2005). Anatomic And Functional Leg-Length Inequality: A Review And Recommendation For Clinical Decision-Making. Part 1, Anatomic Leg-Length Inequality: Prevalence, Magnitude, Effects And Clinical Significance. Chiro Man Therap 13,11. DOI: 10.1186/1746-1340-13-11

Hespanhol Junior LC, de Carvalho AC, Costa LO et al (2016). Lower Limb Alignment Characteristics Are Not associated With Running Injuries In Runners: Prospective Cohort Study. Eur J Sp Sci. 16(8): 137-144. DOI: 10.1080/17461391.2016.1195878

Rauh MJ (2018). Leg-Length Inequality And Running-Related Injury Among High School Runners. Int J Sp PT. 13(4): 643-651. PMID: 30140557

Sunday, December 3, 2023

Simple Hopping Exercise Improves Running Performance

Last week's topic was on when to change your running shoes, with a key finding showing that energy consumption while running with newer PEBA midsoles was 1.8 percent less compared to EVA misoles. And using less energy means we can run further and faster. Running performance is thus dependent of how efficiently we move, which is defined as running economy  (RE).

In case some of you are not willing to shell out a few hundred dollars for a new pair of PEBA midsole running shoes, let me suggest another way to improve your RE without spending any money.

Here is what authors who investigated the effects of spending just 5 minutes daily doing double leg hopping (similar to plyometrics) over 6 weeks (Engeroff et al, 2023). 

34 amateur runners (29±7 years, 27 males) were assigned to a control group or a hopping exercise group. Those in the control group did not do the hopping exercises but continued with their own exercise. 

Those in the hopping exercise group did the regular exercises plus the hopping. The hopping bouts lasted 10 seconds each initially, (they did 5 times with 50 seconds rest) with the bouts gradually increasing and the rest periods shortening (pictured above). Each week after, they added an additional set of hops and reduced the rest times by 10 seconds to have a total training time of 5 minutes.

RE, peak oxygen uptake (VO2 peak) and respiratory exchange ratio (RER) were measured at 3 running speeds (10, 12 and 14 kmh) before and after the hopping program.

The authors found that the simple double legged hopping exercise can enhance running economy (RE) at higher speeds (12 and 14 km/h) in the subjects. The benefits are pronounced even when the hopping regimen is kept simple and done for 5 minutes daily. Maximum aerobic capacity was unchanged if their regular running and exercise habits were maintained.

The authors sugested that the increase in Achilles tendon stiffness improved RE since stiffer tendons are more capable of transferring energy to help movement. Their data showed significant improvements in RE while the subjects were running at 12 and 14 km/h but not at 10 km/h which provides support that Achilles tendon stretch and recoil increases with running speed (Lai et al, 2014).

What I felt was important was that there were no reported injuries nor side effects from the hopping exercise protocol. It is also not known if the hopping can be done in a fatigued state? Would that then lead to possible injuries? 

The hopping described in this study is really simple. The subjects hopped as high as they could using both legs with both legs either straight or slightly bent. So no need to do box or squat jumps! Other than packing my skipping rope with me when I'm traveling later this month, I'm going to try this as well.


Engeroff T, Kalo K, Merrifield R et al (2023). Progressive Daily Hopping Exercises Improves Running Economy In Amateur Runners: A Randomized And Controlled Trial. Sci Rep 13, 4167. DOI: 10.1038/s41598-023-30798-3

Lai A, Schache AG, Lin YC et al (2014). Tendon Elastic Strain Energy In The Human Ankle Plantar-Flexors And Its Role With Increased Running Speed. J Exp Biol. 17: 3159-3168. DOI: 10.1242/jeb.100826

Sunday, November 26, 2023

How Long Does Your Running Shoe Last?

Picture from Run Repeat
Ever wondered how long before you need to change your running shoes? A bit of history on midsole technology. Previously, the midsoles in running shoes were all made with ethylene-vinyl acetate (or EVA). Then Adidas managed to secure (Adidas bought the technology from BASF) their Boost midsole out of thermoplastic polyurethane (TPU) in 2013 which led to many marathon world records falling. In 2017, Nike's super shoe, the Vaporfly, was made of polyether block amide (PEBA) and it is still the current dominant midsole.

Previous anecdotal evidence and hearsay suggest EVA midsole running soles tend to last between 300 to 500 miles (480 to 800 km). There was an older study supporting this information (Cook et al, 1985). The researchers measured shoes shock absorption at frequent intervals between 0 to 500 miles. 

