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.

Cardiopulmonary Resuscitation Update in Sports Emergencies

Oxford UK, 28 November 2005. New guidelines for the resuscitation of adults and children have been published today (28th November) in the international journal Resuscitation, announced the European Resuscitation Council (ERC) and Elsevier Ltd.

The guidelines are aimed at all healthcare workers; a section on basic life support also provides information for laypeople and first responders. The recommendations made by the ERC are based on a comprehensive, evidence-based review of resuscitation science that was undertaken over the last two years by experts from all over the world. These experts debated their findings in a Consensus meeting held in Dallas in January 2005 and their conclusions, also published today, form the basis for establishing best practice worldwide.

The last CPR guidelines were published in 2000; since then, science has moved forward and our understanding of the evidence has improved. The new CPR guidelines focus on a ‘back-to-basics’ approach and are easier for lay-people and healthcare professionals to learn. The steps to successful resuscitation are described by the links in the revised Chain of Survival. Early recognition of the patient who is very ill will enable medical assistance to be called immediately, providing an opportunity for early treatment and the prevention of cardiac arrest. In the event of cardiac arrest, early chest compressions and breathing may keep enough blood going to the heart and brain to buy time until the heart can be restarted by an electric shock (defibrillation). Once the heart has been restarted new treatments aim to improve the chances of the patient making a full recovery.

In comparison with the 2000 guidelines, the 2005 guidelines recommend giving more chest compressions (30 compressions for every 2 breaths instead of the traditional 15 compressions for every 2 breaths). The ratio of 30:2 applies to all adults and children (except for newborn babies) — this should make it easier for everyone to learn and remember. Advances in defibrillator technology (the device that gives an electric shock to restart the heart) enables healthcare workers and trained lay-people to give an electric shock earlier and more effectively to a person in cardiac arrest.

It's almost 2 years since the International Resuscitation 2005 guidelines are available. The European Resuscitation Council and American Heart Association guidelines are available on their websites. Athletes, coaches and sports officials are encouraged to undergo the basic life support training in the event of collapse of a participant during sports. Sports event organisers are advised to ascertain that medical services covering sporting events have AED equipment and trained personnel.

Knee Contusion

A young lady came in this morning with a swollen knee complaining that she could not kneel down and pray as her knee hurts. She informed me that she slipped after cleaning the floor the previous day.
She had normal range of movement but the bruised area (see photo) was tender and swollen. I advised her to use a pillow to support the knee during prayer, apply Arnica Comp gel and use a Cox-2 selective NSAIDS for 5 days. She was also encouraged to use to use the RICE treatment. The bruising would probably get worse after a day or two and then subside within 1-2 weeks.

Fractured Clavicle

Mohamed came in last Saturday holding onto his right elbow with a deformed 'collar-bone' (see photo) after a fall from his motorbike. He was in severe pain and requested for immediate 'painkiller' injection. I examined him and found that he had a fracture of the midshaft of his clavicle (commonest site) with the proximal part displaced upward. We splinted the left upper limb with a triangular bandage. His peripheral pulses were normal and his ribs and lungs were not injured. I referred him to my Orthopaedic colleague to reassess the need for surgery due to the displacement and overlap. Usually, non-displaced fractures of the midshaft are treated non-surgically with a triangular or figure of eight bandage (see how to apply) and NSAIDS.

In a retrospective study, 132 patients with united fractures of the middle third of the clavicle and a follow-up of up to 30 months after conservative management were reviewed. Of the patients, 34 (25.8%) were dissatisfied with the result of their management possibly due to shortening of the clavicle.J Shoulder Elbow Surg. 2006; 15(2):191-4



A small study in Belgium suggests that semi-professional athletes may benefit from surgical plate fixation of the fractured clavicle with a possible early return to sports (45 days)at the expense of a significant risk for complications (e.g. infection, non-union, refracture) which would not be considered acceptable in patients with lower functional demands. Acta Orthop Belg. 2005; 71(1):17-21

The patient actually had surgery done and was having full function of his right shoulder within 2 weeks. He was advised to return to his surgeon for removal of the plate after 1 year.

