Sunday, May 21, 2017

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck
I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement
Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.


Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Saturday, May 13, 2017

Rachel Plays Her Part Helping VJC Win 5th Straight Football Title

On Sunday night (7/5/17), my colleague Rachel asked me if she could leave work early on Tuesday 10/5/17. She wanted to watched her alma mater play in the 'A' division girls football final against Meridian Junior College.

Rachel was top scorer before in her time at Victoria Junior College (VJC) when she herself represented VJC. As I wrote previously, she scored a hat trick when VJC beat my alma mater's team 10-1 in the semi finals of the same tournament eight years ago.

When I introduced her to a physical education teacher from the losing school, he immediately remembered the trashing our school received and he was in awe of her. Still famous as ever eight years on. Well done Rachel!

Of course she could go! She had been volunteering her time (with the clinic's blessings) most Wednesday's afternoons at VJC since the beginning of the year.

On days before a match, if you come to our Holland Village clinic you might be lulled into thinking VJC was near our  clinic (and not in Marine Parade) or that our clinic was a mini VJC gathering place.

Definitely businesses near our clinic like Sunday Folks and The Daily Scoop have benefited when the students come for treatment as they go there after treatment.

So congratulations to VJC for the fifth consecutive football title and Rachel Wong for a job well done!
Rachel with the victorious team.
Note: Rachel also treats students competing in other sports and not just the girls from football. So perhaps next year we'll see more VJC students in our clinic this time of the year?

Saturday, May 6, 2017

Eccentric Exercises

Ting Jun and Rachel going down stairs outside our clinic
I was talking with a patient of mine earlier who exercised by climbing up and going down the stairs at his 40 storey flat while carrying a 16 kg backpack. He knew about my past results climbing stairs and wanted to know why walking down a flight of stairs seems to be more effective at building his muscle strength than walking up the same flight of stairs.

Going down the stairs with his 16 kg backpack meant he had to really control his step and lower himself down slowly rather than just letting himself go. This meant that he was doing an eccentric exercise.

Say you want to train your biceps (arm muscles). When you bring the dumbbell up, the muscle is shortening, that is also known as a concentric muscle action. If you lower the dumbbell slowly (which is more difficult), the muscle is lengthening or an eccentric muscle action.

Eccentric exercises are more demanding on the muscles and fatigues then far more than concentrically. It also damages (or breaks down the muscle) to a greater extent, so there is greater stimulation and subsequent growth.

Try this if you want get better leg strength in a shorter time. Bend your legs more deeply when going down stairs of hills. Your legs will be sore from DOMs or delayed onset of muscle soreness. Once your muscles recover (after a few days), they'll be stronger and it will require much more eccentric exercises to get the same effect.

In fact, this was exactly what researchers found in a group of elderly men with chronic heart failure. Going down stairs appeared to be easier and more pleasant compared to the climbing stairs which the subjects found to be more demanding.

Changes in muscle strength were similar or even greater when going down stairs compared to going up stairs after six weeks of training.

To put this into practice, try bending your legs more deeply when going down stairs or slopes, lower your body more slowly doing push ups or pull ups. You'll be amazed at the results ..... after recovering from  the soreness.


Theodoru AA, Panayiotou G et al (2013). Stair Descending Exercise Increases Muscle Strength In Elderly Males With Chronic Heart Failure. BMC Res Notes. 6:87. DOI: 10.1186/1756-005-6-87.

Sunday, April 30, 2017

Retired Pharmacist Comes To Kinesio Taping Course

I forgot to mention yesterday that we have Mrs Chong, who's a grandmother (and trained pharmacist) at 73 years young attending the course with her daughter Alyce.
Mrs Chong in action
Mrs Chong's granddaughter (and Alyce's daughter) competes in gymnastics and equestrian and both of them decided to come and attend the course together (to bond) and to be able to tape competently for their granddaughter and daughter respectively. Now that's real love.

By the way, Mrs Chong also paints, takes many other classes and still takes exams to keep her pharmacist license.

I really respect Mrs Chong's attitude. Note to self - never stop learning.

Back to the course and the day started with some questions on whether participants left their tape on overnight (and many did) and what they felt. None reported any adverse reactions

We continued Day 2 of the course learning all about the six different corrective techniques in Kinesio Taping. Mechanical correction, fascia correction, space correction etc.

A few of the participants brought along different brands of tape to try and none (according to the participants) matched the high standards of the Kinesio FP tape.

Check out the "Heroll" tape

Here are some pictures from the course.

Theresa and her amazing technicolor dream tapes
Both the netball coaches admiring a Team Singapore attire?
Group picture of the participants

Saturday, April 29, 2017

Explaining About The Homunculus At The Kinesio Taping Course

Sports Solutions hosted the Kinesio Taping Level 1-2 course today and no surprises, the course was fully subscribed.

It was bright sunshine after the early morning storm and the day started with explaining the science and rationale behind how Kinesio Taping works.

After my own learning journey from the Anatomy Train courses, lessons from Andrew Hutton, Flossband (with Sven Kruse) and David Butler, I can definitely explain and teach the course better. Well, I'd better because I had to explain what the homunculus was to the class.