A machine was used to simulate running impact as well as 2 vounteers who actually ran 500 miles (pictured above). The 2 human volunteers show similar patterns compared to the machine (see diagram). Human testing showed that EVA midsole shoes retained 80 percent of shock absorption after 150 miles (240 km) and 70 percent after 500 miles (800 km). The curve then flattens out between 300 to 500 miles which is probably where we get shoe lifespan information from.

More recently, a bunch of researchers teamed up with the brand On and manufactured prototype running shoes that were almost identical (Rodrigo-Carranza et al, 2023). One had the new PEBA super foam while the other had the traditional EVA midsole. 
Shoe testing from Rodrigo-Carranza et al (2023)
Both versions also had a curved carbon fiber plate. They tested the shoes before and after 280 miles (448 km). 22 runners performed a running economy test to measure how much energy they used at a given pace, once in fresh shoes, once with pre-worn shoes. The researchers themselves actually ran 280 miles (448 km) in each pair of shoes to pre-wear them for the research!

The researchers found that the new super foam did lose their powers quicker. In fact they were no better than the traditional EVA midsole when they did. A key finding was that energy consumption while running with the new PEBA midsole shoe was 1.8 percent less than using the new EVA shoe. This strengthens the case that the super foam itself is more important ingredient since both versions of the prototypes had carbon plates in them.

Another key finding was that after 280 miles (448 km), there was no significant difference between the 2 shoes. The EVA did not lose anything while the PEBA super foam shoe got 2.2 percent worse. Please note that not all PEBA foams are created equal. On's super foam may not be totally similar to Nike's and other brands.

I have not converted to super shoes yet as I do not like them stacked too high. Moreover, I currently only run 2-3 times a week and I rotate between 2 to 3 pairs of shoes with EVA and TPU midsoles. I run in them until they start to feel "flat". It is relatively easy to feel especially if one of my other newer pairs still feels supportive by comparison. I usually retire that "flat pair" from running but will still use them for walking. If you're using the PEBA foam super shoes, you may have to change them earlier.

If you are interested, have a look at Run Repeat, where infomation on a huge range of high performance super foams are available. The author, Carlos Sanchez runs 100 km a week and has run three sub 3 hours marathons. Sanchez suggests that shoe foams take more than 24 hours to 'recover' and some foams recover faster than others so you may want to rotate your running shoes to maximise comfort and shoe life.


Cook SD, Kester MA and Brunet ME (1985). Shock Absorption Characteristics Of Running Shoes. AJSM. 13(4): 248-253. DOI: 10.1177/036354658501300406

Rodrigo-Carranza V, Hoogkamer W, Gonzalez-Rave JM et al (2023). Influence Of Different Midsole Foam In Advanced Footwear Technology Use In Running Economy And Biomechanics In Trained Runners. Scan J Med Sci Sp. DOI: 10.1111/sms.14526

Sunday, November 19, 2023

Is There An Ideal Running Cadence Rate?

Picture from Tracksmith
180 steps per minute seems to be the accepted magic number for cadence (or the number of steps) in long distance running. If you read the old Runners World magazine, you will know that legendary running coach Jack Daniels got that magic number by counting the number of steps the elite runners took at the 1984 Los Angeles Olympics.

This is also part of the 'ideal running form' criteria. It is also a relatively simple quantity to measure and change since it's much easier to tell a runner to increase their cadence than altering than heel strike.When you take smaller, quicker steps, it optimizes your efficiency and minimizes your injury risk by reducing impact on your knees and hips with each step. 

What if you can turn over your legs even faster? Watch the elite female Japanese marathoners when they race, they get close to 200 steps per minute. Does more mean better? What does current research say?

Burns and colleagues (2019) found that running cadence varies greatly. It actually depends on your running speed. Your cadence will differ when doing a track interval session versus an easy recovery run.

They studied 20 males and females who placed in the top 25 male and female finishers at the 2016 Ultra Running100 km world championships. The race was held in Spain and consisted of 10 laps of 10 km each lap along an almost completely flat course. This is ideal to determine if there were any specific characteristics that had an effect on cadence. Data was collected from the smart watches of the runners.

A survey was done after the race via email asking about their age, weight, height, training, racing experience and their racing speed.

