Sunday, July 30, 2023

Train Your Breathing Muscles To Run Faster?

Picture from Power Lung
I first learnt to train my inspiratory muscles back in 2004 when my former colleagues at Sport Singapore (previously known as Singapore Sports Council) told me about the "Power Lung". It's a simple hand held device that is really easy to use to increase lung capacity so one can improve your breathing efficiency to race faster. 

After I returned the "Power Lung" (pictured above), I tried to replicate that by breathing in and out only through a straw while watching movies with my wife hoping to get the same training effect. That's what I tried to do by just breathing in and out through a straw since it is a much smaller channel. Or recently trying to exercise with a mask on to some extent. 

My wife said I sounded like Darth Vader breathing. She threatened not to watch movies with me if I persisted. 

There are respiratory muscles that help us breathe in and out. Just like your leg muscles or any other muscles, your respiratory muscles can get tired. When they do get tired, they work less efficiently and draw oxygenated rich blood away from where they are needed like your legs. Especially when you are cycling or running. The best way to get them stronger and work more efficiently is to strength train them. 

While strength training, you work against a resistance (or weights) by lifting and lowering the weight. When you get stronger, you can increase the resistance. Similarly, to train your inspiratory muscles you can make it harder to breathe in and out. 

That is the rationale for training your breathing muscles by doing exercises with a "Power Lung" device that makes it harder to inhale and exhale. Numerous studies have investigated whether inspiratory muscle training can make one faster in sports like runningcycling and swimming. Especially swimming since you have limited time with your head above water which makes breathing even more difficult. 

Illidi and colleagues (2023) concluded that respiratory muscle training can improve the strength and endurance of respiratory muscles and that it can improve performance in athletes.

Picture from RJ McNichols from Twitter
Not so for nasal dilators made popular by Galen Rupp (pictured above) who used to train with Alberto Salazar. This looks like a small plaster or band-aid across the nose. Remember them? I've definitely raced in them before after getting some to try in a race goodie bag, but felt no difference.

The goal is to keep your nasal passages open and make breathing easier. They are even advertised to help snoring and sleep apnea. Plenty of research concludes that they do help you breathe better but find no benefits in heart rate, lactate, oxygen consumption and recovery.

How about nasal breathing (or just breathing in and out through your nose)? Evidence suggest breathing through your nose only generates higher levels of nitric oxide. Nitric oxide helps dilate bood vessels and potentially helps keep your airways relaxed and open. Easier said than done since it is extremely difficult to breathe through your nose during intense exercise. 

During a hard interval session or ride when my friends are trying to drop me on a climb especially, you will experience the unacceptable sensation of air hunger if you can't use both you nose and mouth to breathe. To help conditions like asthma and chronic obstructive pulmonary disease is one thing, for endurance athletes while racing and pushing their breathing systems to its limits - nah, I personally don't think so.

Canned oxygen? Maybe if you plan on climbing Everest or K2. All these and more discussed by Illidi et al (2023) referenced below. There's plenty of pseudoscience to help you breathe better in the flourishing wellness and fitness industry currently and I hope that this post helps to clear things. 

As for me, I'll stick to practicing diaphramatic breathing with a straw to strengthen my inspiratory muscles since I do not have access to a Power Lung now. Start with a bubble tea straw if you find a normal straw too difficult.


Illidi CR, Romer LM, Johnson MA et al (2023). Distinguishing Science From Pseudoscience In Commercial Respiratory Interventions: An Evidenced Basd Guide For Health And Science Professionals. Eur J Appl Physiol. 123: 1599-1625. DOI: 10.1007/s00421-023-05166-8

Sunday, July 23, 2023

Super Shoes, World Records & Navicular Bone Injuries

Picture by Getty images from BBC
On Friday night, Faith Kipyegon set another world record in the women's one mile by almost 5 seconds with her 4:07.64 min timing. Track fans were stunned since previous world records often were improved by mere tenths of seconds. Earlier in June last month, she broke both the 1500 and 5000 meters world record as well while Lamecha Girma set a new mark in the men's 3000 m steeplechase.
Picture by Marta Gorczynska
The ever evolving breeds of super shoes and spikes (have a look above) - those thick springy midsoles with a carbon fiber foot plate by giving higher rebound / energy return must definitely play a part.

