Know Change Know Pain

Blue marker indicates cleat postion

My last patient yesterday came in to see me with anterior knee pain. This patient recently changed to a new pair of cycling shoes and started having knee pain since 15/10/18.

Despite resting for a few days, the anterior knee pain was still there after trying to cycle on 19th and 24th October.

This patient tells me "cycling is an almost daily affair" and spends a considerable amount on the saddle.

After asking my patient a few more questions and assessing thoroughly, I was convinced the pain was triggered after changing cycling shoes.

I'm reminded of a previous post back in 2012 when Rafael Nadal changed his tennis racquet in his quest to serve better. Tennis fans would clearly remember how Roger Federer had problems affecting his back after a racquet change in 2013. In fact, after an extended period on the sidelines because of an elbow injury Novak Djokovic had to make adjustments to his tennis racquet early this year as well.

Back to my cycling patient. Before my accident when Sports Solutions was still at 108 Amoy Street, I used to cycle to work and back daily. I was very aware of the riding position on my bike. Any slightest change in saddle height, stem length or "strange noises" on the bike I would be able to notice it quickly. If you ride you bike regularly enough, you'll know I'm not exaggerating.

Superficial Front Line

After treating my patient's Superficial Front Line, it's back to cycling yesterday (after treatment) and today albeit on the trainer first and a slight change in pedaling technique.

Able to ride yesterday and today

Don't try to make key changes to your cycling, running shoes, swim technique or golf swing etc right smack in your regular season if you're competing. Just like you wouldn't use a new pair of racing shoes without trying it way before the race.

In my opinion, it's much better to use the new gear after your time off at the end of your season after you've not been riding or running etc. Your body will not be so sensitive to the changes. This I've learnt the hard way.

White marks the spot

Just in case you're wondering, we do mark the insert inside the cycling shoe too.

Tensegrity Of The Spine

Lining up half the participants to compare their necks and backs

After Aized and Rachel did Arches and Legs last week, it's the turn of the three amigos this this two days as we do "Tensegrity of the Spine" over the next two days.

Range of movement in the spine

This course is very intense and heavy going as there's a lot of rationale behind the theory involved. Everyone (yes, you read correctly) got lost at some point today, including yours truly.

Let's hope we get a clearer picture tomorrow.

The Amazing Fiona Oakes

Picture from Livekindly.co

I've never heard or read about Fiona Oakes before. Until my wife told me about her two days ago. She is so unassuming, humble and in her own words "I'm not really a runner". Actually she is a fantastic runner. Fiona Oakes is the fastest woman in the world to run a marathon on all seven continents and the north pole both in cumulative and elapsed time.

I thought I had it bad when I've had three knee operations before but Fiona has had seventeen knee operations and no patella (or knee cap)! Can you even imagine the rehab she has had to go through?

She was told when she was fourteen that she would find it hard to walk properly, let alone run again. It is truly amazing that she is still able to run so well. All this while being a vegan who eats one meal a day while while running an animal sanctuary.

So maybe we really don't need to eat meat and definitely not the sports and dietary supplements that are being marketed at us.

Watch the video, her partner Martin wonders how she can wake up at 3:30 am to start feeding the animals, run 20 km, come back and work all day cleaning and tending to the animals.

This just shows that the human body is truly resilient, amazing and and can perform really tremendous feats when there is a bigger cause (saving animals in Fiona's case).

If you're a runner, you have to watch the film, it's free until tomorrow.

*In case you're wondering why her running shoes look odd (I did) in the Marathon Des Sables, she's taped them up to avoid them falling apart.

Does Exercising Later In The Day Affects Your Ability To Sleep?

Zzz after a hard ride ...

I've written before in a previous post that I'm a poor sleeper. If you're like me, when I pushed myself too hard at training, I actually found it harder to fall asleep. The more I need (and want it), the harder it is for me to get it.

And sleep you know is critical for your mental and physical well being. If you're athlete, sleep is the easiest and cheapest intervention you can utilize to help your performance.

Hence, I was quite intrigued when I saw work from researchers who tested the effects of whether morning or evening workouts will affect your sleep by measuring melatonin levels. Melatonin is a hormone secreted in the pineal gland that regulates sleep and wakefulness.

Melatonin levels start to rise around your bedtime. It helps to lower your body temperature (now you know why it's so hard to fall aslleep when it's been so hot recently) and a rise in sleepiness. Melatonin levels usually peak around 3 am for most people.

The volunteers in the study were tested on three different days. A day with no exercise, a day when they exercised at 9 am or another at 4 pm. Their workout was a 30 minute  run at 75 percent VO2 max. Melatonin levels were measured with a saliva test at 8 pm, 10 pm and 3 am.

