Medial Collateral Ruptured!

She was running down the hill slope when she landed her foot into a small hole and felt something snap and felt a sharp pain in the inner part of her left knee. She fell over and grimaced in pain. Her athlete quickly took her by the shoulders and helped her up to the clinic at the sports complex.

Elaine knew that her knee was in bad shape. She could hardly stand properly and the knee seemed to be twisted outwards. 10 years ago she had an injury to the same knee but she could still walk with little support.

"Looks like you've really torn your medial collateral ligament", I said to her. We quickly got her to ice the knee and prepared her file for physical examination. She had the full range of movement(ROM) which was quite 'pain-free' but she had severe tenderness and moderate swelling at the femoral attachment of the MCL. There was mobility of the leg when it was stressed outwards. Her tests for Anterior Cruciate and Posterior Cruciate ligaments were normal. She was lucky that there was no joint effusion (swelling in the joint due to accumulation of fluid e.g. joint fluid, blood, pus).

"Your MCL is complete torn clinically, but you should be back in 2-3 months time with rehabilitation if nothing else is torn", I said. She was given a functional knee brace and sent for an X-ray. Her X-rays came back normal except for the fluid shadow. We planned her for an MRI within the next 3 days to ensure that the other structures like meniscus and cruciate ligaments were not torn.

She was told to continue icing her knee every 4 hourly and focus on isometric exercises for her quadriceps and hamstrings for the next 1 week. Zul, the physiotherapist was quick to show her the rehabilitation chart. He told Elaine that she would need to progress in stages as she improves her strength, stability and function of her knees. he also planned hydrotherapy sessions for her to maintain her 'aerobic' fitness

Basics in First-Aid

Rest: Modified your physical activity to reduce or stop moving the injured part to ensure that you do not worsen the injury. You could do so by reducing the intensity and duration of training. If the injury is serious, you may have to stop training altogether.





Ice: Apply a towel on the injured part before you apply a bag of crushed ice or ice cubes. Do not apply ice directly on skin and do not wrap the crepe bandage too tightly as this may cause cold burns. Only apply for 15-20 minutes and you may repeat the procedure every 4 hourly if swelling and pain remains.






Compression: Apply a crepe bandage to compress the affected part to reduce swelling. Do not wrap the bandage too tightly as it may interfere with blood circulation. Check by pressing the fingers and you should see the colour return immediately. Often the athlete will tell you that he/she has more pain due to a very tight compression strangulating the blood supply.




Elevation: Keep the affected limb elevated above the level of the heart to 'drain' the swelling and hence reduce pain. As long as there is still visible swelling this may be beneficial.

Footwear and my feet

I don't really look at the price of the pair of running shoe when I go shopping for one. More often than not, I would already have an idea of a reputable shoe manufacturer. My brother and I both have flat feet and overpronation. For obvious reasons, we would look for something light, breathable, durable, an insole with proper arch support, semi-rigid mid-sole with good stability. However, my requirements are generally for running on the treadmill and some cycling. Even my working leather shoes are selected with such specifications to allow me to occasionally jog down the alley when I need to. I have a 2 pairs of running shoes, 4 pairs of costly leather shoes and another 2 pairs of cheap shoes.


Every athlete should find out whether they have special requirements due to abnormalities in walking, running and jumping pattern (gait) required during training and competition. Check with your shoe manufacturer whether they have shoes which are specific for your condition. Not all expensive shoes have such requirements. Check whether the mid-sole provides sufficient stability, support and flexibility. Check whether the outer-sole is suitable for the different surfaces of the court or field. You may need to check with a podiatrist if you constantly find it difficult to obtain good shoes which do not cause pain to your feet, ankle and knees. A video of your walking and running pattern could highlight some possible problems and solutions.


You should always try out the shoe first and do all the different skills required in your sport with it. However, it will often take 2 weeks (at least) before you will find the shoe comfortable enough to be worn (break-in). I also use some preformed orthotics for some of my patients if they have abnormalities in gait and recurrent ankle, foot and knee problems with good results.