Since both elite and recreational runners wear these super shoes in races, almost all of them use super shoes in training too to get a good feel for them too.

Super shoes may store and return more energy than standard footwear so your legs are fresher thus leading to improved running economy. This energy return is possibly from the compression of the midsole cushioning material and the lever effects of the carbon foot plate and a higher toe spring.

Previous studies have demonstrated different biomechanical demands on the foot and lower extremities between super shoes compared to standard competitive running footwear. Runners using super shoes were observed to have decreased cadence, correspondingly longer steps and a longer flight time. 

Red arrows outline the carbon plate
Peak vertical ground reaction forces and vertical impulse per step were also higher when running in super shoes. There were no changes in hip or knee mechanics but differences were observed in ankle and the metatarsophalangeal (foot) joint mechanics. Ankle range (dorsiflexion) during stance phase was found to be reduced during running in super shoes compared to standard competitive footwear (racing flats in the study).

This change in foot and ankle biomechanics introduced by the super shoes may contribute to the navicular bone injuries as previous studies have shown that reduced ankle dorsiflexion and subtalar range are risk factors.

I have written about how an ankle sprain can trigger navicular bone pain in your ankle if you have an accessory navicular bone. Well, there are also runners who get much more serious navicular bone injuries from using super shoes.

A published article documented 5 cases of navicular bone injuries in both elite teenage runners and older professional triathletes that arose from the atypical stresses on the bones and soft tissue from using super shoes.

In all cases, the athletes developed acute pain during or after running in super shoes. 2 out of the 3 teenage runners were steeplechasers while the other ran middle distance. The 2 older athletes were triathletes. They were quickly diagnosed by the experienced healthcare providers that they saw and this hastened their recovery time. Otherwise navicular bone stress injuries can take up to 9 months to diagnose (Saxena et al, 2000). 

Recognizing possible associations of navicular bone stress injuries in runners who present with vague midfoot or ankle pain especially if they use super shoes may be important to identify this high risk injury.

The performance benefits of super shoes are definitely considerable. If you do use super shoes to train and race and do have foot or ankle pain near the navicular bone region, show this article to your health care provider or come and see us at our clinics.

I'm looking forward to see if any more word records are broken at next month's track and field World Championships in Budapest.


Saxena A, Fullem B and Hannaford D (2000). Results Of Treatment Of 22 Navicular Stress Fractures And A New Proposed Radiographic Classification System. DOI: 10.1016/s1067-2516(00)80083-2

Tenforde A, Hoenig T, Saxena A et al (2023). Bone Stress Injuries In Runners Using Carbon Fiber Plate Footwear. Sports Med. 53: 1499-1505. DOI: 10.1007/s40279-023-91818-z.

Sunday, July 16, 2023

Know Exactly Where Your Achilles Tendon Hurts

Back view of L calcaneus 
I had right Achilles tendon pain earlier in the year. After doing some Alfredson protocol exercises, wearing the Strassburg sock and getting my colleagues and wife to treat me, I could run pain free. 

Yes, I still ran twice a week even though I had some pain while running. Some of that same pain came back during our recent holiday in Japan. I did not cycle nor run during the trip but did some skipping for the first few days of our trip. 

Then I came across an article (with nice pictures) of what makes up the Achilles tendon and how it attaches on the calcaneus (heel bone), pictured above. While skipping, my gastrocnemius (or calf) muscle, was used more than the soleus. I realized that this was what led to the recurrence of my Achilles pain.

