X-ray Based Diagnosis Leads To Potientially Unnecessary Surgery

Picture by Balint Botz from Radiopaedia

I've written previously that many patients had back surgery when a doctor sends them for an MRI within the first 6 weeks of an initial visit.

Well, guess what? Taking an X-ray to diagnose knee arthritis may make you more likely to consider potentially unnecessary surgery (Lawford et al, 2025) as well.

Many of my patients who go to a doctor or surgeon for their knee pain end up being sent for an X-ray or even an knee MRI. Many of these patients have osteoarthritis (OA) in their knees. Actually, routine X-rays may not be necessary to diagnose the condition. A skilled and thorough assessment based on symptoms and medical history is good enough to make the diagnosis. 

A huge and common misconception is that OA is caused by 'wear and tear'. Research clearly shows that the structural changes seen in a joint X-ray does NOT correspond with the level of pain or disability a person feels. Nor can X-rays predict how symptoms will change.

In fact, X-rays are NOT recommended in Australia to diagnose knee OA. Nearly half of new patients there with knee OA get sent for a knee X-ray and cost their health system A$104.7 million each year.

Researchers in Australia showed that using X-rays to diagnose knee OA can affect how a person thinks about their knee pain and prompt them to consider potentially unnecessary knee replacement surgery.

Many patients with 'terrible' X-rays have no pain while patients with no damage on X-ray have a lot of knee pain. Hence, X-rays are not recommended for diagnosing knee OA or guiding treatment decisions.

The Australian study had 617 subjects across Australia who were randomly assigned to watch one of three videos. Each video showed a hypothetical consultation with a general practitioner (GP) about knee pain. 

The first group received a clinical diagnosis of knee OA based on their age and symptoms and were not sent for an X-ray. The other 2 groups had X-rays done to determine their diagnoses (the doctor showed one group thier X-ray images but not the other group). After watching their assigned video, the subjects completed a survey of their beliefs about OA management.

The results showed that the group who received an X-ray based on their diagnosis and were shown their images had a 36 percent higher perceived need for knee replacement surgery compared to those who received a clinical diagnosis without X-ray.

What was worse was, they even believed that exercise and physical activity could be harmful to their joint. They were also worried about their condition worsening and were more fearful of movement.

The subjects were slightly more satisfied with a X-ray based diagnosis than a clinical diagnosis. This may reflect the common misconception that OA is caused by 'wear and tear' and the joint needs to be replaced.

The study's finding shows that it may be important to avoid unnecessary X-rays when diagnosing knee osteoarthritis. Changing this can be challenging, since many people still expect or want  X-ray imaging. If we can change this mindset, it will minimize unnecessary concern about joint damage, reduce demand for expensive and potentially unnecessary joint replacement surgery.

In my opinion, we as health professionals should not focus on joint 'wear and tear' since it can make patients more anxious about their conditions and concerned about damaging their joints. There are a range of non surgical, non invasive options that can reduce pain and improve your mobility. Exercise is one of many if you read this Cochrane review.

Our health minister says healthcare spending in Singapore could hit 30 billion a year by 2030 in a Straits Times article just 2 days ago. Perhaps this is an area where we need to be more mindful of unnecessary X-ray imaging and joint replacements to bring healthcare spending lower.

You can read about what actually causes your joints to wear out here if you are keen.

Reference

Lawford BJ, Bennell KL, Ewald D et al (2025). Effects Of X-ray-Based Diagnosis And explanation Of Knee Osteoarthritis On Patient Beliefs About Osteoarthritis management: A Randomised Clinical Trial. Plos One. DOI: 10.1371/journal.pmed.1004537 

Brain Myelin Levels Takes 2 Months To Recover After A Marathon

Picture from MSIF

I ran my first marathon when I was 16 years old, just after finishing my GCE 'O' levels. Despite not training as much as I would have liked, I finished in 4:00:16 hrs. If  I had ran just 17 seconds faster, I would have gone under 4 hours. 

I can still remember the exhaustion and agony I felt after the finishing line. I had willed myself to keep going despite hitting the proverbial wall and that led me to wonder about the brain's response to endurance exercise.

So I am not surprised that a recently published study shows that marathon running can cause a temporary reduction in brain myelin content. Full recovery only takes place after 2 months. Myelin is a fatty substance that covers and protects nerve fibers in the brain and spinal cord. It makes up 40 percent of the brain's white matter. The white matter is in charge of nerve signaling to enable learning, memory, sensory perception, motor control and cognition.

Other than allowing faster transmission of nerve impluses (which helps you move more quickly or learn with better focus), myelin helps convert glucose into energy for the brain. This is very important since so much energy is needed for all those nerve signals, especially when running a marathon.

Researchers used advanced MRI with multicomponent relaxometry to assess the myelin water fraction (MWF) to measure the amount of myelin in the brain. This was done on 10 runners ages 45 to 73,  both before and 48 hours after completing a marathon. 