Teaching the homunculus
Of course we spent some time going through anatomy and surface landmarks.

Palpating for C1 after finding the mastoid process
Finally after all the talking, it was time to tape.

All eyes and ears
Stay tuned for Level 2 tomorrow.

Sunday, April 23, 2017

Don't Ignore That Ankle Sprain

Now that's a nasty ankle sprain
We've seen quite a few cases of ankle sprains in our clinics recently. Most of these patients are young school athletes representing their school or participating in sports.

We've always managed to get our patients playing/ competing again quite quickly. Even ankle cases that were deemed serious, we've managed to get them up and running so quickly that their parents/ coaches were pleasantly surprised.

Hence I was surprised to read that ankle even if sprained only once but not treated properly can have lifelong consequences. Especially if the sprains keep recurring.

In the study referenced below, the researchers had students who had chronic ankle instability (caused by ankle sprains) wear a pedometer for a week. Their steps taken were compared with a control group of students who had normal ankles. Gender, BMI and general health were the variables controlled in both groups.

Turns out that the students with chronic ankle instability moved significantly less than the other group. They took about 2000 steps fewer on average.

The researchers were concerned with the obvious decrease in step count as this decrease may be secondary to other functional limitations. If this decrease in physical activity continues for an extended period,it may lead to other more substantial heal risks.

Next time you sprain your ankle, make sure you get it checked and treated properly, even if it seems to be mostly healed as it can lead to lifelong consequences.


Hubbard-Turner T and Turner MJ (2015). Physical Activity Levels In College Students With Chronic Ankle Instability. J Athl Trg. 50(7): 742-747. DOI: 10.4085/1062-6050-50.3.05.

Note to self and my colleagues: be wary even of a simple ankle sprain

Friday, April 14, 2017

Is It Necessary To Cool Down After Exercise?

Stretching after a run in the rain
Back when I was working at the old National Stadium, I'll very often before work or during lunch time run on the track or grass surrounding the track.  Straight after I was done, I'll head right in to the clinic. A person walking past commented how I could do that.

I said I just stopped after running and am heading for the showers as my next patient was due soon. He said I should be doing a cool down after such a hard run.

Well, I was in a hurry to get ready for my patient. I'm sure the patient wouldn't like a sweaty, dripping physiotherapist treating him.

Looking back since primary school, I recall our physical education teachers telling us that we need to cool down after exercise and especially after a race/ competition.

Personal trainers will tell their clients that slowing to a jog and/ or lessening the intensity of the workout followed by stretching to transition out of the exercise session so as to prevent muscle soreness and improve recovery.

Some exercise machines in the gym automatically include a cool down period. After your work out time that you keyed in, the machine automatically reduces the workload and continues for five minutes so you can cool down.

I tried looking for scientific evidence regarding that and it seems none of those beliefs were true.

A study had subjects do a strenuous one time session of forward lunges while holding barbells. This is certain to make untrained people extremely sore due to DOMs over the next few days.

Some of the subjects warmed up before by cycling 20 mins gently. Others didn't warm up but did a cool down after the lunges with a similar 20 mins of gentle stationary bike riding. The rest of the group just did the lunges without warm up or cool down.

The next day, the subjects who warmed up had the least pain while there those who did the cool down and the control group had similar pain. Cooling down brought no benefits to the group.

Two other studies I found on professional football players performing cool down versus no cool down yielded the same result. Measures of performance, flexibility and muscle soreness were similar.

One valid reason to cool down after exercise is to prevent venous pooling (or build up of blood in your veins) after vigorous exercise. Blood vessels in your legs expand during prolonged vigorous exercise, allowing more blood to move through them to supply oxygen. When you stop exercise abruptly, the blood stays in your lower body. This can lead to dizziness or even fainting.

It's easy to avoid venous pooling, just keep walking for a few minutes at the end of your workout/ race and you'll maintain normal blood supply to the brain. Would you consider that as a cool down?

So, there's no real published research showing any negative effect if you don't cool down. If you are used to performing a cool down after your exercise, you can definitely carry on. If you don't feel like it, then you probably don't have too.

Unless future research shows otherwise, don't worry if your friend/ trainer/ coach tells you that you need to cool down after exercise.


Olsen O, Sjohaug M et al (2012). The Effect Of Warm-up And Cool Down Exercise On Delayed Onset Muscle Soreness In The Quadriceps Muscle: A Randomized Controlled Trial. J Human Kinetics. 35: 59-68. DOI: 10.2478/v10078-012-0079-4.

Rey E Lago-Penas C et al (2012). The Effect Of Immediate Post-training Active And Passive Recovery Interventions On Anaerobic Performance And Lower Limb Flexibility In Professional Soccer Players. J Human Kinetics. 31: 121-129. DOI: 10.2478/v10078-012-0013-9.

Rey E Lago-Penas C et al (2012). The Effect of Recovery Strategies On Contractile Properties Using Tensiomyography And Perceived Muscle Soreness In Professional Soccer Players. J Strength Cond Res. 26(11): 3081-3088.