Magnesium Supplements For Muscle Cramps?

Available from my local pharmacy

A patient came in today saying she went to a local running store and was advised to take some magnesium supplements as she cramps occasionally while racing. So she went ahead and bought some. She wanted my thoughts on whether they truly work since they seem to be the latest "silver bullet" that most runners seem to be taking.

Magnesium is an essential nutrient that's actually found in many of the foods we're already eating. It is actually abundant in our bodies. Our bodies need it to create new proteins, for energy production in cells, DNA synthesis etc. As it is essential, our bodies store it in our bones, where it can easily be accessed if needed. Since our bodies cannot produce it, we need to get it from our diet.

An adequate magnesium is needed for a healthy pregnancy and to produce enough milk after giving birth. It is also useful if you take diuretic drugs, proton pump inhibitors and if you're diabetic.

It is suggested that adults need 300-400 milligrams a day and you will get enough if you eat enough legumes (chickpeas, black and kidney beans), nuts, seeds, veggies (broccoli, cabbage, asparagus, kale and spinach), fatty fish (tuna, salmon and mackerel) and some fruits (avocado, bananas, figs, guava and raspberries).

It is estimated that 10-30 percent of people in developed countries may have a mild deficiency in magnesium (DiNicolantonio et al, 2018). Severe deficiencies are uncommon but easy to spot. Symptoms include loss of appetite, vomiting and fatigue and following that numbness, muscle cramps, seizures, personality changes and heart artery changes if the deficiency continues.

It is why those who sell these supplements tell athletes to take them - to prevent muscle cramps! But note that the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Note that the muscle cramps that occur when you have a magnesium deficiency happens with activities of daily living (not while exercising/ racing). Not only the muscles in your feet and legs cramp, but also your facial and masticatory (chewing) muscles.

Those who sell magnesium tablets, body sprays, serum and bath salts will tell you their products will boost recovery, energy levels and promote DNA synthesis, bone strength and other important body functions. When something sounds too good to be true, it probably is. If you eat a healthy diet of the food listed above that is rich in magnesium, then you wouldn't need any magnesium supplements.

You will not benefit from taking magnesium supplements unless you're deficient. This can only be verified via a blood test.

If you are lacking magnesium, you can either eat food sources rich in magnesium or take supplements. There is no evidence that any form of magnesium (whether it is magnesium oxide, aspartate or citrate) is more easily absorbed by our bodies. So don't buy the most expensive brand or version of it.

As for magnesium creams, oils, sprays, flakes and bath salts etc, evidence suggest that they are not as effective as claimed (Grober et al, 2017).

So if you have done a blood test and have a magnesium deficiency, load up on magnesium rich food or go ahead take a cheap supplement.

"So that means I wasted my money" went my patient? Now you know. And you've read what causes muscle cramps.


References

Grober U, Werner T et al (2017). Myth Or Reality- Transdermal Magnesium? Nutrients 9(8): 813. DOI: 10.3390/nu9080813.

DiNicolantonio JJ, O'Keefe JH et al (2018). Subclinical Magnesium Deficiency : A Principal Driver Of Cardiovascular Disease And A Public Health Crisis. Open Heart. 5:e000668. DOI: 10.1136/openhrt-2017-000668.

Shin Splints Back In 1415!

R shin(top) shows obvious wear

I had a runner who came to see me this week. She had recently done a marathon in Australia and recently got back to training again after a break. She said she had been asking a fellow runner with shin pain to come see me. This friend of hers had been suffering from shin splints for the past six months!

Just in case you thought that was long. I saw an article that showed a case of documented shin splints from way back in the year 1415. Yes, you read correctly, it's 1415.

Researchers found a skeleton from a graveyard in Greece that showed medial tibial stress syndrome (or shin splints). They estimated that the man died between 500-800 years ago and was between 20-30 years old.

The researchers mentioned that shin splints are commonly thought to be an exercised induced injury. and that shin splints are most common in new runners.

Osteoarthritis in the ankle

The skeleton also showed signs of osteoarthritis in the ankle joint (which is rare); this suggest that the man probably engaged in some repetitive loading of his lower limbs. An indication that perhaps even in those days they participated in running as well.