They found substantial reduction in MWF in 12 areas of white matter after the race. The most significant reductions were observed in the pontine crossing (28%) and corticospinal tracts (26%). The affected areas are crucial for motor function and integrating sensory and emotional inputs, suggesting impact on movement and emotional regulation.

Since this was a small study, they did follow up scans 2 weeks after the marathon and 2 months after to track recovery.

MWF levels begin to rebound within 2 weeks and recovered fully to pre-race levels by 2 months. These findings suggest that brain myelin content is temporarily and reversibly diminished by severe exercise. Analyses of brain volume and hydration status showed that dehydration was not responsible for the changes in MWF. 

Since the brain and your legs are both competing for glucose while running a marathon, the brain turns to myelin lipids for energy. Previous studies have shown that lower brain myelin content is linked to cognitive decline - in areas related to verbal fluency and excutive function.

Should those of us who participate in endurance sports be concerned about myelin depletion in our brains? The authors say the breakdown of myelin from endurance exercise is actually beneficial, especially since it generates between 2 weeks to 2 months as it 'exercises' the brain's metabolic machinery.

Reduction in myelin levels can be similar to how muscles react to strength training. Your muscles break down as glycogen levels get depleted during weight training and endurance exercise before building back stronger with adequate rest. 

Better fueling with carbohydrates help sustain effort during training and races and may possibly reduce the amount of myelin used. Some runners in the research took carbohydrates during the marathon while others none, but there were no differences in this research. 

The authors did not investigate running speed. Perhaps running faster if underfueled may exacerbate brain myelin reduction.

So I was drawing on my myelin lipids to support my brain function in my maiden marathon and many times subsequently while exercising and competing for all those years. 

Can repeated depletion and restoration of myelin have long term consequences for people who frequently engage in prolonged, strenuous exercises and competitions?

The reversible nature of MWF is definitely reassuring (to me at least) and as I am still able to write an article for you readers weekly, I think all those hammer sessions and races definitely helped improve my brain function. 

I don't do those long, intense sessions much compared to before, but  I will make sure to have enough rest after. Make sure you do too.

Reference

Ramos-Cabrer P, Cabrera-Zubizarreta A, Padro D et al (2025).Reversible Reduction In Brain Myelin Content UponMarathon Running. Nat Metab. DOI: 10.1038/s42255-025-01244-7

Kinesio Foundations Course

I will be teaching the Kinesio Foundations course at Sports Solutions on the 21st and 22nd of June this year. This replaces the Kinesio Taping Assessments, Fundamental Concepts and Techniques (or Kinesio Taping Level 1-2) course previously.

The course is now a two day (16 hours) in person course with a 4 hour online pre course. Most if not all other taping courses takes place over just 2-4 hours. Compared to the 2 previous versions of the course, there is now a much bigger emphasis on the Kinesio Medical Taping section instead of just the Kinesio Taping Methods where muscles, joint and tendons were the main focus. 

Unlike other tapes, Kinesio Medical Taping utilizes much lower tensions (no pulling/ stretching of the tape) and thinly cut applications. There is a much bigger focus on skin and fascia stimulation to improve superficial, lymph and interstitial circulation. Hospitals in Singapore only use Kinesio tapes (and not other brands) when they have to treat patients with lymphedema.

Personally, I have great results using the EDF (epidermis, dermis and fascia), jellyfish and the Space Correction webcut applications with bruising and swelling. A patient with a partially torn calf muscle yesterday immediately felt better and could walk with less limping after the jellyfish application (pictured below.

Attendees will learn multiple taping techniques and be able to treat clinical cases using Kinesio tape alone or in conjunction with other strategies. There will be ample time to practice assessments, screenings and taping techniques to a variety of upper and lower body conditions.

Past participants have said that they were able to "immediately use the taping on the patients with good results" when they resumed work the day after attending the course.

Interested to attend the course? I have attached the link to sign up here. You can also email us if you need more details.

Muscle Damage Affects Your Running Gait

Picture from Aspetar

I was away for my Kinesio Taping recertification for Instructors last week and had to exercise in a new environment. As the gym was much bigger and had equipment that I do not normally have access to, I chose to use mostly those. 

As a result I ended with muscle soreness almost all over. I went for a run a day after I came home and my running stride felt 'off.' Turns out I was not imagining it. That is how our bodies try to protect itself. So is that good or is that a problem?

Turns out it may be both (Markus et al, 2025). The muscle soreness indicate that adaptations are beginning. However, that soreness can also change our running form, increasing injury risk.

To assess how exercise induced muscle damage (EIMD in this study) or delayed onset of muscle soreness (DOMS) affects running biomechanics and recovery, researchers got their subjects to run downhill for 60 minutes. This was done on a treadmill at -10 percent gradient. The runners ran at 65 percent of their max heart rate.

The researchers tracked running gait changes, muscle soreness, blood markers for muscle damage and also did MRI scans of thigh muscles immediately post run, 24, and 48 hours after.

