HSBC Rugby 10's

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Right Biceps Tendon Rupture

Mr K was tugging onto the rope in a tug-of-war when he suddenly felt a snapping sensation with a sharp pain in his right arm a month ago. He thought he had torn his muscle but after a few weeks he seemed to have recovered fully except for the bulge in his right arm (see photo and compare with the normal left arm). He told me that he used to work out regularly at the gymnasium and hence had a much bigger arm. It looks as if it had shrunk significantly in size.

He only came to see me today and I examined his arm and found the 'popeye sign' and smaller biceps muscle with reduced power against resisted flexion. His forearm supination and pronation seemed as strong as the left. His long head of biceps was not palpable suggesting that it was ruptured completely. He only had mild pain with flexion of a fully extended elbow. He reminded me of an older case of a rugby player who had a similar biceps tendon rupture a few years earlier.

I referred him to an Orthopaedic Surgeon who suggested an MRI to detect the location of the edge of the long head. We agreed that he probably needed surgery if he wanted full function and active sports participation. If he was much an elderly patient, some physicians prefer a conservative non-surgical approach.

According to Klonz et al, ruptures of the long head of the biceps are commonly caused by degenerative changes within the tendon. Non-operative treatment gives good results, the loss of power regarding elbow flexion and supination amounts to only 8-21%. Refixation may be indicated for cosmetic reasons and offers a small but evident improvement of flexion and supination power. Deformity of the slipped muscle can be corrected effectively. Residual complaints after conservative treatment often result from associated subacromial problems.

Useful Links:-
Arthroscopic-assisted biceps tenodesis for ruptures of the long head of biceps brachii
Functional results after suture repair in ruptures of the long biceps tendon with special consideration of subacromial impingement
MRI or MR arthrography: a useful tool for evaluation of the biceps tendon rupture
Proximal and distal ruptures of the biceps brachii tendon

Extensor Digitorum Brevis Ganglion Cyst

Mr Chin is an ardent 45 yrs old runner who plays badminton occasionally. Since 2 years ago he noticed a swelling on his right midfoot when he runs marathons or plays badminton more frequently. The swelling goes of after several weeks. I examined the swelling and found it to be non-tender, like a fluid-filled sac (cystic) and seem to arise from the fascia covering the Extensor Digitorum Brevis muscle (Inferior Extensor Retinaculum). This chap also has Hallux Valgus.

I told him that he could do an Ultrasound to confirm the diagnoses and a possible X-ray to rule out any bony anomaly which could cause the swelling. He was quite content as the swelling was usually painfree and decided to leave it alone for the time being.

Lateral Collateral Ligament Ganglion Cyst or Meniscal cyst?

Mr Tan came with a localised swelling in his right knee since 4 years ago. He told me that he landed awkwardly and subsequently a month later a swelling progressively developed. He would have pain with jogging or sitting cross-legged. He had seen an Orthopaedic surgeon who told him to undergo Arthroscopic surgery to determine the extent of damage.

I examined his knee and found that he had normal range of motion and his ligaments were all intact. He only localised tenderness over the 2cm by 2cm cystic swelling which appeared to be arising adjacent to the lateral collateral ligament and lateral meniscus. His tests for meniscus were inconclusive. I have referred him for another Orthopaedic surgeon for a thorough work-up (X-ray and MRI Right knee).

Since he is usually asymptomatic, if the swelling does not affect his normal function I would tend to leave the swelling alone.

Ganglion Cyst

Ms N is a 4 years old girl who had a fall on her palm two weeks ago was brought by her father showing a small pea-like swelling on the palmar surface of the proximal phalanx of her right little finger.

The swelling was only painful upon palpation. She otherwise had full function and power of her right little finger. It was difficult to tell whether she had the swelling previously as children do not usually complain until there is pain. I suggested an ultrasound of the swelling which should demonstrate a cystic (fluid-filled sac)swelling with some inflammation. I referred her to a Hand Orthopaedic Surgeon for further evaluation and treatment.

Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. (Nahra etal, 2004)

Usually Ganglion cysts may be treated non-surgically. If it becomes painful or restricts normal function, cyst aspiration and corticosteroid injection may help. Surgical excision usually has low recurrence rate.

