Left Teres Minor strain (Grade II)

A wushu ex-elite athlete came with complaints of pain and weakness in his left shoulder after landing awkwardly with his arm hyperextended during training yesterday. He could only lift (abduction) his left arm with much difficulty above the level of his shoulder. He would feel more pain as he lifts his arm further.

Upon examination, I found that he had difficulty rotating his arm outwards (External Rotation) and lifting sideways (abduction).There was tenderness of the insertion of the teres minor muscle. He also has a lesser shoulder muscle bulk on his left and some multidirectional instability.



He was advised to continue RICE treatment for another 2 days and prescribed isometric exercises. He was also given simple exercises for the painfree range of motion while starting early proprioceptive exercises using the wall and ball. However, he was advised not to abduct his arm above the level of his shoulder initially.

He would be reviewed in 1 week to reassess his progress. An elite athlete would undergo an ultrasound scan to determine the extent of muscle strain. Clinically, he was having a Grade II strain.

Bad Ankle Contusion after hit by hockey stick

In the midst of an important hockey match, one of my players had a hard hit by the follow-through of the hockey stick by an opposing player. The burly defender hit the ground at an instant holding onto his ankle and the umpire immediately signalled me to run in to evacuate the player.

There was a large soft swelling (2cm X 3cm X 8cm) on the outer (lateral) aspect of his left ankle which looked really angry looking. He was carried out with 2-man carry and immediately examined on the bench. He was extremely lucky that it was just a soft tissue injury and the tendons and bone was spared.

We treated him with RICE treatment, NSAIDS medication and Arnica gel. He played in the finals yesterday despite having mild pain.

Urticarial rash due to Allergy?

A gentleman came to see me this evening with itchy multiple red patches on his trunk, upper and lower limbs. He remembered going to a Christmas event and putting on an old jacket (belonging to his dad). He thinks he is allergic to the dust mites or fungal spores on the jacket, or is it the food served at the dinner?

He was given an injection of Anti-Histaminics to relieve his symptoms and given some new generation oral histaminics to take in the day time and a drowsy 1st generation Anti-histaminic for the severe itch at night. If his symptoms are severe, he may benefit from some corticosteroids orally or by injection (However, care needs to be taken as these should be given to athletes in emergencies only as they are on the Prohibited list and require TUE).

MHL Finals on 27th December 2008

Here's an invitation to all the lovers of field hockey to join in the hockey match of the year between Sapura and Ernst & Young. Be there early before 5pm to catch the match as the Pantai Hockey Stadium will be full to the brim.

All the best to the nationals, ex-internationals, and ex-nationals, coaches and officials involved in both teams. A job well done!

1st Asian Indoor Hockey Championships 2008

The 1st Sultan Azlan Shah Asian Indoor Hockey Championships was held in Stadium Indera Mulia, Ipoh from the 11th - 14th December 2008. The experience of covering an indoor hockey tournament is that you have lot's of opportunities to see defensive and offensive tactical measures executed by players to meet the challenges of their opponents. There were lots of bruising, contusions, several ankle sprains and muscle cramps and strains but there were no serious injury.

Congratulations to the Malaysian Team A for putting up a splendid display of courage and determination during the finals. Malaysia Team A lost 2-3 to Iran. A big pat on the back to the coaching team for the tactical strategy which worked well to counter the opponent's game.

Here are some of the injury photos taken from the championships:

Malaysian Hockey League 2008

We have just started the 2nd round into the Malaysian Hockey League for 2008. Field hockey is still one of the most interesting sports to be the attending Sports Physician. There were lots of contusions and bruises; several ankle sprains and minor knee injuries; a few hamstring strain and calf strains; and a scalp contusion and a fractured facial bone. On a good day, absolutely nothing happens and you'd be bored to death. Otherwise on a terrible day, you'd be running across the pitch after watching your athlete hit by the ball or stick or collide with another player. What could be worse, you loose your belongings in the process of carrying out your duty and are left to attend to the athlete when everyone else have gone home.

For those who are interested in getting your hands laden with sports medicine adventure, field hockey is the sport to be involved in. Keep a lookout for photos after the season is over!

Anterior Shoulder Dislocation after Epileptic Seizures

A known epileptic in his twenties came in with complaints of fainting (with epileptic seizure) and sustaining a left shoulder stifness and severe pain upon 'waking-up'. There was a bulge in front of his left shoulder and a small depression (sulcus sign) under the left acromion (see photo). He could not lift his left arm at all due to the pain and stiffness.

We iced his shoulder and gave him an analgesic injection for the severe pain. He was then referred to an Orthopaedic Surgeon for imaging and to reduce the dislocation since it was already several hours after the incident. If he is an athlete who requires vigorous upper limb strength and mobility, he has a high risk of recurrent shoulder dislocation and would usually need surgery.