The runners took shorter steps 24 and up to 48 hours after that run, likely as a compensating mechanism since taking a smaller stride is the body's way of reducing impact when muscles are fatigued or damaged. Damaged muscles were verified (significantly elevated) using blood markers (creatine kinase and lactate dehydrogenase) and MRI scans showed thigh muscles damage. 

Take home message? If you just had a hard training session or especially a race, you have to expect some biomechanical changes for at least 48 hours after that if you still want to run. Since you have a reduced stride length, your pace will be slower and you will be running less eficiently. 

Anything else that will help? My personal experience suggests that performing reduced intensity and low volume exercise will increase blood flow to the affected muscles and often reduce pain. Pedaling at low resistance on a stationary bike is ideal as you don't have to worry about traffic (if you ride on the roads). An easy swim or just walking in waist or chest height water works well too.

 Wearing compression garments will help reduce it as well. These above mentioned strategies do have some support in the research.

Or better still, give yourself a few days of well earned rest (especially after a race) before going hard again. 

Reference

Markus I, Arutiunian A, Ohayon E et al (2025). Kinetics Of Recovery And Normalization Of Running Biomechanics Following Aerobic-Based Induced Muscle Damage In Recreational Male Runners. J Sci Med Sport. DOI: 10.1016/j.sams.2025.01.002

Kinesio Taping Instructor Recertification (CKTI) In Bangkok

I have not taught any Kinesio taping courses since 2019 in Malaysia, just before Covid-19 struck. In fact, the last course I taught in Singapore was in August 2018.

Kinesio Taping Association International needs our licence as a CKTI (certified Kinesio Taping Instructor) to be renewed  every 3 years to be able to teach again. There was an online recertification during the Covid years in 2021 which I attended, but due to the many rules in place I did not teach since then.

So I chose to come to the recertification in Bangkok since Alburqurque (held in October 2024) and Barcelona (January 2025) were much further away.

There was a memorial for Dr Kenso Kase (who passed away in August 2024) and Jim Wallis (December 2024) (a very senior instructor) at the event to honour them.

The course has definitely evolved. It is now called the Kinesio Foundations course (over 2 days) and we spent a lot of time (pictured below) over the last 2 days learning how to teach the new syllabus.

Sports Solutions will definitely be teaching the new Kinesio Foundations course. They will be held on 21st to 22nd June. Here's the link to sign up.

With Elisa Kase

Race Pace Versus Heart Rate Variability Guided Training

Picture taken from Flowly

A patient came in this week after he raced the Tokyo marathon last weekend. He was not happy as he started cramping in his hamstrings after 'only' 5 km.

I asked about how his training went. He told me he did 4 runs a week, all on a treadmill, mostly easy runs. His longest run was by time, 2:55 hrs (which he thought was equivalent to about 20 km).

He did all his runs with a heart rate monitor, training at "Zone 2" mostly and followed recovery metrics like heart rate variability *(HRV). Zone 2 training is low intensity exercise that involves training at 60-70 percent of maximum heart rate. He did not do any interval training nor any race pace training.

I discussed with him how he can do better since he will be running the Chicago marathon on October 12th this year. He really wants a improvement after his self described disastrous Tokyo race. I shared with him a study that tested 3 different approaches of training (Ranieri et al, 2025).The researchers split the runners into 3 different groups for 6 weeks. 

First, a heart rate based training group where training is prescribed by heart rate zones. Next a race pace training group in which training is prescribed running at percentages of race pace. Lastly a HRV guided training group. The HRV training group did training prescribed by heart rate zones but this was adjusted daily based on HRV readings. Hence their intensity was based on how well they recovered. 

All the runners did lab tests before and after the study. V02 max, running economy, ventilatory thresholds and other key endurance metrics. Participants were assessed by a 7 km time trial after the training period.

Results? Race pace training was the most reliable for improving race performance. Every single runner in that group went faster in the 7 km time trial with an average improvement of 3.8 percent. The runners also had gains in fat loss and maximal aerobic speed. The heart rate training group improved their ventilatory threshold readings but this did not lead to V02 max or time trial improvement. It did not deliver clear performance advantages over race pace training.

The HRV training group led to bigger physiological improvements. They had significant increases in ventilatory thresholds and V02 max, but this did not translate as well to race performance. Some participants also put on weight (fat mass) perhaps due to more frequent easy training days.

The authors concluded that race pace training had the least variablilty in response, meaning it worked reliably across runners. HRV based training showed individual differences, some saw gains, others did not. This is not surprising since HRV itself is highly variable.

I suggested to my patient that he needed to do some race pace training if he wanted to achieve his target timing. He can take his target finishing time and calculate how fast he needs to do his 1 km, 5 km or even 400m repeats. This teaches his body to gauge the pace he needs to run and not go too fast especially at the start. It will also prepare his body for the demands of race day.

I also suggested running more outdoors rather than solely indoors on a treadmill since the treadmill is softer and will not mimic the road conditions that he races on. Specificity is key. The gym environment is temperature controlled unlike outdoors. So if the race location is hotter and more humid then he will be less able to handle it.

