If you stayed up to watch the opening ceremony of the XXXIII Olympic Games in Paris, you would have witnessed the historic boat parade down the River Seine. This display was the first time the Olympic opening ceremony was staged outside the main stadium, making it the biggest ever launch for the greatest sports show on earth.
Alas, that gamble made 300,000 people who lined the river banks very wet from the torrential rain as the athletes went past the Effiel Towel, the Lourve and the Notre Dame Cathedral.
Other than watching the games, I will be watching the athletes who continue to blend proven, unproven and even disproven strategies at the games.
It may have all started in Beijing, 2008 when Kinesio Taping donated more than 50,000 rolls of kinesio tape to athletes and sports teams at that Olympic games. You would see kinesio tape on body parts of athletes in many televised sports especially beach volleyball (pictured below) and track and field (pictured above). That exposure catapulted Kinesio Taping to the big time.
Many subsequent studies showed no evidence of 'improved lymphatic drainage', no decreased risk of injuries etc. But most if not all of the reviews and meta-analyses were done by researchers not trained in the correct taping techniques. Some researchers outright rejected offers to show them the proper taping techniques.
Of course there were many research papers showing Kinesio taping works if done correctly. These were conducted by researchers who have learnt the correct taping techniques.
In 2016, Michael Phelps 'poisoned' the pseudoscience well with large purple bruises across his back and shoulders while adding 5 gold medals to his haul. Cupping therapy was the next big thing for recovery as demonstrated by Phelps, who later launched his own cupping device in 2023.
Also popular are cold (ice) water immersions for recovery. Mo Farah, the British Olympic gold medalist who famously won 4 gold medals at the 2012 and 2016 Olympics in the 5,000 and 10,000 metres made cold water immersions a regular part of his recovery as he was convinced that it would reduce inflammation. The opposite was true since cold water immersions after hard exercise suppressed signaling pathways associated with recovery for several days. At best, it is just perceived benefits on muscle soreness, although it does help reduce pain.
Other than pseudoscience (termed by Novella, 2016), there are are undertones of superstition too. If you watch Rafa Nadal's rituals (above) like how he places his bottles with labels facing the sides he plays and always letting his opponent cross the net first during changovers etc.
Sha'carri Richardson, who won the 100m at last year's world track and field championships always prays and acknowledges with her fingers before the start (pictured above).
We know that rituals and superstitions do not work to make one run faster, jump higher or throw further. They may however, give athletes a form of control and subsequently confer a performance advantage.
Having worked with athletes and going to 2 Olympics in the past, I can say that elite athletes are a stubborn lot. They have immense determination and will not quit even when sick or injured. I will not mention some of Team Singapore athlete's rituals and superstitions.
Definitely true that science, pseudoscience and superstitution are connected at the highest sporting levels. Pseudoscience is lucrative and thriving as it extends into society with tik tok health experts/ gurus, fitness influencers and snake oil salesmen. They will not have a nuanced understanding of the science nor their audiences' best interests at heart.
Of course there are also athletes who are also driven by data, power output stroke rate, stride length and other metrics that can be recorded with modern technology.
Our clinics will try, through our practice, readings and treating our patients, to sort out the science from the pseudoscience and we'll let you know.
I recently saw a patient who had pain resulting from her sural nerve. Let me go through a little about the anatomy and location of the sural nerve.
The sural nerve sits superficially below the skin's surface at the back of the calf. It is formed from the medial sural cutaneous nerve and the lateral sural cutaneous nerve.
It is usually between the medial and lateral gastrocnemius (calf) muscles, running parallel to the saphaenous vein. At the ankle, the sural nerve 'wraps' around the outer ankle near the peroneal tendons before it splits into 2 branches at the level of the 5th metatarsal.
The sural nerve is a sensory nerve, it provides sensation to the lower one third of the outer leg, outer heel and foot. It's main function is to let you feel sensation on your skin. It can also detect your foot position, temperature, pain, vibration and touch.
Since the sural nerve is positioned so superficially, it can be irritated from any muscular of fascial entrapment and sometimes from a simple outer ankle sprain. It can also be 'over stretched' from sitting too long with the foot pointed down and out or after a long driving trip. When the nerve is irritated, it can result in burning pain in the lateral shin or foot (known as sural neuritis).
A common cause of sural nerve pain is after a sprained ankle when the foot is rolled outwards quickly. This can over stretch the sural nerve causing pain over the area it covers.