Nike + iPod Sports Kit

Nike and Apple has come out with a gadget and software which gives athletes another excuse to run. The Sport Kit2 allows your Nike+ shoe to talk to your iPod nano. The sensor uses a sensitive accelerometer to measure your activity, then wirelessly transfers this data to the receiver on your iPod nano.



What do you need?: Get in gear.

A pair of Nike+ shoes, an iPod nano, and the Nike + iPod Sport Kit (see photo).

How it interacts?:Rock ’n’ run.

With a sensor in your shoe and a receiver on your iPod nano, your run takes on a whole new dimension. See the minutes tick by. Watch the miles unfold. Hear real-time feedback. All to your favorite music — including the one song that always gets you through the home stretch.

Review your run and interact with your trainer:Stay in sync.

Sync up after you cool down. Just as seamlessly as it syncs your music, photos, and calendars, iPod nano also syncs your run. Simply connect iPod nano to your Mac or PC, and your workout data syncs to both iTunes and nikeplus.com, where you can see your runs, set goals, and discuss with your trainer or coach. You could also utilise a running site by Nike.

Here's how the Sports Kit2 is advantages for our workout:-

1.Connect
Any mere pedometer can show you stats while you run. But thanks to the Nike + iPod sensor and receiver, iPod nano also transfers your workout data to the Internet as soon as you sync. Connect your iPod, and iTunes takes over, automatically syncing all your run data and sending it to nikeplus.com.

2.Compare
Remember each run. Analyze your performance. Break your last record. Stay in tune with your goals. Nikeplus.com keeps stats on every step. Check your speed, distance, and calories burned — by run, by week, or by month — all from a graphical interface as intuitive as it is stunning.

3.Compete
Nikeplus.com keeps you connected with runners from every corner of the web. And that’s where the real race begins. Use nikeplus.com to challenge anyone, anywhere to a virtual race. Run on your own time, on your home turf, then log on to nikeplus.com to retrieve your results. Users have cloked more than 20,000,000km globally and is increasing every second.

Disadvantages:
1. You will need a pair of Nike shoes and an iPod before you start.

What's the price? US$29 for the kit; (RM138 at Nike, One Utama)

Leg Contusion after kick!

A futsal player came in walking this morning. He showed me his swollen right leg and I thought it was just a contusion (soft tissue injury). He was able to do heel-raises and even hop on the injured leg!

After careful examination, I found a defect in his right tibial bone (as he received the kick from the midline outward). I took a marker to delineate the defect (see picture). I gave him some NSAIDS, Arnica Comp gel and told him to apply RICE treatment. He was also sent for an X-ray but it came back normal. He was told to return for a review in 1 week's duration.

He should have been wearing his shin guard!

National Sports Science and Sports Medicine Conference 2007

The Perak Sports Council and Ipoh Hospital will be hosting the National Sports Science and Sports Medicine Conference 2007 in collaboration with National Sports Council, Olympic Council of Malaysia and University Malaya and Malaysian Association of Sports Medicine. The theme for this conference is "Science of Sports". Sports scientists, coaches, trainers, athletes, physiotherapists, doctors and paramedics are encouraged to attend. The details are available here.

Date: 15th-17th June 2007
Venue: Bangunan SUK Negeri Perak, Ipoh, Perak

Catch your early bird discounts before 15th May 2007. Do not miss the opportunity to visit the historical and beautiful Ipoh city!

Rt Big Toe Gouty Arthritis

Mr Lim came in walking on his heel with a painful and swollen base of the right big toe (see photo) yesterday. He could not remember having any falls or trauma to the toe but had a little too much beer, seafood and peanuts for the past week.

