Malaysian Male Kata 8th AKF 2007

Japan Male Kata 8th AKF 2007

8th Asian Karetedo Federation Senior Championship

An exciting world class karatedo competition called the 8th AKF Senior Championships will be held on the 24th - 26th August 2007 at the Nilai Indoor Stadium* (near Nilai International College).

On the first day, Malaysia won 2 gold medals, 1 silver and 2 bronzes. There will be 3 fights simultaneously from 9am to 6pm. My medical team will be in the middle of the three competition mats. We have to observe in 3 smaller teams to ensure that we see the way the athletes fight so that we can gauge the severity of injury even before we examine the athlete.

For the sparring (kumite) competition, each bout lasts for 3 minutes between the Red (Aka) and Blue (Ao) athlete. If there is a draw, there will be another minute of competition with sudden death score. The skills performance (kata) competition will be a show of finesse of the various skills perfected by the athlete.

*Getting there: (A map of the destination is not available)
Take the KL-Seremban Highway (North-South Highway), exit Nilai (Exit 215). After the toll gate go straight and hit a T-junction, turn right go straight until you reach a roundabout. Take the 3 o'clock turn and go straight to pass through an empty area, housing area and you will see the huge red colour building on your right i.e Nilai Indoor Stadium.

Important links you need to know:
Competition Schedule
WKF Rules & Regulations

Recurrent ankle pain

Ms Wong is a 25 yrs old lady who does hiking twice a month. Each short hike would usually last 4 hours. She has been regularly training in the gymnasium for a hike up Mount Kinabalu recently and found that her left ankle gives her pain in the mornings and after her 'short' hikes. She also remembered twisting her left ankle several years ago.

Clinically, she has bilateral Anterior Talofibular ligament (ATFL) laxity (left > right). Her ankles were otherwise quite normal. She would be planned for a Plain X-ray of both ankles to rule out any fractures. Meanwhile, she was advised to continue lower limb propriorceptive exercises. She was to consider using ankle bracing or ankle taping when she is to go cross-country running or hiking. We may plan for an MRI of her left ankle if her X-rays are normal and her symptoms fail to subside.

She is due to return after testing the hikes with ankle taping.

Find out more from these links:-
Climbing Mount Kinabalu
ATFL Laxity Test
CFL Laxity test

Medial Collateral Ligament Rupture

Ahmad is a 24 yrs old cook with a gourmet restaurant met with an accident on his way back from work. He had severe pain on the inner aspect of his left knee and could hardly walk. He had difficulty straightening his knee fully and could not bend his knee.















I examined his knee and found that he had some localised swelling over the femoral attachment of the Medial Collateral Ligament (MCL). Ahmed told me that that was the spot that he collided with the motorcycle. I did the valgus stress test and found that the MCL was torn completely. He was advised to use a Functional knee brace for another 4 weeks while starting his rehabilitation programme. He was concerned as he would not be able to come for the rehabiltiation exercises. He opted instead to use a crepe bandaged wrapped to support the MCL. He was advised to apply RICE treatment to reduce the pain and swelling. He may benefit from an X-ray of his knee and an Ultrasound scan of the MCL.

To be continued...

24 hour Walk Swollen and Bruised Toes

Mr Singh is an ex-athlete and junior walking coach who participated in the 4th Malaysia International 24-hour walk at Dataran Merdeka on the 11th August. He came back with a pair of swollen feet with both big toe badly bruise when I saw him on the next day.

It is common for marathon runners to have such lesion after competition. I advised him to keep his feet elevated, have them iced, use the lysozyme tablets (for swelling) and NSAIDS (for pain and swelling). He would need to have the subungual hematoma (blood accumulation under the nailbed) relieved by the doctor using a sterile needle. Surprisingly he only a few small blisters.

He told me today that his feet were perfectly fine after doing the RICE treatment.

Malaysia International Fireworks Competition 2007 (MIFC)

Putrajaya International Convention Centre will be the venue for the 1st Malaysia International Fireworks Competition held from the 18 August 2007 till 2 September 2007.
The skies over Putrajaya will be lit up by a sequence of firework performances to celebrate Malaysia's 50th year of Independence. The Malaysia International Fireworks Competition, or MIFC, will be a festival of light, music, colour and culture; providing magical experiences.
During MIFC, world renowned firework teams will gather to compete in one of the world's greatest Musical Fireworks Competitions. Regular fireworks displays will be dwarfed by the pyrotechnic artistry and meticulously choreographed to inspirational musical compositions.
Each competitive night, the teams from Australia, Japan, Italy and Malaysia will amaze spectators with breathtaking presentations, judged by a panel of celebrities, who will select a winner. The victorious team will receive a prestigious award but their ultimate trophy is the audience delight!.

Here are the links for this event:-
MIFC Website
Schedule
Getting there
International Pyrotechnics Society

ACSM and AHA Release Updated Physical Activity Guidelines

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) have updated physical activity guidelines. These guidelines outline exercise recommendations for healthy adults and older adults and are an update from the 1995 guidelines.


Guidelines for healthy adults under age 65

Basic recommendations from ACSM and AHA:

Do moderately intense cardio 30 minutes a day, five days a week, Or
Do vigorously intense cardio 20 minutes a day, 3 days a week And
Do eight to 10 strength-training exercises, eight to 12 repetitions of each exercise twice a week.

Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of physical activity may be necessary. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

Tips for meeting the guidelines
Starting an exercise program
Frequently Asked Questions

Guidelines for adults over age 65
(or adults 50-64 with chronic conditions, such as arthritis)

Basic recommendations from ACSM and AHA:

Do moderately intense aerobic exercise 30 minutes a day, five days a week Or
Do vigorously intense aerobic exercise 20 minutes a day, 3 days a week And
Do eight to 10 strength-training exercises, 10-15 repetitions of each exercise twice to three times per week And
If you are at risk of falling, perform balance exercises And
Have a physical activity plan.

Both aerobic and muscle-strengthening activity is critical for healthy aging. Moderate-intensity aerobic exercise means working hard at about a level-six intensity on a scale of 10. You should still be able to carry on a conversation during exercise.

Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account. This will maximize the benefits of physical activity and ensure your safety.

Use the links below to learn more about the guidelines and to make physical activity a regular part of your life.

Key points to the guidelines for older adults
Starting an exercise program
Frequently Asked Questions

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.