Doping Prohibited List 2007

Every elite athlete i.e. international, national, state or club athlete should be aware of the latest Doping Prohibited list updated at least once every year. The Prohibited List is an International Standard identifying Substances and Methods prohibited during competition (in-competition), outside competition or during training (out-of-competition), and in particular sports. Substances and methods are classified by categories (e.g., steroids, stimulants, gene doping).

In Malaysia, the National Sports Council Doping Control Unit coordinates 'no notice' doping control testing and some of the in-competition testing for international, national and state athletes. National Sports Associations (NSA) undertakes some of the other doping control testing for their respective sports. Meanwhile, International Sporting Federations may appoint their own doping control officials to carry out the doping control testing.

It is vital for such athletes to inform their treating doctors of their status as athletes and the need to review the Prohibited list to ensure that they avoid taking the 'illegal' substances unknowingly and risk being sanctioned or losing their medals. Ignorance of the Prohibited List shall not constitute any excuse and athletes may face a ban of up to two years or a lifetime ban.

Athletes should also be cautioned that some traditional supplements and nutritional supplements may contain Prohibited substances as they may not be subject to such stringent manufacturing and labelling processes as drugs ( 1,2)

Some Prohibited Substances may be used by an athlete for medical reasons by virtue of a Therapeutic Use Exemption. For example inhaled beta-agonists in asthmatics. However, such use must have adequate documented laboratory evidence submitted to the respective NSA or International Federations.

For further information, go to http://www.wada-ama.org/en/index.ch2. If you are a Malaysian athlete you may also approach the Doping Control Unit of National Sports Council at 03-8992 9600.

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Multiple Joint Pain and Bodyache

Chong was a regular gymnasium user who was as fit as an elite athlete. He did 2 hours of regular workout including 30 minutes run, core stability exercises, moderate weight training and an occasional dance routine at a popular gymnasium. At 40 years of age, he could run faster than most men half his age.

He came in a day after his hard workout thinking that he probably overdid it. Most of his joints were aching and his muscles were sore. For some reason or other, he was still sweating profusely. "Doc, I think I shouldn't have worked out so much last week!", he said. I smiled, saying "Told you you needed to recover after each exercise session!". He wasn't quite impressed as usual. In went the mercurial thermometer. "Ahhh! 38 degrees centigrade. You're down with fever!", I said.

"How many days have you been feeling feverish?", I asked. "Three", he answered. He also had a rapid pulse rate and a slight raise in the Blood Pressure. Hess test (a special test to check for petechiael rash) was positive. "Let me send a blood sample to check for your blood counts. The last thing we want is dengue fever", I said. "You need to rehydrate a little more than usual and take a day off. I will call you in a few hours time". It took the laboratory an hour to fax me the result and true enough his white cell count and platelet counts were low. He was lucky that the levels were not critical and it resolved the next day.

To play or not to play!

It was 7.15pm and I was late for a pharmaceutical talk. John called as I was just approaching the venue. "Shucks!", I said. I needed the CME points but the player needed an urgent decision. To play or not to play!

I quickly returned to my apartment and he was already waiting there. He was walking and that was good news but he had a slight limp. I know some players who walked 'funny' after training due to a back problem and leg-length discrepancy.

A quick examination revealed a localised area of tenderness (pain upon application of pressure), muscle spasm adjacent to the junction between the medial gastrocnemius and soleus muscle. Tried a few light skills and he could not 'push-off' as required to play badminton.

He knew the consequences of injecting steroids and so he didn't ask me to do that. He had seen talented players who had muscle tears and tendon ruptures after indiscriminate injections done for the sake of competing.

"No-play!", I said. "I could give you a muscle relaxant to help relieve the spasm and you can continue with another 3 days of NSAIDS (anti-inflammatory and pain medication), but no play!". He was keen to improve his performance and insisted that he would decide the next day.

