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.

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!

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

Samsung Champions Trophy 2007

Kuala Lumpur is hosting the 29th Champion's Trophy featuring 8 world class national teams from 29th November 2007 to 9th December 2007 at the National Hockey Stadium, Bukit Jalil. Entrance will be free to promote the exciting and highly tactical sport in the country.


The teams participating in the championships are:-
1. Australia
2. Germany
3. Great Britain
4. Korea
5. Malaysia
6. Netherlands
7. Pakistan
8. Spain

Although the host Malaysia is fielding young players, the team promised to surprise their stronger opponents with fine skills and courage. I will be watching the team from the stands (instead of the bench) and cheering them on. You may also find a live commentary (with live feeds every 30 seconds) on the official website. All the best to the participating teams!

Find out more here:-
Official Website
The fixtures (schedule) and results
Points Table
Players and Officials
Photo gallery
News Updates
Samsung Official website

Bilateral Knee Osgood Schlatter's Disease

Jimmy (not his real name) is a 15 yrs old hockey junior state player who has been suffering from pain in both knees since 3 years ago. He also noticed that his tibial tuberosity was more prominent than other players. The pain would worsen with intensive weight training and running on hard turf surface. His dad was planning to give him some additional quadriceps strengthening exercises for his 'thin' legs but decided to ask for my opinion.

I examined his knees and found that he indeed has a protruding tibial tuberosity on both knees. It was painful for him to attempt to bend his knees fully but he was able to do so with my assistance (passive movement). He had pain squatting beyond 120 degrees.

In most cases, Osgood-Schlatter disease is caused by microtrauma in the deep fibers of the patellar tendon at its insertion on the tibial tuberosity and which may be associated with avulsion. The condition is usually self-limiting and symptoms resolve with skeletal maturity in over 90% of cases, when the tibial tubercle fuses to the remainder of the tibia.

He would require a plain X-ray to demonstrate any bone ossicles or avulsion and an ultrasound scan by an experienced sonographer may confirm the diagnoses.

I advised him to lay off running on the turf and focus on light skill workout. He was also encouraged to do some aqua-jogging for fitness. His pain would usually take 2-4 weeks to subside. He was also prescribed NSAIDS to relieve his pain and a patella band to unload the stress from the tibial tuberosity. Surgery is very rarely indicated.

Links of Interest:
Osgood Shlatter's Disease
Tibial tubercle avulsion

Malaysian Indoor Hockey Team

Hamstring Strain

Raju (not his real name) is an ex-International hockey player who suddenly suffered from a sharp pain in the back of his right thigh while sprinting towards the 'D'. He thought that it was just a muscle cramp and wanted to play. I ran on the pitch and took him off. He tried to stretch himself but he could not due to the pain. He refused to be strapped and wanted to go into play again but he could hardly straighten his leg.

I quickly iced his hamstring and wrapped it with crepe bandage. After 10 minutes, I reviewed the injury and found that he could hardly lift leg against gravity. Upon palpation, I found out that he had a deep tenderness along the sides of the semimembranosus tendon (musculotendinous junction).

He was advised to obtain an Ultrasound scan to determine the extent of damage (partial tear). He was advised to continue RICE treatment and asked to continue treatment of his Sacroiliac Joint Dysfunction. We also advised him to warm-up, stretch and drink-up (rehydrate with sports drinks or water) adequately.

It should take him at least 6 - 8 weeks to recover adequately with rehabilitation exercises. However, he would be reviewed every 2 weekly do assess his progress. He would also require a fitness test before return to sport.

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)

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.

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.

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.