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MESSAGES TO
Sport Injuries & ACL Tears

Sport Injuries & ACL Tears

A DxD Session with Dr Alan Cheung


Ended on Thu Feb 28 2019
Ended
Have a question to ask?

Get Dr Alan Cheung's opinions on your questions! Only approved questions are displayed.

Top Answers


Hello, sorry to hear about your problems.

Hypermobile joints have a range of movement which exceeds the normal range, usually due to laxity of the surrounding ligaments. This determined by the content of various proteins such as collagen and elastin.

Rarely there may be an underlying genetic disorder such as Ehlers Danlos syndrome or Marfan’s syndrome. These conditions may be associated with blood vessel problems – if you have concerns it may be worth seeing a geneticist in Singapore for screening.

Hypermobility may be beneficial for certain sports e.g. gymnastics, dancing and swimming, but is associated with a higher rate of injury and potentially slower rate of recovery.

You should avoid stretching hyperflexible muscles further. Instead, concentrate on isometric or concentric strengthening exercises. In isometric exercise, the muscles are working, but the joints don’t change position. With concentric exercises, muscles shorten as t for example like your biceps during a biceps curl.

Sustained muscle stretches are not recommended for hypermobility syndrome, because muscles and ligaments are already too lax.

Eccentric exercises should be avoided – these occur when a muscle contracts while lengthening. An example of an eccentric contraction is when you lower the weight back down to starting position after a biceps curl.

Keeping muscles strong throughout their entire range of motion is important. Muscles tend to be strongest in their mid-range and weakest at either extreme of motion. That means a joint will be most vulnerable, or least protected, when it is at the end of its range of motion.

Your condition is likely to be managed in a multidisciplinary setting (ie. seeing lots of specialists) due to its nature and the many effects it can have on your body.

I recommended initially working with a sports doctor and physiotherapist to strengthen the muscles surrounding the most vulnerable joints: your shoulders, elbows, knees and ankles, as well as your core musculature.

Here are various resources that will help you understand and manage your condition:

http://hypermobility.org/

http://www.hypermobilityconnect.com/

http://www.mdjunction.com/hypermobile-syndrome

I hope you found this useful and Good Luck!

26 Jan 2018

Pain at the front of the knee is often due to problems from the kneecap (i.e. patellofemoral joint). This can be due to a number of causes. In young females, the most common causes are:

Patellofemoral pain syndrome

Chondromalacia patella

1. Patellofemoral Pain Syndrome

Patellofemoral pain syndrome occurs when nerves sense pain and inflammation in the soft tissues and bone around the kneecap.

In some cases it can be caused by a sudden change in physical activity, improper sports technique or Changes in footwear or playing surface.

Abnormal tracking of the kneecap due to problems in alignment between the hip and ankle, the shape of the groove that the kneecap sits in (trochlear dysplasia), and muscular imbalance / weakness especially of the quadriceps muscles (at the front of the thigh) may contribute to patellofemoral pain syndrome.

2. Chondromalacia patella

Chondromalacia patella is a softening and degeneration of the articular cartilage of the patellofemoral joint as a result of overuse, injury, or abnormal joint mechanics.It may coexist with patellofemoral pain syndrome.

I recommend that you consult a qualified medical specialist who will examine your knees for the above problems and obtain an X-ray.

Initially your doctor may recommend simple painkillers, and refer you to physiotherapy.

For the previously described conditions, surgery is rarely necessary.

26 Jan 2018

The anterior cruciate ligament (ACL) provides stability to prevent the shin bone (tibia) sliding forwards and rotating in relation to the thigh bone (femur).

Patients with a complete ACL tear may find that they are unable to play sports where they need to turn, sidestep or pivot rapidly e.g. soccer, basketball, because their knee keeps ‘giving way’.

Everyone reacts differently to an ACL injury, and your friend may not have had exactly the same injury, activity level and symptoms that you have.

When I meet a patient with a suspected ACL tear I assess them as an individual to determine what effect the injury is having on their lives.

ACL reconstruction may improve the quality of their life and allow them the/ opportunity of returning to sports, but there is a lengthy rehabilitation period of up to a year.

If you are young, your knee is unstable and preventing you from playing the sport(s) you love, then you might benefit from an ACL reconstruction. There is also some evidence that having an ACL reconstruction can reduce (but not completely eliminate) the risk of developing osteoarthritis in later life.

Here are some useful resources for those with an ACL injury:

  1. http://www.anationinmotion.org/value/acl/
  2. http://orthoinfo.aaos.org/topic.cfm?topic=a00297
26 Jan 2018

Anterior Ankle Impingement is a condition where a patient has pain at the front of the ankle, due to compression of the bony or soft tissue structures during activities which involve deep ankle bending (maximal dorsiflexion).

