Knee Gouty Arthritis

Mr Loh is a odd-job worker who came to see me with a painful and swollen left knee this since 3 days duration. He told me that he gets the swelling every time he ate Bak Kut Teh (pork herbal soup). He had been told that he had gout by his doctor but he defaulted his treatment.

I examined him and found that he had a tense left knee joint effusion and restricted joint flexion due to the pain and swelling. He refused to do the X-ray and requested that I remove the joint fluid (he had it done on an earlier episode in a hospital). I aspirated 50ml of bright yellow fluid. He also did not want to send the aspirate sample to the laboratory for analysis. He was also advised to use RICE treatment to assist recovery.



He felt much better after the joint aspiration and was given NSAIDS and told to continue with his gout (Allopurinol) medication with his doctor. He was also advised to avoid high-purine foods.

Extensor Digitorum Brevis Hematoma

Ms Lee is a 40 year old lady who was brought to my clinic in a wheelchair after she slipped a step on the stairs last Saturday afternoon. There was an immediate bluish swelling (the size of a Mc Donald's chicken McNugget) on the side of her midfoot. It didn't look good as she looked like she had fractured her 5th metatarsal as she could not place her foot on her ground*.

I did a simple examination and was surprised that the 5th metatarsal bone was non-tender. The swelling seemed to come from the Extensor Digitorum Brevis (Peroneus Tertius, if present). Her plain X-rays did not show any fracture.





I advised her to use RICE treatment and gave her a Tubigrip sleeve to compress the site. She was also given analgesics and ARNICA Comp gel to reduce the swelling and inflammation. Her review will be in a week's time.

*AAFP article on Fractures of the Proximal Fifth Metatarsal

Left Thumb Contusion and Fracture

Ahmed is a recreational volleyball and soccer goalkeeper at the club level. He accidentally hit the ball trying to save it yesterday and the injury caused severe pain and swelling of the distal part of his thumb.

He came with his painful swollen thumb (despite RICE treatment the previous day) and it was really tender and bruised at the tip and base of distal phalanx. There was a small hematoma in the finger pulp. His thumb movements were still intact.








His plain X-rays showed a minute fracture fragment of the base of the distal phalanx and a non-displaced fracture of the tip. An ultrasound of his finger tendons may be required if he had a suspected extensor tendon rupture. I placed his finger in a splint and advised him to return in 2 weeks.

Champion Youth Cup - Malaysia 2007

The Champions Youth Cup 2007 kicks off on the 8th August 2007 with 16 youth teams of the world’s greatest clubs at 4 different venues (Alor Setar, Kuantan, Melaka, Kuching).

The Under 19 age group tournament and aims to:

* Offer football a fresh and unique spectacle.
* Offer the next generation of stars an opportunity to compete against each other.
* Demonstrate their commitment to youth and to the development of the stars of tomorrow.
* Support the communities that have supported them and assist the development of football in Asia.

12 teams are from European, 2 teams from South America, the hosts, Malaysia and a host invitee team from Asia.

The tournament will take place in a league/knock-out cup format with a total of 34 matches over 10 match days. The 2007 preliminary rounds take place between the 8th and 13th August 2007, Quarterfinals are from 14th to 15th August 2007, Semifinals on the 17th August 2007 and the finals on the 19th August 2007.

See you there!!!

Champions Youth Cup 2007
Match Fixtures
Ticket Booking
Shop

PROTON-BWF World Badminton Championships: August 13-19, 2007

Badminton World Federation (BWF)is featuring the world's leading badminton players from China, Indonesia, Malaysia, South Korea, Denmark, England, (all top badminton nations of the world) and other member countries. The tournament will be played by the top 64 players in the world ranking (men's singles, men's doubles, women's singles, women's doubles and mixed doubles).The event would be held at the 15,000 capacity Putra Stadium, Bukit Jalil, Kuala Lumpur.

This tournament is definitely not to be missed!!!

Find out more at the links below:-
Proton-WBF Championships 2007 website
Live Scores
World Ranking

Tibialis Posterior Tendinopathy (Traction apophysitis)

Ms Chia is an 11 years old child who played basketball barefooted last week. She came with Right midfoot pain since a few days duration. She particularly mentioned that she had pain jumping and doing brisk walking. Her mother was worried as she thought it could be cancerous.

I examined her feet and found out that she was flat footed and had a prominent navicular tuberosity(insertion of Tibialis Posterior tendon) on both feet. She had tenderness at that spot but there were no obvious signs except that she had pain standing on her toes and resisting inversion (pushing her forefoot inward against my hand).

I explained to her mother that she would benefit by having good medial longitudinal arch support with orthoses. She could have taping of her foot to provide additional arch support. If symptoms persisted, an X-ray could be done to rule out avulsion fracture (tendon pulls off the tubercle from the bone) or other pathology.