The Achilles tendon is the largest/ longest tendon in the human body and is formed when the medial (inner) and lateral (outer) parts of the gastrocnemius and soleus muscles merges.

The authors dissected 12 fresh frozen leg specimens to find where the Achilles tendon inserts (or finishes) on the calcaneus in relation to their corresponding muscles. They also examined 10 embalmed specimens to confirm an observation on the retrocalcaneal bursa.  A bursa is fluid filled sac/ pouch that acts as a cushion and gliding surface to reduce friction.

The superficial part of where the Achilles tendon finishes is where the medial head of the gastrocnemius muscle attaches (in light blue) on to the lower facet of the calcaneus. The authors (like previous studies) found evidence that tendon of the medial gastrocnemius forming the superficial part of the Achilles tendon is continous with the plantar fascia. Like I written before, in order to get the Achilles tendon better, you need to treat the plantar fascia and vice versa.

The deep part of where the Achilles tendon finishes is where the soleus muscle attaches on the inner part of the middle facet of the calacneus, while the lateral head of the gastrocnemius muscle attaches (in red) on to the outside part of the middle facet of the calacneus.

In the space between the calcaneus and the Achilles tendon, a distinct 2 chamber bursa was present in 15 out of 22 examined specimens (9 out of 12 fresh frozen specimens and 6 of the 10 embalmed). The smaller shallow medial chamber is located in front of the soleus tendon whereas the lateral chamber is in front of the lateral head of gastrocnemius tendon.

Here's what amazes me. From the dissections, the authors found that the Achilles tendon rotates as it goes down the leg. Meaning the fibers from the medial gastrocnemius head forms the back aspect of the tendon while the anterior part of the tendon is formed by the lateral gastrocnemius head and soleus muscles.

This article was helpful as it helped me pinpoint exactly where my problem was and most importantly it helped deepen my understanding of the function of each muscular, connective tissue part of the gastrocnemius, soleus and the Achilles tendon and their clinical relevance in the treatment of Achilles and plantar fascia problems.

So, if you are still having problems with your Achilles tendon and it does not seem to be getting better, show your healthcare practitioner the topmost picture so they know exactly which part to take note of. If they don't you can always come to our clinics.


Ballal MS, Walker CR and Molloy AP (2014). The Anatomical Footprint Of The Achilles Tendon: A Caderveric Study. Bone Joint J. 96B: 1344-1348. DOI: 10.10=302/0301-620X.96B10.33771

Sunday, July 9, 2023

Body Weight Training May Not Be Enough

90 kg squat
Running helps clear my mind. It also has a wide range of benefits like boosting immunity so you are less likely to fall sick. In fact, even 10 minutes of running at really slow speeds can boost your cardiovascular health. However, other than your leg muscles, running is not so good at building your other muscles.

Hence, strength (or resistance) training helps strengthen your muscles and joints which can make you faster and more importantly, decrease injury risk. Research by Lopez et al (2021) suggest it really does help to lift heavy (whatever that means for you since we are all different).

28 studies (with 747 healthy adults) were reviewed. The researchers found that a wide spectrum of loads (or weight) resulted in very similar increase in muscle size. However, it was only with higher or moderate loads that resulted in a significant improvement in strength.

This means that using lighter loads (or weights) may help "grow' your muscle, but it's the heavier weights that will make them much stronger. These findings were more apparent for those new to strength training compared to those who have been strength training for a while.

Those who strength train regularly will benefit by adding more sessions to their routine than simply adding more load. 

One reason for strength increases by higher loads (weight) is greater neuromuscular adaptation (or signaling). Meaning the connection between the brain, central nervous system and muscles adapt to be able to recruit more muscle fibers and increase the frequency of them engaging. This improves coordination within and between muscles in ways that contribute to more force.  Hence you get more strength through increased firing frequency.

The authors suggest that those new to strength training do 2-3 strength sessions a week, performing 8-12 repetitions per exercise. Select a weight you can do for that many reps but feel fatigued at the end of the set.