Simple measures to reduce pain include avoiding walking or running on uneven ground, nonsteroidal anti-inflammatory drugs if tolerated, and ankle bracing.

I would strongly recommend that you see a good physiotherapist. They may use a physical therapy program that includes reducing inflammation, deep soft-tissue work on the gastrocnemius and soleus muscles, stretching of the Achilles tendon, work on improving proprioception and balance, strengthening of the peroneal tendon, and taping.

Although you may not have any bony cause for the pain in your ankle, soft tissue structures such as synovium, scar tissue or fibrocartilage may be being trapped causing pain. This problem may be addressed through keyhole surgery, if non-surgical management fails.

With regards to TCM, I am afraid that I know very little about this topic, as I grew up in England and am a Western trained doctor.

The good news is that 82% of patients with ankle impingement respond well to conservative treatment such as physiotherapy in the long term.

26 Jan 2018

I see many seniors who wish to remain active and enjoy running. Unfortunately many in this age group have degenerative change and osteoarthritis in their knees and other joints. This is often due to several factors like a previous injury, genetics, and mechanical wear and tear over time.

I often explain to my patients that their knees are like the moving parts of a car engine. Over time the parts may wear out, particularly if they are used for heavy activities such as long distance running. To help with symptoms, physiotherapy exercises to strengthen the quadriceps muscles (at the front of the thigh), weight loss and sometimes joint injections may be prescribed by your doctor.

Sometimes however the damage is so severe that your doctor may recommend replacing part or all of your knee joint.

I would suggest to your dad to consider taking up another activity such as brisk walking, swimming or cycling which has less impact to the knees.

If he does insist on running then an elliptical trainer in the gym may place less stress on his joints.

26 Jan 2018

The answer is to these questions is – it depends on the location of the tear, type and size of tear, and whether there are degenerative changes in your knee also. 

The meniscus is a C shaped disc of fibrocartilage. The blood supply comes from the (periphery) outside of the meniscus – the so called ‘red zone’.

Towards the centre of the meniscus (the ‘white’ zone) the blood supply is poor. There are two menisci in the knee – one on the inside of the knee (medial) and one on the outside (lateral).

Small tears in the peripheral red zone where the blood supply is good have a greater chance of healing. Over time, for a small tear in any location, symptoms may improve over time, especially with rest and a supervised exercise program.

Therefore a trial period of conservative (non-surgical) management may be advised before surgery is considered.

The exception to this are large tears e.g. bucket handle type tears, which cause a mechanical block to movement in the knee – so called ‘locking’ of the knee. Under these circumstances the patient may not be able to fully bend or straighten their knee, and may be in excruciating pain.

For these large tears, and in other situations when non-surgicial management has failed, meniscus tears may be treated with keyhole (‘arthoscopic’) surgery, where 2 small incisions are made either side of the kneecap tendon.

Through these incisions, the meniscus tear may be trimmed away (a so called ‘partial meniscectomy’) or repaired using a variety of techniques. Not all tears are suitable for repair.

Younger patients without degenerative changes present in the knee are most likely to benefit from keyhole surgery. Studies have shown that the older patient with degenerative meniscal tears may have no benefit with meniscal surgery compared to placebo or a supervised exercise program. In such patients with severe pain due to degenerative change, a partial or total knee replacement might be suitable.

If you have a meniscal tear and enjoy running, I would not try and run through the pain, as you may make the situation worse.

In the acute stages I would suggest RICE – rest,ice,compression, elevation.

I would then consult a qualified sports doctor or surgeon who would evaluate your knee and might prescribe physiotherapy to begin with.

If your symptoms improve then I would suggest swimming, cycling, rowing or elliptical trainer to begin with. As you recover further, I would slowly build up your running distance and intensity over time.

26 Jan 2018

Thanks for the question which I think is a good one. Often patients who ask this question are answered with a barrage of statistics and percentages which is confusing.

As someone whose mother recently underwent a total knee replacement (TKR) I understand that what patients are really looking for in a surgeon when they ask this question, is someone who can

a) do the best surgery possible,

b) communicate and empathise well, and

c) will care for their family member as if they were their own, which is something I strive for.

The short answer to your question is that – yes, total knee replacement surgery is generally safe, but it depends upon the person having surgery.

Every human being is different and reacts differently to an operation. If your father has a lot of underlying medical problems then that may increase his risk of complications during and after surgery. That is why it is important to find a doctor who treats your father as an individual, rather than having a ‘one size fits all’ approach.

A good doctor will take a careful history asking about underlying medical problems, and perform a thorough examination, not just on the knee, but also of the heart, lungs and abdomen if relevant.

