Wednesday, 28 February 2007

Medial Collateral Ruptured!

She was running down the hill slope when she landed her foot into a small hole and felt something snap and felt a sharp pain in the inner part of her left knee. She fell over and grimaced in pain. Her athlete quickly took her by the shoulders and helped her up to the clinic at the sports complex.

Elaine knew that her knee was in bad shape. She could hardly stand properly and the knee seemed to be twisted outwards. 10 years ago she had an injury to the same knee but she could still walk with little support.

"Looks like you've really torn your medial collateral ligament", I said to her. We quickly got her to ice the knee and prepared her file for physical examination. She had the full range of movement(ROM) which was quite 'pain-free' but she had severe tenderness and moderate swelling at the femoral attachment of the MCL. There was mobility of the leg when it was stressed outwards. Her tests for Anterior Cruciate and Posterior Cruciate ligaments were normal. She was lucky that there was no joint effusion (swelling in the joint due to accumulation of fluid e.g. joint fluid, blood, pus).

"Your MCL is complete torn clinically, but you should be back in 2-3 months time with rehabilitation if nothing else is torn", I said. She was given a functional knee brace and sent for an X-ray. Her X-rays came back normal except for the fluid shadow. We planned her for an MRI within the next 3 days to ensure that the other structures like meniscus and cruciate ligaments were not torn.

She was told to continue icing her knee every 4 hourly and focus on isometric exercises for her quadriceps and hamstrings for the next 1 week. Zul, the physiotherapist was quick to show her the rehabilitation chart. He told Elaine that she would need to progress in stages as she improves her strength, stability and function of her knees. he also planned hydrotherapy sessions for her to maintain her 'aerobic' fitness

Sunday, 25 February 2007

Basics in First-Aid

Rest: Modified your physical activity to reduce or stop moving the injured part to ensure that you do not worsen the injury. You could do so by reducing the intensity and duration of training. If the injury is serious, you may have to stop training altogether.

Ice: Apply a towel on the injured part before you apply a bag of crushed ice or ice cubes. Do not apply ice directly on skin and do not wrap the crepe bandage too tightly as this may cause cold burns. Only apply for 15-20 minutes and you may repeat the procedure every 4 hourly if swelling and pain remains.

Compression: Apply a crepe bandage to compress the affected part to reduce swelling. Do not wrap the bandage too tightly as it may interfere with blood circulation. Check by pressing the fingers and you should see the colour return immediately. Often the athlete will tell you that he/she has more pain due to a very tight compression strangulating the blood supply.

Elevation: Keep the affected limb elevated above the level of the heart to 'drain' the swelling and hence reduce pain. As long as there is still visible swelling this may be beneficial.

Saturday, 24 February 2007

Footwear and my feet

I don't really look at the price of the pair of running shoe when I go shopping for one. More often than not, I would already have an idea of a reputable shoe manufacturer. My brother and I both have flat feet and overpronation. For obvious reasons, we would look for something light, breathable, durable, an insole with proper arch support, semi-rigid mid-sole with good stability. However, my requirements are generally for running on the treadmill and some cycling. Even my working leather shoes are selected with such specifications to allow me to occasionally jog down the alley when I need to. I have a 2 pairs of running shoes, 4 pairs of costly leather shoes and another 2 pairs of cheap shoes.

Every athlete should find out whether they have special requirements due to abnormalities in walking, running and jumping pattern (gait) required during training and competition. Check with your shoe manufacturer whether they have shoes which are specific for your condition. Not all expensive shoes have such requirements. Check whether the mid-sole provides sufficient stability, support and flexibility. Check whether the outer-sole is suitable for the different surfaces of the court or field. You may need to check with a podiatrist if you constantly find it difficult to obtain good shoes which do not cause pain to your feet, ankle and knees. A video of your walking and running pattern could highlight some possible problems and solutions.

You should always try out the shoe first and do all the different skills required in your sport with it. However, it will often take 2 weeks (at least) before you will find the shoe comfortable enough to be worn (break-in). I also use some preformed orthotics for some of my patients if they have abnormalities in gait and recurrent ankle, foot and knee problems with good results.

Friday, 23 February 2007

Doping Prohibited List 2007

Every elite athlete i.e. international, national, state or club athlete should be aware of the latest Doping Prohibited list updated at least once every year. The Prohibited List is an International Standard identifying Substances and Methods prohibited during competition (in-competition), outside competition or during training (out-of-competition), and in particular sports. Substances and methods are classified by categories (e.g., steroids, stimulants, gene doping).

In Malaysia, the National Sports Council Doping Control Unit coordinates 'no notice' doping control testing and some of the in-competition testing for international, national and state athletes. National Sports Associations (NSA) undertakes some of the other doping control testing for their respective sports. Meanwhile, International Sporting Federations may appoint their own doping control officials to carry out the doping control testing.

It is vital for such athletes to inform their treating doctors of their status as athletes and the need to review the Prohibited list to ensure that they avoid taking the 'illegal' substances unknowingly and risk being sanctioned or losing their medals. Ignorance of the Prohibited List shall not constitute any excuse and athletes may face a ban of up to two years or a lifetime ban.

