Distal Radioulnar Joint Subluxation

A video of the wrist of a martial arts exponent who had a fall on his right hand 2 years ago during competition. He sustained an injury to his wrist causing him to have pain during punching. He also had painful full flexion of his wrist and resisted extension.

I have demonstrated the dorsal movement of the ulna with a fixed radius in the video. Although he would maintain some form of wrist stability with taping, he should be seen by a Hand surgeon to correct the instability.

Interesting links:
Radioulnar Joint Instability

Finger (Thumb) Dislocation

Here's a video of a female martial arts exponent who dislocated her left thumb 2 years ago after receiving a kick during competition. I did a test to evaluate the hypermobility of her joint. She is also having some hypermobility of her right thumb but it was less mobile.

Interesting Links:
Dislocation of the Thumb MP Joint

Corneal Laceration

James (not his real name) is a 22 yrs old martial arts sub-elite athlete who sustained a kick to his right eye 6 months ago. He sustained injury to his right cornea laceration due to the contact lens. Although he was seen by an Ophthalmologist and treated for several weeks, he still has blurred vision in his right eye. The corneal injury is visualised as a white patch on the cornea (corneal opacification). It is best seen under slit lamp after fluorescein eye stain. In full thickness corneal laceration, aqueous humour may leak out or there may be bleeding (hyphema) there may be distortion of the shape of the eyeball.


Since he wanted to continue to fight, he has been asked to obtain further treatment with Phototherapeutic keratectomy (PTK) or Corneal Transplant. Failure to do so, he may not be able to clear his Preparticipation examination with 'one good eye'.

Interesting links:
Corneal Laceration
Corneal Abrasion
Corneoscleral Laceration
Sports Pre-participation Examination

PROTON MALAYSIA OPEN SUPER SERIES 2008

The Proton Malaysia Open Super Series 2008 will be held from the 15th January to 20th January 2008 featuring the top world ranked players (e.g. Lee Chong Wei, Bao Chunlai, Peter Gade and Taufik Hidayat). Once again the prestigious event will be held in the Putra Stadium, Bukit Jalil, Kuala Lumpur. The Malaysian Open offers a total purse of US$250,000. For the first tine, winners of the men's and women's singles will get an equal prize money of USD15,000 while the men's and women's doubles champions will get US$13,800 each.

The qualifying rounds started on the 15th January 2008 and Championship events started a day later. It would be interesting to see who will feature in the Semifinals (19th January 2008) and Finals(20th January 2008).

It was upsetting for the Chinese that women's singles top seed Xie Xingfang pulled out of the competition due to an elbow injury. Anita Kaur shocked 2005 Sea Games champion Adriyanti Firdasari of Indonesia by defeating her 16-21, 25-23, 21-19. There will be more surprises as the championship progresses.

All the best to the players for this tournament!

Important links:
Seeded Entries
Badminton Association of Malaysia Website: News Updates
Match Schedule and Results
Tickets
Players
BWF Rankings

Knee Hyperextension in Ex-Rhythimic Gymnast

Ms Lim is a 35 yrs old ex-rhythmic gymnast who came to see me after a fall on her right knee. It was interesting that she had an extremely flexible left knee with an additional range of 35 degrees in extension. She had been perfectly normal in the left knee and did not suffer from any nagging pain.

She was advised to maintain an active lifestyle to ensure that she looses some weight and also strengthen her back, abdomen, hip and lower limb muscles to prevent injuries.

Blister after unmonitored heat therapy

An adult male patient came yesterday with back pain 2 days after injuring his back carrying a light object at work. He did not complain of any 'shooting pain' (radiating pain) to mentioned that the pain did not subside despite placing a hot water bottle (heat therapy) overnight. He had no pain bending forwards (flexion) but pain getting up from bent position (deflexion).

I examined him and found that he had 4 blisters (fluid filled sac in the skin) on his back (see photo) and spasm of his right erector spinae muscle. He didn't know that some of the pain was due to the blisters!

His muscle strain would recover with a week of physiotherapy and some medication for pain and muscle relaxation. He was not advised any treatment for the blister as it would heal on its own. I advised him to avoid using the hot water bottle directly onto skin or longer than 30 minutes to avoid blisters.