Takeaway message? The best approach is not to train solely on a single approach. It is best to know when to use each approach. For example, you cannot train exclusively by race pace. The body will not be able to handle the load, one would likely get injured. 

Heart rate based training can definitely be used but should not be relied on exclusively too. It will improve physiological markers and your lab based testing (V02 max, lactate threshold), but may not result in faster race timings. 

HRV is a useful tool for monitoring stress and how well your body is recovering. Many professional athletes use it. However this study raises an important question of whether better physiological markers lead to better performance.

If you're looking for a fool proof way to inprove your race times, this study suggest that training at your race pace sould be a part of your training routine.

Reference

Ranieri LE, Casada A, Martin D et al (2025). Performance And Physiological Effects Of Race Paced-Based Versus Heart Rate Variability-Guided Training Prescription In Runners. Med Sci Sp Ex. DOI: 10.1249/MSS.0000000000003671

*Heart rate variability (HRV) is a measure of how much time passes between each heart beat. It is better to have a higher than lower number. It is physiological measurement that is used to understand how your body is coping with life and environmental changes. A low HRV may suggest that your body is not rested, less resilient  and may not handle changing situations. You can measure HRV with a smart watch, fitness tracker etc. 

Most People Will Never Sprint Again After ..

Sprinting behind our clinic

... they turn 30 for the rest of their lives.

Actually, I started doing a few 200 m sprints upslope along Warna Road once a week on Wednesday mornings about a month ago. This is usually after a 5 km warm up run. I have not done any sprints like this for a long, long time.

From Twitter (or now known as X)

Coincidently, I saw this 2 days ago (above) on Twitter (or X) and the title caught my eye. 95 percent of men and women will never sprint again by the time they reach 30 years of age. 

Do you think there's any truth to that claim? 

How's my running form?

Perhaps I should address why I started sprinting again after so many years? I felt my runs were stagnating. I only run twice a week now and though I entertain no dreams of competing, I long for the moments when I feel like it is 'effortless' to run. I also want to avoid sarcopenia.

I was never a high mileage runner previously. In the past when I was still competing, track intervals really helped me improve. So I thought it was a good time to restart some sprint work.

You can definitely improve performance by swapping distance for speed (Jin et al, 2025). In the quoted study, the researchers split well trained runners into 2 groups. These runners had an average VO2 max of 67 mL/kg/min and personal best of 14:38 mins for their 5k time. 

One group did sprint interval training (SIT). They did 10x30 seconds all-out sprints with 3.5 minutes rest twice a week for 6 weeks. The traditional training group continued running long distance twice a week.

Both groups also kept up their regular endurance base training (40-60 minute runs) 4 times a week other than the above sessions.

You can probably guess the results. After 6 weeks, the SIT group outperformed the traditional group in all endurance metrics. Their time to run exhaustion (which is a key indicator of endurance) was better.

They had a 5 seconds improvement in a 3000m time trial versus no change in the traditional training group. The SIT group also had faster 100 m and 400 m times, suggesting better speed and neuromuscular efficiency.

Surprisingly, there was only slight V02 max improvement in the SIT group even though running economy improved moderately. This shows that the SIT group became more efficient runners.

Now you know that sprint intervals are not just for sprinters. This study proves that endurance runners can gain real benefits when they add speedwork 1-2 times a week. 

You definitely don't have to follow this protocol in the quoted study. I started with just faster striding upslope before even attempting to sprint. Definitely not all out sprinting. I clocked about 50 seconds each rep when I first started and it's gone down to 40 seconds during my last rep 2 days ago.

All of us should sprint from time to time to recruit muscles that we don't normally use. I would also suggest jumping as high as you can too to build your explosive power. But not both at the same time. I do the jumps on my weight training days.

For those who still race, sprint training will definitely help improve performance without adding volume. You can improve your running efficiency while also improving your kick should you need to pass other runners at the last part of the race.

Reference

Jin K, Cai M, Zhang Y et al (2025). Effects Of 6-Week Sprint Interval Training Compared To Traditional Training On The Running Performance Of Distance Runners: A Randomized Controlled Trial. Front Physio. 16: 1536287. DOI: 10.3389/fphys.2025.1536287

If You Want Buns Of Steel ....

Ok I admit, that was a heading to get you to read this post. But seriously, I had a patient who was referred to our clinic by a GP across the road.  He hurt his groin while doing Brazilian jiu-jitsu 2 months ago and had not gotten better. He said his previous physiotherapist just got him to do clam shell exercises and it did not help at all. 

Want to know the best exercise for packing the biggest punch for the gluteal area? Let me share the results of the following study by Collings et al (2023).

Their study compared and ranked gluteal muscle forces in 8 hip focused exercises performed without and with external resistance, i.e. dumbbells or loaded barbell.

This 8 hip focused exercises in the study were single leg (S/L) squat, S/L Romanian deadlift (RDL), split squat, S/L hip thrust, banded side step, hip hike, side plank and side lying leg raise. The exercises were performed with and without weights for 12 reps max (RM)  and measured by electromyography (EMG). 