Only speed and height of the runners have an effect on each individual runners' cadences. The study showed that when the runners run faster, their step frequency increased. Taller runners also had lower step counts compared to shorter runners. This study found that every extra inch in height was associated with a decrease of just over 3 steps per minute in cadence. A 6 foot tall runner in the race took about 18 steps per minute less than another runner who is 5 foot 6 inches.

Makes sense that longer legs will take fewer steps each minute to cover the same distance. 

The lead author, Burns, finished 5th in the race and included himself in the study. The runners' cadences differed greatly, ranging from 155 to 203 steps per minute. The highest and lowest averages actually finished within a couple of minutes of each other. 

Guess what number came up when Burns took an average of all the runners' cadences? 182 steps a minute. Now, that is really close to the optimal 180.

The study also showed that fatigue had no effect on cadence, possibly due to the very flat course. Even when the ultra runners were in the later stages of the race, they held the same pace from the start. In fact they had even faster step counts near the finish when they ran faster despite being tired.

According to the article, there are only 2 ways to increase your cadence, become shorter (like the elite female Japanese marathoners) or go faster. Bear in mind that everyone has a different optimal cadence. Having a higher cadence (than 180) does not necessarily make you a better runner. 

Burns finds that when he is fitter, his cadence is lower at a certain pace since his steps are longer. When his cadence is faster than normal at the same pace, he uses that as a sign that he needs hill work or speed work to get stronger. 

That is a much better way to use cadence to improve your running rather than aiming for a specific number. Especially when everyone's mechanics are different. It is also a good and simple aspirational goal for runners since many runners overstride and land on their heels, putting excessive forces on their knees. 


Burns, GT, Zendler JM and Zernicke RF (019). Step Frequency Patterns Of Elite Ultramarathon Runners During A 100-km Road Race. J Appl Physiol. 126(2): 462-468. DOI: 10.1152/japplphysiol.00374.2018

Sunday, November 12, 2023

How To Be A Better Trail Runner

Picture by Melvin Lee
Many of my patients are now running on trails, making the switch from running on the road which they say is boring. There are also many more organized trail races world wide, and many of our patients participate in these trail races.

What does it take to become a better trail runner? A recent published study compared elite and recreational trail runners in a series of lab tests and found that the elite runners were more efficient over both hilly and level terrain (Besson et al 2023). As a result, they required less energy to maintain a given pace. They were found to have greater leg strength compared to recreational runners. 

The same researchers found similar results when they compared elite trail and elite road runners. The trail runners had stronger leg muscles and were more efficient on hilly terrain (Sabater et al, 2023)

So, do leg strengthening exercises if you want to run better on the trails. Other than visiting the weights room, you can carry a heavier backpack while climbing stairs or walking/ running up and down stadium steps. I used to wear a weight vest while training for the Oxfam Hong Kong Trailwalker event at the old National Stadium steps. It definitely made the uphill sections easier during the event.

Another pattern that has turned up in studies of hilly running trail races is to keep your effort and not your pace constant. The faster finishers showed greater variability in their pacing. They ran slower (or walked) on the steeper sections and ran faster on the downslopes to make up time (Corbi-Santamariaet al, 2023). 

Most trail runners tend to have a fixed pace and try maintain that regardless of terrain. A more efficient strategy is slow down on the uphills and speed up on the downhill sections relative to your average pace. So don't push harder on the up slopes to keep pace, slow down instead to keep your effort constant. You can run faster on the downslopes to get back the time you lost for those who are racing.

Please bear in mind that there's a skill to running fast downhill, particulary on technical terrain. More so during ultras as more than10 hours of racing makes one very fatigued. Not worth having a catastrophic fall while running downhill.

Are trekking poles useful? Usage of trekking poles can be contentious among trail runners.  Giovanelli and colleagues (2023) tested runners on the steepest treadmill in the world, in their lab. Their treadmill can be set to 45  degrees, at a grade of 100 percent! They found that using trekking poles does not save energy, but they do save your legs. On a hill climb of 20 degrees incline, runners applied 5 percent less force on their legs but reached the top 2.5 percent faster.

Picture from
Even Killian Jornet uses trekking poles (pictured above). Why shouldn't you?

There you go, three ways to become a better trail runner. Strength training, varying your pace and trekking poles. Watch out for tree roots on the trails while running!