2008 Volkswagen Women's World Cup

The Table Tennis Association of Malaysia (TTAM) will be hosting the prestigious 2008 Volkswagen Women's World Cup from the 6-8th September 2008 at the Cheras Badminton Stadium, Kuala Lumpur.

Guo Yue (China, 2nd in world ranking), Li XiaoXia (China, 3rd in world ranking), Li JiaWei (Singapore, 6th in world ranking), Wang Yue Gu (Singapore, 7th in world ranking), Jiang HuaJun (Hongkong, 8th in world ranking) are expected to feature in the competition.

Those of you who fancy a tongue biting excitement, get your tickets (priced at RM30 for 3 days) at the TTAM office in Taman Maluri, Cheras. Call 03-92811497 for further enquiries.

Useful links:-
Schedule
Live Scoring
Qualification matches
Main Draw
News
Getting there

Athletic Taping

Athletic Taping is a type of treatment which utilises woven fabric (rigid or elastic) to provide additional proprioceptive stimulus and additional support to enable participation in sports while limiting the risk of re-injury or further injury. It is often used in rehabilitation of muscle and tendon injuries. Athletes and coaches should be aware of various techniques of taping which could come in handy when the need arises during training or competition. Taping can provide additional stability while allowing flexibility unlike some bracing devices.

Ankle joints are most commonly taped to prevent lateral ankle sprain. Other common parts which may benefit from taping are knee, shoulder, wrist, Interphalangeal joints (fingers and toes), hamstring and quadriceps, foot and Achilles tendon.

You may contact me at draston@gmail.com if you are interested in organising a course for your athletes or coaches.

Here are some of the photos taken from the work of students in a taping workshop:-

Lee Chong Wei - Qualifies for Badminton Olympic Finals

Congratulations to Lee Chong Wei and coach Misbun Sidek for achieving the feat of qualifying for the Men's singles for the Beijing 2008 Olympics. He defeated South Korean Lee Hyun-il 21-18, 13-21, 21-13 in the semi-finals Friday at the Beijing University of Technology Gymnasium. Looking forward to see you play again on Sunday, Chong Wei. Malaysia will cheer on for you!

Beijing Olympics 2008 - One World One Dream

As the world braces itself against economical socio-political turmoils and environmental challenges, the focus of 6 billion people will be on the greatest sporting event of all times, the Beijing Olympic 2008. The games starts on the 6th August 2008 with soccer and closes on the 24th August 2008. The highlights for most would be the Opening Ceremony on the 8th August 2008. Beijing will play host to the 28 summer sports and 10,500 athletes are expected to demonstrate the Olympic Motto, "Citius, Altius, Fortius".

Athletes will compete in 31 venues in Beijing, Qingdao(sailing), HongKong (Equestrian), Tianjin, Shanghai, Shenyang and Qinhuangdao to determine the worthy recipients of the Olympic medal.

Malaysia is proud of the 33 athletes from 10 sports who have fought hard for their place in the Olympics.
The Malaysian Contingent:
1) Archery: Cheng Chu Sian, Muhammad Marbawi Sulaiman, Wan Mohd Khalmizan Wan Ab Aziz
2) Athletics: Roslinda Samsu, Yuan Yu Fang, Lee Hup Wei
3) Badminton: Lee Chong Wei, Wong Choong Hann, Koo Kien Keat , Tan Boon Heong , Lee Wan Wah , Choong Tan Fook , Wong Mew Choo , Wong Pei Tty, Chin Ee Hui
4) Cycling: Azizul Hasni Awang, Josiah Ng, Mohd Edrus Yunus, Rizal Tisin
5) Diving: Bryan Nickson anak Lomas, Leong Mun Yee, Elizabeth anak Jimie, Pandelela Rinong anak Pamg
6) Sailing: Dr. Kevin Lim
7) Shooting: Hasli Izwan Amir Hasan
8) Swimming: Daniel William Henry Bego , Siow Yi Ting, Khoo Cai Lin, Lew Yih Wey, Leung Chii Lin
9) Taekwondo: Elaine Teo Shueh Fhern, Che Chew Chan
10) Weightlifting: Amirul Hamizan Ibrahim

Good luck and all the best to all of you!

Vastus lateralis tendinitis (tendinoses) and Iliotibial Band Syndrome

A forklift driver came this morning with complaints of left knee pain since the past 1 week with prolonged driving. His pain is worse at the end of the day and it was so bad that he could not sit or squat. He apparently felt better after massaging his thigh.