I was keen to find out whether he had any insect bites or previous injury but he had none. I took a blood sample for his uric acid levels and sent him off with an NSAIDS for 5 days. Had to give him some gastric preventive medication i.e. Proton-Pump Inhibitors to prevent any gastric side-effects. Also warned him not to take NSAIDS on his own as it could cause hypertension or heart problems if given indiscriminately.

True enough his serum uric acid levels came back elevated. He was advised to avoid excessive intake of protein and beer. If he had recurrence in his condition, he may have to be on medication to lower the uric acid levels e.g. cholchicine or allupurinol.

Forefoot contusion after supper!

The local council is going to get a complaint from this patient. He was walking back from 'Mamak' (a spicy, not so fancy, local fast-food) when he accidentally stepped into a pothole in Subang Jaya last Saturday.

He had a painful swelling on the dorsum of his right foot (see photo) and could only walk on his inner side of his foot. He had a painful gait when he walked into my clinic yesterday. I was getting a bit worried as he could not put weight on the side of the foot. After examination, I felt that he could be spared from an X-ray as most of the pain came from the superficial swelling and not the 5th metatarsal (common site of injury for such falls). I once had a 50 year old colleague who fractured her 5th metatarsal in the same manner walking along the pavement! Her risk was higher as she was having Osteoporosis.

Told him to do the RICE treatment (see first-aid) and gave him some Arnica gel and oral NSAIDS. He was advised to avoid excessive walking for another 5 days and return for a review if pain and swelling persisted.

Josiah fractures his clavicle?

Josiah Ng, who currently ranks 7th in the world suffered a hip contusion after hitting the training motor-pace bike on the 22nd March 2007. Just a week later he had a terrible mishap after an illegal technique used by an Italian rider caused him to loose control and crash. It was reported by the Star newspaper that he suffered a 'broken collar-bone.

Wrist injury in Badminton player (Scapho-lunate Subluxation)

Chris is a 16 years old club badminton player who fell on his right palm 6 weeks ago while playing singles competition. He tried to play in the doubles soon after but couldn't as the wrist started to swell and the pain was unbearable. He was seen by a doctor and his pain was on the ulna styloid. He could not do any lobs and smashing after that as he had pain on the back of the wrist (dorsum).

He did not have any problems with wrist range of movement. "Ouch!", he squealled when I palpated the lunate bone. There seemed to be more mobility of the bone adjacent to the scaphoid bone (see picture). After discussing with him, we decided to do an X-ray to rule out fracture of the lunate bone followed by an Ultrasound or MRI of the Right wrist to rule out scapholunate ligament tear.

Meanwhile, I told him to start pain-free strengthening exercises for his wrist and suggested he tape his wrist during play. He was not to do any 'lobs' and 'smashing' until we obtained the results from his X-rays and MRI.

Tibialis Posterior Tendinopathy

Ms Wang, a young lady executive shuffled slowly into my clinic. "I think I sprained my right ankle on the treadmill 2 days ago", she said. I was expecting a large swollen ankle but it was not that swollen. Then she pointed at the spot on the navicular tubercle (marked 'o' on the picture). She had a previous 'twist' of the same ankle several years earlier.

It sounded like a foot injury seen in my gymnasts, diving and dance sports athletes. She had mild pain when asked to flex and extend her ankle but she could not twist her foot outwards (eversion). She also had pain twisting her foot inwards (inversion) against the resistance of my palm. I palpated (felt with my fingers) the tibialis posterior tendon insertion on the navicular tubercle and she had severe tenderness.

