Port Dickson International Triathlon 19-20th July 2008

The Port Dickson International Triathlon is one of the major triathlon events held in Admiral Cove, Port Dickson yearly. This year I had the opportunity to be an unofficial observer as some of my patients were enrolled for the event! I wanted to compare it with the Manchester Commonwealth Games in 2002 where I was assigned to accompany the triathletes of the Malaysian team. The swim start has always been a scramble comparable with a stampede where a competitor needs to be fend off the flailing limbs of other triathletes. After surviving the 1.5km swim by the beach, the able bodied triathletes change to their cycling gear while getting onto their bicycles. The 40 km ride would often be interspersed with hills and valleys (and a beautiful scenery of Port-Dickson). By the time they return their bicycles and start running, they would be bathing in the morning sun for another 10km.

They had a full team of ambulances, Civil Defence forces, Police and paramedics to attend to emergencies. There were a few who sustained minor bruising and muscle cramps during the event.

I had these photos to tell about the event.

Shock Wave Treatment for Achillis tendon Calcific Tendinitis

A young male hockey player came with chronic pain in his Achilles tendon several months ago. His earlier Ultrasound scan showed calcification of his Achilles tendon adjacent to the insertion to the calcaneal bone. He was given extracorporeal shock wave therapy(ESWT) (2000 pulses) weekly and felt much better after the second treatment. He went on to play the Kuala Lumpur Hockey League without any symptoms after 8 weeks rehabilitation and has been symptom-free since then.

ESWT has been approved for plantar fasciitis and has been found to be useful in treating calcific tendinitis.

I took a few photos of the treatment session.





Related websites:
International Society for Musculoskeletal Shockwave Therapy
FDA New Device Approval
EMS Website
Principles of Shockwave Treatment

Foot Contusion and bruise from bike fall

A young lady in her 20s came in with a swollen and bruised right forefoot and toes from a fall off her bike. I sent her for an X-ray which did not show any signs of fracture. She was treated with RICE Treatment, topical Anti-Inflammatory gel and some Cox-2 Selective NSAIDS. The swelling and bruising should subside within 1 week but she will be reviewed in a week.

Hip-hop Dance and Fracture in the foot

An 11 yrs old girl came yesterday complaining of a swollen and painful left foot after hearing something snap in her foot while doing hip-hop barefoot. She had been training barefoot for 1 year but it did not cause any pain. Now, she could not walk or put pressure on the side of her foot or even tip-toe.

I examined her left foot and found that she had some bruising and swelling around outer part of her midfoot (lateral aspect adjacent to the base of 5th metatarsal). There was severe tenderness at the base of the the 5th metatarsal.

Her X-rays shown that her left foot had a non-displaced transverse fracture of the base of 5th metatarsal (Jones Fracture). She was treated non-surgically with non-weight bearing posterior slab crutches to allow the swelling to subsides. She would benefit from a daily dose of low frequency ultrasound (Exogen) to promote healing. Once the swelling subsides we may consider placing her foot in a functional walking brace but she would not be allowed to walk until after 6 weeks later.

Interesting links:
Diagram of metatarsal fractures

Finger fracture with long extensor tendon rupture

A gentleman came in this morning clutching his wrist with a profusely bleeding left middle finger. His finger was hit by a falling panel which dislodged his wedding ring and cut his finger while deforming it instantly.

The left middle finger had a swan neck deformity and a gaping laceration across the middle phalanx oozing out with blood. There was crepitus (indicating a fracture) and he could not extend his distal phalanx suggesting a ruptured long extensor tendon.


I quickly cleaned his wound with Povidone iodine, applied a pressure bandage to stop bleeding, did a buddy taping with a finger splint running across the hand on both sides. He was referred to an Orthopaedic surgeon for further evaluation and treatment. If he was an athlete who had to use his upper limb, he should be out of training for at least 4 weeks.

Lateral Ligament Complex Sprain: Anterior Drawer's Test

Toe abrasions from cycling without proper footwear

I took these 2 photos of the right forefoot of a young cyclist who decided to ride to a grocery shop in slippers instead of cycling shoes. It would be prudent for cyclists to wear suitable footwear even if they are making short trips as abrasions like these are quite common otherwise.

Foot contusion from soccer

A recreational soccer player came to me showing off his bruised left foot 2 weeks ago. He told me he was kicked by an opponent and had difficulty sprinting fully although he was a forward.

I examined him and found that he only had slight difficulty toeing-off while running and was able to do resisted ankle dorsiflexion. Besides the RICE treatment, he was given an anti-inflammatory gel e.g. Reparil and 5 days of Cox-2 selective NSAIDS as he has previous history of gastric pain. He was advised him to avoid full sprints and jumps for the next week. If he was to play, he needs to tape his ankle and foot to avoid the full plantarflexion (to allow pain-free range of motion). I expect him to be better within 1 to 2 weeks.