He played against a lesser known player and lost the next day. The press gave him such a bashing that I felt sorry for him. I know the player and he made the right choice to hold back and not push to win. He told me later that he just couldn't move and the pain worsened as he played. He had to play as he was required to by the coach to try. After a week he played much better in another major competition after undergoing rehabilitation and taking precautionary measures

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Non-specific Knee pain

She could not bear the pain in her left knee anymore. It has been 1 month and the pain was still present. In fact, it worsened after she went to 'service' her clients to ensure that they continued her company's products. She thought it felt better after application of 'the stinking yellow stuff' the chinese doctor applied. "Maybe I should have rested", she thought.

Mei Lee then decided to see sports physician in the neighbourhood. "My knee is more important than the job", she said gritting her teeth in pain as she hobbled along the corridor (as she could not find parking in the Subang Jaya business area).

I was surprised that she was having recurring episodes of left knee pain over the past few years and lived with it. She has had blood test, several X-rays and even an Ultrasound scan done but nobody prescribed exercises to get her back on her feet. "Uhmm..., where did we go wrong in medical school? Or is it just that it's difficult for clinicians to spend time talking to the patient and teaching some basic exercises? Or it's just that nobody bothered to send her to the physiotherapist. At least that could have helped!", I said. "I did see the physio, but they only did electrical stimulation. Since it didn't seem to help, I decided to seek treatment elsewhere", she lamented. Maybe they tried to help her but she was not receptive to their suggestions.

Back to the drawing board!. Her blood investigations for joint disease and inflammatory markers were normal. Her left knee X-rays were normal and so was the ultrasound scan. She had a painful gait, sacroiliac joint inflammation (dysfunction), tight hip adductors, knocked knees and hyperlaxity of both knee joints (in extension)but she had a very tight Achilles tendon due to frequent use of high heels and not enough stretching. This would take a lot more time to unravel the problems.

She was prescribed topical NSAIDS gel and a whole series of exercises to strengthen her quadriceps, hamstring, gluteal muscles, abdomen and lower back. I also did some myofascial release (manual work to release muscle spasm and pain) for immediate effect. After 2 weeks, she was much better and able to run upstairs without pain. She was prescribed more exercises and we added a weight reduction programme for her too!

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Golfer's elbow (medial epicondylitis)

An 18 yrs old club-level badminton player came with the complaints of pain in his left elbow 2 weeks ago. It was during a local competition that he started having some dull aching pain until the final mixed doubles match that he could not tolerate the pain and had to avoid smashing. His coach had warned him that he needed treatment but he complained that the clinic was too far away and needed the sleep instead.

"I told you so", said coach Lim. He did however win the match as they were a better pair. The inner part of the elbow (medial epicondyle) was really sore and the forearm flexors (in front of the arm) was also in spasm. It was as if he had only trained on smashing and nothing else for a week. I wished he did not have 'cubitus valgus' which increased the risk of developing the injuries (cubitus valgus - elbow joint with the forearm turned outward).

Nevertheless, he was quite please after I sent him to the physiotherapist for some 'muscle release'. The following day the anti-inflammatory, muscle relaxants and 2 sessions off training helped relieve the pain and swelling. He could even carry his groceries and start some 'stroke-play'. I cautioned him that if he returned too soon to normal training and failed to complete his rehabilitation exercises he would be back very soon.

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Getting a training partner

Here are some of my rules:-

1. Someone more motivated than I am to train regularly.
2. Punctual
3. Have the same routine or schedule for training
4. More or less the same physical condition
5. Not one of those who just chatter away and never do anything really during training except talk and oogle at others
6. Reads up about what to do and how to do it right
7. Not too pushy but not too a drag either
8. On the go and living life fully
9. Hygienic and dress moderately
10. Someone who will pay me to workout!!!

Can I use this drug?

