Thursday, 30 August 2007

Sudden Deaths in Soccer: Are we doing anything about it?

There is an interesting write up of the series of sudden deaths in soccer by The Star (Malaysia) on Thursday August 30, 2007.

A history of sudden deaths in football

# Aug 28, 2007: Spain and Sevilla defender Antonio Puerta (pic) died on Tuesday following a heart attack, becoming the latest footballer to die suddenly while playing.

# April 11, 2006: Colombian teenager Victor Alfonso Guerrero, 17, died during a training session for the reserve side of Colombian First Division club Envigado FC. He collapsed and lost consciousness, and died on the way to hospital.

# June 25, 2005: Hugo Cunha, a 28-year-old midfielder with Portuguese top flight side Uniao Leiria, died while playing a match with friends. Cunha suffered a heart attack and was unable to be resuscitated by the emergency services.

# Oct 27, 2004: Brazilian Serginho, 30, collapsed during a Brazilian First Division match between his club Sao Caetano and Sao Paulo and later died. His death caused a huge controversy after the autopsy revealed that his heart weighed 600 grams, twice the normal size. Sao Caetano, the club’s president and the doctor were sanctioned by Brazil’s sporting authorities.

# Jan 25, 2004: Benfica’s Hungarian international striker Miklos Feher, 24, collapsed during a Portuguese Premier League match against Vitoria Guimaraes and never regained consciousness. The autopsy revealed he had suffered from a heart malformation.

# June 26, 2003: Cameroon international Marc-Vivien Foe died while playing against Colombia in the semi-final of the Confederations Cup. The Manchester City player collapsed in the centre circle and all efforts to save him failed. An autopsy revealed he had a disorder of his heart’s electrical system.

# December 2002: Macedonian defender Stefan Toleski died of a suspected heart attack. He collapsed halfway through the first half of his side FK Napredok’s league match against Kumanovo and later died in hospital.

# February 2000: John Ikoroma, a 17-year-old Nigerian youth international, suffered a heart attack during a friendly in the United Arab Emirates. He was in a trial match for Al-Wahda against Kazakh club Astona when he collapsed 20 minutes before the final whistle. He died in hospital.

# 1997: Emmanuel Awanegbo, a Nigerian playing in Germany, died after only 12 minutes of play. The death was attributed to cardiac arrest.

# 1995: Amir Angwe, 29, a striker for the Julius Berger Club of Nigeria, collapsed a minute before the end of an African Cup Winners’ Cup semi-final match with Maxaquene of Mozambique. Doctors believe he died of a heart attack.

# 1989: Nigerian international Samuel Okwaraji, who had signed as a professional for AS Roma in Italy after stopping his university studies in Rome, died during a World Cup qualifier between the Super Eagles and Angola.

This is a reminder to all who conduct sporting competition that efforts are needed to prevent the occurence of sudden deaths in elite athletes. Although elite athletes are routinely screened for medical conditions, some are done without exercise stress test. Some have in the past linked such deaths to fatigue, severe dehydration, doping, alcohol and illicit drugs. In some parts of the world, soccer and field hockey tournaments are still held without cardiac resuscitation equipment to give some hope of saving the athlete in the event of sudden cardiac arrest.

What are we doing to prevent sudden cardiac deaths in our sport?

Medical Coverage for Karatedo

Every time I am asked to assist in medical coverage of a martial event, I would ask for the assistance of hospital teams to ensure that the whole mechanism for emergency care is activated. During the 8th AKF, the organisers had the commitment of the Negeri Sembilan Health Department to ensure that the medical services offered during the 3 day competition was adequate and did not endanger the participants' lives.

The most important factors responsible for keeping the injury risks low were:-
1. The high standards of referreeing
2. The high fitness and skill levels of participants
3. Adequate rehydration in between bouts

Despite having a team for each 'tatami', we were busy with minor lacerations, bruises, contusions, muscle strains and mild joint sprains. We only had one participant who injured her neck, was immobilised using the hard cervical collar and long spinal board and transferred safely to the hospital. Two participants had mild concussion and were sent to hospital for further evaluation and observation for 24 hours. We only had to stitch up a bad laceration on an official who had fallen before the second day's competition. The Atomated External Defibrillator (AED) was available on stand-by in the event of patient collapse due to cardiac arrhythmias.