Reference

Protopapa AS, Vladchadis N et al (2014). Medial Tibial Stress Syndrome: A Skeleton From Medieval Rhodes Demonstrates The Appearance Of The Bone Surface- A Case Report. Acta Ortho 85(5): 543-544. DOI: 10.3109/1753674.2014.942587.

My Patient Was Told Her Knee Alignment was "Off"

Have a look

My patient came in complaining of pain in both her knees after running. She had been to another physiotherapist who told her that her "kneecap alignment was off". He proceeded to give her some strengthening exercises for her quadriceps and asked to return for another session. He checked on her exercises and did some ultrasound and "electric current" therapy.

After the two sessions, she didn't get any better doing the quadriceps exercises and was referred by her friend to see me. I told her that all of us have highly variable alignment in our knees and she shouldn't worry too much about what the other physiotherapist told her.

Yes, just in case some other healthcare professional tells you the same, there is a very good article published on this topic. In fact the article is a systematic review, which means a search aided by computer for all randomized and clinically controlled trials. When it comes to quality, there is none higher than a systematic review or meta-analysis.

The systematic review concluded that healthy knees have a highly variable alignment, although this may be due to variables when doing x-rays/ MRI scans, measuring techniques and the people studied.

The exact role of knee joint alignment in development of knee pain/ symptoms remains unclear.

So we should not be telling patients that their knee joint alignment is in any way abnormal at all, not if we do not even know what normal alignment is.


Reference

Hochreiter B, Hess S et al (2019). Healthy Knees Have A Highly Variable Patellofemoral Alignment: A Systematic Review. Knee Surg Sp Trauma Arthr. pp 1-9. DOI: 10.1007/s00167-019-05587-z.

Is this knee's alignment abnormal?

I know some of you will be asking what did I do to make my patient better? After assessing the knee joint, I usually make sure there is no hip dysfunction or shortening in the calf muscles. In this particular patient's case I started with her Superficial Back Line (SBL) and her Spiral Line.

Superficial Back Line

Since she runs, I made sure I checked her running style/ technique too.

Spiral Line

My Patient Has A Cyclops Lesion!

How the cyclops lesion looks on MRI

Two to three months after her anterior cruciate ligament (ACL) reconstruction, my patient presented with pain at the front of the knee especially when trying to straighten her knee. There is sometimes an audible clunk with the  straightening.

Her quadriceps muscles were weakened and she can't straighten her knee fully. There is often mild swelling too. There is also some soreness at the back of knee in the hamstrings and calf area.

If you haven't read the heading above, would you be able to guess what problem my patient has? There is a 4 percent chance of this happening after an ACL reconstruction.

For those not familiar, a cyclops lesion is usually a localized form of arthrofibrosis (or scar tissue) in the front of the knee joint. The cyclops lesion is a stump of tissue at the front portion of the intercondylar notch, which sits above the tibial tunnel that is drilled for the graft. The cyclops lesion usually gets impinged between the tibial and femur when straightening the leg.

intercondylar notch

How does the cyclops lesion come about? One theory suggest that it may be a remnant of the previous torn ACL stump that remained after surgery. Another theory suggest it may be fibrocartilage formed after drilling the tibial tunnel or from broken graft fibres.

Femur on top of tibia

There is also some evidence to suggest that the cyclops lesion may be a result of inappropriate surgical technique during the ACL reconstruction (Delince et al, 1998). So make sure your choose your surgeon carefully.

So how do we manage the cyclops lesion for the patient? Best way to avoid getting it is to work on regaining full knee extension immediately after the operation.

Once the tell tale signs are present (in the first paragraph of this article), not much else can be done. Yes, you read correctly, there's nothing much a physiotherapist can do. From experience, no amount of pushing, joint mobilizations, exercise or injections etc will help.

The only available option is to refer the patient back to his/ her surgeon to order an MRI to rule out or confirm the cyclops lesion. If it is a cyclops lesion, the best and actually only option is to have a knee arthroscopy and remove that naughty piece of scar tissue. This has shown to have good results (Sonnery-Cottet et al, 2010), especially if aggressive straightening commences after removing the cyclops lesion.


Reference

Delince P, Descamps PY et al (1998). Different Aspects Of The Cyclops Lesion Following Anterior Cruciate Ligament Reconstruction: A Multifactorial Etiopathogenesis. Arthroscopy. 14(8): 869-876.

