Team Physician 'trouble' in Field Hockey

You are required to arrive at the game venue earlier than everyone else to prepare set up your things and prepare the drinks. Prior to that you make sure that your medication and taping inventory in your bags (and trolley) are updated and your water and ice supply is ready. Ensure that you identify yourself to the tournament medical officer (if available) and assess the availablity of medical assistance in case of emergency. For best practice, organisers need to have an emergency service crew and ambulance on standby for the match. They should also have an AED and spinal board ready for cervical fracture immobilisation and evacuation.

Once the athletes arrive, you give them their sports drink bottles, review the injury status (and any other medical condition), tape the joints and assist in stretching. We watch the athletes warm-up (and join in if possible, as you are required to run on the pitch in the event of injury) and do their sports-specific drills before the match. You have to have your rigid tape and powder ready in case some of the sticks needed minor adjustments for grip. You may also need to have self-adhesive tape (e.g. Powerflex or Coban) to hold the shin pads and support the wrists (also prevent sweat from wetting the sticks). You need to ensure that you have 4-5 bags of cube/crushed ice for injuries. Have your Ethyl Chloride spray, scissors, suture set, tubigrip, gauze, povidone iodine ointment and surgical spirit ready in case of cuts, abrasions, lacerations and contusions. The coach and manager will need you to give your injury status report prior to selection of the team.

During the match, you need to be watching the match at all times. Ensure that there is free flow of sports drinks and mineral water for athletes (and officials). Athletes coming in and out of the pitch are 'checked' to ensure that are rehydrating well and injury free. You need to assist them in RICE treatment if there are injuries. Assess the injury and give an immediate injury status report to the coach as he may need to return to play. The decision to play should be based on medical facts and not on the need to play. Clean and dress bleeding wounds immediately and you may need to suture the patient on site if you are able to get a relatively clean environment with your sterile equipment. (to be continued)

Montelukast Option for Asthmatic Athletes

I have been treating asthmatic elite athletes with Montelukast (Singulair)for at least 4 years as a single monotherapy drug. Most of these athletes who had Intermittent Asthma and Moderate Persistent Asthma were well controlled with the medication and needed few rescue medication with Salbutamol Inhalers. Salbutamol, other beta-agonist and Corticosteroid inhalers/turbuhalers require Therapeutic Use Exemption.

The new guidelines for asthma treatment is available here. Athletes should discuss the options of treatment with their team doctor or Family Physician. Find out about the Doping Prohibited List 2007.

In a recent clinical trial, the authors suggested that Montelukast provided significant protection against Exercise Induced Bronchoconstriction (narrowing of the airways) having an onset within 2 h following a single oral dose and lasting for at least 24 h. This medication could be useful for athletes who have asthma as an option for prevention of asthma and better control of symptoms.

Adductor Tendinopathy

Bob (not his real name) is an elite level hockey player who sustained a right sided groin injury during a match 2 weeks ago. His pain was spot on the insertion of the adductor longus muscle and he was diagnosed with Adductor Traction Apophysitis. He did ice (see RICE treatment) regularly and I did myofascial release and taught him some stretching and strengthening exercises. He returned symptom free after 3 days.

Last Sunday he had a tough match and started feeling the pull in the right groin during the last quarter of the match. He was taken out of the match and we immediately iced his injury and gave him some fluids (sports drinks). This time the injury had traversed along the adductor longus muscle to the muscle belly. I asked him to lie down on his back (with knees flexed) and he had pain squeezing my fist between his knees. (The last time he could squeeze the whole length of my arm without much pain). He underwent acupuncture and massage to release his muscle yesterday and felt much better. He continued to do the exercises I have given him earlier.

I spoke to him again about taking the necessary precautions with adequate warm-up and stretching. I reminded him that he needed to do his own rehabilitation program to ensure that he strengthens not only the hip adductors but also the hip abductors, hip flexors and extensors, maintains core stability and general fitness (hydrotherapy). If his condition was not treated adequately, it may persist with persistent groin pain and restriction of hip mobility and loss of muscle power in sprinting and jumping.

Sapura Team - Malaysian Hockey League

The team after training.

Medial gastrocnemius (calf) myofascial pain

Mohamed is a 24 yrs old talented ex-junior hockey player who has tight painful calf muscles towards the 2nd half of every match but he noted that seemed to be symptom free during training session. He would request to be replaced to get time to ice and try to return to play after 10 minutes. As he plays in more matches, the pain becomes more unbearable and may even take a few days rest to be relieved. I evaluated his injury 5 days ago and found that he had localised muscle spasm in both his medial gastrocnemius heads (see photo)in both calf muscles.

He had an aversion for massage and has difficulty stretching his calf muscles. After trying myofascial release he seemed to be quite sore and requested injection to relieve the muscle spasm in the right medial gastrocnemius. After a short discussion about the pros and cons, we both decided to do myofascial injection* (Lignocaine 1% plus water**) to relieve his symptoms. (This was done as we were sure that he did not have a muscle tear. An ultrasound scan is required if a tear is suspected). The procedure went on smoothly (with 'some' pain as he told me he did not like needles) and he was told not to do any running or jogging. He was told to go into water to undergo aqua-jogging to assist in his recovery and undergo a rehabilitation program. I assured him that he would feel better after 2 days.

I reviewed him before player selection on match day 2 days ago and he was running without pain. The following day we had another training session whereby he said he felt better in the injected leg and wanted an injection in the untreated leg.

*see Injection of Lignocaine vs Dry Needling.
** see Advantage of Lignocaine Plus water vs Lignocaine 1% Neat.