Sultan Azlan Shah Asia Cup 2007

Bilateral Knee Osgood Schlatter's Disease

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

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

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

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

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

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

Morton's Neuroma (Interdigital Neuroma) and Ankle Instability

My ex-colleague referred a housewife in her forties with complaints of left forefoot pain since 4 months duration. The excruciating pain is worse while taking the first few steps after sitting or lying down. She got herself a pair of soft Japanese slippers at home to help her walk at home. Hence, she places her weight on her right lower limb and just drags the left lower limb (painful gait). Her back started to hurt when she needed to walk a while longer. She told me she had seen multiple surgeons (received 2 Corticosteroid injections with pain-relief lasting for 2 months), traditional medicine practitioners, massage therapists and general practitioners but the pain relief was inadequate and short-lived.

After probing a little more, she told me that it first started when she twisted her left ankle 4 months ago. She then visited a traditional chinese medicine practitioner who massaged her foot and ankle. Apparently her foot started hurting after the treatment.

Upon examination of her posture and gait, I found that she had overpronation and unstable ankle. Her anterotalofibular ligament was torn and she had poor muscle tone in her left lower limb due to disuse atrophy. She had tenderness between the 4th and 5th metatarsal heads (uncommon for Morton's Neuroma) and a positive squeeze test. She would probably need an Ultrasound scan (more economical than MRI) for definitive diagnoses.

Taping her medial longitudinal arch seem to reduce her pain. A further double ankle lock and lateral stirrups seemed to complete eliminate the pain. I was concerned that she had lost muscle power and tone since she was placing her weight on the opposite side. I left her with some NSAIDS and athletic tape after teaching her the technique but she would need at least 4 - 8 weeks rehabilitation to return her normal function.
We will look into getting her a suitable orthoses for her feet. She may not require Corticosteroid or Alcohol injections if symptoms subside with the use of corrective insoles. If conservative treatment fails after 3-6 months, surgical excision could be done.


Articles of interest:
Morton's Neuroma
Alcohol Injections under Ultrasound guidance
Investigations for Morton's Neuroma
Interventions for the treatment of Morton's neuroma (Cochrane Review)

Non-dsplaced fracture neck of radius and avulsion fracture of olecranon

John (not his real name) is a 28 yrs old recreational basketball player who slipped while playing and landed on his outstretched arm (on his left palm). He got up and felt a sharp pain in his left forearm and could not straighten or bend his elbows fully. He also could not twist his wrists (supinate and pronate).

He immediately came over to see me yesterday evening and I examined him and found that he had a very tender common extensor tendon suggesting that he might have partially torn his tendon. He could not do the extensor muscle testing (resisted extension) due to the pain. There was no crepitus but I suspected a possible greenstick fracture of his left radius bone. His pain was still quite unbearable despite getting an injection for pain.

I sent him off for an X-ray of his ulna and radius along with an Orthopaedic consultation as he may need further intervention if there was a fracture. His report from the surgeon shown a non-displaced fracture of the neck of radius with minimal avulsion of his triceps insertion into the >olecranon. He was treated conservatively with Plaster of Paris cast and was due for a review in 3 weeks. This may be followed by support with a functional brace to expedite his rehabilitation process.

Links to articles of interest:-
Radial Head Fractures
The Use of Ultrasonography in the Diagnosis of Occult Fracture of the Radial Neck
Olecranon Fracture

Now Everyone Can Fly: Air Asia

The Malaysian contingent travelled on the no frills air carrier, Air Asia for the Asian Indoor Games in Macau. We had a pleasant trip taking approximately 4 hours from KLCCT to Macau on the 24th October 2007. Although there was a slight delay the passengers were comfortable in the well ventilated Airbus. I was surprised that the leg room was even more spacious than some European flights I've been in. No wonder my parents in their sixties fly with them routinely to the Asian sectors.

Although we had to purchase our own food and drinks, the price was quite affordable. True enough Air Asia has made flying where "Now everyone can fly!". Our Malaysian athletes were happy to gobble up the nasi lemak on the return flight on the 4th November 2007. Despite having full or almost full flights, the flight crew managed the passangers professionally with a smile.

I would recommend Air Asia to anyone who wants to fly and has budget constraints. It will get you where you want to go in pretty decent shape. Good work, Air Asia!

Intraarticular treatment of osteoarthritis using autologous interleukine-1 receptor antagonist (IL-1Ra) conditioned serum

Intra-articular injections of an autologous conditioned serum relieved pain and improved quality of life in osteoarthritis patients better than hyaluronic acid or saline injections in a recent trial reported in the ORTHOPAEDICS TODAY INTERNATIONAL 2007.

The German researchers found that injecting patients with their own blood after conditioning it elevated the levels of endogenous anti-inflammatory cytokines — relieved pain and inflammation, and is beneficial in the treatment of knee osteoarthritis (OA). They presented results with the procedure and serum [Orthokine; Orthogen] at the 8th European Federation of National Associations of Orthopaedics and Traumatology Congress.