She should recover swiftly with proper footwear, modified activity, isometric and theraband resistance exercises within 2-4 weeks.

Macau Asian Indoor Games

Malaysia will send a contingent of 95 men and 29 women to participate in the
2nd Asian Indoor Games slated for Oct. 26 to Nov. 3 this year in Macau, China, a local official said here on Monday.

The Malaysians were expected to take part in nine of the 17 sports for contest, said Sieh Kok Chi, secretary of the Olympic Council of Malaysia (OCM).

Malaysian athletes would not participate in aerobic gymnastics, snooker billiards, muay (Thai boxing), E-sport, fin swimming, indoor athletics, indoor hockey* and short course swimming.

Source: Xinhua

*Sapura Team will be representing Malaysia in Indoor Hockey.

Peroneal Tendon Subluxation

Nadia (not her real name) was sub-elite gymnast when she came with sudden pain and snapping sensation in her right ankle after twisting her ankle during training 3 years ago. She was seen by another physician who diagnosed her condition and was treated conservatively with bracing for 1 month's duration followed by rehabilitation exercises for 8 weeks.

She had the snapping sensation when she stands on her toes ("On toes") and pointing her toes. I asked her to dorsiflex her ankle and evert the foot and her peroneal tendon would slip in front of the bony prominence (see photo). She only had mild pain everting her foot against resistance. As expected, there was a tendency for the opposite peroneal tendon to slip forward too due to increased laxity. Ultrasonography may be useful if we suspect a tendon tear.*

According to Ferran et al, the diagnosis and management plan are based on clinical evidence. Conservative management may be attempted in acute dislocations, and can be successful in up to 50% of patients, although there is a trend for operative management in athletes. Recurrent dislocations should be managed surgically.**

*J Ultrasound Med.2007; 26: 243-246
**Sports Med. 2006;36(10):839-46.

Ankle sprain without much swelling?

Nicole (not her real name), a part-time fitness instructor came to see me yesterday with a painful right ankle joint. She told me that she twisted the ankle 3 weeks earlier but did not do much for it as she did not have much swelling. She explained that despite a nagging pain she continued to do some classes after a week's rest. She soon realised that the pain was getting more unbearable that she decided to see a doctor.

I examined and found out that she had a tenderness of the antero-lateral aspect of the right ankle, a partially torn ligament (ATFL) and poor sense of balance on the right lower limb. He peroneal tendons and the medial malleolus seemed to be problem free. True enough both ankles seemed more flexible than usual.

She was advised to avoid doing running or jumping without taping. I taught her how to tape her ankle if she had to take classes. I ran through with her the isometric exercises, theraband resistance exercises and balancing exercises she should do. Since she had a grade II sprain, I advised her to do at least 8-12 weeks rehabilitation although she would feel much better within 2 weeks.

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.

Flexor Hallucis Longus (FHL) Partial Rupture

Samson (not his real name) is a club soccer player who felt a sharp pain his right ankle injury during competition last Saturday. He felt pain in the inner aspect of the right ankle and could not 'push-off' to run or sprint after that. He used RICE treatment immediately after injury. The next morning he noticed a bluish discolouration of his hindfoot (see photo) due to dependent hematoma.

He saw me 2 days later and I had him dorsiflex his ankle and curl his toes downward against resistance (to strecth his FHL tendon). He grimaced in pain. He also had pain doing heel-lifts. I suspected a mild strain of his Tibialis Posterior tendon too.

He was seen by an experienced physiotherapist who told him he would be 'out-of-action' for at least a month. I told him that could be accurate but encouraged him to do some isometric exercises (without pain) and keep his fitness level by doing some aqua-jogging. He was prescribed some theraband resistance exercises and told to follow-up with his physiotherapist for electrotherapy.

For most practical purposes, he would need an ultrasound to evaluate the extent of the FHL partial rupture. Tendon partial ruptures may often require at least 12 weeks rehabilitation exercise followed by progressive return to play.

BLOODCARE spray

I have found a useful new product for First-Aid kits called BLOODCARE spray recently. It is an aerosol type of a local haemostatic preparation formed hydrogencalcium salt of oxidised cellulose and pressurised propellant. I have used it several times on skin abrasions and found it useful in stopping bleeding during matchplay.

According to the product description, the content of carboxyl groups (16-24%) and calcium ions present in active powder substance supports the biological healing process, and has the proven features of being bactericidal and bacteriostatic.

To apply the spray, ensure that the superficial wound is cleaned with a running water or disinfectant, apply pressure to dry the wound, shake the can well, hold the can upright and spray from a distance of 10-15cm for 2-3 seconds. The layer formed saturated with blood does not need to be removed. If necessary apply bandage or plaster.