Analysis of muscle forces were limited to gluteus maximus (pictured above), medius and minimus (below). The results show that varying demands were placed on the individual gluteal muscles. Peak gluteal muscle forces significantly increased when all exercises were performed with weights compared with body weight alone. 

R gluteus medius and minimus

This is the first study to investigate a wide range of hip focused exercises that also includes isometric hip and hip abduction exercises. Clam shell exercises which you already know from my earlier  blog post is not great at activating gluteus medius and was not even included in this study. The S/L RDL and side plank  produced the highest peak gluteus medius and minimus muscle forces. 

Side plank

This is what I found most interesting. I was surprised that this variation of the side plank (pictured above) really targeted the gluteus medius and minimus too. It will be a good choice for physiotherapists to teach their patients this since no equipment is needed. Patients can easily do it at home or during on field/ court training.

Single leg RDL

We already know that the S/L RDL (pictured above) is good for  hamstrings strengthening. Done with weights, the S/L RDL activated high gluteus minimus force (100 percent observed) while gluteus maximus (98 percent) and gluteus medius (84 percent). S/L RDL is the go to exercise if you need to target all 3 gluteal muscles simultaneously along with the hamstrings.

To sum up, for the gluteus maximus, the split squat, S/L RDL and S/L hip thrust are the exercises that you want to do if that is what you want to train. The S/L RDL and side plank  produced the highest peak gluteus medius and minimus muscle forces. Those who are injured may start by doing the lower tier exercises and/ or reduce load (pictured above). You may want to remember this if your goal is to prevent injury, as part of rehabilitation or for performance.

Reference

Collings TJ, Bourne MN, Barrett RS et al (2023). Gluteal Muscle Forces During Hip-Focused Injury Prevention And Rehabilitation Exercises. Med Sci Sp Ex. 55(4): 650-660. DOI: 10.1249/MSS.0000000000003091

Bow Legged Or Knocked Knees? Or Normal?

Different knee shapes

Visual inspection of lower limb alignment is common standard practice for us in our clinics (and elsewhere I am sure) when a patient comes in with ankle, knee, hip and low back pain.

You would think that as a trained health professional, we would be able to see if a person has normal, bow legs (varus) or knocked knees (valgus) quite easily. If it was an extreme valgus or varus it would be fairly easy to differentiate. What if you saw the following pictures below?

Varus or valgus?

How about this? Confused?

Hence I was rather surprised when a published study (Nguyen et al, 2022) found that visual inspection of lower limb alignment is not valid nor reliable when compared to the gold standard of whole leg radiography (WLR).

The study involved 50 patients who underwent a WLR and a standardized digital photograph of the lower limbs (pictured below). The patient's feet were placed 10 cm apart and in 10 degrees of external rotation with knees in full extension and both arms alongside the body. Pictures were taken from knee height, 2 meters away from the patient. 

WLR and digital photograph

There were 4 assessors who rated the digital photograph twice. Two are orthopaedic surgeons with 10 and 5 years experience respectively. The remaining two were an orthopaedic resident and a researcher. They were unaware of the patients' hip knee angle (HKA).

Knees were rated with severe valgus (>5 degrees), moderate valgus (2-5 degrees), neutral, moderate varus (2-5 degrees) and severe varus (>5 degrees).

Ready for the results? The percentage of incorrect visual leg assessments ranged between 46-75 percent. Now that's high! The errors were lowest in patients with moderate valgus alignment (knock knees) and highest when the patient presented with a severe varus deformity (bow legs). See the picture below of a patient I saw recently. How can the error be highest when it is bow legged? Isn't that fairly obvious?

Surely this varus is obvious

There were patients with a neutral leg alignment but were assessed to be pathological in 50.7 percent of cases. I am concerned about this since the wrong diagnosis of normal presentation as pathological/ dysfunctional may potentially cause the patient to opt for surgical intervention. This will lead to increased health care cost for patients and insurers.

Interestingly, there were no significant differences between the accuracy of more experienced verus less experienced assessors.You would think that the ability to assess alignment would improve with practice through one's working life.

The results also show that there were gender influences. Women do present an increased risk for incorrect readings due to the difference in the angle of the thigh bone between men and women.

The authors concluded that visual assessment of lower limb alignment does not provide clinically relevant information. Physical examinations and X-ray assessments are advised.

Limitations for this study? My biggest gripe was that visual assessments were done on 2-dimensional (2D) digital photographs instead of in person assessment. It is definitely easier (and more accurate) to visually assess a patient than to look at a digital photograph. Only 1 assessor measured the HKA on the WLRs, so there is no comparison for inter-assessor reliability.

Hopefully our surgeons here in Singapore are better are visually assessing patients. They should also do whole leg x-rays and in clinic assessments. Make sure yours does.

We see many of these cases. Come see us in our clinics if you have any pain or discomfort. While we cannot alter the shape of your knees, we can definitely reduce or take away the symptoms.

