Tarsal Tunnel Syndrome

Picture from Orthopaedia.com

A patient came in to our clinic declaring she has plantar fascia pain in her right foot. She had seen another physiotherapist a few years ago for plantar fascia pain in her left foot and had gotten better. This time she tried orthotics, lots of stretching and even shockwave (or ESWT) with the same physiotherapist, but there was no improvement.

This is how she described her foot pain. She said there was a burning, aching pain at the bottom of her foot and on the inner heel. She said it almost feels like an electric shock. Her pain gets a lot worse after prolonged standing and sometimes wakes her up at night. She also gets numbness in her toes. 

None of those symptoms sound like plantar fascia pain to me. Patients with plantar fasciitis usually have pain during the first few steps when they get out of bed in the morning. There is rarely numbness, burning or electric shock sensations in the toes.

Upon assessment, there was no pain on the posterior calcaneal tubercle (where the PF inserts) nor along the plantar fascia itself. 

I elicited her pain when I did a modified Straight Leg Raise test by holding her foot in full dorsiflexion and eversion. However, there was no tingling or zinging in the foot when I tap on the medial malleolus (over the tarsal tunnel) - also known as Tinel's test. Online articles often describe a positive Tinel's test.

I explained my findings to her. My patient actually has Tarsal Tunnel Syndrome. This is when the posterior tibial nerve gets 'trapped' and irritated in the tarsal tunnel at the inner part of the foot (pictured below). 

Picture from Teachmeanatomy

The tarsal tunnel is a space just behind and below the medial malleolus and serves as a passageway for the posterior tibial artery, nerve and what we call Tom Dick and Harry muscles (tibialis posterior, flexor digitorum longus and flexor hallucis longus). The 'roof' of this tunnel is covered by the flexor retinaculum. It is a thick and strong fibrous band that holds Tom, Dick and Harry in place.

Tom, Dick and Harry- back of R leg

Entrapment of the posterior tibial nerve in the tarsal tunnel caused my patient's foot pain, not plantar fasciitis.

Online or AI* searches always say that flat feet or severe overpronation can cause tarsal tunnel pain as it can stretch the nerve although my patient does NOT have flat feet.

My patient did have a severe right ankle sprain a few months ago that caused swelling and perhaps thickening in the connective tissue in the tunnel that eventually caused this. It was also not treated properly, causing her to compensate and stand and walk differently possibly 'tractioning' her posterior tibial nerve.

A ganglion cyst in the canal may also cause this since it reduces the space in the tunnel. I have never come across this though in the 27 years of being a physiotherapist.

When a patient complains of bottom of foot pain, plantar fasciitis is usually the diagnosis one thinks of. The symptoms of tarsal tunnel syndrome pain can be similar to lumbar radiculopathy, diabetic and peripheral neuropathy or plantar fasciitis. Hopefully this article will correct that. 

 (*All the articles in this blog are written by me not by AI).

Reference

Boers N, Haverkamp M, Eligh AM et al (2026). Differences in Diagnosing Tarsal Tunnel Syndrome Across The Literature: A Systematic Review And A Call For Standardization. JBJS Rev. 14(2): e25.00222. DOI: 10.2106/JBJS.RVW.25.00222

L flexor retinaculum

Picture from https://drjustindean.com/retinaculaofthefoot/

Warming Up Body And Mind

Picture from Healthywomen.org

All of us are familar with warm ups. Before you run, exercise and especially before a race. You are trying to increase your core temperature, send more blood flow to the limbs and 'wake' the muscles up. Before a running race you may even try some race pace striding so the actual start of the race does not feel like a shock.

So I was surprised to read that combining mental and physical warm ups can improve running times. Curious? Please read on to find out more.

Researchers in that study investigated whether combining cognitive tasks with a standard physical warm up could improve 1-mile performance in runners. 25 runners (11 male, 14 females) with an average weekly mileage of 20 miles (32 km) and 5km personal best timing of 23:31 min were recruited for the study. Each runner completed 3 separate testing sessions.

First was with only a physical warm up which included a 1200m easy jog, 800m alternating 100m jogs and 100m strides and 3 minutes of active stretching drills. 