In the procedure, the blood is withdrawn from the patient using a specialized Orthokine syringe. The white blood cells contained in the blood immediately begin to produce IL-1Ra and other anti-inflammatory and regenerative proteins. The concentration of the lead substance IL-1Ra increases up to 140-fold compared to normal basal levels, said lead investigator Carsten Moser, MD.

Moser and his colleagues performed a prospective, randomized, double-blind, placebo-controlled multicenter trial which included 376 patients with knee OA with an intent-to-treat analysis. Patients received treatment from October 2003 to February 2005, and were randomized to receive injections of one of the following:

* 2 ml of autologous conditioned serum (ACS) six times, twice a week, for 3 consecutive weeks (134);
* hyaluronan (HA) in a series of three injections given once a week (135); or
* saline, given as three injections in 3 weeks (107).

Follow-up exams were conducted at 6 weeks, 3 and 6 months, and 2 years.

According to the study abstract, patients with knee OA treated by ACS injection showed significant clinical improvements during the 26-week study compared to HA and saline injections on all scales.

The Visual Analog Scale (VAS) of pain was lowest in the ACS group associated with the largest reduction in VAS. The pain on weight-bearing decreased after the ACS injections from mean scores of 70.2 mm to 30.3 mm at week 13, and 30.4 mm at week 26.
The mean decrease for patients treated with HA and placebo was less than half in the ACS group. For example at week 26, the treatment difference between ACS and HA was 21.8 mm, and the difference between ACS and placebo was 22.5 mm.

The differences between the ACS group and the HA and placebo groups were highly statistically significant, favoring the ACS treatment (P<0.001) at weeks 7, 13 and 26.

Researchers found no significant difference between the HA and saline groups. The mean reduction of pain intensity in the HA and saline groups on the WOMAC scale were less than half that of the ACS group. However, reductions in pain intensity in the targeted knees in the HA and placebo groups were similar (P>0.05), and there was no statistically significant difference between the HA group and placebo group at all time points (P>0.05).

Two-year results were available for 89.9% of participants. The investigators excluded patients who had received subsequent pharmacologic or surgical treatment for their OA. According to the abstract, there were still statistically significant differences at 2-year follow-up between the ACS group and the HA and saline groups.
(adapted from Ortho Supersite).

The use of Orthokine has been approved in EU and Australia. It should be a useful treatment for athletes who suffer from early Osteoarthritis due to repetitive loading of their joints or trauma. Find out more from your doctor about this treatment option.

Reference:
* Moser C, Baltzer AW, Wehling P, et al. Treatment of knee osteoarthritis with autologous conditioned serum (ACS): A prospective, randomized, placebo-controlled, patient- and observer-blind, parallel-design trial. #F802. Presented at the 8th European Federation of National Associations of Orthopaedics and Traumatology Congress. May 11-15, 2007. Florence.

Useful links:
Orthogen Website
International Society for Molecular Orthopaedics

FEI 5* KL Grand Prix 2007

For the very first time, riders in Asia will be able to compete in the FEI Nations Cup CSIO event to be held in conjunction with the FEI 5* KL Grand Prix 2007 from the 23rd - 25th November 2007. Aside from the FEI Nations Cup CSIO, other highlights at the FEI 5* KL Grand Prix 2007 include the Future Champion Search, designed to provide an opportunity for young riders aged 21 and below, who would be Malaysia’s future gold medallists and Olympians to compete in an international event. These riders will also have the chance to observe, interact and learn from Olympians, world champions and gold medallists and be inspired. The event was first conceptualised in 1998 to bring the very first top international equestrian event to Asia, in Malaysia, in fulfilment of the objective of the Federation Equestre Internationale (FEI), to spread the sport in Asia.

An estimated 30,000 visitors are estimated at Stadium Putra to be thrilled by 30 of the world’s top riders and their prized horses, 40 riders from the Asian region and 30 Malaysian riders.

Come and be entertained by the world's best athletes and their beautiful and dedicated horses. See you there!

Find out more from these links:-
Official Website
Venue
Competition Schedule
Ticketing
Getting There
Who are the riders?

Malaysian Indoor Hockey Team

Tibial Bone Bruise and Dependent Hematoma

Ms Lee is a lively lady in her forties who visited 'A' Famosa with her family members during the Hari Raya festive season. Little did she know that there were several youths who ran down the stairs pushing their way through. A teenage girl knocked into her causing her to loose balance and fall down the stairs. She hit her shin (anterior border of Tibial bone) causing it to swell in pain. She had to be carried to a Chinese traditional practitioner who applied medication and massaged the leg. The next day she noticed that there was a lot of bruising from her leg downward to her foot.

She was lucky that she did not have any crack (greenstick fracture) of the tibial bone but it would take her another 1 - 2 weeks to get rid of the bruising and swelling with medication. She should have done the RICE treatment.

2nd Asian Indoor Games: Indoor Hockey