Right forefoot contusion

Dave played soccer 2 days ago and had slight right forefoot pain during the match but completed the game despite the pain. The pain worsened in the evening and he was given a hot ointment (Methyl Salicylate) by his mother. He faithfully massaged his right foot with the ointment and found that the foot was swollen (the light shade in the picture). He limped into my clinic yesterday and I thought that he had had a fall and or suffered from a stress fracture of one of his metatarsal bones.


He had oedema and tenderness of the softhis 5th metatarsophalangeal joint and both 4th and 5th metatarsal bones.

He was given some RICE treatment, Arnica Comp gel and 5 days of NSAIDS to reduce the swelling and pain. He is expected to get much better and I will review his injury once the swelling subsides over the next 48 hours.



Interesting links:-
Jones Fracture

Right knee lateral meniscus tear

Ms JW, a 21 yrs old lady was walking on her high-heels when she suddenly twisted her ankle and knee yesterday. The knee swelled up slightly and she could hardly walk. She was brought in by her father yesterday evening and could not bear her weight on the right knee.

Clinically, she had moderate effusion and slight slight restriction of knee flexion. She had tenderness of the joint line (lateral aspect) and a positive McMurray's test. She also had mild tenderness of the proximal attachment of the Lateral Collateral Ligament (LCL). She was treated with RICE treatment and sent for further evaluation with plain X-rays and MRI of the Right knee (to evaluate extent of meniscus injury and injury to other structures e.g. ACL). She has been started on isometric exercises. However, she may require early surgical intervention if the meniscus tear restricts movement or can be repaired. Post-surgical rehabilitation would often require up to 12 weeks commitment before return to play.

FOr further reading:-
Meniscus injury
Lateral discoid meniscus

Right Axillary Follicular Abscess

Ramli is a 30 yrs old club soccer player who came with painful right armpit (axillary region) painful swelling of 3 days duration. He usually shaves his armpit hair for hygiene purpose but this is the first time he suffered this fate.

I examined him and found several peasized tender, firm swelling in his right axilla but there were no other enlarged lymph nodes. The skin in the groin and axilla is commonly colonised by Staphyloccus Aureus. Minute skin cuts or abrasion could have introduced the infection to the hair follicles. We treated him with a course of antibiotics and some topical antibiotic ointment for 5 days duration. His symptoms resolved quickly as the infection was still at early stage. If the swelling failed to subside, he would have required incision and drainage surgery.

For further reading:-
Folliculitis
Lympadenitis

Tinea Pedis (Athlete's Foot) and Onychomycosis

Tinea pedis (athlete's foot) is a common fungal condition occuring in the feet of athletes or workers who routinely wear their shoes without drying and cleaning them properly. Although it is more common to find the itchy, scaly (not always) and smelly skin lesion in between the toes, they can also infect the sole of the foot. Athletes who have the habit of wearing shoes belonging to their team mates may transmit the disease to others. This condition is easy to treat with foot hygiene, topical anti-fungal creams and occasionally require oral anti-fungal medication.

The nails may also be infected (see 2nd photo) causing Onychomycosis. This condition is more difficult to treat often requiring oral anti-fungal medication, topical anti-fungal lotion after filing the infected nail.

Links of interest:-
Athlete's Foot: MayoClinic.com
Nail Fungus

Wrist (Radiocarpal ) Impingement and mild arthritis

Mr White (not his real name) is a 120kg weightlifter in his 20s who suffered from right wrist pain since 2 weeks duration. Prior to his competition he came to see me as the pain was preventing him from lifting beyond maximal capacity during 'clean and jerk'. His earlier X-ray did not show any fracture or osteophytes.

I examined his wrist yesterday morning only to find tenderness and slight fullness (synovitis) over the lunate bone in his right wrist. Forceful wrist hyperextension ellicits the same pain he experiences doing 'cleans'. Resisted extension was unaffected (ruling out extensor digitorum communis tendon involvement) He would need to rule out a lunate stress fracture (Radioisotope Bone Scans would be useful). He did not have any scaphoid bone tenderness although it is more common amongst weightlifters.