Next was the same physical warm up plus a low load cognitive task and finally same physical warm up with a high load cognitive task.

In the cognitive warm up conditions, the runners completed four 3-minute cognitive tasks before and between the physical components.These tasks targeted mental functions like switching between tasks, decision making, inhibiting responses to stimuli and memory. They were doing short bursts of focused mental work designed to activate the brain without exhausting it.

 

After that all the runners ran 4 laps of a 400m track with their watch face covered so that they could only rely on feel rather than constant pace feedback.

Ready for the results? The runners were faster after both cognitive plus physical warm ups compared to only doing the physical warm up. The  low load cognitive task improved 1-mile timing by about 8 seconds (2.3%),  while the high load cognitive task improved performance by about 11 seconds (2.8%).

The runners did not appear to muscle their way to faster timings since their perceived effort was lower after the combined warm ups and their average heart rate during the time 1-mile run was also lower. Their readiness to perform was higher, meaning the runners felt more prepared to run hard.

Stride length and cadence did not change meaningfully suggesting that performance boost was not explained by obvious mechanical changes.

Take home message? No, you do not need to download an app to challenge your cognitve skills before every workout or race. However, this study does suggest that the best warm up should prepare both mind and body.

Before you do your track interval sessions, time trials or short, hard and fast sessions or even up to a 5 km race, it may be useful to add a small cognitive task that perhaps include coordination games, quick reaction tasks, fast feet with visual cues to make you engage attention before you start running hard.

The important thing to note is dose. A few short mental tasks coupled with jogging, drills and race pace striding may help you feel sharper and more ready for your workout. A long, draining task may do the opposite.

This sharpens the nervous system rather than stressing your brain. Keep it brief and engaging and please try it in your training first before trying it on race day.

Reference 

Mortimer, H Dallaway N, Diaz-Garcia J et al (2026). Warming Up The Body And Mind: Bombined Cognitive And Exercise Priming Improves 1-Mile Time Trial Performance In Recreational Runners. Eur J Sp Sci. 26(5): e70163. DOI: 10.1002/ejsc.70163

Can Neurodynamic Mobilization help DOMs?

Picture from The Sensitive Nervous System

We invited our neighbours over for dinner on Friday night. She had just done circuit training at Virgin Fitness a few days ago (for the 1st time in a few years) and was sore and aching all over. She definitely had delayed onset of muscle soreness (DOMs).

There's not much we can do to recover quickly from DOMs. So I was very surprised to read that neurodynamic mobilization (NM) helped with DOMs.

NM (or neural mobilization) is a physiotherapy technique (made popular by David Butler, who first wrote about this in 1991) that can treat nerve dysfunction by mobilizing the nerves. Manual techniques involve stretching, moving and even 'pulling' on nerves to improve/ restore balance between neural tissue (nerves) and surrounding structures. It helps the nerves glide (or slide) better, decreases adhesions around nerves and surrounding structures to enhance nerve function.

Our brain and the spinal cord are packed in fluid in the skull and the spinal canal. Similarly, our nerves are covered with fluid too, in a sheath like structure. It's sort of like a fluid-fluid tube (nerve) inside another fluid filled tube. 

Neurodynamic mobilization helping DOMs? Now that is news to me.

Researchers had 34 untrained males randomized into the neurodynamic mobilization (NM) or random group. Femoral nerve NM and a placebo technique were performed for 3 weeks in both groups. 

Each session consisted of 3 sets of 10 repetitions with a 2 minute break between sets. Nine sessions were conducted within 3 weeks. The participants were lying sideways on their non-dominant leg side. The physiotherapist stood behind, supporting their upper leg to have the hip in a neutral (no adduction or abduction) position. The upper dominant leg was flexed and the hip extended until soreness/ pain was felt by the patient. This was held for 3 seconds before being released. See picture A below.

Picture from article Sozlu et al, 2025

For the placebo group. the participants were also lying sideways on their non-dominant leg side. The physiotherapist was behind with the upper leg held in full extension and the hip abducted for 3 seconds while the pelvis was stabilized. Each session also consisted of 3 sets of 10 repetitions with a 2 minute break between sets. Nine sessions were also conducted within 3 weeks. See picture B above.