Besson, T, Sabater PF, Varesco G et al (2023). Elite Vs Experienced Male And Female Trail Runners: Comparing Running Economy, Biomechanics, Strength, And Power. J Strength Cond Res 1: 37(7): 1470-1478. DOI: 10.1519/ JSC.0000000000004412

Sabater PF, Besson T, Berthet M et al (2023). Elite Road Vs Train Runners: Comparing Economy, Biomechanics, Strength, And Power. J Strength Cond Res 1: 37(1): 181-186. DOI: 10.1519/ JSC.0000000000004226

Corbi-Santamaria P, Herrero-Molleda A, Garcia-Lopez J et al (2023). Variable Pacing Is Associated With Performance During The OCC Ultra-Trail Du Mont-Blanc (2017-2021_. Int J Environ Res Pub Health. 13: 20(4): 3297. DOI: 10.3390/ijerph20043297

Giovanelli N, Pellegrini B, Bortolan L et al (2023). Do Poles Really "Save The Legs" During Uphill Pole Walking At Different Intensities? Eur J Appl Physiol. DOI: 10.1007/s00421-023--05254

Sunday, November 5, 2023

Strength Matters More Than Size

Pawel Poljanski's legs at the Tour De France
My colleague was wondering why I was not 'big' (or muscular) despite exercising regularly. I explained to her I was more Type I muscle dominant (or slow twitch muscle) as most endurance athletes are. Those who have predominantly Type I muscle fibers are lean, not big and muscular.

Her obesrvation is accurate. I actually lift weights twice a week and even though I can squat 90 kg, my thighs are still skinny.

I also explained to her that it is better to be strong than have big muscles. Weight training can make you stronger and your muscles bigger. They are both related since bigger muscles are usually stronger. However, they are not identical. You can get stronger without adding muscle bulk. 

This happens when the signaling from your brain to your muscles become more efficient and how effectively your muscle fibers are recruited. You can add muscle without getting stronger, this typically happens when you gain weight.

Strength is also a much better predictor of cognitive performance than muscle mass. Storoschuk and colleagues (2023) studied 1424 adults above 60 years of age between 1999 and 2002 in a health and nutrition examination study (NHANES). These subjects had DEXA scans to assess body composition, leg strength tests, a digit symbol substitution test (cognitive test) and questionnaires that assessed physical activity habits. The DEXA scan is used to determine how much muscle one has in their arms and legs and fat-free mass index (FFMI), which shows total muscle to height.

The figure above presents the benefits of different variables on cognitive performance. The farther on the right each square is, the greater the cognitive benefits. You can see that low FFMI (low muscle mass) has no significant effect on cognitive scores, while peak leg force (a measure of strength) definitely have a significant benefit. Those who did resistance training (or weight training) for at least once a week has an even stronger effect.

Strength explained about 5 percent of the variance in cognitive scores, while muscle mass explained only 0.5 percent. Low strength levels raised the risk of premature death, but low muscle mass did not. In contrast, another study by Tessier et al (2022) found that low muscle mass predicted more rapid cognitive decline over a 3 year follow up period, after accounting for differences in strength. Perhaps it would be premature to conclude that muscle mass (being big) does not matter.

Confused? Storoschuk et al (2023) explained that there is a difference between the muscle you get from physical activity and muscle you get in the process of gaining weight. Greater muscle mass may just be a larger body size rather than greater strength, which does not seem to translate into protection from cognitive decline and other health benefits.

Moreover the conflicting results from the 2 studies are possible due to different popolulations, different cognitive tests and different sample sizes. 

My take on this? It is good if you have big muscles and I will still lift weights twice a week to at least maintain and avoid losing what I have. Getting stronger is much better, and that is the main reason why I do weight training. Even though I do not seem to gain muscle I am able to increase the reps and quality of the exercises I perform. 

So, to ward off cognitive decline, strength training is just as important as aerobic exercises.


Tessier A, Wing SS, Rahme E et al (2022). Association Of Low Muscle Mass With Cognitive Function During A 3-Year Follow-up Among Adults Aged 65 To 86 Years In The Canadian Longitudinal Study On Aging. JAMA Netw Open. 5(7): e2218826. DOI: 10.1001/jamanetworkopen.2022.19926

Storoschok KL, Gharios R, Potter GDM et al (2023). Strength And Multiple Types Of Physical Activity Predict Cognitive Function Independent Of Low Muscle Mass In NHANES 1999-2002. Lifestyle Med. 4: e90. DOI: 10.1002/lim2.90

Sunday, October 29, 2023

Rob It To Get It Free

What if you could go to a running store, pick something you like and run away with it free? No, I am definitely not suggesting that you shoplift from a running store. 

