Severe low backache and stiffness

Mr Tan is an ardent badminton player who plays once a week for 1 to 2 hours in the St John's Institution hall (enclosed and no air-conditioning). He came in with severe backache yesterday (a day after playing with younger opponents) and wanted quick pain relief. His back was so stiff (stiffness was worse than the pain) that he had difficulty bending forwards and backwards. I was surprised when he informed me that he does not drink before the match or during the match and he only drinks a small bottle of 500ml after the session! He also never believed in warm-up or cool-down. No wonder he had severe muscle spasm in his both paraspinals and quadratus lumborum.

I gave him 5 days of NSAIDS* and a muscle relaxant injection but told him to rehydrate adequately for the next 48 hours. If symptoms did not improve, I would review his back condition in 3 days. He should try sports drinks e.g. Horley's Replace or Gatorade before, during play and after play to prevent recurrence. Even if you don't feel thirsty, you need to drink up!, I said.





Find out what the experts recommend:-
ACSM Position Stand on Exercise and Fluid Replacement
*US FDA Advisory on NSAIDS use

Supraspinatus tendon partial rupture and mild impingement

Simon (not his real name) was playing hockey 3 days earlier when he decided do hit a slapshot across a longer distance during a training match. After the hit he felt pain in his right shoulder and he could not lift his shoulder above the level of his shoulder. He continued playing but he refrained from lifting up his shoulder.

He saw me today and I found that he had a painful arc (abduction > 70 degrees), a positive "Empty Can Sign" (resisted abduction) and loss of power of abduction against resistence. He still had tenderness at the tip of the right shoulder.

I informed him that he needed an X-ray ( to rule out bony impingement) and an Ultrasound of his shoulder (to rule out tendon rupture).

I advised him to continue apply RICE treatment for another 1-2 days to allow the inflammation to resolve. He was also advised to avoid abducting his shoulder > 90 degrees. I encouraged him to do active pain-free diagonal movements against the wall or panel (Closed-Chain Exercises) and start strengthening exercises progressively using Theraband. Later, he may proceed to do some wobble board exercises to assist coordination and balance. I was concerned as he has had several similar episodes in the past due to inadequate rehabilitation treatment and possibly incomplete investigation.

Malaysian Shooters tested positive for Propranolol

Three Malaysian national shooters was tested positive for propranolol in March during a local Competition (President Ally T.H. Ong Trophy) along with 4 other athletes. It's quite shocking news as all the national shooters know that they are to stay away from beta-blockers. Although, the National Shooting Association of Malaysia maintains that the athletes did not dope intentionally, it raises our concern that our national athletes are not careful enough to protect themselves from consuming contaminated products e.g. Over-the-Counter medication, traditional herbal medication and nutritional supplements. Read more here.

According to the WADA Code even if the athlete unintentionally consumes a banned substance, the athlete could be sanctioned (see Strict Liability in Anti-Doping).

The standard/normative sanction for a first doping violation is two years, and a second violation calls for a lifetime sanction.
That standard for sanctions (two years and lifetime) can be lessened or enhanced based on several factors relating to the particular case, including:
􀂃 The type of doping violation
􀂃 The circumstances of the individual case (level or absence of fault or negligence)
􀂃 The substance in case of the detection of a prohibited substance
􀂃 Repetition of an anti-doping rule violation

I urge athletes and officials to read the Athlete's Guide so as to understand the complexity of the doping issue. Educational videos are also available free here. Athlete's should take precautions during competition so as to avoid consuming contaminated drinks or food due to the severity of the sanctions.

Malaysia and Australia in the Hockey Finals!

Australia and Malaysia have reached the final of the Sultan Azlan Shah tournament in Ipoh, Malaysia on the 11th May 2007. Malaysia, in superb form beat India 2-1 in what was a cliff-hanger of a match between the hosts and last years’ bronze winners. Tribute to Coach Sarjit (see photo) for reaching the finals once again after 22 years.

Come and support your team for the finals on the 13th May 2007!!!

*See photo of the Malaysian team thanking the full stadium of supporters after the match here.

Congenital Venous Malformation

Mr Tan saw me and thought he'd show me his left leg. "Doc, I've had this since I was 10 yrs old. I was hit by a book and the whole thing swelled up in pain! Since, then it seemed to grow slowly but doesnt give me any trouble". His left leg and foot was swollen. I thought it was not that obvious and possibly that's why his parents didn't notice it until then. He was seen by several doctors in Singapore and had his MRI's taken. Now, 12 years later it didn't give him any problems but just a little unsightly deformity.

