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