This promotion is exactly what a running store in Paris came up with last month to steal whatever you want. The catch is you will have to outrun the store's security guard, who happens to be Meba Mickael Zeze. 

Zeze happens to be a two time Olympian, who can run the 100m in 9.99 seconds and the 200m in 19.97 seconds!

Zeze had as much fun as the participants, looking at the video. He said the job reminded him of playing tag as a child, adding that he needed only a third of his top speed to catch most of the 'thieves'.

Only 2 managed to evade him, most probably as a result of Zeze having to run all day.

Distance Paris was super happy with the result despite losing 2 out of 76 attempts to 'thieves', so much so that it was turned into an video (see below).

This is a super clever idea by Distance Paris and it definitely gave them a lot of eyeballs. Any running store in Singapore willing to try this? 

Perhaps Shanti Pereira can be the security guard.

Thursday, October 26, 2023

Embroidery For Our Team Building Event

You read correctly, we had Isabel Lim from Isabel Lim Designs teach us this morning. It was great fun and we had a great time together.

Isabel was really patient when it came to explaining and teaching us what to do. Here are some of the designs.


Kaylee did this

Pretty cool huh? We definitely have some hidden talents in our midst.

We then proceeded to have lunch at Bumbu. Also a farewell lunch for Byron who is leaving us to move to Adelaide, South Australia. All the best to you Byron.

Saturday, October 21, 2023

Sports Solutions is 14!

Yes, Sports Solutions is 14! Has it really been that long? Yes, it has. We started at Amoy Street and moved to Chip Bee Gardens in Holland Village in 2014.

A big thank you to all our families, staff, friends and patients for all your support all this while. We wouldn't have done it without all of you.

Our goal is the same all this while. To make our patients better quicker. "As long as we're happy and enjoy treating our patients, it's not really work."

Here's to many more years to come!

Friday, October 20, 2023

Accepting Payment For Online Reviews

I read with interest in a Straits Times article as restaurant owner Charlene Yan posted online on Oct 4th that food website asked for $2300 to be featured on their food blog. In addition, the email she received from one of Seth Lui's employee's offering her a spot on that list to be placed 1st, 2nd or 3rd position for an additional $400 to $600. No research, no actual food tasting done, just asking for money straight up to be featured on that list.

No prices for guessing when ST reported in the newspapers on 20th October, 2023 that paid restaurant reviews are "standard practice". Singapore chef Benny Se Teo said paid food reviews are definitely on the rise and raise concerns about objectivity since financial interests are entangled with the restaurants they are reviewing. 

The Advertising Standards Authority Of Singapore states on its website that it should be clear that "anyone who looks at the advertisement is able to see, without reading it closely, that it is an advertisement and not editorial matter".

That means any compensation like a free drink or dessert that a food blogger receives, should be clearly disclosed to the reader or viewer. If payment by the establishment is made, to be on such lists, it is then no longer an editorial decision but an advertisment and that must be clearly stated otherwise that list has no credibility.

Will you be surprised that this happens in the healthcare industry too. I received a total of 3 emails (pictured above and below) dated 14th, 16th and 20th October, asking if we want our clinics to be featured in the "25 Best Physiotherapy Clinics in Singapore (2023)". Their fees range from $500 to $2000.

You would think that the employee sending me the emails would have kept in touch with the brouhaha regarding paid restaurant reviews after it went viral on RedditFacebook and of course the newspapers.

At least I know the employee is persistent since I received 3 emails asking if our clinic wanted to be on that 'best' physiotherapy clinic list.

Aized tells me that we have been approached multiple times as well to be on such lists on print copies of magazines targeted at the expatriate coummunities too. 

The authenticity of such reviews for physiotherapy clinics are definitely questionable. Our clinics probably will not be on such lists since we do not pay to be on them.The main criteria for compiling a list like this is monetary and without full disclosure to the readers. Now you know.

Thankfully, majority of patients who see us and get better refer us to their family members and friends so we do not have to be on such lists.

Sunday, October 15, 2023

Regarding Prepaid Packages

A patient told me she was 'convinced' to buy a 100 session prepaid chiropractic package that she had to use within 6 months to 'maintain' her neck and back health after she went for a free trial. 