Find out more about Bloodcare spray here.

Navicular Stress Fracture

Crystal is an elite basketball player who landed on her right foot after doing a jump shoot and suffered from severe foot pain a week ago. She was taken off the court as she could not continue weight-bearing. Subsequently, she was seen by another colleague and found to be having tenderness and fullness (oedema) over the inner portion of the dorsum of her right foot. Her X-rays showed a Type III Navicular Fracture.

Anatomy:

The navicular bone, located in the midfoot, articulates with the head of the talus, cuboid, and the three cuneiform bones that are involved in the acetabulum pedis. It gives attachment to the spring ligament (superomedial and inferior calcaneonavicular ligament)that can be injured in a failure of the posterior tibialis tendon and cause an adult acquired flatfoot deformity. The navicular bone provides insertion for the posterior tibialis tendon. Some pathologies can be related to the presence of an accessory navicular bone.Osteonecrosis or stress fractures can affect the navicular bone because of its poor vascularization, especially in its central portion.

Radiological classification of Navicular Fracture: dorsal cortical break (type I), fracture propagation into the navicular body (type II), and fracture propagation into another cortex (type III). It includes modifiers "A" (avascular necrosis of a portion of the navicular); "C" (cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture).


She was placed in a non-weight bearing cast for 4 weeks (as she wanted play if there was no pain!). I saw her at 4 weeks post-injury and her repeat X-ray did not show much callous formation. She was placed in a functional walking brace (Donjoy) and advised minimal weight bearing for another 2-4 weeks. She was told that such fractures may take a longer period to heal and some studies suggest that surgery (ORIF) may be an option. I prescribed her low frequency ultrasound treatment (Exogen) to encourage bone healing. Most studies suggest that conservative (non-surgical) management provide good results for non-displaced navicular fracture but a few small studies suggest that elite athletes may benefit from surgery in type II or III fractures. Return to sporting activity varies from 3.0 months (Type I), 3.6 months (Type II) and 6.8 months (Type III) according to Saxena et al*.

*J Foot Ankle Surg. 2000;39(2):96-103

Stopping Smoking

Cigarette smoking has been known to adversely affect sporting performance. Despite efforts by the honorable Sports Minister to discourage smoking amongst athletes, elite athletes have found it difficult to stop smoking. Despite making sports venues and training centres smoke-free areas, the general public continue to smoke in these places due to lack of implementation of the smoking ban by the health and sports authorities. Recent developments in medicine has shown that new pharmacotherapy may offer better options to assist athletes in this cause.

The efficacy of smoking cessation methods was systematically reviewed by a United States Public Health Services (USPHS) committee during the development of an evidence-based clinical practice guideline for physicians released in 2000. Based on meta-analyses of the existing data, the USPHS panel concluded that 2 smoking cessation methods had the best evidence of efficacy: behavioral counseling and pharmacotherapy (nicotine replacement products -- gum, patch, lozenge, oral inhaler, and nasal spray -- or the antidepressant bupropion*., known as Zyban or Wellbutrin SR). A combination of counseling and pharmacotherapy produced the best results. There was no evidence to support the efficacy of other methods, such as hypnosis or acupuncture. An independent systematic review of this evidence, conducted by a global network of researchers (the Cochrane Collaboration), came to the same conclusions.

In a randomized trial in which bupropion was compared directly with the nicotine patch, patients using bupropion had significantly higher quit rates at 1 year than those using either the patch or placebo. However, nicotine replacement products and bupropion are considered fairly equivalent by most experts, so patient preference and medical conditions should dictate choice of therapy. The USPHS clinical practice guideline states that combining the patch with other forms of NRT resulted in higher quit rates than use of the patch alone, and recommends that combining nicotine replacement products be encouraged if the patient has failed on monotherapy. Ad lib use of nicotine gum or lozenge with the patch may help to reduce acute cravings. Bupropion SR may also be used in combination with nicotine replacement products, although as mentioned above, combining the patch and bupropion has not resulted in significantly higher rates than bupropion alone.

These meta-analyses also found that physician advice to quit improved adult cessation rates, and the addition of brief counseling (less than 3 minutes) was even more effective. Effectiveness further increases with greater counseling contact time, including proactive telephone counseling. (adapted from a Medscape CME article).

4 weeks treatment with Bupropion costs RM300 to the athlete. It is estimated that the treatment would last 7 to 12 weeks to be effective. Nicotine patches are often not a treatment of choice as the profuse sweating of athletes may affect the effective use of the patch.

Disclaimer: Athletes are advised to seek your doctor's advice before taking these medication.

*2008 Update: In the WADA 2008 Prohibited list bupropion is considered as a Substance under the WADA Monitoring Programme 2008.

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.

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.