Informed her that her tendon was strained but the deltoid ligament was spared. She needed to ice every 4 hourly (15 minutes/session), avoid high heeled shoes, possibly tape her ankle if she wanted to do more vigorous walking or running, have another look at her walking gait with her shoes, start some isometric exercises and progress to some theraband exercises. "I will see you after a week and expect the injury to heal within 3 to 4 weeks if you do your exercises"

Glucosamine for knee osteoarthritis

Athletes with osteoarthritis of the knee joint often suffer from recurrent pain and swelling of the joints after intensive running and jumping. Current research provides good evidence to support the use of glucosamine sulfate in the treatment of mild-to-moderate knee osteoarthritis. Most studies have used crystalline glucosamine sulfate supplied by one European manufacturer (Rotta Research Laboratorium). Results of a recent large clinical trial (GAIT) comparing the effects of glucosamine / chondroitin sulphate for treatment of knee osteoarthritis did not show any additional benefit except in the patients with moderate to severe pain from osteoarthritis. A more recent study (GUIDE) shows in a 6 months random placebo controlled trial that oral glucosamine sulphate (1500mg/day)is more effective that placebo or acetamenophen (3gm/day). ARTHRITIS & RHEUMATISM Vol. 56, No. 2, February 2007, pp 555–567

Most of my athletes with mild to moderate Osteoarthritis have had symptom relief and functional improvement after taking Glucosamine for a tleast 1 to 3 months. Those with recurrent swelling and pain would also benefit from a course of three to five Intra-articular Hyaluronic Acid weekly injections. Athletes who undergo this injection are advised not to continue with vigorous running and jumping during the course of treatment. These athletes would also be given other forms of exercises to improve strength and stability.

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F1 Malaysian Grand Prix

Read that the organisers are giving attractive offers for the F1 Malaysian Grand Prix in Sepang. Offers are valid until 31st March 2007. Let the wheels roar!!! Visit the website at Sepang International Circuit.

Champions Youth Cup Malaysia 2007

16th March 2007 – 14 of the world’s greatest football clubs will play in a single tournament and all in one place – when Malaysia hosts the Champions Youth Cup Malaysia 2007 from 5th to 19th, August 2007. The inaugural event is supported by the Ministry of Youth and Sports, the Ministry of Tourism and is backed by the FA of Malaysia (FAM).

Four groups of four teams will play round robin matches in Alor Star, Kuantan, Melaka and Kuching with the knockout stages and the final to be held in Kuala Lumpur.

“The tournament shows that Malaysia matters to these clubs – a two weeks football festival of the world’s greatest clubs, the world’s finest young players and 34 matches across seven venues,” said Jonatan Price, chairman of UK-based Gifted Group Limited.

“The clubs make a huge investment in these players through their academy structures and Malaysians will enjoy a very special privilege because for the first ever, these clubs will be introducing their next generation of stars to a world wide television audience as a prelude to them playing in the Champions League and the Copa Libertadores.”

Among the more notable players to have matured from the various development programmes of these clubs are Franz Beckenbauer (Bayern Munich), Johan Cruyff (Ajax Amsterdam), Zico (Flamengo) and Lionel Messi (Barcelona).

In the meantime Datuk Azalina Othman Said, the Minister for Youth and Sports said that the organisation of the Champions Youth Cup Malaysia 2007 is subjected to the approval from FIFA as well as the Asian Football Confederation (AFC).

The official draw for the tournament will be held in Malaysia on 19th April, 2007.

THE PARTICIPATING TEAMS

AC Milan (Italy),Ajax Amsterdam (Holland),Arsenal (England),Boca Juniors (Argentina),Barcelona (Spain),Bayern Munich (Germany),Chelsea (England),Flamengo (Brazil),Juventus (Italy),Inter Milan (Italy),MALAYSIA,Manchester United (England),Paris St. Germain (France),PSV Eindhoven (Holland),Porto (Portugal),Qatar,(adapted from FAM website);

We want to hear your comments and your support for this affair! I have enclosed the official website for further information. You may also find more information about tourism in Malaysia at Tourism Malaysia. Join us to make this championship a success.

Ingrown Toenail

Anthony is a 10 year old basketball player and cyclist who weighs 60 kgs. He came this afternoon with a recurrent left big toe painful swelling since 1 year duration. He has seen several doctors but he said, "Nothing they did worked!".