He or she should be able to take the time to explain the procedure and potential complications in understandable language, as well as answer your and your father’s questions. This is the ideal scenario, but I understand that in a busy clinic sometimes it can be difficult for doctors to do so.

MEDICAL COMPLICATIONS AND RISK ASSESSMENT

Before your surgery, your surgeon and anaesthetist should make a risk assessment of your father’s fitness for surgery and may decide whether he is a normal healthy patient, or someone who has a mild/severe disease.

They will look at any underlying medical problems related to each organ system – e.g. heart, lungs, blood vessels, liver, and may organise further investigations and refer to a particular specialist if there is a problem.

Once all medical problems have been addressed, the anaesthetist will discuss with your father what he thinks is the safest anaesthetic to use. In the operating theatre many precautions are taken to minimise risk of infection.

After the surgery your father will be given antibiotics via a drip, and measures will be taken to reduce his risk of developing a ‘blood clot’ in his legs or lungs. He will be given strong painkillers which may enable him to stand and walk immediately after the procedure. If your father is at higher risk of complications then he may be observed closely in a High Dependency Unit (HDU) overnight.

With regards to specific complications, infection is perhaps the most feared complication following TKR. 

INFECTION

Fortunately the rate of deep joint infection following TKR is low (less than 1%). There are many risk factors for infection, and a good surgeon will try and control/optimise these factors to reduce risk of infection.

A recent study from Cornell University in the USA1 looked at nearly 18000 patients undergoing TKR and the risk factors for infection. They found that patients with liver, lung or kidney disease, undergoing blood transfusion or having a urine infection in hospital increased the risk of joint infection.

Diabetes mellitus, rheumatoid arthritis, smoking, obesity have also all been identified as potential risk factors for joint infection and should be addressed prior to surgery.

VENOUS THROMBOEMBOLISM

A blood clot in the deep veins of the legs is called a deep vein thrombosis or “DVT” and can occur following a surgical procedure such as a TKR. Rarely, a DVT can travel to the lungs and form a “PE” or pulmonary embolism which can be life threatening.

Fortunately PE’s are not common and occur in only around 1% of patients. The risk of DVT and PE can be reduced through the use of certain ‘blood thinning’ medicines and/or mechanical devices such as foot pumps. Early walking and mobilisation following surgery may also be important, which is why I prepare my patients to walk immediately following surgery and avoid resting in bed for long periods.2  

BLEEDING

If a patient has liver disease, low platelet count (cells that help the blood clotting process), or clotting abnormalities, then they will be at higher risk of bleeding following surgery and may need a blood product transfusion.

Some patients are already on blood thinning medicine such as clopidogrel or warfarin and will need to stop these 10-14 days before surgery. If your father is a follower of TCM then he should avoid taking TCM herbal medicine for at least 2 weeks prior to any operation.

Cordyceps (冬虫夏草) in particular may increase risk of bleeding. Other Chinese herbs which have blood thinning effects include Szechwan lovage rhizome (chuanxiong), radix salviae miltiorrhizae (danshen), safflower (honghua), red peony root (chishao) and motherwort herb (yimucao). 

FINAL THOUGHTS

In summary, total knee replacement is a very common and effective surgery performed worldwide to replace worn out joints, and is generally safe and well tolerated. As each person has a different medical history and response to surgery, its best to find a surgeon who will treat your father as an individual and not take a ‘one size fits all’ approach.

Complications can never be completely eliminated, but with a careful risk assessment and modern techniques, they can be minimised. I hope all goes well with your Father’s operation, thanks for asking your question.

Dr Alan Cheung

References:

  1. Poultsides LA et al. Infection risk assessment in patients undergoing primary total knee arthroplasty. Int Orthop.2018 Jan;42(1):87-94.
  2. https://www.aaos.org/research/guidelines/vte/vte_full_guideline.pdf
31 Aug 2018

Top Questions


Hi Doctors, I'm a 21 year old male with recurring knee pain and weakness for about 1 year now. I have problems walking down steps and walking fast / running. I experience sharp pain around my knees when I try to do so. My legs feel weak in general and I walk at a very slow pace. What are possible causes, and what should I do next? 

I have had Patellar Instability in both knees since I was a child. I have received physiotherapy treatment. However, I was wondering if this condition will affect me or cause me problems when I'm older? 

I am 39 years old. I have been experiencing knee pain after accidentally twisting my knee. An MRI report showed a chondral ulcer. I have tried physio for about 6 months. Each time, the exercise just causes my knee to swell up and become more painful. May I know what are my treatment options? Are there any alternatives to surgery?

I'm a 20 year old female. I recently injured my right knee during my sports training. The doctor has diagnosed a damaged meniscus. What are the recommended treatment options for a damaged meniscus?