Subsequently, all participants did 300 maximal isokinetic contractions of their dominant leg knee extensors (thigh muscles). 

Creatine kinase, lactate dehydrogenase (both markers of muscle damage), inflammation (IL-6, TNF-α), muscle soreness, pressure pain threshold (PPT) were compared. These were measured at baseline, immediately before exercise (pre) and after (0 hours) the exercise induced muscle damage (EIMD) protocol. Measurements were also taken at 24, 48 and 72 hours after exercise.

Muscle soreness peaked at 24 hours after EIMD, while PPT was at its lowest. The NM group had significantly lower muscle soreness and higher PPT values compared to the placebo group at 0, 24, 48 and 72 hours. Muscle function scores was at its lowest at 0 hours, withe the NM group demonstrating significantly higher function scores than the placebo group both before EIMD protocol and at 0 hours. 

The researchers concluded that 3 weeks of femoral nerve NM applied to healthy untrained individuals had positive effects on DOMs. NM may help sooth inflammation and muscle damage symptoms and shorten recovery time following DOMs.

Now that will be music to my neighbour's ears!

Reference

Sozlu U, Basar S, Semsi R et al (2025). Preventative Effect Of The Neurodynamic Mobilization Technique On Delayed Onset Of Muscle Soreness: A Randomized, Single-Blinded, Placebo-Controlled Study. BMC Muscskel Diso. 26: 464. 

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.

Still Doing Those Pendulum Exercises For Shoulder Pain?

Quite a few patients who came to our clinic this week had frozen shoulder. Almost all of these patients had been prescribed pendulum exercises (also know as Codman pendulum exercises) by their previous healthcare provider. The intention is to move/ rehabilitate the glenohumeral (or shoulder) joint while not worsening recently injured or operated tissue.

This is done with the patient standing with a slightly bent torso with the affected arm hanging downwards, using the momentum of the torso/ trunk to move the arm without activating the muscles in the shoulder girdle. The arm can be moved side to side, forwards and backwards, or in a circular motion. Codman pendulum exercises are also always  prescribed after shoulder surgery . In fact, they are the mainstay of many shoulder rehabilitation protocols.

However, Cunningham et al (2020) demonstrated that Codman pendulum exercises involved minmial glenohumeral and scapular-thoracic movement. Movement is mainly from the trunk. They may be a safe way to start early movement/ stretching of the upper limb but may be of limited further use in restoring passive shoulder range of motion.

In fact Gurney et al (2016) found that Codman pendulum exercises induced the least muscle contraction in rotator cuff activity when they investigated several tasks, common rehabilitation exercises and ambulation. Wearing and taking off a shirt induced the highest. Even walking produced substantially higher muscle activity than the Codman exercises. 

Of course if the movement is directly generated from the shoulder rather than the trunk as well as performing larger pendulum circles, there will be increased rotator cuff muscles activity.

Personally, in our clinic, I find that teaching patients 3 basic exercises with elastic resistance bands work much better for the shoulder. Intensity, dosage and exercise position will have to be modified dependent on the surgery and condition the patient has. 

I show them the one arm shoulder frontal raise (pictured above), the lateral raise and a simple basic rowing exercise where the shoulder blade is retracted (or pulled back). In fact, the same few exercises and the single arm reverse fly (pictured below) were found to be effective for office workers to perform daily for 10 minutes to reduce neck and shoulder pain (Saterbakken et al, 2020). 

From Saterbakken et al (2020)

You can definitely stop doing those Codman pendulum exercises.

References

Cunningham G, Charbonnier C, Ladermann A et al (2020). Shoulder Motion Analysis During Codman Pendulum Exercises. Arthrosc Sp Med Rehab. 2(4): e339. DOI: 10.1016/j.asmr.2020.04.013

Gurney AB, Mermier C, LaPlante M et al (2016). Shoulder Electromyography Measurements During Activities Of Daily Living And Routine Rehabilitation. Ex J Orthop Sp Phy Ther. 46(5): 375-383. DOI: 10.2519/jospt.2016.6090.