I examined his toe and found that the swelling was already resolving. There were signs that probably it was oozing pus over the past few days. Somehow he came in as he felt it was "too much of a hassle".

I got him to agree not to trim his toenails so deep. I was also concerned whether he was diabetic as he had a strong family history of diabetes in his family. I gave him a course of oral antibiotics and an antiseptic for dressing. Told him to bring his footwear for examination and stay off playing games until it healed. I thought, who would stay with this for a whole year?!!

Ulna Neuritis in Cyclist

Mark is a 45 years old road cyclist with a mileage of 200 km per week. He came to see me 2 months ago with complaints of numbness and tingling sensation of his little finger and adjacent side of the hand. He mentioned that he was 'riding harder' than usual and had occasional wrist pain 2 weeks earlier as he 'felt good' and wanted to do more.

He was quite happy to lay off riding for 2 weeks and was given some isometric and resistance exercises with theraband. Subsequently, when I reviewed him again last month, he was slightly better. I gave him some neurotonics (vitamin B12) and allowed him to ride but advised against putting excessive pressure on the handlebars.

He came back last week without any symptoms and he said that he was riding better now that his wrists were stronger.

Plantar Fasciitis (Ouch!)

Brian is a 'recreational' badminton player who just returned to play after a 1 month celebration of Chinese New Year. For obvious reasons he wanted to get rid of some of the 'excess' weight that he gained. 2 days after play he started having severe hindfoot pain in the mornings. The pain subsides after walking for half and hour. He seemed to feel better walking in his leather shoes but playing badminton was a painful affair.

The pain was spot on the calcaneal attachment of the plantar fascia (see the mark 'X' on the photo). He also had tightness in the calf muscles and was flat footed. He had difficulty doing calf stretching. "I never did this before", he said.

We got him to wear a slipper with raised heel support (1/4"), a pair of preformed insoles for his flat foot, daily calf stretching when he got back from work, and ice-massage over the spot. He also saw a physiotherapist for myofascial release for his calf. Within 2 weeks he was back playing. Obviously, he was told to avoid playing to vigorously!

Low Backache

Ms Lim, a lady in her twenties came to see me this morning with complaints of low backache after waking up from sleep. She told me that she did not do any physical activity except the washing the corridor the previous day. However, she was able to sit with mild pain and did not have 'shooting' pain to her legs. She was previously seen by my colleague 1 month ago for the same problem but it resolved with some vitamin B12 supplementation and an analgesic.

She bent her back backward and forward and had moderate pain on the left side but her range of movement was full. She had some tenderness of the left quadratus lumborum muscle and the posterior superior iliac spine on both sides.

She was not keen on doing exercises or investigating further as she felt it was not a serious injury. I left her with a muscle relaxant, 5 days of moderate analgesics and advice to remain 'active'. She was told she could return to see me again if symptoms did not resolve as 50% of non-specific low back pain tends to resolve on their own within a week. I informed her that she probably should not use the corset (see picture attached) for longer than 2 weeks duration.

Diet only is as effective for weight loss?

A randomized controlled trial (CALERIE) done by Redman et al to test the effect of a 25% energy deficit by diet alone,CR or diet (12.5% Energy deficit) plus exercise (12.5% increase in exercise energy expenditure),CR+EX for 6 months on body composition and fat distribution. Thirty-five out of 36 healthy overweight (16M/19F) subjects completed the study. Participants lost 10% of body weight (CR:-8.3±0.8, CR+EX:-8.1±0.8kg, p=1.00), 24% of fat mass (CR:-5.8±0.6, CR+EX:-6.4±0.6kg, p=0.99), and 27% of abdominal visceral fat (CR:0.9±0.2, CR+EX:0.8±0.2kg, p=1.00). This study suggests that diet restriction may be equivalent to diet restriction and exercise.
Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2006-2184
Blog Authors comment: This study does not rule out the additional benefits of doing physical exercise which has cardiovascular and metabolic implications. However, it is encouraging as a weight loss of 10% has additional benefits on cardiovascular risk reductions for obese or overweight patients.