Hypermobility Syndrome

Ankle Posterior Impingement

Ms Ann (not her real name) is an elite level badminton athlete who came with complaints of pain in the back of both ankles with net-play and jumping smashes since 3 months duration. To her dismay, she still had the pain despite taking a month off from training. These symptoms are also common in gymnasts and dancers who do repeated jumps and en-pointe. Soccer players have been reported to have similar symptoms in literature.

I examined her ankles and found that she had tenderness and bogginess (oedema) of the posterior aspect (back) of her ankle joint (between the Achilles tendon insertion and the calcaneal and talus bones). She had pain when I compressed her hindfoot with her foot plantarflexed (Impingement test). If he jumped repeatedly on the spot, it would give her the same pain. She also had tenderness of her Achilles tendon insertion (Insertional tendinopathy) and associated hindfoot varus.

I have advised her to do some calf stretching with the knees bent slightly and knees straightened. She was also taught to tape her ankle to prevent full plantarflexion. She was planned for an X-ray to rule out Os Trigonum or fracture of the lateral tubercle of Talus. An MRI of the ankle would identify bone bruising, tendon and joint capsule inflammation.

Ultrasound guided corticosteroid has been shown to benefit most athletes with capsule or tendon inflammation. Most of these athletes are symptom free after 2 weeks and return to play within 4 weeks rehabilitation. A selected few with persistent symptoms, os trigonum or a possible nerve entrapment may require arthroscopic surgical intervention.

Find out more about the injury here:-
Posterior Ankle Impingement in Professional Soccer Players: Effectiveness of Sonographically Guided Therapy
MRI features of foot and ankle injuries in ballet dancers

Knee pain after swimming breaststroke

Ms Lim is a lady is her twenties who walked in limping this morning with complaints of left knee pain after swimming breaststroke for an hour the previous day. She does 'gym-workout' for 2 sessions per week, dance lessons for 3 sessions per week and swimming for 2 sessions a week. She has never had any previous falls or similar episode.

She had tenderness on the femoral attachment of the medial collateral ligament. She had no laxity of the ligament. I taped her knee to give her some pain relief while putting on a knee sleeve. She was given several strengthening exercises for her quadriceps, hamstrings and gluteal muscles. I will review her condition in 2 weeks duration to decide on return to play.

Rugby World Cup 2007 (France 7th Sept - 20th Oct 2007)

20 world class teams will be engaging in a sport which requires agility, power and strategy in the IRB Rugby World Cup 2007 from the 7th September 2007 to 20th October 2007. 3 teams (USA, Canada, Argentina) represent the Americas, 9 teams (England, France, Georgia,Ireland, Italy, Portugal, Romania, Scotland, Wales)represent Europe, 2 teams (Namibia, South Africa) represent Africa and 6 teams (Australia, Japan, Fiji, New Zealand, Samoa and Tonga)represent Asia-Oceania divided into 4 pools (A-D).

The Pool Stages will be held from 7th September 2007 to 30th September 2007 and the Knockout Stages will be held from the 6th October 2007 to 20th October 2007 after a 5 day break. Matches will be played in 12 different venues in France (Bordeaux, Lens, Lyon, Marseille, Montpellier, Nantes, Paris, St Denis, St Etienne and Toulouse) and UK (Cardiff, Edinburg).

Which team will make it to the finals on the 20th October 2007 in St-Denis?

Find out more at the links below:-
World Rugby Cup 2007 Official Website
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Osgood Schlatter's Disease

Matt is a 23 years old store-keeper who doubles up as a forklift driver. He recently developed a left knee painful swelling during work and prolonged walking. He used to have knee pain during his teens when he was actively playing sports.

I examined his knee and found that he had a prominent tibial tuberosity which was tender and inflammed. I applied a patella knee brace for him but he refused to wear it. We ended up taping his knee (see photo) and it seemed to offer him some pain relief. I sent him off with some NSAIDS and advised him about RICE treatment.

Since it was quite mild, I would expect his pain to subside in 2 weeks but he should strengthen his core muscles, hamstring and quadriceps. He would only be fit to lift heavy weights after at least 4 weeks.