Sonnery-Cottet B, Lavoie F et al (2010). Clinical And Operative Characteristics Of Cyclops Syndrome After Double-bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy. 26(11): 1483-1488.

Picture from kneeguru.co.uk

Who Says Slouching Is Bad?

 Not all slouching is bad!

How many of you have been told that you have bad sitting or standing posture? Or it is incorrect to bend your back while lifting.

The fitness industry publicly recommends protecting your spine. A lot of personal trainers will often tell you that the "core" muscles of your spine must be consciously activated to maintain a "correct" posture to protect your spine. They also give advice about "good form" during weight training and after as well.

Sit up straight - Nah not for everyone

Well, fret not, as evidence is now suggesting that there is no perfect posture. Or at least there is no one posture that fits everyone.

Despite there being a lack of strong evidence that low back pain is caused by sitting, a huge business that claims to improve posture has grown. Many of these companies provide products and interventions claiming to "correct your posture" and help prevent pain.

In addition, there are fear inducing messages in the media that by avoiding incorrect posture like slouching, pain can be avoided.

Unfortunately, many health care professionals provide advice along this non evidence-based practice too. It is generally agreed by health care professionals that avoiding spinal flexion is the safest way to sit and bend.

Yes, awkward postures and lifting something heavy may indeed cause some episodes of acute low back pain. Indeed, some links between lifting and injury have been reported. Despite all these widespread beliefs about correct posture, research has not shown that avoiding incorrect posture prevents low back pain or that any single curve in your spine is strongly associated with pain.

Even though there is evidence that people with low back pain find certain postures provoke their pain, it cannot be concluded that these postures causes pain (Slater et al, 2019).

There is also no evidence to support posture assessment or screening for pain prevention in the work place (Slater et al, 2019). Ouch! There goes all the "ergonomic" screenings/ assessments done by physiotherapists down the drain. Fortunately, our clinic does not do any of these ergonomic assessments.

People come in many different shapes and sizes, with normal variation in their spine curvature. Depending on how your spine is shaped, you will have your own preferred lifting technique and sitting style.

Advice and suggestions given by physiotherapists and other health professionals can lead to fear and encourage hyper vigilance/ paranoia.

Despite a lack of strong evidence that "sitting up straight" prevents pain, asking our patients to work hard to achieve that may set them up for failure and cause more anxiety when their pain persists.

Prior to reading this article (Slater et al, 2019), I too am guilty of telling patients to sit up straight.

Movement and changing positions can be helpful since sedentary lifestyles are a risk for low back pain. However, we should not perpetuate worry that sitting for more than 30 minutes in one position can be dangerous and should be avoided (Slater et al, 2019).

We should in fact help people to sit, stand and move more easily. Comfortable postures vary among all of us and patients should be encourage to try different postures. A position that hurts now may not hurt in future.

Moving ahead, there will be challenges to change the idea of having one "correct" posture. Evidence does not support this view and "core" beliefs held by physiotherapists, personal trainers, doctors and society.  40 years ago, bed rest was prescribed for low back pain. Evidence now shows that bed rest is definitely not an appropriate recommendation anymore.

Our spine is strong, robust and adaptable. A campaign to change this may encounter resistance even in the physiotherapy and ergonomic professions as their business model may not be in line with what we now know to be best practice for managing low back pain.


Reference

Slater D, Korakakakis V et al (2019). "Sit Up Straight": Time To Re-evaluate. JOSPT. 49(8): 562-564. DOI: 10.2519/jospt.2019.0610

Please email me if you want the article.

Run Longer Or Run Faster?

Picture by Richseow from Flickr

Your coach many plan a different variety of training runs for you. You can do a steady long run, threshold runs, add in some fartleks, some hard core intervals / HIIT and of course the recovery runs.

However, it boils down to really just two options if you want to fitter and faster. You can train harder with a higher intensity or you can train more. In an ideal world, I would run long and run hard daily. That doesn't happen of course, otherwise injuries would soon be knocking on your door.

Those two variables, intensity and volume are the "bread and butter" of all training programs for running, cycling, football, all sports really. Sports psychologists would add mental skills training to the mix.