This is definitely a competition involving the whole team of referrees (rules and regulations), officials (traffic), doctors and paramedics, ambulance driver, registar-on-call and surgeon-on-call (immediate hospital care).

We still need qualified volunteers to provide a safer medical coverage during such sports events. You may contact me at

Tuesday, 28 August 2007

Friday, 24 August 2007

8th Asian Karetedo Federation Senior Championship

An exciting world class karatedo competition called the 8th AKF Senior Championships will be held on the 24th - 26th August 2007 at the Nilai Indoor Stadium* (near Nilai International College).

On the first day, Malaysia won 2 gold medals, 1 silver and 2 bronzes. There will be 3 fights simultaneously from 9am to 6pm. My medical team will be in the middle of the three competition mats. We have to observe in 3 smaller teams to ensure that we see the way the athletes fight so that we can gauge the severity of injury even before we examine the athlete.

For the sparring (kumite) competition, each bout lasts for 3 minutes between the Red (Aka) and Blue (Ao) athlete. If there is a draw, there will be another minute of competition with sudden death score. The skills performance (kata) competition will be a show of finesse of the various skills perfected by the athlete.

*Getting there: (A map of the destination is not available)
Take the KL-Seremban Highway (North-South Highway), exit Nilai (Exit 215). After the toll gate go straight and hit a T-junction, turn right go straight until you reach a roundabout. Take the 3 o'clock turn and go straight to pass through an empty area, housing area and you will see the huge red colour building on your right i.e Nilai Indoor Stadium.

Important links you need to know:
Competition Schedule
WKF Rules & Regulations

Tuesday, 21 August 2007

Recurrent ankle pain

Ms Wong is a 25 yrs old lady who does hiking twice a month. Each short hike would usually last 4 hours. She has been regularly training in the gymnasium for a hike up Mount Kinabalu recently and found that her left ankle gives her pain in the mornings and after her 'short' hikes. She also remembered twisting her left ankle several years ago.

Clinically, she has bilateral Anterior Talofibular ligament (ATFL) laxity (left > right). Her ankles were otherwise quite normal. She would be planned for a Plain X-ray of both ankles to rule out any fractures. Meanwhile, she was advised to continue lower limb propriorceptive exercises. She was to consider using ankle bracing or ankle taping when she is to go cross-country running or hiking. We may plan for an MRI of her left ankle if her X-rays are normal and her symptoms fail to subside.

She is due to return after testing the hikes with ankle taping.

Find out more from these links:-
Climbing Mount Kinabalu
ATFL Laxity Test
CFL Laxity test

Saturday, 18 August 2007

Medial Collateral Ligament Rupture

Ahmad is a 24 yrs old cook with a gourmet restaurant met with an accident on his way back from work. He had severe pain on the inner aspect of his left knee and could hardly walk. He had difficulty straightening his knee fully and could not bend his knee.

I examined his knee and found that he had some localised swelling over the femoral attachment of the Medial Collateral Ligament (MCL). Ahmed told me that that was the spot that he collided with the motorcycle. I did the valgus stress test and found that the MCL was torn completely. He was advised to use a Functional knee brace for another 4 weeks while starting his rehabilitation programme. He was concerned as he would not be able to come for the rehabiltiation exercises. He opted instead to use a crepe bandaged wrapped to support the MCL. He was advised to apply RICE treatment to reduce the pain and swelling. He may benefit from an X-ray of his knee and an Ultrasound scan of the MCL.

To be continued...

Friday, 17 August 2007

24 hour Walk Swollen and Bruised Toes

Mr Singh is an ex-athlete and junior walking coach who participated in the 4th Malaysia International 24-hour walk at Dataran Merdeka on the 11th August. He came back with a pair of swollen feet with both big toe badly bruise when I saw him on the next day.

