Team Physician 'trouble' in Field Hockey

You are required to arrive at the game venue earlier than everyone else to prepare set up your things and prepare the drinks. Prior to that you make sure that your medication and taping inventory in your bags (and trolley) are updated and your water and ice supply is ready. Ensure that you identify yourself to the tournament medical officer (if available) and assess the availablity of medical assistance in case of emergency. For best practice, organisers need to have an emergency service crew and ambulance on standby for the match. They should also have an AED and spinal board ready for cervical fracture immobilisation and evacuation.

Once the athletes arrive, you give them their sports drink bottles, review the injury status (and any other medical condition), tape the joints and assist in stretching. We watch the athletes warm-up (and join in if possible, as you are required to run on the pitch in the event of injury) and do their sports-specific drills before the match. You have to have your rigid tape and powder ready in case some of the sticks needed minor adjustments for grip. You may also need to have self-adhesive tape (e.g. Powerflex or Coban) to hold the shin pads and support the wrists (also prevent sweat from wetting the sticks). You need to ensure that you have 4-5 bags of cube/crushed ice for injuries. Have your Ethyl Chloride spray, scissors, suture set, tubigrip, gauze, povidone iodine ointment and surgical spirit ready in case of cuts, abrasions, lacerations and contusions. The coach and manager will need you to give your injury status report prior to selection of the team.

During the match, you need to be watching the match at all times. Ensure that there is free flow of sports drinks and mineral water for athletes (and officials). Athletes coming in and out of the pitch are 'checked' to ensure that are rehydrating well and injury free. You need to assist them in RICE treatment if there are injuries. Assess the injury and give an immediate injury status report to the coach as he may need to return to play. The decision to play should be based on medical facts and not on the need to play. Clean and dress bleeding wounds immediately and you may need to suture the patient on site if you are able to get a relatively clean environment with your sterile equipment. (to be continued)

Montelukast Option for Asthmatic Athletes

I have been treating asthmatic elite athletes with Montelukast (Singulair)for at least 4 years as a single monotherapy drug. Most of these athletes who had Intermittent Asthma and Moderate Persistent Asthma were well controlled with the medication and needed few rescue medication with Salbutamol Inhalers. Salbutamol, other beta-agonist and Corticosteroid inhalers/turbuhalers require Therapeutic Use Exemption.

The new guidelines for asthma treatment is available here. Athletes should discuss the options of treatment with their team doctor or Family Physician. Find out about the Doping Prohibited List 2007.

In a recent clinical trial, the authors suggested that Montelukast provided significant protection against Exercise Induced Bronchoconstriction (narrowing of the airways) having an onset within 2 h following a single oral dose and lasting for at least 24 h. This medication could be useful for athletes who have asthma as an option for prevention of asthma and better control of symptoms.

Adductor Tendinopathy

Bob (not his real name) is an elite level hockey player who sustained a right sided groin injury during a match 2 weeks ago. His pain was spot on the insertion of the adductor longus muscle and he was diagnosed with Adductor Traction Apophysitis. He did ice (see RICE treatment) regularly and I did myofascial release and taught him some stretching and strengthening exercises. He returned symptom free after 3 days.

Last Sunday he had a tough match and started feeling the pull in the right groin during the last quarter of the match. He was taken out of the match and we immediately iced his injury and gave him some fluids (sports drinks). This time the injury had traversed along the adductor longus muscle to the muscle belly. I asked him to lie down on his back (with knees flexed) and he had pain squeezing my fist between his knees. (The last time he could squeeze the whole length of my arm without much pain). He underwent acupuncture and massage to release his muscle yesterday and felt much better. He continued to do the exercises I have given him earlier.

I spoke to him again about taking the necessary precautions with adequate warm-up and stretching. I reminded him that he needed to do his own rehabilitation program to ensure that he strengthens not only the hip adductors but also the hip abductors, hip flexors and extensors, maintains core stability and general fitness (hydrotherapy). If his condition was not treated adequately, it may persist with persistent groin pain and restriction of hip mobility and loss of muscle power in sprinting and jumping.

Sapura Team - Malaysian Hockey League

The team after training.

Medial gastrocnemius (calf) myofascial pain

Mohamed is a 24 yrs old talented ex-junior hockey player who has tight painful calf muscles towards the 2nd half of every match but he noted that seemed to be symptom free during training session. He would request to be replaced to get time to ice and try to return to play after 10 minutes. As he plays in more matches, the pain becomes more unbearable and may even take a few days rest to be relieved. I evaluated his injury 5 days ago and found that he had localised muscle spasm in both his medial gastrocnemius heads (see photo)in both calf muscles.