Check out this site for weight loss strategies

Rotator-Cuff Injury

Ahmad has been playing for several weeks in preparation for a major badminton competition in 2 months time. His coach wanted him to perfect his skills with multi-shuttle drills involving lobs and smashes. He would be sore in the right shoulder tip after each training session. Moreso after repetitive smashing. His coach asked him to ice after training but yesterday despite icing his shoulder he had persistent pain and his smashes were getting weaker.

I saw him and found out that if he abducts his shoulder (brings his shoulder up on the sides) more than 90 degrees and rotates it backwards, he has some pain. He also has pain in front of his shoulder lifting his arm behing his back. He was able to do the empty can test (where he pushes his abducted shoulder upwards with the thumb pointing downwards)with some pain. Between 1 and 10, the painscore was 5-6.

Our radiology colleague did an ultrasound scan for him showing some inflammation of the rotator cuff and grade I strain of the supraspinatus tendon. He was lucky not to have any impingement demonstrated clinically or on X-rays.

We talked with the player and his coach and decided that he was going to concentrate on his footwork and aerobic fitness for 3 to 4 weeks. He was allowed to do skills without 'overhead' work. Part of his training programme would involve work with theraband and core stability. THe physiotherapist got him to do some 'car-wash' wiping movements diagonally to improve his shoulder proprioception (sense of position and balance).

Within 2 weeks his shoulder was feeling much better and he was able to swing his shoulders without pain. At 4 weeks he regained most of his strength and was able to smash even harder without pain.

Medial Collateral Ruptured!

She was running down the hill slope when she landed her foot into a small hole and felt something snap and felt a sharp pain in the inner part of her left knee. She fell over and grimaced in pain. Her athlete quickly took her by the shoulders and helped her up to the clinic at the sports complex.

Elaine knew that her knee was in bad shape. She could hardly stand properly and the knee seemed to be twisted outwards. 10 years ago she had an injury to the same knee but she could still walk with little support.

"Looks like you've really torn your medial collateral ligament", I said to her. We quickly got her to ice the knee and prepared her file for physical examination. She had the full range of movement(ROM) which was quite 'pain-free' but she had severe tenderness and moderate swelling at the femoral attachment of the MCL. There was mobility of the leg when it was stressed outwards. Her tests for Anterior Cruciate and Posterior Cruciate ligaments were normal. She was lucky that there was no joint effusion (swelling in the joint due to accumulation of fluid e.g. joint fluid, blood, pus).

"Your MCL is complete torn clinically, but you should be back in 2-3 months time with rehabilitation if nothing else is torn", I said. She was given a functional knee brace and sent for an X-ray. Her X-rays came back normal except for the fluid shadow. We planned her for an MRI within the next 3 days to ensure that the other structures like meniscus and cruciate ligaments were not torn.

She was told to continue icing her knee every 4 hourly and focus on isometric exercises for her quadriceps and hamstrings for the next 1 week. Zul, the physiotherapist was quick to show her the rehabilitation chart. He told Elaine that she would need to progress in stages as she improves her strength, stability and function of her knees. he also planned hydrotherapy sessions for her to maintain her 'aerobic' fitness

Basics in First-Aid

Rest: Modified your physical activity to reduce or stop moving the injured part to ensure that you do not worsen the injury. You could do so by reducing the intensity and duration of training. If the injury is serious, you may have to stop training altogether.





Ice: Apply a towel on the injured part before you apply a bag of crushed ice or ice cubes. Do not apply ice directly on skin and do not wrap the crepe bandage too tightly as this may cause cold burns. Only apply for 15-20 minutes and you may repeat the procedure every 4 hourly if swelling and pain remains.