Reference

Nguyen HC, Egmond N, De Visser HM et al (2022). Visual Inspection For Lower Limb Malalignment Diagnosis Is Unreliable. Cartilage. 13(4): 59-65. DOI: 10.1177/19476035221113952

Should You Strength Train On Unstable Surfaces?

On the BOSU ball

A patient come to our clinic this week injured after lifting weights on an unstable surface. The studio he went to had them do chest presses and flys with a glute bridge on a BOSU ball (knees bent, buttocks up and feet resting on BOSU ball). 

Indo board

I often use the BOSU ball, wobble board and/or  Indoboard (much later on - see end of article) when my patients require proprioceptive training to prep them before they return to sport. Also for those if they have lots of metalwork (pictured below) in the ankle after a fracture. I find that challenging my patients on unstable surfaces may enable them to rehab faster compared to stable surfaces when it is safe to do so.

Check out all the metal work in the leg

Other than working on their balance and proprioception (joint position sense), I get them to step on and off, lunge sideways, forward, backwards and sideways so they will be ready when the terrain that they are on are cambered or cobblestones (especially overseas).

However, I never use them while doing strength training. Turns out there is some research supporting that. I came across the following article to investigate if there are benefits or cross over effects of strength training on an unstable surface.

The following study evaluated subjects undergoing stable and unstable resistance training for muscle power. The subjects were randomly assigned into 2 groups. Each group performed resistance exercises under stable or unstable conditions 3 times a week for 8 weeks. 

Before and after 4 and 8 weeks of the training program, the subjects underwent squats and chest presses on either a stable surface or BOSU/ Swiss ball with increasing weights of up to 85 percent 1RM (rep max). 

There were significant improvements of mean power during chest presses on a Swiss ball at weights up to 60.7 percent 1RM after 4 and 8 weeks of raining on an unstable surface. Mean power also increased significantly during squats on a BOSU ball at weights up to 48.1 percent for 1RM after 4 weeks but not after 8 weeks of training on an unstable surface.

There were no significant changes in mean power during bench presses and squats on a stable surface after the same training. We do know from previous studies (Zemkova et al, 2014) that lower pre training values of power during resistance exercises on unstable surfaces are expected when compared to stable surfaces, especially at higher weights.

The researchers concluded that there is no cross over effect while weight training on unstable surfaces. Training has to be specific, if you want to get really strong and increase your 1RM max, you do not train on unstable surfaces since you cannot lift as heavy compared to on a stable surface.

Now you know, so you do not get hurt while trying something different that your gym suggests you do.

References

Zemkova E, Jelen M, Cepkova A et al (2021).There Is No Cross Effect Of Unstable Resistance Training On Power Produced During Stable Conditions. Appl Sci. 11(8): 3401. DOI: 10.3390/app11083401

Zemkova E, Jelen M, Kovacikva Z et al (2014). Weight Lifted And Countermovement Potentiation Of Power In The Concentric Phase Of Unstable And Traditional Resistance Exercises. J Appl Biomech 30: 213-220. DOI:10.1123/jab.2012-0229.

How's that for balance?

What Happens If You Have A Bone Bruise?

R knee bone bruise from Theinjurysource

A patient I saw recently had quite a big bone bruise on his tibia (shin bone) and femur (thigh) after tearing his ACL. They are also known as bone contusions. It is similar to a bruise you may get on your skin after a fall or when you bump into the corner of a table or chair. It can also be more serious than a bruise under your skin.

A bone bruise (or contusion) refers to blood that is trapped under the surface of your bone after an injury. Since bone is also living tissue, it can also get injured or bruised like your skin and muscles. It usually takes much more force to bruise your bone to injure it without breaking it. A bone bruise usually feels like a deep, dull and throbbing ache that's coming from deep inside the body.

We normally see bone bruises in our clinic after an acute ankle sprain or ACL tear. What's the implication of having a bone bruise? An article (Kia et al, 2020) looked at the incidence of changes on the articular cartilage surfaces on MRI five years after the ACL tear. Note that this is done without correlation with clinical and functional outcomes.

The authors found that the lateral (outside) tibia (shin bone) and femur (thigh) are more frequently involved. The area that was initially bruised sigificantly correlated with increasing chondral (articular cartilage) wear over time. The larger the bone bruise, the higher the chances of having a significant change in the articular cartilage 5 years post surgery.

Absence of a bone bruise on initial MRI was the greatest predictor of no cartilage wear at 5 years in all compartments of the knee. If there was a lateral meniscus injury, there was an increased risk of wear in the lateral tibial plateau (shin bone).

We do not know if this wear leads to pain or even the need for a joint replacement further down the road since the scans DO NOT always correspond with the patients' symptoms.

I always communicate this with the rest of my team seeing patients with bone bruises since this will affect and influence progression to activities of daily living and especially back to sport.

No one knows how long the bone bruises take to heal. In my case before I had the first of my 3 knee surgeries, the bone bruising was still seen on my repeat MRI 9 months later despite me not running or jumping while waiting for it to heal.