Saterbakken AH, Makrygiannia P, Stien N et al (2020). Dose-response Of Resistance Training For Neck-and Shoulder Pain Relief: A Workplace Intervention Study. BMC Sp Sci Med Rehab. 12:8. DOI: 10.1186/s13102-020-0158-0

Can You Prevent Running Injuries?

We have been seeing some runners in our clinic recently. Some seasoned runners, but quite a few new, novice runners. My definition is unless the runners have been training, running and/ or racing for at least 5 years, they are still considered novice runners.

As a runner I would love to run long and hard daily, alas if we do that injury definitely beckons. How do we prevent that from happening? Can we actually prevent running injuries?

I came across an article investigating if it was possible to prevent running injuries. In this particular study (Leppanen et al, 2024), there were 325 participants who were fairly new runners (less than 2 years of running experience) and aged between 18-55 years. Interventions were completed before the actual runs. The runners attended group training twice a week with a physiotherapist for 6 months.

They were divided into 3 training groups, 2 intervention and 1 control group. All 3 groups followed a similar training program and all runners were taught about the basics of running technique. The first intervention group (108 runners) did strength and conditioning exercises for the hip and core. The 2nd group (111 runners) did exercises to strengthen the ankle and foot, while a third control group (106 runners) did static stretching.

Each training session lasted about 30 minutes twice a week with the exercises and difficulty level progressing over the course of 6 months. Each exercise had 4 different versions with different levels of difficulty and intensity. After the training session, the participants ran outdoors for 30-75 minutes. The participants reported all running related injuries each study week using a mobile application.

Results show that the group that focused  on hip and core training sustained the least injuries among the 3 groups. They had 39 percent lower prevalence of all overuse injuries and 52 percent lower prevalence of overuse injuries compared to the control group. 

I was surprised that the  ankle and foot exercise group did not prevent running related injuries compared to the stretching group. The incidence of acute injuries was lower in the control group than ankle and foot exercise group perhaps suggesting that stretching may help prevent acute running injuries. However, do take note that there were a low number of acute running injuries in this study so this observation should be approached with caution.

This study shows that beginner or novice runners injury rates can be significantly reduced by training the hip and core muscles. Overuse injuries can be cut by about half by strengthening this area compared to stretching which has always been traditionally thought to prevent injuries. And it's really easy to do with just body weight and/ or resistance bands.

Come see our physiotherapists at Physio Solutions and Sports Solutions to learn about what stregthening exercises would help prevent running injuries for you.

Reference

Leppanen M, Viiala J, Kaikkonen P et al (2024). Hip And Core Exercise Program Prevents Running-related Overuse Injuries In Adult Novice Recreational Runners: A Three-arm Randomised Controlled Trial (Run RCT). BJSM. 58: 722-732. DOI: 10.1136/bjsports-2023-107926.

Sural Nerve Pain

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. 

Tight Or Just Tired?

Who says my hamstrings are tight?

I always hear my patients telling me that their muscles are feeling 'tight' or tense. Does this mean that their muscles are 'short' or have poor range of motion? Or is it that the area that they complain about is tight and does not feel relaxed or 'loose'. Perhaps there is a vague sense of discomfort, not pain, just an unpleasant feeling, but too mild to be painful.

I always explain that when I put both my hands on their e.g. trapezius muscles that they feel the same, one side is not 'tighter' than the other. 

If I get a dollar each time my patients tell me how tight they feel when they come and see me I will have many extra dollars for sure.

A patient ran a very hard 21 km road race recently and complained of 'tightness' in his hamstrings for the past 5 days came to see me in our clinic this week. He said his hamstrings felt very hard, achy and 'tight' of course. They even threaten to cramp when he tried running or doing some strengthening exercises. 

However, he can easily put his palms on the floor in a forward bend. (Note: there are other patients whose hamstrings do not feel 'tight' but they can barely get their hands past their knees while bending forward).