Compression: Apply a crepe bandage to compress the affected part to reduce swelling. Do not wrap the bandage too tightly as it may interfere with blood circulation. Check by pressing the fingers and you should see the colour return immediately. Often the athlete will tell you that he/she has more pain due to a very tight compression strangulating the blood supply.




Elevation: Keep the affected limb elevated above the level of the heart to 'drain' the swelling and hence reduce pain. As long as there is still visible swelling this may be beneficial.

Footwear and my feet

I don't really look at the price of the pair of running shoe when I go shopping for one. More often than not, I would already have an idea of a reputable shoe manufacturer. My brother and I both have flat feet and overpronation. For obvious reasons, we would look for something light, breathable, durable, an insole with proper arch support, semi-rigid mid-sole with good stability. However, my requirements are generally for running on the treadmill and some cycling. Even my working leather shoes are selected with such specifications to allow me to occasionally jog down the alley when I need to. I have a 2 pairs of running shoes, 4 pairs of costly leather shoes and another 2 pairs of cheap shoes.


Every athlete should find out whether they have special requirements due to abnormalities in walking, running and jumping pattern (gait) required during training and competition. Check with your shoe manufacturer whether they have shoes which are specific for your condition. Not all expensive shoes have such requirements. Check whether the mid-sole provides sufficient stability, support and flexibility. Check whether the outer-sole is suitable for the different surfaces of the court or field. You may need to check with a podiatrist if you constantly find it difficult to obtain good shoes which do not cause pain to your feet, ankle and knees. A video of your walking and running pattern could highlight some possible problems and solutions.


You should always try out the shoe first and do all the different skills required in your sport with it. However, it will often take 2 weeks (at least) before you will find the shoe comfortable enough to be worn (break-in). I also use some preformed orthotics for some of my patients if they have abnormalities in gait and recurrent ankle, foot and knee problems with good results.

Doping Prohibited List 2007

Every elite athlete i.e. international, national, state or club athlete should be aware of the latest Doping Prohibited list updated at least once every year. The Prohibited List is an International Standard identifying Substances and Methods prohibited during competition (in-competition), outside competition or during training (out-of-competition), and in particular sports. Substances and methods are classified by categories (e.g., steroids, stimulants, gene doping).

In Malaysia, the National Sports Council Doping Control Unit coordinates 'no notice' doping control testing and some of the in-competition testing for international, national and state athletes. National Sports Associations (NSA) undertakes some of the other doping control testing for their respective sports. Meanwhile, International Sporting Federations may appoint their own doping control officials to carry out the doping control testing.

It is vital for such athletes to inform their treating doctors of their status as athletes and the need to review the Prohibited list to ensure that they avoid taking the 'illegal' substances unknowingly and risk being sanctioned or losing their medals. Ignorance of the Prohibited List shall not constitute any excuse and athletes may face a ban of up to two years or a lifetime ban.

Athletes should also be cautioned that some traditional supplements and nutritional supplements may contain Prohibited substances as they may not be subject to such stringent manufacturing and labelling processes as drugs ( 1,2)

Some Prohibited Substances may be used by an athlete for medical reasons by virtue of a Therapeutic Use Exemption. For example inhaled beta-agonists in asthmatics. However, such use must have adequate documented laboratory evidence submitted to the respective NSA or International Federations.

For further information, go to http://www.wada-ama.org/en/index.ch2. If you are a Malaysian athlete you may also approach the Doping Control Unit of National Sports Council at 03-8992 9600.

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Multiple Joint Pain and Bodyache

Chong was a regular gymnasium user who was as fit as an elite athlete. He did 2 hours of regular workout including 30 minutes run, core stability exercises, moderate weight training and an occasional dance routine at a popular gymnasium. At 40 years of age, he could run faster than most men half his age.

He came in a day after his hard workout thinking that he probably overdid it. Most of his joints were aching and his muscles were sore. For some reason or other, he was still sweating profusely. "Doc, I think I shouldn't have worked out so much last week!", he said. I smiled, saying "Told you you needed to recover after each exercise session!". He wasn't quite impressed as usual. In went the mercurial thermometer. "Ahhh! 38 degrees centigrade. You're down with fever!", I said.