For the athletes, impact related activities should only be considered 16-20 weeks after surgery, especially running and plyometrics so as to decrease pain and swelling.

The patient needs to be progressed slowly to have long term success. Slower will always be better in these cases.

Reference

Kia C, Cavanaugh Z, Gillis E et al (2020). Size Of Initial Bone Bruise Predicts Future lateral Chondral Degeneration In ACL Injuries: A Radiographic Analysis. Orth J Sp Med. 2020: 8(5). DOI: 10.1177/2325967120916834.

Physical Activity And Pain Tolerance

Picture from Science News

Almost all of my patients tell me they have a high tolerance for pain. That seems to be the most common reason why they sometimes do not come in early for treatment, thinking that they can tolerate the pain until it somehow goes away on its own. Some patients do have a higher tolerance for pain compared to others. Consuming too much sugar can be a contributing factor, I've written on that before. The following article may give further clues on why.

Since there are limited information on the association between lifestyle factors and pain severity in older adults, a group of researchers decided to investigate if unhealthy lifestyle variables were linked to feeling more pain.

Subjects who were above 50 years living in 27 European countries and Israel were sampled and their data retrieved. Association between lifestyle actors (smoking, sleep, diet and physical inactivity) and how they tolerated pain (mild, moderate or severe) were assessed. Age, sex, geographic region, education, history of chronic disease were all mutually adjusted for each lifestyle.

A total of 27,528 cases were included. The average age was 73 years and 63.3 percent of the cohort were female. A significant association was observed between those who hardly ever or never engaged in activities that required a moderate level of energy and severe pain (pictured above).

In addition, sleep problems, smoking and an inadequate diet were also significantly associated with severe pain, although with lower odds. 

The authors concluded that older adults that were physically inactive were more likely to experience severe pain. Sleeping poorly, smoking and an inadequate diet were less associated with experiencing severe pain. 

Since the above mentioned lifestyle factors are modifiable, they suggested that they may be useful as preventative measures to reduce pain and ensure healthy living.

Previously, I wrote about how strength training helps prevent frailty, especially when you grow older. Well, that's another very good reason to be active.

Reference

Numez-Cortez R, Cruz-Montecinos C, Lopez-Bueno R et al (2025). Physical Activity Is The Most Important Unhealthy Lifestyle Factor For Pain Severity In Older Adults With Pain. A SHARE-based Analysis Of 27,528 Cases From 28 Countries. Musc Sci Pract. DOI: 10.1016/j.mskp.2025.103270

Get Smarter By Taking Creatine?

Picture from Runnersworld

I first wrote about creatine supplementation and its role in improving physical performance back in 2022. So why am I writing about creatine again? Other than its role in improving physical performance, creatine has been shown in several clinical trials to improve mood and help symptoms of depression. It can help with short tem memory and reasoning (Avgerinos et al, 2018).

More importantly, there also seems to be data that research scientists gathered (but not studied yet) that there was a link between creatine and brain health.

Creatine may ease symptoms with certain neurodegenerative diseases (like Alzeimer's, Parkinson's etc), stroke and also adolescent depression. It may also help prevent as well as treat traumatic brain injuries and concussion.

In a meta-analysis of 16 creatine studies published last year, researchers found that creatine supplementation may improve memory, attention and information processing in adults (Xu et al, 2024).

Those of you who take mega doses of melatonin to sleep may want to try creatine instead. A dose of 15-20 grams of creatine monohydrate actually lessen the effects of a bad night's sleep by stimulating the brain's mitochondria (Gordji-Nejad et al, 2024).

Researchers suggest that our brain consume energy just like our muscles, accounting for as much as 20 percent of our body's energy consumption. Adenosine triphosphate (ATP) which is made from creatine may also be stored in our brain which is used for tasks and general health.

Creatine is also safe to take long term (21 months) with no health changes to the liver and kidneys (Kreider et al, 2003). A 2007 statement by the International Society of Sports Nutrition said that creatine was "safe, effective and ethical."

But, before you run out and buy some creatine or order online, I would urge some caution since another 2024 review concluded that creatine supplementation had no significant effect on the brain health of healthy and young participants. It had mixed results for those with creatine deficiences - vegans/ vegetarians, the elderly, the sleep deprived and mentally fatigued (McMorris et al, 2024).

If you decide to start taking creatine, note that 5 grams per day is for muscle growth and performance benefits only. Research has not found what dosage is required for cognitive gains. Some research suggest at least 10 grams and as much as 15 grams each day. The bulk of research indicates that taking 0.1 grams per kilogram of body weight per day is safe.