It is common for marathon runners to have such lesion after competition. I advised him to keep his feet elevated, have them iced, use the lysozyme tablets (for swelling) and NSAIDS (for pain and swelling). He would need to have the subungual hematoma (blood accumulation under the nailbed) relieved by the doctor using a sterile needle. Surprisingly he only a few small blisters.

He told me today that his feet were perfectly fine after doing the RICE treatment.

Thursday, 16 August 2007

Malaysia International Fireworks Competition 2007 (MIFC)

Putrajaya International Convention Centre will be the venue for the 1st Malaysia International Fireworks Competition held from the 18 August 2007 till 2 September 2007.
The skies over Putrajaya will be lit up by a sequence of firework performances to celebrate Malaysia's 50th year of Independence. The Malaysia International Fireworks Competition, or MIFC, will be a festival of light, music, colour and culture; providing magical experiences.
During MIFC, world renowned firework teams will gather to compete in one of the world's greatest Musical Fireworks Competitions. Regular fireworks displays will be dwarfed by the pyrotechnic artistry and meticulously choreographed to inspirational musical compositions.
Each competitive night, the teams from Australia, Japan, Italy and Malaysia will amaze spectators with breathtaking presentations, judged by a panel of celebrities, who will select a winner. The victorious team will receive a prestigious award but their ultimate trophy is the audience delight!.

Here are the links for this event:-
MIFC Website
Getting there
International Pyrotechnics Society

Saturday, 11 August 2007

ACSM and AHA Release Updated Physical Activity Guidelines

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) have updated physical activity guidelines. These guidelines outline exercise recommendations for healthy adults and older adults and are an update from the 1995 guidelines.

Guidelines for healthy adults under age 65

Basic recommendations from ACSM and AHA:

Do moderately intense cardio 30 minutes a day, five days a week, Or
Do vigorously intense cardio 20 minutes a day, 3 days a week And
Do eight to 10 strength-training exercises, eight to 12 repetitions of each exercise twice a week.

Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of physical activity may be necessary. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

Tips for meeting the guidelines
Starting an exercise program
Frequently Asked Questions

Guidelines for adults over age 65
(or adults 50-64 with chronic conditions, such as arthritis)

Basic recommendations from ACSM and AHA:

Do moderately intense aerobic exercise 30 minutes a day, five days a week Or
Do vigorously intense aerobic exercise 20 minutes a day, 3 days a week And
Do eight to 10 strength-training exercises, 10-15 repetitions of each exercise twice to three times per week And
If you are at risk of falling, perform balance exercises And
Have a physical activity plan.

Both aerobic and muscle-strengthening activity is critical for healthy aging. Moderate-intensity aerobic exercise means working hard at about a level-six intensity on a scale of 10. You should still be able to carry on a conversation during exercise.

Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account. This will maximize the benefits of physical activity and ensure your safety.

Use the links below to learn more about the guidelines and to make physical activity a regular part of your life.

Key points to the guidelines for older adults
Starting an exercise program
Frequently Asked Questions

Wednesday, 8 August 2007

Knee Gouty Arthritis

Mr Loh is a odd-job worker who came to see me with a painful and swollen left knee this since 3 days duration. He told me that he gets the swelling every time he ate Bak Kut Teh (pork herbal soup). He had been told that he had gout by his doctor but he defaulted his treatment.

I examined him and found that he had a tense left knee joint effusion and restricted joint flexion due to the pain and swelling. He refused to do the X-ray and requested that I remove the joint fluid (he had it done on an earlier episode in a hospital). I aspirated 50ml of bright yellow fluid. He also did not want to send the aspirate sample to the laboratory for analysis. He was also advised to use RICE treatment to assist recovery.

He felt much better after the joint aspiration and was given NSAIDS and told to continue with his gout (Allopurinol) medication with his doctor. He was also advised to avoid high-purine foods.

