Ankle Sprain? No, It's Cuboid Syndrome

R cuboid bone in the foot

I had a patient who came to our clinic today complaining of pain in the outside of his left foot. He thought he had sprained his ankle about 3 weeks ago while playing football barefoot. He rested, iced it  etc but it did not seem to get a lot better.

He then went to a Sports Doctor who diagnosed him with an ankle sprain and suggested that he see a Physiotherapist, which he did, but the one he saw did not make his ankle any better.

He still had most discomfort/ pain on the outer part of his left foot/ankle. Pain was worse during the push off phase of walking. He also couldn't run properly without pain.

However, his ankle proprioception (or joint position sense) was also not affected. Usually for ankle sprains, a patient's proprioception is usually worse on the affected side.

After a thorough assessment I found his ankle joint to be stable and free of pain. His pain increased on firm palpation of his left cuboid bone. The left cuboid also was sitting in a lower position compared to his right foot.

I explained to him that he did not sprain his ankle but instead there was probably a subluxation (or mild dislocation) in his cuboid bone. (I had actually seen two other cases of cuboid syndrome in the last few months).

The cuboid bone sits at the outer aspect of the mid foot and his connected to adjacent bones by strong connective tissue and ligaments (see picture above). During certain weight bearing activities like running, excessive forces placed on the cuboid bone (from the peroneal longus muscle especially) can sublux (or dislocate) the cuboid bone. This is exactly what happened to my patient. I've also seen this condition fairly frequently in ballet dancers that I've treated before.

How did I treat my patient? After the diagnosis, this is the easy part, or so I thought. I got him to lie on his tummy and gently tried to coax (or mobilise) his cuboid back into where it should be sitting. For some strange reason, it took a lot longer than I expected. My last two patients with cuboid syndromes had their cuboids back into position in less than five minutes.

It took me almost 20 minutes before my patient, his mother and I heard a loud click (of course I felt it with my hands too) suggesting I had relocated the bone.

I got my patient to stand up and try and he gave me a big smile after trying to walk and run. Job done, next patient waiting .....

Have a look at the reference below if you want to know more about cuboid syndrome.

Reference

Durall CJ (2011). Examination And Treatment Of Cuboid Syndrome. A Literature Review. Sports Health. 3(6): 514-519. DOI: 10.1177/1941738111405965.

Which Drink Hydrates You Best?

Ever wondered which drink is best after a hard training session or race? I've written before that as a recovery drink, chocolate milk is as effective as Gatorade and even superior to Endurox.

Quite a few factors affect how quickly you pee out a certain drink. Drinks with more calories or electrolytes tend to stay in your system longer. How much you drink at a time also plays a part according to an article I read.

Researchers recruited 73 subjects to test 13 different drinks. Each subject tested water and three other beverages. At each session, the subjects drank a litre of the chosen beverage and collected their urine for the next four hours.

A "beverage hydration index" showed how much of that drink was retained after two hours compared to a litre of water.

Picture from American Journal of Clinical Nutrition

Looking at the picture above, you can see that a higher bar means more fluid retained. The dotted line represents twice the coefficient of variation away from water (meaning you can be real sure of a positive result).

The chart shows that milk stays longer in the body probably because of its calorie content. Milk and an oral rehydration solution (or sports drink, due to its calories and sodium) also stays in your system.

Personally, I was quite surprised that tea, coffee and beer did not seem to produce significantly more urine.

In fact coffee seems to have the lowest reading in the chart. The authors suggested that the diuretic properties of alcohol may be counterbalanced by its retention promoting calories (although another previous study that compared regular and alcohol free beer showed that regular beer drinkers had 12 percent more urine).

The authors also pointed out that larger doses of caffeine or alcohol may trigger more urine

Well, now you know not all drinks take the same time to reach your bladder. Choose your drinks wisely after your hard training session or race.


Reference

Maughan RJ, Watson P et al (2016). A Randomized Trial To Asess The Potential Of Different Beverages To Affect Hydration Of Different Beverages To Affect Hydration Status: Development Of A Beverage Hydration Index. Am J Clin Nutr. 103(3): 717-723. DOI: 10.3945/ajcn.115.114769.

Drink It or Pour It?

Picture by richseow from Flickr

You've often seen the elite athletes pour water over their heads to cool themselves while racing. So is it really better to pour the water over your head on a really hot day or is it better to drink it?

Picture by richseow from Flickr

Well, here are some numbers obtained in the paper referenced below. In the article, kilojoules and calories are a measure of the energy dissipated as heat. The heat is produced as a by product of muscular exertion, which is powered by the energy from food.