Disabled Sailing using the Single Person Boat (Access 2.3)

Here are some photos I took during the Malaysian Paralympiad 2008. The Disabled sailing was held at Admiral Cove, Port Dickson featuring 10 disabled sailors. The male and female athletes competed against each other in the single person boat called Access 2.3.

Achilles Tendon Paratenonitis

Mr Lim is a businessman who does regular brisk walking. He came 2 weeks ago with complaints of painful swelling in his back of his left ankle (Achillles Tendon). He started using a pair of leather shoes with a high heel tab which comes in contact with the Achilles tendon every time he walks.



He was examined and I found that had pain standing on his toes (ankle plantarflexion) but little pain stretching his calf (ankle dorsiflexion). He had severe tenderness, oedema and mild redness over the middle of his Achilles tendon.


I advised him to use a low-cut shoe, apply RICE treatment and Anti-Inflammatory gel (e.g. Reparil, Volteran Emulgel). His gait was otherwise normal and he did not have any calf muscle spasm. He would do well with a course Ultrasound treatment.

14th Paralympiad Malaysia Kuala Lumpur 2008

The 14th Paralympiad Malaysia Kuala Lumpur 2008 will be held at National Sports Complex and University Putra Malaysia (UPM) from the 3-9 May 2008. More than 1500 athletes from the 15 states will be competing in this games. The official opening ceremony will be held at the National Stadium, Bukit Jalil, Kuala Lumpur at 7.45pm 3rd May 2008 and the closing ceremony will be held at 7.45pm on the 9th May 2008 at Putra Stadium, Bukit Jalil, Kuala Lumpur. Entrance is free!

Doctors and physiotherapists will be involved in medical coverage and Classification of athletes according to the various disabilities. Classification will be held from 1-2 May 2008 at the Engineering College, UPM just adjacent to the Games Village. The athletes who do not have valid classification would need to be classified. However, athletes who are unsure of their status should get their classification status confirmed at the classification station before 3pm of 2nd May 2008.




Athletes are reminded that there would be doping control testing during the competition. Hence, caution should be taken to avoid medication which are on the WADA Prohibited list 2008.

Enjoy the games!

Extensor Retinaculum Injury and Extensor Digitorum Longus tenosynovitis

A male artistic gymnast was seen a few days ago with complaints of pain in the dorsum of the left foot after intensive training involving runs and jumps since 2 weeks earlier. He had difficulty standing on-toes, taking-off from jumps and landing.

After examining his ankle, I found that he had slightly reduced range of plantarflexion in the left ankle due to pain. There was tenderness and mild oedema of the extensor retinaculum and mild tenosynovitis of the Extensor Digitorum Longus tendons. However, resisted extension was pain free.






I did a simple taping to prevent extreme plantarflexion while enabling him to point his toes during his routine(Two figure of 6, and a double medial and lateral ankle locks and closed up the 'holes'). That seemed to do the trick and he should be back doing some training. However, he was told to refrain from sprinting or jumping to his maximal height as it may aggravate the injury. He was advised to undergo physiotherapy to reduce the symptoms and strengthen his lower limb.

Hallux Valgus

A fencing athlete was seen with her big toes (hallux) turned outwards (valgus), hence crowding into her second toe. She was lucky as she did not have any symptoms of pain usually seen in the prominent bunions. Gymnasts and dance athletes often suffered from painful bunions. She could consider using nights splints for the big toe, taping during training and some icing after training to assist her. If she wanted something off-training, she could buy a broad forefoot footwear and use a silicone gel spacing device between the toes.

Just don't wear the toe spreader to run or play badminton or table-tennis. You might get really bad blisters.

Bilateral Peroneal Subluxation

The videos of a fencing athlete showing both feet plantarflexed and going into eversion to initiate subluxation of the peroneal tendons.

The left peroneal subluxation (suffered after a game of futsal) causes pain with sprinting and quick lunges hence limiting his performance in his sport. His rehabilitation may take up to 8 weeks before return to sport.


The right preoneal tendon partially subluxes but doesn't seem to give the athlete any problems as he is still able to plantarflex comfortably without pain.

Also see a previous post on peroneal subluxation here.

Calf Cramps (with Medial Gastrocnemius strain)

A young lady in her 20s came this morning complaining of right calf residual pain after having a cramp while waking up this morning. Her mother gave her a hot traditional oil which she massaged on her calf but the pain persisted. She walked into my room with a limp and supported her weight on her forefoot.

She had several localised areas of tenderness along the medial gastrocnemius muscle but no apparent swelling. She also had an almost full ankle dorsiflexion and plantarflexion. She is likely to have suffered from a Right medial gastrocnemius Grade II strain. She was advised to undergo rice treatment and her calf was support with a crepe bandage to partially restrict movement and reduce pain. She would require an ultrasound scan to determine extent of the muscle injury if she wants to participate in sports.


Isometric exercises and hydrotherapy could be instituted to start her rehabilitation process along with electrotherapy. The duration of the rehabilitation will depend on the severity of the strain and her response to treatment (evaluate weekly).