Tuesday, 7 August 2007

Extensor Digitorum Brevis Hematoma

Ms Lee is a 40 year old lady who was brought to my clinic in a wheelchair after she slipped a step on the stairs last Saturday afternoon. There was an immediate bluish swelling (the size of a Mc Donald's chicken McNugget) on the side of her midfoot. It didn't look good as she looked like she had fractured her 5th metatarsal as she could not place her foot on her ground*.

I did a simple examination and was surprised that the 5th metatarsal bone was non-tender. The swelling seemed to come from the Extensor Digitorum Brevis (Peroneus Tertius, if present). Her plain X-rays did not show any fracture.

I advised her to use RICE treatment and gave her a Tubigrip sleeve to compress the site. She was also given analgesics and ARNICA Comp gel to reduce the swelling and inflammation. Her review will be in a week's time.

*AAFP article on Fractures of the Proximal Fifth Metatarsal

Left Thumb Contusion and Fracture

Ahmed is a recreational volleyball and soccer goalkeeper at the club level. He accidentally hit the ball trying to save it yesterday and the injury caused severe pain and swelling of the distal part of his thumb.

He came with his painful swollen thumb (despite RICE treatment the previous day) and it was really tender and bruised at the tip and base of distal phalanx. There was a small hematoma in the finger pulp. His thumb movements were still intact.

His plain X-rays showed a minute fracture fragment of the base of the distal phalanx and a non-displaced fracture of the tip. An ultrasound of his finger tendons may be required if he had a suspected extensor tendon rupture. I placed his finger in a splint and advised him to return in 2 weeks.

Saturday, 4 August 2007

Champion Youth Cup - Malaysia 2007

The Champions Youth Cup 2007 kicks off on the 8th August 2007 with 16 youth teams of the world’s greatest clubs at 4 different venues (Alor Setar, Kuantan, Melaka, Kuching).

The Under 19 age group tournament and aims to:

* Offer football a fresh and unique spectacle.
* Offer the next generation of stars an opportunity to compete against each other.
* Demonstrate their commitment to youth and to the development of the stars of tomorrow.
* Support the communities that have supported them and assist the development of football in Asia.

12 teams are from European, 2 teams from South America, the hosts, Malaysia and a host invitee team from Asia.

The tournament will take place in a league/knock-out cup format with a total of 34 matches over 10 match days. The 2007 preliminary rounds take place between the 8th and 13th August 2007, Quarterfinals are from 14th to 15th August 2007, Semifinals on the 17th August 2007 and the finals on the 19th August 2007.

See you there!!!

Champions Youth Cup 2007
Match Fixtures
Ticket Booking

Friday, 3 August 2007

PROTON-BWF World Badminton Championships: August 13-19, 2007

Badminton World Federation (BWF)is featuring the world's leading badminton players from China, Indonesia, Malaysia, South Korea, Denmark, England, (all top badminton nations of the world) and other member countries. The tournament will be played by the top 64 players in the world ranking (men's singles, men's doubles, women's singles, women's doubles and mixed doubles).The event would be held at the 15,000 capacity Putra Stadium, Bukit Jalil, Kuala Lumpur.

This tournament is definitely not to be missed!!!

Find out more at the links below:-
Proton-WBF Championships 2007 website
Live Scores
World Ranking

Wednesday, 1 August 2007

Tibialis Posterior Tendinopathy (Traction apophysitis)

Ms Chia is an 11 years old child who played basketball barefooted last week. She came with Right midfoot pain since a few days duration. She particularly mentioned that she had pain jumping and doing brisk walking. Her mother was worried as she thought it could be cancerous.

I examined her feet and found out that she was flat footed and had a prominent navicular tuberosity(insertion of Tibialis Posterior tendon) on both feet. She had tenderness at that spot but there were no obvious signs except that she had pain standing on her toes and resisting inversion (pushing her forefoot inward against my hand).

I explained to her mother that she would benefit by having good medial longitudinal arch support with orthoses. She could have taping of her foot to provide additional arch support. If symptoms persisted, an X-ray could be done to rule out avulsion fracture (tendon pulls off the tubercle from the bone) or other pathology.

She should recover swiftly with proper footwear, modified activity, isometric and theraband resistance exercises within 2-4 weeks.