Drinking a 250 mL cup of water at just above freezing ( 1 degree Celsius or 34 degress Fahrenheit) helps you get rid of 39 kJ of heat (about 9 calories).

If you drink a slushie that is half water and half ice, it's better as the ice can melt inside your body. A 250 mL slushie will get rid of 81 kJ of heat (or 19 calories).

Pouring a 250 mL cup of water on your head will get rid of 607 kJ (145 calories) if the water can be spread around your body surface so it all evaporates rather than dripping to the ground. Yes, evaporation is a great way of dissipating heat.

But, that's a very big "if" in my opinion as it's hard to pour a bottle over your head without spilling any water. although the authors suggested that even if you spill 85 percent of the water you still get more heat loss from pouring than from drinking the slushie.

Do take note that the water you pour over yourself has to evaporate. If it's a hot and super humid day like it always is in Singapore where your sweat is dripping like there's no tomorrow you won't have the water evaporating. Pouring cold water over your head probably makes your feel cooler (and hopefully better) for a while.

It works best when the weather is dry and breezy so that your sweat can evaporate. (Local runners who race overseas take note).

My suggestion would be to drink when you need and pour some cold water over your head and neck too to cool off if you don't mind your running shoes getting a little wet.

Best to be sure it is water and not a sports drink that you pour over yourself. Yes, I've accidentally poured 100 Plus over myself before when I was racing, so beware.


Reference

Morris N and Jay O (2016). To Drink Or To Pour: How Should Athletes Use Water To Cool Themselves? Temperature. 3(2): 191-194. DOI: 10.1080/23328940.1185206.

A Running And Glucosamine Article I Do Not Agree With

ST 240516

"The point of journalism is to tell the truth. It is not to improve society. There are facts and truths that feel regressive, but that doesn't matter. The point of journalism isn't to make everything better; it's to give people accurate information about how things are." Sebastian Junger.

I've never started an article with a quote before, but the above quote caught my eye and I feel it is only fair to give our patients and readers accurate information about how things are (even though I'm not a journalist. Don't get me wrong I'm not blaming the writer, I just want to present an evidence based view.

Not another running bashing article - that was my first thoughts glancing through the papers today "When running wears out the knees (ST 240516). This is under DocTalk on page B10.

I totally did not agree with the author on that. There is more than sufficient evidence to show that running does not wear out your knees.

The author's article also quoted studies saying that 35 percent of patients taking a regular dose  of 1500 mg of glucosamine sulphate daily can increase cartilage regeneration.

May I kindly draw your attention to a Cochrane review where authors showed that glucosamine was generally safe to ingest but does not help with pain. I've written about glucosamine back in 2010 and 2009. Go and have read if you're keen.


Reference

Townheed T, Maxwell L et al (2008). Glucosamine Therapy For Treating Osteoarthritis. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CDOO2946.pub2.

Tendon Damage Linked To Antibiotics

Picture by Oliver.Dodd from Flickr

I thought my patient was kidding when he mentioned that his ruptured Achilles was due to his antibiotic medication. He had to have surgery repair his ruptured Achilles tendon and came to our clinic for treatment and rehabilitation.

I did a quick search and found that the US Food and Drug Administration (FDA) has (since 2008) made it compulsory for drug companies to put a warning label on the side effects of ingesting fluoroquinolone (FQ).

Now if you have taken antibiotics (especially fluoroquinolone), regardless of whether you're active or not, you might want to read on.

FQ are a popular class of broad spectrum antibiotics. They are able to kill a wide range of harmful bacteria and will often work against infections that are resistant to other drugs.They are commonly prescribed for sinus, chest, stomach, kidney and urinary tract infections.

Levaquin (levofloxacin) and Cipro (ciprofloxaxin) are the more commonly prescribed medications. Basically, beware of any antibiotic medications that end with floxacin.

FQ's are also ideal for joint and bone infections and Achilles tendinopathy (or wear and tear in the tendon) or rupture is among the most serious side effects associated with FQ use.

The average person taking FQ has a 70 percent greater risk of tendinopathy and a 30 percent greater risk for a full blown rupture compared to another person taking a different antibiotic. As the Achilles tendon has very little blood supply, it is more prone to injury. It is also the tendon most affected by FQ. The risk of Achilles tendon rupture is quadrupled with FQ. Other serious side effects include nerve damage, confusion and hallucinations.

I found enough data to suggest that FQ's should be used cautiously in a selected group of patients. Older male runners (> 60 years), people with kidney disease, those taking corticosteroid medications (commonly used to treat asthma) are the most vulnerable.

The higher your dosage and the longer you take the medication the greater the danger. The risk does not go away when you stop taking the medication. Tendon problems linked to FQ can appear weeks, months or even years later.