While awaiting his Radioisotope Bone Scan to rule out a stress fracture or Kienbock's Disease he would need to avoid doing 'cleans' and reduce the load of lifts. An ultrasound scan would be able to determine the extent of joint and tendon involvement with a musculoskeletal radiologist. Meanwhile, he should not participate in competition as it could worsen his condition. He would benefit from daily low frequency ultrasound (Exogen) for another 2 - 4 weeks. If symptoms persists he would need to be reviewed. MRI Scan could be an option then.

Interesting links:-
Wrist arthritis
A possible complication: Kienbock Disease

Posterior Cruciate Ligament Rupture

Posterior Drawer Test

Samsung Champions Trophy 2007

Kuala Lumpur is hosting the 29th Champion's Trophy featuring 8 world class national teams from 29th November 2007 to 9th December 2007 at the National Hockey Stadium, Bukit Jalil. Entrance will be free to promote the exciting and highly tactical sport in the country.


The teams participating in the championships are:-
1. Australia
2. Germany
3. Great Britain
4. Korea
5. Malaysia
6. Netherlands
7. Pakistan
8. Spain

Although the host Malaysia is fielding young players, the team promised to surprise their stronger opponents with fine skills and courage. I will be watching the team from the stands (instead of the bench) and cheering them on. You may also find a live commentary (with live feeds every 30 seconds) on the official website. All the best to the participating teams!

Find out more here:-
Official Website
The fixtures (schedule) and results
Points Table
Players and Officials
Photo gallery
News Updates
Samsung Official website

SEA Games Korat 2007

The 24th Southeast Asian Games (SEA Games) will be held in 3 different venues i.e. Korat, Bangkok and Chonburi (Pattaya), Thailand from 6th December to 16th December 2007 in conjunction with the commemoration of 80th birthday of His Majesty King Bhumibol Adulyadej.

The sports featured at the games are:-

* Category I - Athletics and Aquatics including Diving and Water Polo.
* Category II - Archery, Badminton, Basketball, Baseball, Billiards & Snooker, Tenpin Bowling, Boxing, Canoeing, Rowing, Cycling, Equestrian & Polo, Fencing, Football & Futsal, Golf, Gymnastics, Handball, Hockey, Judo, Karate, Rugby 7’s, Sailing & Windsurfing, Sepaktakraw, Shooting & Skeet & Trap, Softball, Table Tennis, Taekwondo, Tennis, Triathlon & Duathlon, Volleyball & Beach Volleyball, Weightlifting and Wushu.
* Category III - Dance Sport, Lawn Bowls, Mauy, Pentanque, Pencak Silat and Traditional Boat Race.

Find out the location of sports here:-
1. Korat: Venues and maps
2. Bangkok: Venues and maps
3. Chonburi (Pattaya): Venues and maps

Find out more about SEA Games 2007 here:-
Official Website for Sea Games Korat 2007
Competition Schedule
Events
Results
News Updates and more news
Sports and logos

Pretibial Bursitis (Preacher's Bursitis)

Ms Lee is a lady in her 30s who came to see me with a painless swelling in her right knee for the past 2 weeks. She mentioned to me that she knocked her knee at a pillar last month but it did not swell then. The swelling came after she started doing more home cleaning on her knees.

I found the swelling to be non-tender, soft and cystic, sitting just on top of the tibial tuberosity. I suggested that she stay away from doing work on her knees for another 2 weeks. Meanwhile, the X-ray of her Right tibia was normal (to rule out any bony abnormality due to her fall or any tumours). An ultrasound of the swelling would be able to demonstrate any fluid. If the swelling failed to subside after 1-2 weeks we would investigate further.

If she was an athlete playing field hockey, soccer or rugby, we would investigate for infection (abscess).

Sultan Azlan Shah Asia Cup 2007

Bilateral Knee Osgood Schlatter's Disease

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

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

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

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

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

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

Morton's Neuroma (Interdigital Neuroma) and Ankle Instability

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

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

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

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


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

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

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

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

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

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

Now Everyone Can Fly: Air Asia

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

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

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