I also remember a previous patient who had very tight fitting ballet shoes with a strap over the outside ankle which compressed her sural nerve.
A lot of metal work
Another patient had irritation from her metal implants (pictured above) after orthopaedic surgery from fracturing both tibia and fibular.
Patients may describe their pain being constantly present, made worse with activity but present even at rest. This constant pain at rest is what differentiates the symptoms of sural nerve pain from other conditions, where pain normally eases with rest.
I usually do a modified Straight Leg Raise tension test to compare both sides. The patient will tell you the affected side will worsen their symptoms. It may also be tender to touch along the path of the nerve.
Appropriate manual therapy will easily relieve and treat sural nerve pain. Mobilizing the ankle, stretching the nerve and of course treating the fascia that is putting tension on the sural nerve.
With the Paris Olympics around the corner, many of my patients have been asking me about recovery, ice immersions and the Singapore women's swimming Olympic selection fiasco (no, I am not discussing that).
A patient I saw yesterday mentioned that an ice immersionrecovery center just opened near his home and he was hoping it will help his sore muscles.
I told him that evidence shows that ice baths/ immersions does not help recovery. In fact cold water immersion after hard exercise suppressed signaling pathways associated with recovery. This suppression lasted several days. In addition, ice bathing reduced the body's muscles uptake of dietary proteins, which is important for growth and cell maintenance. Grgic (2022) showed that cold water immersion reduced exercise related strength gains while (Pinero et al, 2024) showed that ice bathing immediately after weight training inhibited muscle growth.
On the contrary, hot water immersion (below) improved recovery follwing exercise induced muscle damage (Sautillet et al, 2024).
Following exercise induced muscle damage, Sautillet and colleagues (2024) put 30 active males through one of the following recovery interventions : cold water immersion (11 degrees Celcius), hot water immersion (41 deg Celsius) and control group of warm-bath (36 deg Celcius).
Quadriceps maximum strength and explosive strength were measured pre, 24 and 48 hours post exercise. Pressure pain threshold (PPT), or was also measured to quantify the recovery from muscle soreness
Here are the results. 48 hours post exercise, quadriceps maximal strength returned to baseline values after both cold and hot water immersions. However, explosive strength levels and PPT (muscle tenderness) returned to baseline levels post 48 hours only after hot water immersion.
In addition, surface electromyography (electrodes) signals from the vastus lateralis (outer quadriceps) was significantly increased following cold water immersion. Meaning more muscle fatigue. Or as patients like to say, their muscles are 'very tight'.
The authors concluded that a single session of hot water immersion (rather than cold water immersion) improved the rate of explosive strength followed exercise induced damage. When explosive power is a key performance requirement, hot water immersion should be preferred over cold.
*Note that the cold bath temperature used in this study (Santillet et al, 2024) was 11 degrees Celcius. Wim Hof (the Dutch iceman), others on Tik Tok, other social media and purveyors of commercial health and wellness have different protocols.
For those who are keen the temperature of the hot bath was 41 degrees Celsius for a duration of 15-30 minutes.
References
Grgic J. (2023). Effects Of post-exercise Cold-water Immersion On Resistance Training-Induced Gains In Muscular Strength: A Meta-analysis. Eur J Sp Sci. 23(3): 372-308. DOI: 10.1080/17461391.2022.2033851.
Pinero A, Burke R, Augustin F et al (2024). Throwing Cold Water On Muscle Growth: A Systematic Review With Meta-analysis Of The Effects Of Postexercise Cold Water Immersion On Resistance Training-induced Hypertrophy. Eur J Sp Sci. 24: 177-189. DOI: 10.1002/ejsc.12074
Sautillet B, Bourdillon N, Millet GP et al (2024). Hot Bt Not Cold Water Immersion Mitigates The Decline In Rate Of Force Development Following Exercise-Induced Muscle Damage. Med Sci Sp Ex. DOI: 10.1249/MSS.0000000000003513
I never thought I would be reading up on Ozempic and Wegovy. I have a patient who told me he started taking Ozempic as he's trying to lose weight. They are both injected medications that contain semaglutide. Ozempic is approved (in USA) to treat Type II diabetes while Wegovy is a higher dosed version (of semaglutide) that is approved (again in USA) for weight loss.
According to results from the STEP-9 trial (by Novo Nordisk) reported at the World Congress on Osteoarthritis (OARSI 2024), Wegovy, containing peptide receptor agonist (GLP-1) semaglutide not only induced weight loss but improved knee pain in people with knee osteoarthritis (OA).