If we had to choose one, which is better? Which gives you more bang for your buck?

That was exactly what two groups of researchers were debating over a recent article published recently. The paper investigated whether exercise intensity trumps volume to promote increases in skeletal muscle mitochondria (power generators of our cells).

With more mitochondria in our cells, the stronger we become, so the debate was whether running faster or running longer is better at boosting endurance.

Nice to do a long run here

Those in favor of high intensity training explained that when comparing training programs where subjects do an equal amount of work, those training at higher intensities and lower volume see the biggest gains in mitochondria. That group also suggested that vast majority of people are unwilling or don't have the time to spend long periods of time doing high volume training anyway (Gibala et al, 2019).

The second group of researchers presented evidence of a combined analysis of 56 studies that showed a strong relationship between total training volume and mitochondrial changes suggesting that volume is really the key variable (Bishop et al, 2019). That same analysis did not find any significant relationship between intensity and mitochondrial changes.

The second group also conceded that higher intensity exercise will result in a greater mitochondrial response per minute of exercise. This is a crucial point as we live in a time where everything competes for our time and attention. Getting stronger and fitter in less time may be more efficient for people to meet their fitness goals (Gibala et al, 2019).

In competitions however, we race to see who can be the fastest runner, cyclist etc, not who spent the least amount of time training. Those of you who train to race would definitely do a combination of long slow distance, interval/ HIIT training and medium paced runs. I did all of the above anyway when I was still competing.

And I can tell you many roads lead to the podium. Since both intensity and volume helps trigger mitochondrial adaptations, you should do which you enjoy and helps you improve more.

There are times I really enjoy the camaraderie of doing long runs and long rides. However I also love that adrenaline rush, the release of endorphins I get when putting the hammer down while running or cycling hard.

If you do the same long slow runs or interval training over and over again, it will eventually lead to diminishing returns. Or it will drive you crazy. I know I will go nuts if I just do long slow distance and nothing else.



References

Bishop DJ, Botella J and Granta C (2019). Cross Talk Opposing View: Exercise Training Volume Is More Important Than Training Intensity To Promote Increases In Mitochondrial Content. J Physiol. DOI: 10.1113/JP277633.

MacInnisMJ, Skelly LE and Gibala MJ (2019). Cross Talk Proposal: Exercise Training Intensity I More Important Than Volume To Promote Increases In Human Skeletal Muscle Mitochondrial Content. J Physiol. DOI: 10.1113/JP277634.

I wish I can fly ....

You Definitely Do Not Need Extra Sodium Supplementation, Not Even In Hot Conditions

A few weeks ago I wrote about why it is not necessary to consume sodium to prevent muscle cramps. That post was popular as many runners shared it.

Well, here's further proof and confirmation that you do not have to consume sodium, even in a long ultra marathon.

Researchers found that majority of ultra runners (66 percent) in a race feel that sodium supplements should be made available at aid stations to prevent hyponatremia  and muscle cramping.

Previous research shows that consuming extra sodium does not prevent cramps, dehydration or nausea. Findings actually show that excessive sodium consumption can lead to the extra sodium left as residue on your skin and clothes. This is commonly seen as a white deposit left on your skin especially after a long training session or race.

After you consume too much sodium, it may lead to drinking too much water causing hyponatremia. Trust me here, as I'm guilty of this actually. I spent 2 days in the intensive care unit of a Hong Kong hospital when I had hyponatremia during a 100 km race in November 2000.

The researchers also found that a typical race diet (sports drinks, gels and bars) will usually provide enough sodium for your needs. Moreover sodium itself is not a source of fuel that can help sustain your efforts.

The researchers concluded that that study showed that no sodium supplements are required for ultra marathons in hot conditions lasting 15 to 30 hours (Hoffman et al 2015).


References

Hoffman MD et al (2015). Sodium intake During An Ultramarathon Does Not Prevent Muscle Cramping, Dehydration, Hyponatremia, Or Nausea. Sp Med Open. 1(1): 39.


Hoffman MD  and White MD (2019). Belief In The Need For Sosium Supplementation During Ultramarathons Remains Strong: Findings From The Ultrarunners Longitudinal Tracking (ULTRA) Study. Appl Physiol Metab. DOI: 10.1139/apnm-2019-0238.