He had tenderness at the insertion of the vastus lateralis tendon, Iliotibial band (ITB)insertion and gluteus medius origin. He also had restriction of knee flexion (0-80 degrees) and had pain extending his knee against resistance.

As part of the treatment, he was given a day off, reassigned to other duties, told to do RICE treatment,given some stretching exercises for gluteal muscles, quadriceps and ITB and some NSAIDS for 5 days. He would also benefit from ultrasound, TENS, myofascial release and he had some taping done to restrict the pull on the vastus lateralis tendon.

Port Dickson International Triathlon 19-20th July 2008

The Port Dickson International Triathlon is one of the major triathlon events held in Admiral Cove, Port Dickson yearly. This year I had the opportunity to be an unofficial observer as some of my patients were enrolled for the event! I wanted to compare it with the Manchester Commonwealth Games in 2002 where I was assigned to accompany the triathletes of the Malaysian team. The swim start has always been a scramble comparable with a stampede where a competitor needs to be fend off the flailing limbs of other triathletes. After surviving the 1.5km swim by the beach, the able bodied triathletes change to their cycling gear while getting onto their bicycles. The 40 km ride would often be interspersed with hills and valleys (and a beautiful scenery of Port-Dickson). By the time they return their bicycles and start running, they would be bathing in the morning sun for another 10km.

They had a full team of ambulances, Civil Defence forces, Police and paramedics to attend to emergencies. There were a few who sustained minor bruising and muscle cramps during the event.

I had these photos to tell about the event.

Shock Wave Treatment for Achillis tendon Calcific Tendinitis

A young male hockey player came with chronic pain in his Achilles tendon several months ago. His earlier Ultrasound scan showed calcification of his Achilles tendon adjacent to the insertion to the calcaneal bone. He was given extracorporeal shock wave therapy(ESWT) (2000 pulses) weekly and felt much better after the second treatment. He went on to play the Kuala Lumpur Hockey League without any symptoms after 8 weeks rehabilitation and has been symptom-free since then.

ESWT has been approved for plantar fasciitis and has been found to be useful in treating calcific tendinitis.

I took a few photos of the treatment session.





Related websites:
International Society for Musculoskeletal Shockwave Therapy
FDA New Device Approval
EMS Website
Principles of Shockwave Treatment

Foot Contusion and bruise from bike fall

A young lady in her 20s came in with a swollen and bruised right forefoot and toes from a fall off her bike. I sent her for an X-ray which did not show any signs of fracture. She was treated with RICE Treatment, topical Anti-Inflammatory gel and some Cox-2 Selective NSAIDS. The swelling and bruising should subside within 1 week but she will be reviewed in a week.

Hip-hop Dance and Fracture in the foot

An 11 yrs old girl came yesterday complaining of a swollen and painful left foot after hearing something snap in her foot while doing hip-hop barefoot. She had been training barefoot for 1 year but it did not cause any pain. Now, she could not walk or put pressure on the side of her foot or even tip-toe.

I examined her left foot and found that she had some bruising and swelling around outer part of her midfoot (lateral aspect adjacent to the base of 5th metatarsal). There was severe tenderness at the base of the the 5th metatarsal.

Her X-rays shown that her left foot had a non-displaced transverse fracture of the base of 5th metatarsal (Jones Fracture). She was treated non-surgically with non-weight bearing posterior slab crutches to allow the swelling to subsides. She would benefit from a daily dose of low frequency ultrasound (Exogen) to promote healing. Once the swelling subsides we may consider placing her foot in a functional walking brace but she would not be allowed to walk until after 6 weeks later.

Interesting links:
Diagram of metatarsal fractures

Finger fracture with long extensor tendon rupture

A gentleman came in this morning clutching his wrist with a profusely bleeding left middle finger. His finger was hit by a falling panel which dislodged his wedding ring and cut his finger while deforming it instantly.

The left middle finger had a swan neck deformity and a gaping laceration across the middle phalanx oozing out with blood. There was crepitus (indicating a fracture) and he could not extend his distal phalanx suggesting a ruptured long extensor tendon.


I quickly cleaned his wound with Povidone iodine, applied a pressure bandage to stop bleeding, did a buddy taping with a finger splint running across the hand on both sides. He was referred to an Orthopaedic surgeon for further evaluation and treatment. If he was an athlete who had to use his upper limb, he should be out of training for at least 4 weeks.

Lateral Ligament Complex Sprain: Anterior Drawer's Test

Toe abrasions from cycling without proper footwear

I took these 2 photos of the right forefoot of a young cyclist who decided to ride to a grocery shop in slippers instead of cycling shoes. It would be prudent for cyclists to wear suitable footwear even if they are making short trips as abrasions like these are quite common otherwise.