A young person in his twenties came to see me one fine day for a medical problem. He then asked me whether it was true that I am also a trained Sports Physician. "Yes", I said. "How may I be of help?". He then shuffled backwards in the chair and reached out for something in his shorts. He showed me a white coloured box (rather poor quality packaging, I would say) with the words, Stanazolol staring at me. "Can I use this drug? Is it legal?"It was definitely not something approved by the Ministry of Health for normal use. Besides, it was only supposed to be sold in India for Rs 32 and he got it for 25 times the price from a gymnasium instructor. Funny, I thought I'd never had to hear of the product now that I dont deal with weightlifters are much as before. The medical fraternity never prescribed the drug unless the doctor is linked with clandestine doping activities.

Refer http://www.wada-ama.org/en/prohibitedlist.ch2 for the latest Prohibited list. Take note of the "Therapeutic Use Exemption" for asthmatics.

I gave him a quick description of the possible side effects and consequences of taking the drug. I advised him to also get assistance from a trained conditioning expert using scientific safe methods of 'bulking' up without the use of doping substances. Besides, without hard work there will not be any hypertrophy of the muscles!

Volunteers needed for medical coverage

If you've got time, lots of guts, determination to learn, attention to detail and love for sporting activities, you're the person we are looking for.

I am recruiting volunteers from all walks of life to assist in medical coverage of training and competition involving club, state, national or international level athletes. We would need to have the volunteer familiarise with the safety protocols and tag along with more experienced volunteers before we launch you to head your own team. You do not necessarily need medical training as we will always have trained medical staff with you. Besides, trained medical staff also needs to know how to conduct themselves during sports injury, field emergencies and evacuation. You will have the assistance of the Malaysian Association of Sports Medicine members (you are welcome to be a member too!).

I can be contacted at draston@gmail.com or 019-2103787 (before 9pm).

No Pain No Gain?

"Jump higher! Faster! Up! Up! Up!", shouted the soccer coach. The 14 yr old boys had never trained so hard in their lives. Their quadriceps and calf muscles had been sore over the past 1 week since the new coach came. They had breaks every 20 minutes for drinks but it was often too short to even to catch their breath.

Ahmad wished he was still in the injured list so that he didnt have to 'suffer' so much. Suren noticed that his team mate was lagging behind and offered him some encouragement. "Cheer up!", he said. "At least you are booked in the massage therapist list this evening", he quipped.

"No pain No gain, men!", the coach shouted again. "When you are done with this training you'd thank me when your fitness surpasses your opponents this season", he added. The physiotherapist Zul watch in disbelief as he would have to work harder to stretch and relieve those stiffened sinews over the next few days.

Exercise 5 times a day....

"Exercise 5 times a week for at least 30 minutes", said the researcher presenting the paper. "If you lose 10% of your body weight... you will reduce the cardiovascular risk factors". Easier said then done. During every medical conference on Diabetes, Hypertension and Heart Disease, the same sentences are repeated over and over again. But does anyone really know what it means to "exercise 5 times a week, at least 30 minutes each session"? Most of those patients hardly could walk two flights of stairs without 'huffing and puffing' and are at the risk of having a cardiac event (or heart attack) if they exercised more than a brisk walk.

We need to look at the guidelines for safe participation of such patients with coronary arterial disease or metabolic syndrome given by the American College of Sports Medicine. Such patients probably need to be adequately assessed physically before embarking on such vigourous exercise. They would probably benefit from a heart rate monitor and learn how to gauge the difficulty level of physical activity with Perceived Exertion (Borg's scale). We would also need to look into the type of medication that they are taking to ensure that they prepare for possible complications like hypoglycaemia and fractures from falls for elderly patients.

Where is the medical team?

"Where is the medical team?" Shouted the spectators in the far side of the Cheras Badminton Stadium. The officials pointed to the table where the medical team was seated. There were three doctors watching the match although only one was officially on duty. The rest of the medical team consisting of a nurse, a medical assistant, a physiotherapist, an ambulance driver and 2 students were seated just behind the doctors.

Two of my doctor colleagues immediately ran up the stairs to reach the patient. But since they were not dressed in their uniform as I was, nobody could recognise them. The crowd was not helpful. They blocked the access route to the stands just to catch a better glance at the women's doubles finals match between China and Indonesia. I didnt have much of a choice. Everyone was gesturing to me to attend to the patient although I was the last doctor standing for the competition. I had to leave my post to run after my other colleagues.

