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.