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.
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.
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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"
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.
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.
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.
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?!!
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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.
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!
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.
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.
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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.
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
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.
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.
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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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.
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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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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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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