STEP-9 was a multi national, multi center phase 3 clinical trial that enrolled subjects that had a BMI of >30, a clinical diagnosis of kneeosteoarthritis with moderate radiographic changes and were experiencing knee pain.
There were 407 subjects in STEP-9, randomly allocated 2:1 to receive once a week a subcutaneous injection of either semaglutide 2.4 mg or a placebo for a total of 68 weeks. Mean age of the subjects were 56 years and 81.6 percent were women. 60.9 percent were White, 11.8 percent Native American, 7.6 percent Black and 19.7 percent were of other ethnic origin.
Another finding was that the use of pain medication went down in the semaglutide group compared to the placebo group. This was maintained throughout the study.
Of course the are suggestions that the weight loss itself helped with the knee pain since weight loss fell by a significantly greater amount in the people treated with semaglutide versus those given a placebo. Weight loss was 13.7 percent versus 3.2 percent from baseline after 68 weeks.
The authors questioned if there is a specific action of GLP-1 receptor agonist on the knee joint itself and not through weight loss only. Especially since results from previous LOSEIT trial using liraglutide (also used to treat Type II diabetes) showed that subjects lost 2.8 kg versus a gain of 1.2 kg in the placebo group over a year did not have any change in the Knee injury and Osteoarthritis Outcome scores. The patients in that study had to undergo weight loss first before they were given the liraglutide.
Obesity is a worsening problem world wide in developed countries and Singapore has increasing numbers in people with diabetes. This is certainly going to add to the boom in weight loss drugs.
Morgan Stanley projects that the market for weight loss drugs will reach $54 billion by 2030, a 400 percent increase from today. Especially since so many celebrities have gushed about how much weight they have lost since taking them. Eli Lilly and Novo Nordisk (who owns Wegovy and Ozempic) together have at least 12 more obesity medications under development.
We are living through a cultural shift in which obesity is viewed as a disease rather than the result of lifestyle choices.
Should my patient try Wegovy instead especially since he does have knee pain from osteoarthritis? Wegovy has a higher dose of 2.4 mg semaglutide versus 2 mg for Ozempic.
*Please note that the STEP-9 study was funded by Nova Nordisk and the principal investigator Henning Bliddal acknowledged that research grants were given by Novo Nordisk to his institution as well as consulting fees and honoraria. He also received congress and travel support from Contura
Prior to joining Physio Solutions and starting up Sports Solutions, Gino Ng worked as a senior sports physiotherapist at the Singapore Sports Council (SSC) from 1999-2009. He graduated with a double masters in Musculoskeletal and Sports Physiotherapy from the University of South Australia on a SSC sponsorship.
Gino's position is perhaps most unique amongst sports physiotherapists in Singapore having seen all sides of the field as a practitioner, an athlete and as a patient.
His special interests are in the treatment of articular cartilage injuries having done research in the area whilst undergoing his postgraduate training. He specializes in treating sports injuries, as well as devising sports rehabilitation programmes after reconstructive surgeries to the shoulder, knee and ankle joints.
As a former national triathlete, Gino is a 2-time Singapore National Triathlon champion (2000-2001), National Duathlon champion (2001), 10-time winner of the National Vertical Marathon (1998-2001, 2004-2005, 2007-2010). He has also placed 4th at the 2001 Asian Duathlon Championships in Hong Kong and made several podium finishes in the Asian Cup Triathlon Series events over the years while holding down a full time job as a physiotherapist.
Partly as a result of his gruelling training regime, Gino needed 3 knee surgeries in 2002 and 2003. After which he made a comeback and placed 4th in the 2005 SEA Games triathlon event.
When not participating, Gino has kept close to sports, travelling widely with the Singapore medical teams for major overseas events such as the various SEA Games, 2002, 2006 Commonwealth Games, the 2006 Asian Games and he is the only local Singaporean physiotherapist to have been to both the 2004 Athens and 2008 Beijing Olympics.
Gino is also one of only two certified Kinesio Taping Instructors (CKTI) in Singapore and teaches the Kinesio Taping Level 1, 2, 3 & 4 courses. He is also a frequent speaker at symposiums and sporting events.
While out cycling in April 2013, Gino had an accident and fractured his skull and spine. Lightning does strike twice, as he was rear ended by a motorbike, while out cycling in September 2021 and fractured his thoracic spine. Thankfully, he is a lot better now and is back working part time.
Having neck and back pain? Well, now you know who came back from a broken skull and back.
.png)