True to my suspicion. The patient was an epileptic male who was poorly controlled on medication . He just had a tonic-clonic convulsion on the stands possibly due to the hot, humid and extremely noisy environment with every spectator banging away on the sponsored plastic air-balloons. There was not much we could do but to ensure that the patient was comfortable and did not choke on his own tongue or secretions. He was slightly dazed when we got to him and it took three men to carry him up the stairs and down the stairway into the medical room. We were relieved to see that he was better. His mother was not perturbed by the incident and wanted to return to the game immediately. She was not sure what medication the son was on. Neither could she tell us more about the condition. To our surprise, she refused our offer to take the son to the nearest hospital by ambulance. I informed my colleague that we could not have the patient return to the spectator stand without risking another episode that we may not be able to manage. Finally, the patient's mother relented and took the boy home.

Right Ankle Lateral Ligament Complex Sprain

An athlete's swollen right ankle is shown in the photo above. He had twisted his ankle while landing awkwardly from a jump in the morning. It did not swell up much as he had applied RICE treatment and had it wrapped with crepe bandage. (Note: Do not massage a new ankle injury as it would worsen the swelling and pain).

I examined his ankle and found that he had a partially torn ATFL ligament and lots of soft tissue swelling in the outer part of his ankle. He also had pain when he plantarflexed or inverted his foot. There was difficulty balancing on his right ankle due to the loss of sense of position and balance (proprioception).

He was able to walk with a slight limp due to the pain but he was advised to rest from footwork or excessive walking for a few days. He was given an option to use an Aircast ankle brace to provide additional support. After applying RICE therapy for 3 days, there was only minimal swelling and he could walk normally. Although, the foot looked almost normal, he still had to undergo rehabilitation exercises to strengthen and provide the normal proprioception in his ankle. It often takes up to 4-8 weeks for rehabilitation of an ankle lateral sprain.

An athlete's day...

Fancy waking up at 6am while picking up his favourite CD to energise his day. The pain in his calf and hamstring muscles is screaming for some attention but he just did not have another 15 minutes to catch up with the much needed recovery. A quick check on the Polar Heart Rate monitor indicated that he probably still lacked recovery from the hard training over the past few days. He just couldnt wait for the weekend.

"Guys, breakfast at 6.30am and review your training log!" He was busy burying his head in the workbooks the previous night as Ms Tan (lecturer) insisted that the assisnments were complete before the week was up. The athlete had to have a quick look through the training log and started down the common bath.

The 10 minute shower was a real blessing as the powerful gush of warm water numbed the pain while allowing the pleasant blood circulation through the sinews and muscles. All the clothes had to go into the laundry to be collected after training. Had to clean up to ensure that the 5' by 4' area alloted to the athlete was spick and span in case of a surprise visit by a VIP. The cotton training jerseys have slightly faded but they were still the best in the market.

Breakfast was quick and 2 glasses of juice and water was gulped up in the process to ensure that he does not develop cramps during training. He wished he didnt have replacement classes so that he could have gone for relaxation massage earlier.

The assistant coach checked to ensure that everyone was injury free and had their specific skill training for the day after the warming up run and stretching. The sprints after that was always interesting as he would work hard to ensure that he could beat others who were supposed to be faster than him. He could last longer as he has had several years of training on endurance and speed with his previous coach in the state team.

The chief coach then called for a short briefing on the days agenda to point out the purpose of the various drills during training. He was keen on trying out new tactics with the forwards and defenders. It was often tough to follow the pace of the coach but each athlete was expected to keep trying. Drink breaks were allowed in between to ensure that the athletes were well hydrated. 2 hours was up and the chief coach had a brief chat with his assistant followed by a discussion with the team. Training was up to the mark but there was more to be done. There would be another session of training in the pool in the evening followed by a session with the team psychologist at night.