A chiropractic clinic offered a free trial session at a roadshow in a mall and she went to try. She had appointments to go 3 times a week, which is terrible for a working adult's schedule. To add salt to injury, each appointment lasted less than 5 minutes. 

You may have heard similar horror stories or even experienced them personally. Not just chiropractors, it can also be the beauty therapist pointing out all you flaws while offering you a limited time promotion to treat them while you were in a vulnerable position. 

Actually, the beauty industry received 1454 complaints last year, accounting for about 10 percent of all complaints that the Consumers Association Of Singapore (CASE) received.

My wife was in a similar position too previously. She had gone for a massage and while lying face down was asked to add essential oils and buy a package. She felt trapped in the room until she agreed to buy more sessions.

Prepaid packages often happen in pressure sales tactics where you are told that your crooked back, posture, freckles etc can lead to paralysis or something worse if left untreated. Often they prey on your fears to ensure that they can hang on to you, hoping that they will not lose you to another competitor. You are then locked in as all the money is paid upfront.

There are physiotherapy clinics that sell packages too, despite the Ministry of Health saying physiotherapists cannot do so. Perhaps these clinics pay kickbacks to rouge agents and doctors to refer them patients so they practice such tactics. MOH investigated physiotherapists, doctors, insurance agents and others after a physiotherapy clinic in Camden Medical Centre went bust for inflating insurance claims by selling packages.

As a business owner, I can understand that this helps to protect the businesses that sell them. Running a physiotherapy clinic (or beauty salon) requires significant capital, which includes staff, rent and equipment as part of overhead costs. When patients/ clients buy a package, it helps to allay these costs quickly, especially for a new clinic.

Selling a package does not work in our clinic. For instance, if I treated 5 new patients a day and each of them buys a package of say, 10 sessions. I would owe them 9 sessions after their first session, but I would soon run out of appointment slots to see them if all new patients buy a package. 

It will only work if the patient sees another colleague or each session is less than 5 minutes. In our clinics, initial sessions are 60 minutes long and follow up sessions 30 minutes if needed.

Actually we try to make our patients well as soon as possible instead of hanging on to them. We prefer that they get pain free and be happy patients so that they refer their families and friends to us. 

As patients (or customers), please do not be afraid to say no if you are asked to buy a package. If a promotion sounds too good to be true, it probably is. These salespeople/ healthcare professionals will try hard selling tactics, often by preying on your fears. However, you have the right to decline any offer that does not align with your needs or if you are not ready to make a decision. Stick to your decision firmly and politely.

Remember under the Allied Health Professions Council which registers physiotherapists in Singapore, does not allow physiotherapists to sell packages. You can definitely visit a clinic that does not offer any packages so you do not have to worry about committing to any large upfront payment.

Sunday, October 8, 2023

Front Knee Pain After ACL Surgery?

ACL marked 20mm from each end by Dr Nuelle
While looking for a topic to write this week, I came across a research paper by Rahardja et al (2023) comparing knee pain and difficulty with kneeling between the bone-patella tendon bone (BTB) and hamstring graft after anterior cruciate ligament (ACL) reconstruction. 

I subsequently found a Twitter thread concerning the article where an orthopaedic surgeon says he "don't believe" what the paper says (see picture below).

Compared to now, there were more patients whose surgeons used the BTB graft when they tore their ACL's when I started work as a physiotherapist in the late 1990's. The hamstring autograft (not cadaver graft) is most commonly used now. 

One of the main reasons patients are told not to use a BTB graft  is because it (supposedly) causes anterior (or front) knee pain. 

A total of 10,999 patients who had ACL reconstructions were analyzed at 2-year follow-up. 9.3 percent (420 cases out of 4492 reported consequential knee pain (CKP) while 12 percent (537/4471) reported severe kneeling difficulty (SKP). For those into research, the Knee and Osteosrthritis Outcome Score (KOOS) was used to identify patients reporting CKP, defined as a KOOS Pain subscore of ≤ 72 points. 

The authors wrote that the most important predictor of CKP at 2-year follow-up was having significant pain before surgery while the most important predictor of SKP was the use of a BTB versus hamstring graft.

I do not agree with the authors' observation. I have treated many patients who had ACL reconstructions in the past 24 years. In the first few weeks after the ACL reconstruction, patients who choose either graft do have a little anterior knee pain presumably from the operation itself. After 6 weeks, anterior knee pain is very rare especially for those with the BTB graft. Very occasionally if they kneel onto the BTB graft site, they may have some kneeling pain which goes away quickly once they change position.