He had an aversion for massage and has difficulty stretching his calf muscles. After trying myofascial release he seemed to be quite sore and requested injection to relieve the muscle spasm in the right medial gastrocnemius. After a short discussion about the pros and cons, we both decided to do myofascial injection* (Lignocaine 1% plus water**) to relieve his symptoms. (This was done as we were sure that he did not have a muscle tear. An ultrasound scan is required if a tear is suspected). The procedure went on smoothly (with 'some' pain as he told me he did not like needles) and he was told not to do any running or jogging. He was told to go into water to undergo aqua-jogging to assist in his recovery and undergo a rehabilitation program. I assured him that he would feel better after 2 days.

I reviewed him before player selection on match day 2 days ago and he was running without pain. The following day we had another training session whereby he said he felt better in the injected leg and wanted an injection in the untreated leg.

*see Injection of Lignocaine vs Dry Needling.
** see Advantage of Lignocaine Plus water vs Lignocaine 1% Neat.

Severe low backache and stiffness

Mr Tan is an ardent badminton player who plays once a week for 1 to 2 hours in the St John's Institution hall (enclosed and no air-conditioning). He came in with severe backache yesterday (a day after playing with younger opponents) and wanted quick pain relief. His back was so stiff (stiffness was worse than the pain) that he had difficulty bending forwards and backwards. I was surprised when he informed me that he does not drink before the match or during the match and he only drinks a small bottle of 500ml after the session! He also never believed in warm-up or cool-down. No wonder he had severe muscle spasm in his both paraspinals and quadratus lumborum.

I gave him 5 days of NSAIDS* and a muscle relaxant injection but told him to rehydrate adequately for the next 48 hours. If symptoms did not improve, I would review his back condition in 3 days. He should try sports drinks e.g. Horley's Replace or Gatorade before, during play and after play to prevent recurrence. Even if you don't feel thirsty, you need to drink up!, I said.





Find out what the experts recommend:-
ACSM Position Stand on Exercise and Fluid Replacement
*US FDA Advisory on NSAIDS use

Supraspinatus tendon partial rupture and mild impingement

Simon (not his real name) was playing hockey 3 days earlier when he decided do hit a slapshot across a longer distance during a training match. After the hit he felt pain in his right shoulder and he could not lift his shoulder above the level of his shoulder. He continued playing but he refrained from lifting up his shoulder.

He saw me today and I found that he had a painful arc (abduction > 70 degrees), a positive "Empty Can Sign" (resisted abduction) and loss of power of abduction against resistence. He still had tenderness at the tip of the right shoulder.

I informed him that he needed an X-ray ( to rule out bony impingement) and an Ultrasound of his shoulder (to rule out tendon rupture).

I advised him to continue apply RICE treatment for another 1-2 days to allow the inflammation to resolve. He was also advised to avoid abducting his shoulder > 90 degrees. I encouraged him to do active pain-free diagonal movements against the wall or panel (Closed-Chain Exercises) and start strengthening exercises progressively using Theraband. Later, he may proceed to do some wobble board exercises to assist coordination and balance. I was concerned as he has had several similar episodes in the past due to inadequate rehabilitation treatment and possibly incomplete investigation.

Malaysian Shooters tested positive for Propranolol

Three Malaysian national shooters was tested positive for propranolol in March during a local Competition (President Ally T.H. Ong Trophy) along with 4 other athletes. It's quite shocking news as all the national shooters know that they are to stay away from beta-blockers. Although, the National Shooting Association of Malaysia maintains that the athletes did not dope intentionally, it raises our concern that our national athletes are not careful enough to protect themselves from consuming contaminated products e.g. Over-the-Counter medication, traditional herbal medication and nutritional supplements. Read more here.

According to the WADA Code even if the athlete unintentionally consumes a banned substance, the athlete could be sanctioned (see Strict Liability in Anti-Doping).

The standard/normative sanction for a first doping violation is two years, and a second violation calls for a lifetime sanction.
That standard for sanctions (two years and lifetime) can be lessened or enhanced based on several factors relating to the particular case, including:
􀂃 The type of doping violation
􀂃 The circumstances of the individual case (level or absence of fault or negligence)
􀂃 The substance in case of the detection of a prohibited substance
􀂃 Repetition of an anti-doping rule violation

I urge athletes and officials to read the Athlete's Guide so as to understand the complexity of the doping issue. Educational videos are also available free here. Athlete's should take precautions during competition so as to avoid consuming contaminated drinks or food due to the severity of the sanctions.

Malaysia and Australia in the Hockey Finals!

Australia and Malaysia have reached the final of the Sultan Azlan Shah tournament in Ipoh, Malaysia on the 11th May 2007. Malaysia, in superb form beat India 2-1 in what was a cliff-hanger of a match between the hosts and last years’ bronze winners. Tribute to Coach Sarjit (see photo) for reaching the finals once again after 22 years.

Come and support your team for the finals on the 13th May 2007!!!

*See photo of the Malaysian team thanking the full stadium of supporters after the match here.