He tried stretching but other then feeling a little better for less than a minute the 'tightness' came back quickly. Upon assessment he definitely had some delayed onset of muscle soreness (DOMs). I told him his 'tightness' was actually fatigue from his training and racing.

I suggested resting and focusing on his recovery. Definitely decrease his intensity and mileage. My personal experience after a hard race would be doing any of the 2 aerobic exercses outlined below at reduced intensity and low volume.

These low intensity exercises 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 high water works well too. Wearing compression garments will help reduce DOMs as well. These above mentioned strategies do have some support in the research.

After he recovers fully, I suggested testing for strength imbalances and deficits as weaker muscles do tend to fatigue more rapidly. Specific strength training will address that.

In most other cases of patients feeling 'tight', the reason is obvious. If the stay in the same position/ posture for too long, their muscles need a rest or change of position to reduce the lack of blood flow or metabolic stress that is causing the noxious stimuli. Think of the last time when you spent hours in a car, plane or behind your computer, after you move/ stretch, the symptoms of stiffness/ tightness will be alleviated.

Remember this, when you feel stiff and 'tight', it is just a feeling and not necessarily a physical shortening that needs you to structurally change it. Like other things that you feel, you may feel it more sometimes compared to others. Like other forms of sensitivity, those feelings will change if you improve your overall fitness, strength and health.

Reference

Stanton TR, Moseley GL, Wong AYL et al (2017). Feeling Stiffness In The Back: A Protective Perceptual Inference In Chronic Back Pain. Sci Rep. 791): 968. DOI: 10.1038/s41598-017-09429-1

Ulnar Nerve Entrapment

Left ulnar nerve

My patient who is a Team Singapore cyclist came in with a case of ulnar nerve entrapment on Friday. Ulnar nerve entrapment* is the second most common nerve condition happening in the upper limb after carpal tunnel syndrome.

The ulnar nerve arises from the brachial plexus at C8-T1 and travels down the inner part of the upper arm through the arcade of struthers (pictured below).

At the elbow, the ulnar nerve travels just behind the bony part on the inner part of the elbow. This is also know as the "funny bone" when you can get sensations of pins and needles after bumping the area. 

Picture by Conor Jones

As the ulnar nerve crosses the elbow, it passes through a bony tunnel and up to 2 other potential points for blockage making it vulnerable to pressure or stretching. Prolonged periods of sleeping with the elbow bent can also cause over stretching of the nerve. My patient hurt her ulnar nerve after riding for a few hours in a new position after changing her handlebars. Riding for a few hours on bumpy roads did not help. She had also fractured both her clavicles (R followed by L in the last few months). This is also known as the cubital tunnel syndrome.

The ulnar nerve supplies the sensation and muscles to the 5th and half the ring finger. Symptoms are related to degree of irritation of the nerve. They start off intermittent in nature and may only come on at night after the nerve has been stretched for a longer time. 

Pins and needles, aching or tingling in the little and/ or ring finger will be the common symptoms. This is what my patient felt. If the irritation persists, the symptoms may become constant and progress to numbness in the 5th and/ or ring finger and ultimately weakness in the hand.

As the ulnar nerve exits the bony tunnel, it goes into the flexor carpi ulnaris muscle. Follwing that at the wrist, it travels superficially to the flexor retinaculum and passes into Guyon's canal.  

R wrist

Guyon's canal is formed by 4 borders (pictured above). The roof is the palmar carpal ligament, the floor being the transverse carpal ligament, the ulnar (inner) border is the pisiform and the radial (outer) border is hook of hamate.  If the nerve is irritated at the wrist it is known as Guyon's canal syndrome.

Picture from Medical Art Library

The flexor carpi ulnaris and inner half of flexor digitorum profundus muscles are innervated by the ulnar nerve and the hypothenar muscles (pictured above).

Knowing the exact site of nerve irritation during an accurate clinical examination will help decide what needs to be done for treatment. Some doctors send their patients to do a nerve conduction test, but I personally find that an upper limb tension test (with radial nerve bias) done correctly does a much better job. Others may do ultrasound imaging to help diagnosis. Do not confuse it with thoracic outlet syndrome.

Just remember not to have a steroid/ cortisone injection.