Athletes should also be cautioned that some traditional supplements and nutritional supplements may contain Prohibited substances as they may not be subject to such stringent manufacturing and labelling processes as drugs ( 1,2)

Some Prohibited Substances may be used by an athlete for medical reasons by virtue of a Therapeutic Use Exemption. For example inhaled beta-agonists in asthmatics. However, such use must have adequate documented laboratory evidence submitted to the respective NSA or International Federations.

For further information, go to If you are a Malaysian athlete you may also approach the Doping Control Unit of National Sports Council at 03-8992 9600.

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Thursday, 22 February 2007

Multiple Joint Pain and Bodyache

Chong was a regular gymnasium user who was as fit as an elite athlete. He did 2 hours of regular workout including 30 minutes run, core stability exercises, moderate weight training and an occasional dance routine at a popular gymnasium. At 40 years of age, he could run faster than most men half his age.

He came in a day after his hard workout thinking that he probably overdid it. Most of his joints were aching and his muscles were sore. For some reason or other, he was still sweating profusely. "Doc, I think I shouldn't have worked out so much last week!", he said. I smiled, saying "Told you you needed to recover after each exercise session!". He wasn't quite impressed as usual. In went the mercurial thermometer. "Ahhh! 38 degrees centigrade. You're down with fever!", I said.

"How many days have you been feeling feverish?", I asked. "Three", he answered. He also had a rapid pulse rate and a slight raise in the Blood Pressure. Hess test (a special test to check for petechiael rash) was positive. "Let me send a blood sample to check for your blood counts. The last thing we want is dengue fever", I said. "You need to rehydrate a little more than usual and take a day off. I will call you in a few hours time". It took the laboratory an hour to fax me the result and true enough his white cell count and platelet counts were low. He was lucky that the levels were not critical and it resolved the next day.

Sunday, 18 February 2007

To play or not to play!

It was 7.15pm and I was late for a pharmaceutical talk. John called as I was just approaching the venue. "Shucks!", I said. I needed the CME points but the player needed an urgent decision. To play or not to play!

I quickly returned to my apartment and he was already waiting there. He was walking and that was good news but he had a slight limp. I know some players who walked 'funny' after training due to a back problem and leg-length discrepancy.

A quick examination revealed a localised area of tenderness (pain upon application of pressure), muscle spasm adjacent to the junction between the medial gastrocnemius and soleus muscle. Tried a few light skills and he could not 'push-off' as required to play badminton.

He knew the consequences of injecting steroids and so he didn't ask me to do that. He had seen talented players who had muscle tears and tendon ruptures after indiscriminate injections done for the sake of competing.

"No-play!", I said. "I could give you a muscle relaxant to help relieve the spasm and you can continue with another 3 days of NSAIDS (anti-inflammatory and pain medication), but no play!". He was keen to improve his performance and insisted that he would decide the next day.

He played against a lesser known player and lost the next day. The press gave him such a bashing that I felt sorry for him. I know the player and he made the right choice to hold back and not push to win. He told me later that he just couldn't move and the pain worsened as he played. He had to play as he was required to by the coach to try. After a week he played much better in another major competition after undergoing rehabilitation and taking precautionary measures

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Thursday, 8 February 2007

Non-specific Knee pain

She could not bear the pain in her left knee anymore. It has been 1 month and the pain was still present. In fact, it worsened after she went to 'service' her clients to ensure that they continued her company's products. She thought it felt better after application of 'the stinking yellow stuff' the chinese doctor applied. "Maybe I should have rested", she thought.

Mei Lee then decided to see sports physician in the neighbourhood. "My knee is more important than the job", she said gritting her teeth in pain as she hobbled along the corridor (as she could not find parking in the Subang Jaya business area).

I was surprised that she was having recurring episodes of left knee pain over the past few years and lived with it. She has had blood test, several X-rays and even an Ultrasound scan done but nobody prescribed exercises to get her back on her feet. "Uhmm..., where did we go wrong in medical school? Or is it just that it's difficult for clinicians to spend time talking to the patient and teaching some basic exercises? Or it's just that nobody bothered to send her to the physiotherapist. At least that could have helped!", I said. "I did see the physio, but they only did electrical stimulation. Since it didn't seem to help, I decided to seek treatment elsewhere", she lamented. Maybe they tried to help her but she was not receptive to their suggestions.

Back to the drawing board!. Her blood investigations for joint disease and inflammatory markers were normal. Her left knee X-rays were normal and so was the ultrasound scan. She had a painful gait, sacroiliac joint inflammation (dysfunction), tight hip adductors, knocked knees and hyperlaxity of both knee joints (in extension)but she had a very tight Achilles tendon due to frequent use of high heels and not enough stretching. This would take a lot more time to unravel the problems.

She was prescribed topical NSAIDS gel and a whole series of exercises to strengthen her quadriceps, hamstring, gluteal muscles, abdomen and lower back. I also did some myofascial release (manual work to release muscle spasm and pain) for immediate effect. After 2 weeks, she was much better and able to run upstairs without pain. She was prescribed more exercises and we added a weight reduction programme for her too!

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