After palpating the swelling, I found the swelling on the leg (9cm by 4cm) and dorsum of the foot (10cm by 5cm) to be non-pulsating, painless, boggy, with some induration (a depressed area probably where the vein perforates through). "Good! It's not an artery, not coming from the bone (I hope) and pain-free!", I said. You need to see a vascular surgeon who will work out whether you need further treatment (I was thankful to Mr Yusha from Hospital Kuala Lumpur who shared his experience with me when I was attached to the Vascular Surgical Unit).

Treatment depends on the depth, location, and extent of the venous malformation.

a) Routine observation of smaller lesions that cause minimal cosmetic or functional disturbance

b) Compressive stockings (e.g. tubigrip) to control swelling and pain in lower limbs

c) Injection of irritant solution into the lesion to shrink the abnormal veins. Unfortunately, multiple treatments are often required over time. (Sclerotherapy)

d) Laser treatment. The skin component of a venous malformation, consisting of small vessels, is sometimes treated with a Nd:YAG laser. Generally, several treatments six to eight weeks apart are necessary.

e) Surgery to localized and remove accessible lesions

d) Injection into the blood vessels to stop arterial blood flow in some selected cases in which there are abnormal connections to veins. (Embolization)

* Summary of treatment was adapated from this site.

Achilles Tendinopathy

I remember treating 4 Korean women recreational athletes in the National Sports Institute a few years ago. They used to 'train' harder than some elite athletes often clocking up to 4 hours a day. A few of them suffered from Achilles tendon problems.

I had the opportunity to see another lady who was just as passionate about badminton. Ms Lee (not her real name) came with painful Achillles tendon (see photo) with localised swelling since 1-2 years duration. Her condition worsened over the past few months and she could not play badminton.



I found it rather interesting that she could not do a normal squat and had a thickened tendon an inch above the calcaneal bone attachment. It was certainly tender but more so along the inner side. As I palpated her calf muscles, she had spasm of her medial gastrocnemius causing her much pain stretching her calf muscle (see photo above)

She then told me that she had been playing on her toes thinking that her coach wanted her to literally 'play on her toes'! I was quite concerned that she was receiving various modalities of treatment but failed to undergo proper diagnostic or rehabilitative exercises. She was also an asthmatic on regular Inhaled Corticosteroid therapy provided by the Chest Physician (see Drug Saf, January 2005).

I quickly gave her some topical Arnica Comp gel to relieve the swelling, a mild Cox-2 selective NSAIDS (as she had gastric symptoms and could not tolerate non-specific NSAIDS) and some rehabilitation exercises. The rehabilitation exercises involved calf stretching and strengthening exercises, core stability exercises, hip and gluteal stretching, gluteal and hamstring strengthening and etc. I hope to see some progress in 2 weeks time but she will probably need at least 8-12 weeks before total recovery.

I would probably send her for an Ultrasound scan of her tendon or an MRI if she fails to recover adequately. If she was an elite athlete, she would have been scanned within the next few days to determine the prognosis. The ultrasound may reveal tears and degenerative changes e.g. calclfication.


If she continues to play without proper treatment she may have Achilles tendon rupture (see photo below). I would not recommend local corticosteroid injection for Achilles tendinopathy due to the risks of tendon rupture.

Athletes should also refrain from using Quinolone antibiotics due its toxicity on connective tissue increasing the risk of rupture especially in elderly. Arch Intern Med, August 2003.

Hamstring Strain

A martial arts elite athlete came with pain in his right thigh after doing rapid high kicks during filming of a movie. He added that his hamstring was extremely tight and he could not execute a high kick. He already went for treatment by an acupunturist who did some acupunture and massage to release the spasm. He told me he had forgotten to do RICE treatment. It was only after 1 week that he came in to see me.

I examined him and found that he still had mild spasm of his semitendinosus muscle (one of the 3 hamstrings) and tenderness at the myofascial junction. He was able to fully flex and extend(a good sign) but had pain with resisted flexion. I gave him some muscle relaxants and NSAIDS for another 5 days as he had some bruising from the massage. He was told to undergo hydrotherapy (aqua-joggin) and focus on core stability rehabilitation. Since it was only a mild muscle strain I would expect him to recover fully within 2 weeks. However, he would need to be careful if he was to do the high-speed high kicks.