The results showed that those who did the 4 pm exercise session had much lower melatonin levels at 10 pm and 3 pm compared to the 9 am exercise group. It means that those who exercised in the afternoon (or those of you who can only train after work) will have a tougher time falling and staying asleep. End of story, period?

Not really. Don't worry if you're like most other Singaporeans who mostly have time to train only after work hours.

Melatonin is just one part of the equation in your quest to fall and stay asleep. Melatonin levels may not be the main reason why you cannot fall asleep.

For you to get a good night's sleep, it may depend on what you you eat/ drink, the wavelength of light emitted by your smart phone, the temperature of your room, your exercise routine/ intensity and not just your workout time rather than just your melatonin levels.

If you're going for a "relaxing" evening run, and clearing your head over stresses you've encountered during the day, it's gonna be a lot easier than doing sprint intervals. Although some runners may even say that the intervals make them tired and thus make them sleep better. This alone may be far more important than melatonin levels.

Another factor that is not addressed in the paper by the authors is whether genetically you are a "night owl" or a "lark"? The New York Times has a good article on how there's a strong basis on a person's natural inclination with regards to the times of day when they prefer to sleep or when they're most alert.

Some of you reading this now (after exercising late in the day and not sleeping) are likely to be "owls" and not likely to get up early to exercise since you sleep later. This may may due to your circadian wiring rather than exercise timing. So shifting your exercise timings to the morning may "rob" you of your morning sleep without helping you to fall asleep earlier.

Reference

Carlson LA, Pobocik KM et al (2018). Influence Of Exercise Time Of Day On Salivary Melatonin Responses. Int J Sp Physiol Perform. 30: 1-13. DOI: 10.1123/ijspp.2018-0073.

*Picture by Jeremy Ong

First She Wins 100 Km Race, Now PS Summits Cho Oyu (8201 Meters)

Remember PS, winner of the Cameron Ultra-Trail 100 km race who saw me for her plantar fasciitis three days before her race on 25th July 2018?

Here's another feather to her already impressive list of achievements. She recently climbed to the top of Cho Oyu, a 8201 m high mountain!

She sent me this message last night. Still pain free after seeing just two times for her plantar fasciitis. Once before Cameron Ultra-Trail 100 km race and once after she came home from the race.

Well done PS!!! Come home safely soon.

Popping Vitamins Or Other Dietary Supplements?

I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


References

Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.

PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.

Mid Life Crisis In The Older Athlete?

Singapore National Games 2012 by RS from Flickr

I had a patient who recently turned 50 years young and decided that she would like to finish running a marathon. She had never ran much before (unless you count physical education classes in school) and she would consider herself pretty much inactive previously. She started training with a local running group, and within 6 weeks of training got injured and ended up seeing me in our clinic.

Here's a trend I've been noticing, a fair bit of participants in local races are above the ages of 40. I just looked up the results of the 2017 Singapore Triathlon and the 2018 Singapore OCBC National Road Race Cycling championships. The 40-49 age group has the largest number of participants and among the most competitive. I didn't look up the statistics, but with the number of participants we've treated in our clinic, I'm sure this is similar for the Spartan races too.

If you look up the 2018 Boston marathon results in April this year and last year's New York marathon the statistics are similar.

Research backs this up too. A research paper by Hoffman and Fogard (2012) found that the average age of participants in a 100 mile trail race was 44 years.

My 50 year old patient calls this urge to run her her first marathon her "mid-life crisis". I looked up "mid-life crisis". This concept was first presented in 1957 by Canadian psychologist Elliot Jacques to the British Psychoanalytical Society and later published as "Death and the Mid-life Crisis" in the International Journal of Psychoanalysis in 1965.

His theory was that as we approach middle age, we begin to realize our own mortality (or death) and we begin to freak out. As we grow older, we start to focus on how much time has passed, how much is left and what to do with whatever time is left. That can create anxiety and that anxiety can be multiplied by anxiety, depression and stress.

My 50 year old female patient says that unlike what you usually read or see in movies (where the older white guy buys a sports car and dates a younger girl in a desperate bid to feel young again), her "mid-life crisis" is to take on physical challenges.

Her goal is not to cling on to whatever is left of her "youth" or be young again. It is more about building up for the years ahead. Sounds like a good mid-life crisis to me.

Whether you are a young and older athlete, and starting a new game or beginning to exercise, pace yourself and start gently. There are big benefits from minimal running. However, if you do get injured, come and see us in our clinics.


Reference

Hoffman MD and Fogard K (2012). Demographic Characteristics Of 161-km Ultramarathon Runners. Research in Sp Med. 20(1): 59-69. DOI: 10.1080/15438627.2012.634707.