"How many days have you been feeling feverish?", I asked. "Three", he answered. He also had a rapid pulse rate and a slight raise in the Blood Pressure. Hess test (a special test to check for petechiael rash) was positive. "Let me send a blood sample to check for your blood counts. The last thing we want is dengue fever", I said. "You need to rehydrate a little more than usual and take a day off. I will call you in a few hours time". It took the laboratory an hour to fax me the result and true enough his white cell count and platelet counts were low. He was lucky that the levels were not critical and it resolved the next day.

To play or not to play!

It was 7.15pm and I was late for a pharmaceutical talk. John called as I was just approaching the venue. "Shucks!", I said. I needed the CME points but the player needed an urgent decision. To play or not to play!

I quickly returned to my apartment and he was already waiting there. He was walking and that was good news but he had a slight limp. I know some players who walked 'funny' after training due to a back problem and leg-length discrepancy.

A quick examination revealed a localised area of tenderness (pain upon application of pressure), muscle spasm adjacent to the junction between the medial gastrocnemius and soleus muscle. Tried a few light skills and he could not 'push-off' as required to play badminton.

He knew the consequences of injecting steroids and so he didn't ask me to do that. He had seen talented players who had muscle tears and tendon ruptures after indiscriminate injections done for the sake of competing.

"No-play!", I said. "I could give you a muscle relaxant to help relieve the spasm and you can continue with another 3 days of NSAIDS (anti-inflammatory and pain medication), but no play!". He was keen to improve his performance and insisted that he would decide the next day.

He played against a lesser known player and lost the next day. The press gave him such a bashing that I felt sorry for him. I know the player and he made the right choice to hold back and not push to win. He told me later that he just couldn't move and the pain worsened as he played. He had to play as he was required to by the coach to try. After a week he played much better in another major competition after undergoing rehabilitation and taking precautionary measures

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Non-specific Knee pain

She could not bear the pain in her left knee anymore. It has been 1 month and the pain was still present. In fact, it worsened after she went to 'service' her clients to ensure that they continued her company's products. She thought it felt better after application of 'the stinking yellow stuff' the chinese doctor applied. "Maybe I should have rested", she thought.

Mei Lee then decided to see sports physician in the neighbourhood. "My knee is more important than the job", she said gritting her teeth in pain as she hobbled along the corridor (as she could not find parking in the Subang Jaya business area).

I was surprised that she was having recurring episodes of left knee pain over the past few years and lived with it. She has had blood test, several X-rays and even an Ultrasound scan done but nobody prescribed exercises to get her back on her feet. "Uhmm..., where did we go wrong in medical school? Or is it just that it's difficult for clinicians to spend time talking to the patient and teaching some basic exercises? Or it's just that nobody bothered to send her to the physiotherapist. At least that could have helped!", I said. "I did see the physio, but they only did electrical stimulation. Since it didn't seem to help, I decided to seek treatment elsewhere", she lamented. Maybe they tried to help her but she was not receptive to their suggestions.

Back to the drawing board!. Her blood investigations for joint disease and inflammatory markers were normal. Her left knee X-rays were normal and so was the ultrasound scan. She had a painful gait, sacroiliac joint inflammation (dysfunction), tight hip adductors, knocked knees and hyperlaxity of both knee joints (in extension)but she had a very tight Achilles tendon due to frequent use of high heels and not enough stretching. This would take a lot more time to unravel the problems.

She was prescribed topical NSAIDS gel and a whole series of exercises to strengthen her quadriceps, hamstring, gluteal muscles, abdomen and lower back. I also did some myofascial release (manual work to release muscle spasm and pain) for immediate effect. After 2 weeks, she was much better and able to run upstairs without pain. She was prescribed more exercises and we added a weight reduction programme for her too!

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