Remember your strength training program should be based on your running goals (i.e to run faster) and needs. Do not afraid to lift heavy and if you need a trainer/ physiotherapist to guide you, make sure they know your need for injury prevention and not to get bigger.


Lopez P, Radaelli R, Taaffe DR et al (2021). Resistance Training Load Effects On Muscle Hypertrophy And Strength Gain: Systematic Review And Network Meta-Analysis. Med Sci Sp Ex. 53(6): 1206-1216. DOI: 10.1249/MSS.0000000000002585

Sunday, July 2, 2023

Is Your Scapula The Root Of The Problem?

R scapula lower than L and 'sticking' out more
Both my shoulders have been aching over the past few weeks, even when I was on holiday in Japan (I did not see any patients nor exercise much). I did carry a slightly heavy backpack throughout though. Anyway, it has been estimated that 67 percent of the adult population will experience shoulder pain at some point throughout their lifetime (Luime et al, 2004).

Although there are numerous factors related to the cause of shoulder pain, many clinicians attribute the presence of scapular dyskinesis (SD) as a contributing factor to shoulder pain/ problem.  

SD is defined as mal-positioning/ mal-alignment in scapular position at rest as well as during movement. Since the identification of SD is a common part of patient evaluation, it is often used to guide clinical decision making, although there is considerable debate regarding SD and shoulder pain/ problem. The evaluation is expecially common in predicting or preventing injury in over head athletes even though there is conflicting evidence regarding the link.

Some studies have shown no difference in the prevalence of SD between symptomatic and asymtomatic populations. This then raises the question of usefulness when screening for SD in patients seeking treatment for shoulder pain as well as those asymptomatic patients with SD.

Another patient -R scapula lower than L
Besides, not every clinician agrees what is the best way to classify and assess SD. Clinicians often direct their treatment towards correcting the SD which may be normal movement variability.There is also a lack of evidence to support the idea that identification and correction of SD may help to prevent or treat SD.  

The following systematic review investigated the prevalence of SD among both symptomatic and asymtomatic patients with the hypothesis that SD is a common finding that has been 'medicalized'  i.e. clinical findings suggest treatment but ultimately is a normal finding.

34 studies were found suitable out of 11,619 found. That is a lot out of material to go through.

60 percent among the subjects (total 650) in the systematic review with shoulder pain presented with SD. 48 percent of the asymptomatic (no pain) subjects (1048 total) presented with SD. Almost half of those studied presented with SD even though they were asymptomatic.

Consider the following. 2 studies in the review found that as swim training progessed, the number of swimmers presenting with SD increased with a large number of them presenting with SD at the end of the same training session. All these competitive swimmers were aysmptomatic. 

The initial perception may be that there is some weakness or compensatory mechanism that may require attention. Or it may be normal adaptation related to the overall shoulder complex that caused this change to occur especially since these athletes were competing at high level with no symptoms/ pain.

Yes, there is evidence from this review to support the high incidence of SD among athletes with shoulder pain. However, even more revealing is that there were much more subjects who had SD with no shoulder pain. The authors concluded that SD may be a normal adaptation for those participating in overhead sports and that SD is a relatively normal finding among the asymptomatic population.

So if you have SD, but no pain in your shoulders, you do not need to worry about it nor treat it.


Luime JJ, Koes BW, Hendriksen IJM et al (2004). Prevalence And Incidence Of Shoulder Pain In The General Population: A Systematic Review. Scand J Rheumatol 33(2): 73-81. DOI: 1080/030097403100046676

Salamh PA, Hanney WJ, Boles T et al (2023). Is It Time To Normalize Scapular Dyskinesis? The Incidence Of Scapular Dyskinesis In Those With And Without Symptoms: A Systematic Review Of The Literature. IJSPT. V18(3): 558-576. DOI: 10.26603/001c.74388.