Congenital Venous Malformation

Mr Tan saw me and thought he'd show me his left leg. "Doc, I've had this since I was 10 yrs old. I was hit by a book and the whole thing swelled up in pain! Since, then it seemed to grow slowly but doesnt give me any trouble". His left leg and foot was swollen. I thought it was not that obvious and possibly that's why his parents didn't notice it until then. He was seen by several doctors in Singapore and had his MRI's taken. Now, 12 years later it didn't give him any problems but just a little unsightly deformity.

After palpating the swelling, I found the swelling on the leg (9cm by 4cm) and dorsum of the foot (10cm by 5cm) to be non-pulsating, painless, boggy, with some induration (a depressed area probably where the vein perforates through). "Good! It's not an artery, not coming from the bone (I hope) and pain-free!", I said. You need to see a vascular surgeon who will work out whether you need further treatment (I was thankful to Mr Yusha from Hospital Kuala Lumpur who shared his experience with me when I was attached to the Vascular Surgical Unit).

Treatment depends on the depth, location, and extent of the venous malformation.

a) Routine observation of smaller lesions that cause minimal cosmetic or functional disturbance

b) Compressive stockings (e.g. tubigrip) to control swelling and pain in lower limbs

c) Injection of irritant solution into the lesion to shrink the abnormal veins. Unfortunately, multiple treatments are often required over time. (Sclerotherapy)

d) Laser treatment. The skin component of a venous malformation, consisting of small vessels, is sometimes treated with a Nd:YAG laser. Generally, several treatments six to eight weeks apart are necessary.

e) Surgery to localized and remove accessible lesions

d) Injection into the blood vessels to stop arterial blood flow in some selected cases in which there are abnormal connections to veins. (Embolization)

* Summary of treatment was adapated from this site.

Achilles Tendinopathy

I remember treating 4 Korean women recreational athletes in the National Sports Institute a few years ago. They used to 'train' harder than some elite athletes often clocking up to 4 hours a day. A few of them suffered from Achilles tendon problems.

I had the opportunity to see another lady who was just as passionate about badminton. Ms Lee (not her real name) came with painful Achillles tendon (see photo) with localised swelling since 1-2 years duration. Her condition worsened over the past few months and she could not play badminton.



I found it rather interesting that she could not do a normal squat and had a thickened tendon an inch above the calcaneal bone attachment. It was certainly tender but more so along the inner side. As I palpated her calf muscles, she had spasm of her medial gastrocnemius causing her much pain stretching her calf muscle (see photo above)

She then told me that she had been playing on her toes thinking that her coach wanted her to literally 'play on her toes'! I was quite concerned that she was receiving various modalities of treatment but failed to undergo proper diagnostic or rehabilitative exercises. She was also an asthmatic on regular Inhaled Corticosteroid therapy provided by the Chest Physician (see Drug Saf, January 2005).

I quickly gave her some topical Arnica Comp gel to relieve the swelling, a mild Cox-2 selective NSAIDS (as she had gastric symptoms and could not tolerate non-specific NSAIDS) and some rehabilitation exercises. The rehabilitation exercises involved calf stretching and strengthening exercises, core stability exercises, hip and gluteal stretching, gluteal and hamstring strengthening and etc. I hope to see some progress in 2 weeks time but she will probably need at least 8-12 weeks before total recovery.

I would probably send her for an Ultrasound scan of her tendon or an MRI if she fails to recover adequately. If she was an elite athlete, she would have been scanned within the next few days to determine the prognosis. The ultrasound may reveal tears and degenerative changes e.g. calclfication.


If she continues to play without proper treatment she may have Achilles tendon rupture (see photo below). I would not recommend local corticosteroid injection for Achilles tendinopathy due to the risks of tendon rupture.

Athletes should also refrain from using Quinolone antibiotics due its toxicity on connective tissue increasing the risk of rupture especially in elderly. Arch Intern Med, August 2003.

Hamstring Strain

A martial arts elite athlete came with pain in his right thigh after doing rapid high kicks during filming of a movie. He added that his hamstring was extremely tight and he could not execute a high kick. He already went for treatment by an acupunturist who did some acupunture and massage to release the spasm. He told me he had forgotten to do RICE treatment. It was only after 1 week that he came in to see me.

I examined him and found that he still had mild spasm of his semitendinosus muscle (one of the 3 hamstrings) and tenderness at the myofascial junction. He was able to fully flex and extend(a good sign) but had pain with resisted flexion. I gave him some muscle relaxants and NSAIDS for another 5 days as he had some bruising from the massage. He was told to undergo hydrotherapy (aqua-joggin) and focus on core stability rehabilitation. Since it was only a mild muscle strain I would expect him to recover fully within 2 weeks. However, he would need to be careful if he was to do the high-speed high kicks.

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.