In fact, an orthopaedic surgeon commented that his few "non BTB" (i.e. hamstring graft) patients tend to have more anterior knee pain than his BTB graft patients (see picture below).

Moreover if you have read my earlier post, Spindler et al (2020) suggests that the HS graft is 2.1 times more likely to tear again compared to the BTB graft. Surely this is supporting evidence that the BTB graft is the 'better' and 'stronger' graft? 

There should be no reason to use "anterior knee pain" as an 'excuse' to use other graft choices rather than the BTB graft. 

Choosing your graft after tearing your ACL will definitely be influenced by discussions with your doctor, surgeon and physiotherapist. If you do not want to use your own BTB and hamstring graft, you can also use an allograft (cadaver) now. 

Please keep this information in mind if you were to tear your ACL. Come talk to us if you have any questions.


Rahardja R, Love H, Clatworthy MG et al (2023). Comparison Of Knee Pain And Difficulty With Kneeling Between Patella Tendon And Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry. AJSM. DOI: 10.1177/03635465231198063

Spindler KP, Huston LJ, Zajichek A et al (2020). Anterior Cruciate Ligament Reconstruction In High School And College-age Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? 48(2): 298-309. DOI: 10.1177/0363546519892991.

Sunday, October 1, 2023

Optimal Exercise Form Is Not Always Right

Aized and I had an interview with a physiotherapist last week. She found out physiotherapists in our clinic worked 4 days a week and she was keen to join our team. The interview had a practical component where she had to ask questions, assess and treat my "mid and low back pain" (for my twice broken back). 

After some questions and assessments, she decided that my weight lifting form was causing my discomfort. She then proceeded to "correct my form" for my weight training.

I understand the need to be very strict with textbook form for lifting and making sure technique is efficient to complete the task at hand whether it is during a rehab exercise or just moving a barbell in a strength movement from A to B.

Just so we can be on the same page, I am writing about what most personal trainersstrength coaches and physiotherapists consider textbook form. Feet shoulder width apart, back straight during a squat/ deadlift for instance.

That being said, there are definitely situations where less than "ideal" or "optimal" form is indicated and this is what I will be writing about.

Patients who have anatomical or even mobility limitations cannot do an exercise with textbook form or through full range correctly. Consider the following pictures above and below. Our bones and joints are shaped and angled differently and this will mean that there will be a large variability in individual ranges of motion and variations in exercise form and technique. You may have to squat wider with toes out while others may squat in a narrower stance with toes facing inwards.

Different femoral head angles
The squat technique is usually advised when lifting heavy objects over the stoop technique 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) lifting
However, when we compare squat versus stoop lifting, the squat lifting is not favored over stoop lifting (this is in contrast to current recommendations). 

The following study actually showed that lifting with a flexed spine produced LOWER spinal compression forces than lifting with a neutral spine (Van Arx et al, 2021).

Then there are patients who have widespread chronic pain but no tissue pathology. There is often lots of fear and avoidance of activity in these patients that if you focus too much on form it will be counter productive.These patients may be in a deconditioned state and I will be happy just to get them moving compared to someone who wants to deadlift a 100 kg.

Similarly with patients who are not active and had never play sport their whole lives. They often struggle with what we think are really simple movements and exercises. So long as there is no pain and they are not aggravating anything in low level exercises (example a half squat), I am fine with form that is not ideal for the time being and may work at improving it later.

Older patients often have other multiple health conditions and they may be other things to work on instead of spending too much time trying to teach a single exercise.

Physiotherapists who treat patients with neurological conditions like Parkinson's disease and stroke, will tell you that these patients definitely cannot do exercises with textbook form.

This post is not meant to ridicule anyone who insists on teaching textbook form while teaching exercises. Nor am I suggesting you let your patients have freedom to do whatever they want when exercising. I am simply suggesting that there are situations where insisting on textbook form is not ideal nor practical.


Von Arx M, Liechti M, Connolly L et al (2021). From Stoop To Squat: A Compressive Analysis Of Lumbar Loading Among Different Lifting Styles. Front Bioend Biotech 4: 9: 769117. DOI: 10.3389/fbioe.2021.769117

Please read this for more on squat versus stoop lifting.

Different shaped pelvis