*Ulnar nerve entrapments are commonly seen in cyclists, golfers, weightlifters and construction workers.

References

Kong G, Brutus JP, Vo TT et al (2023). The Prevalence Of Double- And Multiple Crush Syndromes In Patients Surgically Treated For Peripheral Nerve Compression In The Upper Limb. Hand Surg Rehabil. 42(6): 475-481. DOI: 10.1016/j.hansur.2023.09.002

Raut P, Jones N, Raad M et al (2022). Common Peripheral Nerve Entrapments In The Upper Limb. Br J Hosp Med. 83(10): 1-11. DOI: 10.12968/hmed.2022.011

Have a look at this ulnar nerve video.

Does Strength Training Help Runners Prevent Injuries?

Last week I wrote about how we have been told for years that the key to staying pain and injury free can be found somewhere close to your belly button. That got most people obsessed with strengthening their core or abdominal muscles. Which you know by now that it is not totally true.

Likewise many runners also believe that strength training like squats, deadlifts and other power lifting staples can make you faster, more powerful, more efficient and less injury prone.

Ever wonder what sort of strength training do top runners do? Blagrove et al (2020) did a survey of 667 distance runners (local to internationally competitive) about their strength and conditioning exercises. Most common was stretching (86.2 percent), core training (70.2 percent),  weight training (62.5 percent) and plyometric training (35.1 percent).

What was most interesting was the motivation these runners reported for the strength and conditioning routines. There were 2 main answers. Reducing injury risk (63.1 percent) and improving performance (53.8 percent). There was no relationship found between strength and conditioning training and injury history in runners. The key predictor of injury was training volume. The more you ran, the more likely you would get injured.

 In another systematic review published last month, Blagrove and colleagues (Wu et al, 2024) found that strength and conditioning does not appear to reduce the risk and rate of running related injuries (RRI). Please bear in mind that Richard Blagrove has authored a book Strength And Conditioning For Endurance Running and worked with many elite runners on their strength routines in case you think he is against strength training.

Their systematic review consist of 9 articles with 1,904 runners. Exercises done include lunges, squats, plyometric hops/ jumps, core routines, foot strengthening etc. Given the wide variety of of regimens, there was NO significant benefit for the exercise groups compared to the control group in injury risk (runners who got injured during the studies) or injury rate (how many injuries they suffered for a given amount of running).

For now that is the state and level of evidence we have with regards to strength and conditioning exercises preventing RRI. Strange that this approach (strength and conditioning) has robust evidence that it works in soocer, but not in running.

What was most interesting is that 3 of the studies that produced the lowest injury risk also happened to be the 3 studies where the exercise routines was supervised rather than assigned to be performed at home. Research shows that people tend to get bigger gains when they have a spotter or trainer looking on. Similarly, runners tend to run their intervals faster and more consistently when the coach is standing on the track with a stopwatch in hand. It could also be the only way to ensure people actually do the strength and conditioning exercises. 

I can remember many patients who come for a follow up visit claiming they have done their exercises diligently but cannot do it when asked to demonstrate it. A strengthening exercise can only work if you actually do it and have done it correctly.

Take home message? If the study (Wu et al, 2024) is true, strength training or other forms of exercise may not lower your risk of getting injured while running. Even though the logic is sound and evidence from other sports is positive. However, there is very good evidence that strength training improves running economy and boosts long term health. It would be nice to get injury prevention as an added bonus but it still sounds like a good deal to me. So I will still strength train.

Researchers need to have more robust studies that include supervised interventions to investigate further.

References

Blagrove RC, Brown N, Howatson G et al (2020). Strength And Conditioning Habits Of Competitive Distance Runners. J Stren Cond Res. 349(5): 1392-1399. DOI: 10.1519/JSC.0000000000002261.

Wu H, Brooke-Wavell K, Fong DTP et al (2024). Do Exercise-Based Prevention Programs Reduce Injury In Endurance Runners? A Systematic Review And Meta-Analysis. Sports Med. DOI: 10.1007/s40279-024-01993-7.