Right Hamstring Partial Tear in Badminton Player

A 37 yrs old male badminton recreational athlete came in last week after injuring his right thigh doing a 'split' while reaching for a net shot from the baseline 2 days earlier. He felt something snap and had pain lifting his thigh. He found it difficult to bend forward to reach for things due to the pain.

He hobbled onto the examination couch in pain. He was only able to flex his hip up to 40 degrees (Straight Leg Raising) and had a defect in the proximal attachment (see photos) of the semitendinosus muscle with a bulge distally. There was tenderness at the distal bulge of the semitendinosus muscle.

I sent him for an X-ray to rule out avulsion fracture and an MRI to assess the extent of the tear and hematoma. He was given Cox-2 Selective NSAIDS for pain and inflammation and advised to undergo RICE treatment regularly. (awaiting MRI films... )

Clinically, he has at least a grade II strain of the Right semitendinosus which would require at least 12 weeks rehabilitation before return to play. He may have difficulty regaining his full agility and power if he is an elite athlete vying for a place to represent the country in international competition.

Disabled Sailing

I had my first experience with disabled sailing when I was asked to be trained as a classifier for the Malaysian Paralympiad 2008 for the sport. 5 participants from Asia (3 doctors, an occupational therapist and a physiotherapist)attended at 3 day seminar on Classification during the IFDS Skud18 World Championship Singapore (20th - 28th March 2008). The seminar was organised by Singapore Disability Sports Council and endorsed by the Asian Paralympic Committee with the objective of training more regional classifiers for the paralympic sports.









Classification of Disabled sailing is essentially divided into 3 parts:-

1) Functional Anatomical Test (clinic physical examination)
2) Functional Dock Test (assessment in the boat by the jetty)
3) Functional Sailing Test (observation during practice or competition)






The practical sessions were definitely helpful at introducing sailing, sailing equipment, the physical requirements during sailing and safety precautions of disabled sailing. We also learnt about the different types of boats involved in disabled sailing competition e.g. Sonar (3-person boat) and Skud (2-person boat). The excitement of watching the sport while braving the winds (and waves) definitely helps keep the adrenaline pumping. If you are careful to take lots of water, use sunscreen lotion and a hat, you could yourself from heat injuries and sunburn.

I was told to get a sailing license soon to ensure that I could take my classification training a step further. I would recommend this sport to Doctors, physiotherapists or occupational therapists who wouldn't mind getting wet and some tan! You may contact me or your local disabled sailing association if you would like to train to be a classifier.

For further information, here's a few useful sites:
IFDS Skud18 World Championship Singapore
Location: SAF Yacth Club
Live results
ISAF:Disabled Sailing
Singapore Disability Sports Council
Getting Started

Hyperlaxity Syndrome

Here's a badminton athlete who was found to be able to hyperextend his fingers without any discomfort. He does not seem to have hyperlaxity in other joints although he is flat footed.

Flexor Carpi Ulnaris tendinopathy in Goalkeeper

Lance (not his real name) is a badminton and futsal athlete who deflected a fast soccer ball during play 10 months ago. He was given a physiotherapy and wrist brace for several months but he could not resume competitive play due to Ulnar-sided wrist pain. He could not palm-off the ball (hyperextended wrist) and do forceful wrist skills (e.g. lob, flick, repetitive jabbing and smashing) with the badminton racquet.

He had tenderness over the Triangular Fibrocartilage Complex (TFCC) and along the Flexor Carpi Ulnaris tendon, pain with wrist hyperextension and resisted flexion of the hyperextended wrist joint. He also had laxity of the Distal Radio-ulna Joint.



He did not want to do further investigations (plain X-rays, Ultrasound scan and possibly an MRI) despite being advised so. We proceeded to teach him how to tape his wrist and forearm to give him a pain-free range of motion while allowing explosive powerful smashes (badminton) and some goalkeeping. He was given some Theraband exercises and proprioceptive exercises using a soccer ball for balance.

I expect him to take at least 6 - 8 weeks to return to normal play. However, if he is keen on competitive soccer, he would require further investigations and possibly, surgery to rectify the TFCC and DRUJ injury.

Interesting links:
TFCC Injuries
Ulnar-sided wrist pain

Yonex 2008 All England Badminton Championships

The 98th All England Open Badminton Championships(also known as the 2008 Yonex All England Badminton Championships) will be held between the 4th and 9th March 2008. The prestigious tournament will be held in the the National Indoor Arena, Birmingham. It will be sponsored by Yonex for the 25th consecutive year.

I had the opportunity of joining the Malaysian team in 2000 as their Team Physician for the exciting tournament. Don't forget to catch Live action on Sky Sports or just go there to watch the tournament!

Useful links:
About All England Badminton Championships
Official All England Badminton Competition Website
Time-table
Visitor Information and Weather; Getting there and Maps
Booking online & Discounts
Badminton England website