My take is if you're active and if you have sinusitis, bronchitis or a urinary infection, try and ask your doctor if you can take another class of antibiotics instead. This is another good reason to find a doctor/ physiotherapist who understands athletes and knows about your training. Personally I would avoid these medications if at all possible.

In instances where your infection does not respond to other medication and treatment you may still have to take FQ's. You may then have to adjust your training during and after the medication. You may have to cut back your mileage, hill running, intensity for up to nine months after taking FQ's.

Watch out for new pain in any of your lower limb tendons, especially your Achilles (although quadriceps, peroneal, hamstring and rotator cuff tendons have also been reported).

Remember to rest sufficiently after training to avoid picking up any colds that may lead to sinus and chest infections.


Reference

Kim GK (2010). The Risk Of Fluroquinolone-induced Tendinopathy And Tendon Rupture. What Does The Clinician Need To Know? J Clin Aesthet Dermatol. 3(4): 49-54. PMCID: PMC2921747.

Picture by Thirteen Of Cubs from Flickr

Super Full (Again) Today Despite The Heavy Storm

Are we starting yet?

Despite the very heavy downpour this afternoon, we had a super full crowd today. Normal enrolment for the course is 20 participants, we had close to 30 today. Some were late perhaps due to the heavy rain but we soon got the bands rolling ..... Pardon the pun.

Other than members of the public, personal trainers, strength and conditioning coaches, cross fitters, this time there were quite a few Physiotherapists from hospitals and private practices too.

There were some new slides presented today and those who attended the earlier two sessions can look them from up Prezi if they wish.

Once the theory part was out of the way, the practical started.

Lucie from In Touch Physio 

Lingo flossing Terence's wrist

Here's how I will floss Terence's wrist

Hmm Amos looks sceptical ....

Let's do the twist

Is that a smile from Terence?

Thank you to Amy and Danny for setting up everything despite the heavy rain and to Jane (who came from another event) for organizing the course. Next course will be on 9/7/16. Please contact Sanctband Singapore if you're keen to attend.

Too Much Lactic Acid Causes "Crystals" To Form In Your Muscles?

*What a load of  sh--!

One of my massage therapist asked me today if it's true that with too much exercise, lactic acid can form crystals in your muscles? His friend had been been told by a massage therapist that "crystals" can form in his muscles with too much running and no sports massage to "break the crystals."

This is the 3rd time in two weeks someone asked about this. The first two were my patients.

Apparently they had gone to this particular massage place and were told by the massage therapist there that if "the crystals" in the muscles were not "broken up" it's bad for them and they can't run well. The massage therapist(s) then WhatsApp their patients an article to read.

Now I find this really ludicrous to say the least. I've addressed this issue before. Massage does not flush lactic acid from your muscles.

Any textbook on Exercise Physiology (or you can check online) will explain that you can only accumulate lactic acid in your muscles during intense exercise (e.g. while racing or running intervals). As there is not enough oxygen available, a substance called lactate is formed. Our bodies then try to convert this lactate to energy without using oxygen.

However, this lactate or lactic acid can build up faster in your bloodstream than you can use it. The point where lactic acid starts to build up is called the "lactate threshold." So if you run just below your lactate threshold you won't fill the "burn" in your muscles.

That is what interval training is all about - trying the raise your lactate threshold so you can run at your race pace longer without incurring oxygen debt (or that burning sensation in your muscles).

This "burn" you feel is temporary. Once you slow down and/ or stop exercise, your body can then easily convert the lactic acid to energy. After a short while there isn't any more lactic acid in your muscles. The "burning" sensation in your muscles happen only during intense exercise.

Lactic acid clears very quickly on its own. By the time an athlete has a chance to "use" anything that claims to flush out lactic acid, the lactic acid is probably gone. You don't need help to dissipate it.

Lactic acid definitely does not cause soreness. The soreness you sometimes feel in your muscles a day or two (especially if you've pushed too hard) isn't from the lactic acid accumulation in your muscles. It's most likely delayed onset of muscle soreness or DOMs.

Back to my conversation with my colleague. He then said that his friend said that after a massage session there "to break his crystals" he normally can't run for three days! That's how sore he got. More likely how brutal or how heavy handed the massage therapist was.

When I was still racing, I get sports massage done so I can train/ run long and hard the next day and the day after and after. That's what the sports massage is supposed to do. Helping me to recover better so I can run long and run hard every day if possible. As an athlete, that's what I want to do. If I have to rest three days after a sports massage how do I get my training done?

So be very wary if your massage therapist or even physiotherapist tells you that that you need to "get your crystals broken" or that you need to flush the lactic acid out of your muscles.

*Thanks to my patient for forwarding the article to me.