Intense Static Stretching Versus Strength Training For Muscle Growth

Static stretching device

Who says that strength training is needed to make muscles bigger and stronger? A study published 2 days ago showed that intense static stretching of the pectoralis major (chest) muscles 4 times a week produced similar hypertrophy gains to strength training done 3 times a week. 

What? Just as effective as strength training? I was surprised to say the least. Well you know I am not a big fan of static stretching at all. Skeptical? I was too!

81 participants were allocated to 3 groups in this study. A static stretching group, strength training and control group. Pec stretching was done for 8 weeks, 4 days per week for 15 minutes per day. Those in the strength training group trained 3 times a week doing 5 x12 repetitions. All the subjects were instructed to maintain their regular exercise routine during the study. They exercised at least twice a week in a wide range of sports like fitness training, team sports or strength-endurance training. 

Results showed significant strength increase in the static stretching and strength training group compared to the control group. There were no significant differences between the static stretching and strength training group.

There was moderate muscle thickness increases in the static stretching and strength training group compared to the control group. Muscle thickness was measured using ultrasound imaging. There was actually no difference between the static stretching  and strength training group.

Range of motion test

In terms of range of motion (ROM), static stretching group had significant moderate ROM increases compared to the strength training group. No difference in ROM between the strength training and control group.

It has been suggested that the shared underlying physiological mechanism between stretching and strength training is the high stretching tension both produces to induce stretch mediated hypertrophy (Warneke et al, 2023). This tension translates into chemical signals that stimulate anabolic processes to generate new muscle tissue.

Wow. Increased size, strength and range in 8 weeks compared to strength training. However, note that static stretching via a stretching device like in this study needed a second person to assist and adjust the stretching device. Moreover, regular strength training can prevent osteoporosis and sarcopenia.

References

Warneke K, Wirth K, Keiner M et al (2023). Comparison Of The Effects Of Long-lasting Static Stretching And Hypertrophy Training On Maximal Strength, Muscle Thickness And Flexibility In The Plantar Flexors. Eur J Appl Physiol. 123(8): 1773-1787. DOI: 10-.1007/s00421-023-05184-6

Wohlann T, Warneke K, Kalder V et al (2024).Influence Of 8-weeks Of Supervised Static Stretching Or Resistance Training Of Pectoral Major Muscles On Maximal Strength, Muscle Thickness And Range Of Motion. Eur J Appl Physiol. DOI: 10.1007/s00421-023-05413-y

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.

References

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

Hip Adductor Related Groin Pain

If you follow Aussie Rules Football (or AFL), yesterday was the 2nd second semi final with GWS Giants defeating Port Adelaide 93-70. Aized and I had to help Aussie Rules football players back when we were  doing our post graduate physiotherapy studies in 2003. I still follow the AFL league from time to time. AFL footballers often suffer from groin pain.

Other than AFL footballers, soccer (also known as football), rugby players and those who play badminton and squash etc are involved in rapid acceleration, deceleration and sudden changes in direction are all more prone to groin injuries.

Athletes with a previous groin injury are at a greater risk than those with no previous injury. This can be up to 2.4 times greater over consecutive seasons with football players (Haglund et al, 2006).

The hip adductors

Football players have a yearly incidence of adductor related groin pain of 10-18 percent. 53 percent of theses cases are from overuse. Groin injuries in male club footballers accounted for 4-19 percent of all injuries and 2-14 percent in women club footballers.

Different types or groin pain

It can be difficult to diagnose groin injuries since there can be many different complex causes. Hip adductor related groin pain is defined as hip adductor tenderness and pain with resisted hip adduction testing. It is also the more common causes of groin pain. Other than hip adductor groin pain, the iliopsoas, inguinal and pubic symphysis are other causes of groin pain (pictured above).

Exercise therapy is commonly prescribed for groin pain although there is no specific exercise protocol. Exercises, particularly adductor eccentric strengthening seems to be beneficial for pain reduction and return to sports at 16 week follow up in comparison to stretching, electrotherapy (ultrasound, interferential currents) and transverse friction massage.