References

Gordji-Nejad A, Matusch A, Kleedorfer S et aL (2024). Single Dose Of Creatine Improves Cognitive Performance And Induces Changes In Cerebral High Energy Phospates During Sleep Deprivation. Sci Rep. 14(1): 4937. DOI: 10.1038/s41598-024-54249-9

Kreider RB, Melton C, Rasmussen CJ et al (2003). Long-Term Creatine Supplementation Does Not Significantly Affect Clinical Markers Of Health In Athletes. Mol Cell Biochem. 24(1-2): 95-104. PMID : 12701816

McMorris T, Hale BJ, Pine BS et al (2024). Creatine Supplementation Research Fails To Support The Theoretical Basis For An Effect On Cognition: Evidence From A Systematic Review. Beh Brain Res. 466: 114982. DOI: 10.1016/j.bbr.2024.114892

Xu C, Bi SY, Zhang WS et al (2024). The Effects Of Creatine Supplementation On Cognitive Function In Adults: A Systematic Review And Meta-Analysis. Front in Nutr. DOI: 103389/fnut.2024.1424972

Take 12 Weeks Off And Come Back Stronger?

Consider the following scenario. You have trained well and have just taken part in the Swimrun World Championships. You then take 12 weeks off from training. You resume training again for 12 weeks and tests show your VO2 max levels exceeded those just before you took 12 weeks off. 

Too good to be true? Can a long break be that good for you? 

A French exercise physiologist and triathlete Romuald Lepers agreed to take 12 weeks off deliberately (for the sake of science) and allowed himself to be tested. With his colleagues' help, he underwent a whole bunch of tests straight after he competed in the World Swimrun Championships in 2022. After that he rested for 12 weeks and the tests were repeated. He then resumed training for 12 weeks and repeated the same tests. 

The results were published in 2 different journals last year showing what happened when you lose and then regain fitness, raising a possiblity that perhaps a long training break is actually good for you.

The first published article documents Leper's changing fitness. After 12 weeks of rest, his VO2 max measured in a treadmill running test dropped by 10.9 percent. In a similar test on an exercise bike, it dropped by 9.1 percent. That's a big drop equivalent to about 15 years of normal aging. For reference, Edward Coyle's famous paper from 1984 saw a 16 percent drop in VO2 max after 12 weeks of laying off training.

Here's the surprising good news. He gained 5.5 pounds of fat and lost 4.6 pounds of muscle during the 12 weeks rest. After retraining, he lost 9 pounds of fat and regained 2.4 pounds of muscle. His body fat levels  went from 10.1 percent to 13.3 percent then to 8.4 percent. A net loss of 5.7 percent at the end of the experiment. 

Cycling VO2 max levels

After 12 weeks of training again, his VO2 max did not just recover, it was better than before he stopped training (5 percent higher). The running test was 4 percent higher than before. In the cycling test it was 6 percent higher (pictured above). 

The fat loss will explain some of the improvement in his VO2 max as it is calculated relative to body weight, so losing weight can create the 'illusion' that you get fitter without changing your oxygen processing abilities. However, his overall oxygen processing capacity did improve, independent of his weight.

Another possibility documented in the second published journal is that something changed in his muscles making them more responsive to training. Lepers had muscle biopsies (ouch - they are very painful!) at each stage to measure the chemical changes occuring. Fast twitch muscle activity was ramped up during detraining while aerobic capacity and mitochondria function decreased. Retraining mostly reversed those changes and in his case resulted in better than baseline muscle properties.

Now, Lepers is an accomplished triathlete. In his younger days he placed in the top 150 at The Hawaii Ironman World Championships. At the time of the study, he was 53, training 10-12 hours a week and consistently placing near the front in his age category in Ironman 70.3 races. Lepers has trained consistently for more than 3 decades, and never missed more than 2 weeks of training at a time previously. 

Sounds good so far? Leper's results also seem to line up, declining with detraining and impoving to be even better with retraining.  If you're in your 20's, you can take 12 weeks off, train hard again and definitely regain your fitness and more. This case study suggest the same can be true in your 50's.

Note that this is just a case study, where n=1 where we may not get the same results as Lepers. This is different as missing 12 weeks through injury since you may not be able to start training full on especially if surgery was needed.

So here are the not so good bits if you read both articles in detail. Leper's cycling efficiency went down and his running economy worsened. He did not recover the muscle mass he lost and that is worrying (note to self : need to maintain strength training). Fortunately for him, his race results in the following season with similar with the previous season. Actually I thought that was remarkable given the fact that he took 12 weeks off.

I really liked Leper's experiment since I am in the same age group as him. Many of my older patients and friends take shorter and less frequent breaks from training because they are afraid they will lose their fitness from too long a break. I am definitely in the same boat. Now we can all be less paranoid about taking long breaks from training. Even if I do not get better than before, just the fact that one can get back to your previous level is reassuring enough.

Reference

Lepers R, Mater A, Assadi H et al (2024). Effect Of 12 Weeks Of Detraining And Retraining On The Cardiorespiratory Fitness In a Competitive Master Athlete: A Case Study. Front Physiol. DOI: 10.3389/fphys.2024.1508642.

Zanou N, Gremeaux V, Place N and Lepers R (02024). Cardiovascular And Muscular Plasticity In An Endurance-Master Athlete Following 12 Weeks Of Detraining And Retraining: A Case vStudy. JCSM Comm. 7:82-90. DOI: 10.1002/rco2.93.