We do see many patients with groin pain in our clinics. However, our approach to treatment is different. We do not get our patients to do the strengthening exercises when they are in the clinic. We prefer to treat them using mostly our hands instead. For example, for a patient with groin pain, they may also have a higher hip on one side (pictured below).

R hip lower

We can treat the hip with respect to the shorter side. Short in terms of length. It also depends on what our assessments show. The patients can 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 or hip pain.

References

Haglund M, Walden M and Ekstrand J (2006). Previous Injury As A Risk Factor For Injury In Elite Football: A Prospective Study Over Two Consecutive Seasons. BJSM. 40: 767-772. DOI: 10.1136/bjsm.2006.026609

Weir A, Brukner P, Delahunt E et al (2015). Doha Agreement Meeting On Terminology And Definitions in Groin Pain In Athletes. BJSM. 49: 768-774. DOI: 10.1136/bjsports-2015-09486

Yosefzadeh A, Shadmehr A, Olyaei GR et al (2018). Effect Of Holmich Protocol Exercise Therapy On Long-standing Adductor-related Groin Pain In Athletes. BMJ Open Sp Ex Med. 4: e000343. DOI: 10.1136/bmjsem-2018-000343

It's The Hip Not The Knee

My patient came with anterior (or front) knee pain yesterday. She had been to see another physiotherapist who said she needed to strengthen her quadriceps muscle. Who says physios can't prescribe exercises compared to strength and conditioning coaches? 

Pardon the link - it seems that almost every single patient that comes to our clinic (after seeing another physiotherapist) had been given exercises to do during the treatment session itself. Maybe that's why the general public thinks all a physiotherapist does is teach exercises.

In our clinics, we may give an exercise or two to our patients near the end of the session, for them to do at home. However, we do not make our patients do any exercises DURING the treatment session. We treat them, mostly using our hands. We do treatment that the patients cannot do themselves, while they are in the clinic. 

Anyway back to my patient with knee pain who was asked to strengthen her quads. I've written a few times since 2009 that treating (or strengthening the hip) is much more important than strengthening the knee (quadriceps). Well, here is further proof.

In this systematic review referenced below, researchers studied data from 14 suitable studies (out of 119) that were found between 1994 and September 2019. Results from all 14 studies demonstrated that strengthening the hip 2-4 times a week (for 3-8 weeks) effectively relieved pain and improved knee function compared to quadriceps stengthening and no exercise. This lasted for up to 12 months post intervention.

The researchers recommended that hip muscle strengthening be a standard clinical practice while treating patients with anterior knee pain. So if the physiotherapist that you're seeing gets you to do quadriceps strengthening for your anterior knee pain, you need to tell them that hip strengthening is superior to quadriceps exercise. Please note that hip strengthening does not mean clam shell exercises.

Please also note that this present review included  randomized clinical trials that also got their subjects to do both hip plus quadriceps strengthening exercises over just the quadriceps alone. All except one study showed that hip and quadriceps strengthening exercises over just quadriceps alone. There were no no hip plus quadriceps strengthening versus hip exercises alone study done.

Perhaps a combination of hip-quadriceps strengthening may be a more effective strategy in the treatment of anterior knee pain? We can certainly try that in our clinic before more studies are done. It would depend on what we find to be weak at your objective examination ;)

Reference

Alammari A, Spence N, Narayan A et al (2022). Effect Of Hip Abductors And Lateral Rotators' Muscle Strengthening On Pain And Functional Outcome In Adult Patients With Patellofemoral Pain : A Systematic Review And Meta-analysis. J baxk Muscl Rehab. Pre-press. pp 1-26. DOI: 10.3233/BMR-220.

** For those of you wondering, there were no standardized protocol for hip and knee exercises in the various studies. The common hip exercise protocol included hip abduction against an elastic band while standing and with weights in a side-lying position coupled with hip lateral rotation against an elastic band while seated and hip extension (3 sets of 10 repetitions). 

Conversely, quadriceps strenthening in all studies generally involved weight bearing and non weight bearing exercises such as closed kinetic chain exercises, seated knee extension, leg press, squatting and stretching of hamstrings and quadriceps (3 sets of 10 repetitions).